Navidi M;Phillips AW;Griffin SM;Duffield KE;Greystoke A;Sumpter K;Sinclair RCF;

The British Journal Of Surgery [Br J Surg] 2018 Mar 30. Date of Electronic Publication: 2018 Mar 30.

Background: Neoadjuvant chemotherapy may have a detrimental impact on cardiorespiratory reserve. Determination of oxygen uptake at the anaerobic threshold by cardiopulmonary exercise testing (CPET) provides an objective measure of cardiorespiratory reserve. Anaerobic threshold can be used to predict perioperative risk. A low anaerobic threshold is associated with increased morbidity after oesophagogastrectomy. The aim of this study was to establish whether neoadjuvant chemotherapy has an adverse effect on fitness, and whether there is recovery of fitness before surgery for oesophageal and gastric adenocarcinoma.
Methods: CPET was completed before, immediately after (week 0), and at 2 and 4 weeks after neoadjuvant chemotherapy. The ventilatory anaerobic threshold and peak oxygen uptake (Vo2 peak) were used as objective, reproducible measures of cardiorespiratory reserve. Anaerobic threshold and Vo2 peak were compared before and after neoadjuvant chemotherapy, and at the three time intervals.
Results: Some 31 patients were recruited. The mean anaerobic threshold was lower following neoadjuvant treatment: 15·3 ml per kg per min before chemotherapy versus 11·8, 12·1 and 12·6 ml per kg per min at week 0, 2 and 4 respectively (P < 0·010). Measurements were also significantly different at each time point (P < 0·010). The same pattern was noted for Vo2 peak between values before chemotherapy (21·7 ml per kg per min) and at weeks 0, 2 and 4 (17·5, 18·6 and 19·3 ml per kg per min respectively) (P < 0·010). The reduction in anaerobic threshold and Vo2 peak did not improve during the time between completion of neoadjuvant chemotherapy and surgery.
Conclusion: There was a decrease in cardiorespiratory reserve immediately after neoadjuvant chemotherapy that was sustained up to the point of surgery at 4 weeks after chemotherapy.

Roberts TJ; Burns AT; MacIsaac RJ; MacIsaac AI; Prior DL; La Gerche A;

Cardiovascular Diabetology [Cardiovasc Diabetol] 2018 Mar 23; Vol. 17 (1), pp. 44. Date of Electronic Publication: 2018 Mar 23.

Background: The reasons for reduced exercise capacity in diabetes mellitus (DM) remains incompletely understood, although diastolic dysfunction and diabetic cardiomyopathy are often favored explanations. However, there is a paucity of literature detailing cardiac function and reserve during incremental exercise to evaluate its significance and contribution. We sought to determine associations between comprehensive measures of cardiac function during exercise and maximal oxygen consumption ([Formula: see text]peak), with the hypothesis that the reduction in exercise capacity and cardiac function would be associated with co-morbidities and sedentary behavior rather than diabetes itself.
Methods: This case-control study involved 60 subjects [20 with type 1 DM (T1DM), 20 T2DM, and 10 healthy controls age/sex-matched to each diabetes subtype] performing cardiopulmonary exercise testing and bicycle ergometer echocardiography studies. Measures of biventricular function were assessed during incremental exercise to maximal intensity.
Results: T2DM subjects were middle-aged (52 ± 11 years) with a mean T2DM diagnosis of 12 ± 7 years and modest glycemic control (HbA1c 57 ± 12 mmol/mol). T1DM participants were younger (35 ± 8 years), with a 19 ± 10 year history of T1DM and suboptimal glycemic control (HbA1c 65 ± 16 mmol/mol). Participants with T2DM were heavier than their controls (body mass index 29.3 ± 3.4 kg/m2 vs. 24.7 ± 2.9, P = 0.001), performed less exercise (10 ± 12 vs. 28 ± 30 MET hours/week, P = 0.031) and had lower exercise capacity ([Formula: see text]peak = 26 ± 6 vs. 38 ± 8 ml/min/kg, P < 0.0001). These differences were not associated with biventricular systolic or left ventricular (LV) diastolic dysfunction at rest or during exercise. There was no difference in weight, exercise participation or [Formula: see text]peak in T1DM subjects as compared to their controls. After accounting for age, sex and body surface area in a multivariate analysis, significant positive predictors of [Formula: see text]peak were cardiac size (LV end-diastolic volume, LVEDV) and estimated MET-hours, while T2DM was a negative predictor. These combined factors accounted for 80% of the variance in [Formula: see text]peak (P < 0.0001).
Conclusions: Exercise capacity is reduced in T2DM subjects relative to matched controls, whereas exercise capacity is preserved in T1DM. There was no evidence of sub-clinical cardiac dysfunction but, rather, there was an association between impaired exercise capacity, small LV volumes and sedentary behavior.

Gruchała-Niedoszytko M; van der Vlies P; Niedoszytko P; Sanjabi B; Niedoszytko M; Kaczkan M; Pieszko M; Gierat-Haponiuk K; Śliwińska A; Szalewska D; Małgorzewicz S,

Polish Archives Of Internal Medicine [Pol Arch Intern Med] 2018 Mar 26.

INTRODUCTION The impact of obesity requires methods used on a large scale as cardiopulmonary exercise test (CPET). The gene expression may explain CPET results on molecular level.

OBJECTIVES The aim of the study was to compare gene expression in obesity, differences related to the CPET results.

PATIENTS AND METHODS The study group consisted of 9 obese and 7 controls. The treatment consisted of diet, rehabilitation, behavioural therapy. Diet was based on the body composition analysed by bioelectrical impedance (BIA), resting metabolic rate, and subjective patients’ preferences. The rehabilitation was tailored according to the CPET results: VO2peak, FAT g/h. Behavioural intervention focused on the diagnosis of health problems leading to obesity, lifestyle modification, training in self-assessment and development of healthy habits. The intensive treatment lasted for 12 weeks and consisted of consultations with a physician, dietitian and medical rehabilitation specialist. RNA was isolated from the whole blood. The analysis was performed on 47,323 transcripts, among which the high quality of the RNA was confirmed in the group of 32,379 entities. Illumina TotalPrep 96 RNA Amplification Kit was used. RESULTS The results of our study show differences in gene expression related to the CPET results indicating abnormalities in fat oxidation and maximal oxygen uptake. The genes with the crucial differences in expression were CLEC 12A, HLA DRB1, HLA DRB4, HLA-A29.1, IFIT1 LOC100133662.

CONCLUSIONS The differences in expression may be responsible for the effects of the treatment related to inflammation caused by obesity, which influences muscles, fat tissue and metabolism of fatty acids.

Campodonico J; Mapelli M; Spadafora E; Ghilardi S; Agostoni P; Banfi C; Sciomer S

Respiratory Physiology & Neurobiology [Respir Physiol Neurobiol], ISSN: 1878-1519, 2018 Mar 13

Alveolar-capillary membrane evaluated by carbon monoxide diffusion (DLCO) plays an important role in heart failure (HF). Surfactant Proteins (SPs) have also been suggested as a worthwhile marker. In HF, Levosimendan improves pulmonary hemodynamics and reduces lung fluids but associated SPs and DLCO changes are unknown. Sixty-five advanced HF patients underwent spirometry, cardiopulmonary exercise test (CPET) and SPs determination before and after Levosimendan. Levosimendan caused natriuretic peptide-B (BNP) reduction, peakVO2 increase and VE/VCO2 slope reduction. Spirometry improved but DLCO did not. SP-A, SP-D and immature SP-B reduced (73.7 ± 25.3 vs. 66.3 ± 22.7 ng/mL*, 247 ± 121 vs. 223 ± 110 ng/mL*, 39.4 ± 18.7 vs. 34.4 ± 17.9AU*, respectively); while mature SP-B increased (424 ± 218 vs. 461 ± 243 ng/mL, * = p<0.001). Spirometry, BNP and CPET changes suggest hemodynamic improvement and lung fluid reduction. SP-A, SP-D and immature SP-B reduction indicates a reduction of inflammatory stress; conversely mature SP-B increase suggests alveolar cell function restoration. In conclusion, acute lung fluid reduction is associated with SPs but not DLCO changes. SPs are fast responders to alveolar-capillary membrane condition changes.

Thomson IG; Wallen MP; Hall A; Ferris R; Gotley DC; Barbour AP; Lee A; Thomas J; Smithers BM

International Journal Of Surgery (London, England) [Int J Surg], ISSN: 1743-9159, 2018 Mar 16

Neoadjuvant therapy (NAT) for oesophageal cancer may reduce cardiopulmonary function, assessed by cardiopulmonary exercise testing (CPEX). Impaired cardiopulmonary function is associated with mortality following esophagectomy. We sought to assess the impact of NAT on cardiopulmonary function using CPEX and assessing the clinical relevance of any change in particular if changes were associated with post-operative morbidity. This was a prospective, cohort study of 40 patients in whom CPEX was performed before and after NAT. Thirty-eight patients underwent surgery and follow-up with perioperative outcomes measured. The primary variables derived from CPEX were the anaerobic threshold (AT) and peak oxygen uptake (V˙O2peak). There were significant reductions in the AT (pre-NAT: 12.4 ± 3.0 vs. post-NAT 10.6 ± 2.0 mL kg-1.min-1; p = 0.001). This reduction was also evident for V̇O2peak (pre-NAT: 16.6 ± 3.6 vs. post-NAT 14.9 ± 3.7 mL kg-1.min-1; p = 0.004). The relative reduction in V̇O2peak was greater in chemotherapy patients who developed any peri-operative morbidity (p = 0.04). For patients who underwent chemoradiotherapy, there was a significantly greater relative reduction in AT (p = 0.03) for those who encountered a respiratory complication. Cardiopulmonary function significantly declined as a result of NAT prior to oesophagectomy. The reduction in AT and V̇O2peak was similar in both the chemotherapy and chemoradiotherapy groups.

Cornelis J, Denis T, Beckers P, Vrints C, Vissers D, Goossens M

Int J Cardiol. 2017 Aug 1;240:291-296. doi: 10.1016/j.ijcard.2016.12.159. Epub
2016 Dec 29.

BACKGROUND: Cardiopulmonary exercise testing (CPET) gained importance in the
prognostic assessment of especially patients with heart failure (HF). A
meaningful prognostic parameter for early mortality in HF is exercise oscillatory
ventilation (EOV). This abnormal respiratory pattern is recognized by hypo- and
hyperventilation during CPET. Up until now, assessment of EOV is mainly done upon
visual agreement or manual calculation. The purpose of this research was to
automate the interpretation of EOV so this prognostic parameter could be readily
investigated during CPET.
METHODS AND RESULTS: Preliminary, four definitions describing the original
characteristics of EOV, were selected and integrated in the “Ventilatory
Oscillations during Exercise-tool” (VOdEX-tool), a graphical user interface that
allows automate calculation of EOV. A Discrete Meyer Level 2 wavelet
transformation appeared to be the optimal filter to apply on the collected
breath-by-breath minute ventilation CPET data. Divers aspects of the definitions
i.e. cycle length, amplitude, regularity and total duration of EOV were combined
and calculated. The oscillations meeting the criteria were visualised. Filter
methods and cut-off criteria were made adjustable for clinical application and
research. The VOdEX-tool was connected to a database.
CONCLUSIONS: The VOdEX-tool provides the possibility to calculate EOV
automatically and to present the clinician an overview of the presence of EOV at
a glance. The computerized analysis of EOV can be made readily available in
clinical practice by integrating the tool in the manufactures existing CPET
software. The VOdEX-tool enhances assessment of EOV and therefore contributes to
the estimation of prognosis in especially patients with HF.

Spiroski D, Andjić M, Stojanović OI, Lazović M, Dikić AD,
Ostojić M, Beleslin B, Kostić S, Zdravković M, Lović D

Clin Cardiol. 2017 May;40(5):281-286. doi: 10.1002/clc.22656. Epub 2017 Jan 11.

BACKGROUND: Exercise-based rehabilitation is an important part of treatment
patients following coronary artery bypass graft (CABG) surgery.
HYPOTHESIS: To evaluate effect of very short/short-term exercise training on
cardiopulmonary exercise testing (CPET) parameters.
METHODS: We studied 54 consecutive patients with myocardial infarction (MI)
treated with CABG surgery referred for rehabilitation. The study population
consisted of 50 men and 4 women (age 57.72 ± 7.61 years, left ventricular
ejection fraction 55% ± 5.81%), who participated in a 3-week clinical and 6-month
outpatient cardiac rehabilitation program. The Inpatient program consisted of
cycling 7 times/week and daily walking for 45 minutes. The outpatient program
consisted mainly of walking 5 times/week for 45 minutes and cycling 3 times/week.
All patients performed symptom-limited CPET on a bicycle ergometer with a ramp
protocol of 10 W/minute at the start, for 3 weeks, and for 6 months.
RESULTS: After 3 weeks of an exercise-based cardiac rehabilitation program,
exercise tolerance improved as compared to baseline, as well as peak respiratory
exchange ratio. Most importantly, peak VO2 (16.35 ± 3.83 vs 17.88 ± 4.25
mL/kg/min, respectively, P < 0.05), peak VCO2 (1.48 ± 0.40 vs 1.68 ± 0.43,
respectively, P < 0.05), peak ventilatory exchange (44.52 ± 11.32 vs
52.56 ± 12.37 L/min, respectively, P < 0.05), and peak breathing reserve
(52.00% ± 13.73% vs 45.75% ± 14.84%, respectively, P < 0.05) were also improved.
The same improvement trend continued after 6 months (respectively, P < 0.001 and
P < 0.0001). No major adverse cardiac events were noted during the rehabilitation
program.
CONCLUSIONS: Very short/short-term exercise training in patients with MI treated
with CABG surgery is safe and improves functional capacity.

Helsen F, De Meester P, Van De Bruaene A, Gabriels C, Santens B,
Claeys M, Claessen G, Goetschalckx K, Buys R, Gewillig M, Troost
E, Voigt JU, Claus P, Bogaert J, Budts W

Int J Cardiol. 2018 Mar 8. pii: S0167-5273(17)37403-X. doi:
10.1016/j.ijcard.2018.03.029. [Epub ahead of print]

BACKGROUND: To evaluate the relationship between right ventricular (RV) systolic
dysfunction at rest and reduced exercise capacity in patients with a systemic RV
(sRV).
METHODS: All patients with congenitally corrected transposition of the great
arteries (ccTGA) or complete TGA after atrial switch (TGA-Mustard/Senning)
followed in our institution between July 2011 and September 2017 who underwent
cardiac imaging within a six-month time period of cardiopulmonary exercise
testing (CPET) were analyzed. We assessed sRV systolic function with TAPSE and
fractional area change on echocardiogram and, if possible, with ejection
fraction, global longitudinal and circumferential strain on cardiac magnetic
resonance (CMR) imaging.
RESULTS: We studied 105 patients with an sRV (median age 34 [IQR 28-42] years,
29% ccTGA and 71% TGA-Mustard/Senning) of which 39% had either a pacemaker
(n = 17), Eisenmenger physiology (n = 6), severe systemic atrioventricular valve
regurgitation (n = 14), or peak exercise arterial oxygen saturation < 92%
(n = 17). Most patients were asymptomatic or mildly symptomatic (NYHA class
I/II/III in 71/23/6%). Sixty-four percent had evidence of moderate or severe sRV
dysfunction on cardiac imaging. Mean peak oxygen uptake (pVO2) was
24.1 ± 7.4 mL/kg/min, corresponding to a percentage of predicted pVO2 (%ppVO2) of
69 ± 17%. No parameter of sRV systolic function as evaluated on echocardiography
(n = 105) or CMR (n = 46) was correlated with the %ppVO2, even after adjusting
for associated cardiac defects or pacemakers.
CONCLUSIONS: In adults with an sRV, there is no relation between
echocardiographic or CMR-derived sRV systolic function parameters at rest and
peak oxygen uptake. Exercise imaging may be superior to evaluate whether sRV
contractility limits exercise capacity.

Miki K, Maekura R, Kitada S, Miki M, Yoshimura K, Yamamoto H,
Kawabe T, Kagawa H, Oshitani Y, Satomi A, Nishida K, Sawa N,
Inoue K

Int J Chron Obstruct Pulmon Dis. 2017 Apr 3;12:1061-1070

BACKGROUND: COPD patients undergoing pulmonary rehabilitation (PR) show various
responses. The purpose of this study was to investigate the possible mechanisms
and predictors of the response to PR in COPD patients.
METHODS: Thirty-six stable COPD patients underwent PR including a 4-week
high-intensity exercise training program, and they were evaluated by
cardiopulmonary exercise testing. All patients (mean age 69 years, severe and
very severe COPD 94%) were classified into four groups by whether the exercise
time (Tex) or the peak oxygen uptake [Formula: see text] increased after PR: two
factors increased (both the Tex and the peak [Formula: see text] increased); two
factors decreased; time only increased (the Tex increased, but the peak [Formula:
see text] economized); and [Formula: see text] only increased (the Tex decreased,
but the peak [Formula: see text] increased). Within all patients, the
relationships between baseline variables and the post-to-pre-change ratio of the
time-slope, Tex/(peak minus resting [Formula: see text]), were investigated.
RESULTS: Compared with the two factors increased group (n=11), in the time only
increased group (n=18), the mean differences from pre-PR at peak exercise in 1)
minute ventilation [Formula: see text] (P=0.004), [Formula: see text] (P<0.0001),
and carbon dioxide output [Formula: see text] (P<0.0001) were lower, 2) [Formula:
see text]/ [Formula: see text] (P=0.034) and [Formula: see text]/ [Formula: see
text] (P=0.006) were higher, and 3) the dead space/tidal volume ratio (VD/VT) and
the dyspnea level were similar. After PR, there was no significant difference in
the ratio of the observed peak heart rate (HR) to the predicted peak HR (220 –
age [years]) between the two groups. A significant negative correlation with the
baseline time-slope (r=-0.496, P=0.002) and a positive correlation with the
baseline body mass index (BMI) (r=0.496, P=0.002) were obtained.
CONCLUSIONS: PR in COPD patients improves Tex rather than exercise tolerance,
economizing oxygen requirements, resulting in reduced ventilatory requirements
without cardiac loads followed by reduced exertional dyspnea. In addition, the
time-slope and BMI could be used to predict PR responses beforehand.

Panagopoulou N, Karatzanos E, Dimopoulos S, Tasoulis A, Tachliabouris
I, Vakrou S, Sideris A, Gratziou C, Nanas S

Eur J Prev Cardiol. 2017 May;24(8):825-832.
Epub 2017 Jan 1.

Comment in
Eur J Prev Cardiol. 2017 Aug;24(12 ):1283-1284.
Eur J Prev Cardiol. 2017 Aug;24(12 ):1285-1286.

Background Exercise oscillatory ventilation in chronic heart failure has been
suggested as a factor related to adverse cardiac events, aggravated prognosis and
higher mortality. Exercise training is well known to affect exercise capacity and
mechanisms of pathophysiology beneficially in chronic heart failure. Little is
known, however, about the exercise training effects on characteristics of
exercise oscillatory ventilation in chronic heart failure patients. Design and
methods Twenty (out of 38) stable chronic heart failure patients exhibited
exercise oscillatory ventilation (age 54 ± 11 years, peak oxygen uptake
15.0 ± 5.0 ml/kg per minute). Patients attended 36 sessions of high intensity
interval exercise. All patients underwent cardiopulmonary exercise testing before
and after the programme. Assessment of exercise oscillatory ventilation was based
on the amplitude of cyclic fluctuations in breathing during rest and exercise.
All values are mean ± SD. Results Exercise training reduced ( P < 0.05) the
percentage of exercise oscillatory ventilation duration (79.0 ± 13.0 to
50.0 ± 25.0%), while average amplitude (5.2 ± 2.0 to 4.9 ± 1.6 L/minute) and
length (44.0 ± 10.9 to 41.0 ± 6.7 seconds) did not change ( P > 0.05). Exercise
oscillatory ventilation patients also increased exercise capacity ( P < 0.05).
Conclusions A rehabilitation programme based on high intensity interval training
improved exercise oscillatory ventilation observed in chronic heart failure
patients, as well as cardiopulmonary efficiency and functional capacity.