Zhang LY, Liu ZJ, Shen L, Huang YG
Department of Anesthesiology,PUMC Hospital,CAMS and PUMC,Beijing 100730,China

Zhongguo Yi Xue Ke Xue Yuan Xue Bao. 2017 Dec 20;39(6):831-835

Enhanced recovery after surgery (ERAS) is a new perioperative concept that aims
to reduce perioperative stress response and accelerate rehabilitation of patients
through a variety of optimized management. With the wider application of this
concept,the effective implementation of ERAS program has become a new challenge.
Cardiopulmonary exercise testing (CPET) has shown promising value in the
preoperative assessment,perioperative optimization,and postoperative
rehabilitation of ERAS. This article reviews the application of CPET in ERAS,with
an attempt to provide evidence for more detailed and comprehensive ERAS program.

Yen YS, Su DCJ, Yuan KS et al

The Physician And Sportsmedicine [Phys Sportsmed] 2018 Jan 10. Date of Electronic Publication: 2018 Jan 10.

Objectives: The significance of the isocapnic buffering (IB) phase – the period between the first ventilatory threshold (1stVT) and respiratory compensation point (RCP) – has not been adequately established in patients. This study aimed to determine the clinical significance of the IB phase in coronary artery disease (CAD) patients.
Methods: This retrospective study included data of sixty-two CAD patients after coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) performed in a single medical center between 2010-2014. According to their physical conditions, the patients performed incremental cardiopulmonary exercise test (CPET) using a cycle ergometer by the ramp of 5-20 W/min. Correlations between the corrected IB phase duration and age, body mass index (BMI), left ventricular ejection fraction (LVEF), and CPET parameters were evaluated using Pearson correlation coefficients. Variables predicting peak oxygen consumption (VO2) were evaluated using multiple regression.
Results: Peak VO2 (p < 0.001), VO2 at RCP (p < 0.001), ∆O2/∆WR slope (p < 0.001), maximal partial pressure of end tidal CO2 (PetCO2) (p = 0.0012), VE/VCO2 slope (p = 0.010), BMI (p = 0.012), and age (p = 0.017) were significantly correlated, whereas LVEF (p = 0.246) and VO2 at 1stVT (p = 0.179) were not significantly correlated with the corrected IB phase duration. In multiple regression analysis, the corrected IB phase duration, VO2 at 1stVT, and ∆O2/∆WR slope were significantly associated with peak VO2.
Conclusion: The findings indicate that the IB phase duration is a useful indicator of peripheral cardiopulmonary function, endurance performance, and prognosis in CAD patients.

Scheadler CM, Garver MJ, Hanson NJ.

Med Sci Sports Exerc. 2017 Sep;49(9):1911-1916

INTRODUCTION: There is a plethora of gas sampling intervals available during
cardiopulmonary exercise testing to measure peak oxygen consumption (V˙O2peak).
Different intervals can lead to altered V˙O2peak. Whether differences are
affected by the exercise protocol or subject sample is not clear. The purpose of
this investigation was to determine whether V˙O2peak differed because of the
manipulation of sampling intervals and whether differences were independent of
the protocol and subject sample.
METHODS: The first subject sample (24 ± 3 yr; V˙O2peak via 15-breath moving
averages: 56.2 ± 6.8 mL·kg·min) completed the Bruce and the self-paced V˙O2max
protocols. The second subject sample (21.9 ± 2.7 yr; V˙O2peak via 15-breath
moving averages: 54.2 ± 8.0 mL·kg·min) completed the Bruce and the modified
Astrand protocols. V˙O2peak was identified using five sampling intervals: 15-s
block averages, 30-s block averages, 15-breath block averages, 15-breath moving
averages, and 30-s block averages aligned to the end of exercise. Differences in
V˙O2peak between intervals were determined using repeated-measures ANOVAs. The
influence of subject sample on the sampling effect was determined using
independent t-tests.
RESULTS: There was a significant main effect of sampling interval on V˙O2peak
(first sample Bruce and self-paced V˙O2max P < 0.001; second sample Bruce and
modified Astrand P < 0.05). The difference in V˙O2peak between sampling intervals
followed a similar pattern for each protocol and subject sample, with 15-breath
moving average presenting the highest V˙O2peak.
CONCLUSIONS: The effect of manipulating gas sampling intervals on V˙O2peak
appears to be protocol and sample independent. These findings highlight our
recommendation that the clinical and scientific community request and report the
sampling interval whenever metabolic data are presented. The standardization of
reporting would assist in the comparison of V˙O2peak.

VAN Iterson EH, Olson TP, Borlaug BA, Johnson BD, Snyder EM.

Med Sci Sports Exerc. 2017 Sep;49(9):1758-1768

INTRODUCTION: Cardiopulmonary exercise testing (CPET) plays an important role in
properly phenotyping signs and symptoms of heart failure with preserved ejection
fraction (HFpEF). The prognostic value of CPET is strengthened when accompanied
by cardiac hemodynamic measurements. Although recognized as the “gold” standard,
cardiac catheterization is impractical for routine CPET. Thus, advancing the
scientific/methodologic understanding of noninvasive techniques for exercise
cardiac hemodynamic assessment is clinically impactful in HFpEF. This study
tested the concurrent validity of noninvasive acetylene gas (C2H2) uptake,
echocardiography (ECHO), and oxygen pulse (O2pulse) for measuring/predicting
exercise stroke volume (SV) in HFpEF.
METHODS: Eighteen white HFpEF and 18 age-/sex-matched healthy controls
participated in upright CPET (ages, 69 ± 9 yr vs 63 ± 9 yr). At rest, 20 W, and
peak exercise, SV was measured at steady-state via C2H2 rebreathe (SVACET) and
ECHO (SVECHO), whereas O2pulse was derived (=V˙O2/HR).
RESULTS: Resting relationships between SVACET and SVECHO, SVECHO and O2pulse, or
SVACET and O2pulse were significant in HFpEF (R = 0.30, 0.36, 0.67), but not
controls (R = 0.07, 0.01, 0.09), respectively. Resting relationships persisted to
20 W in HFpEF (R = 0.70, 0.53, 0.70) and controls (R = 0.05, 0.07, 0.21),
respectively. Peak exercise relationships were significant in HFpEF (R = 0.62,
0.24, 0.64), but only for SVACET versus O2pulse in controls (R = 0.07, 0.04,
0.33), respectively. Standardized standard error of estimate between techniques
was strongest in HFpEF at 20 W: SVACET versus SVECHO = 0.57 ± 0.22; SVECHO versus
O2pulse = 0.71 ± 0.28; SVACET versus O2pulse = 0.56 ± 0.22.
CONCLUSIONS: Constituting a clinically impactful step towards construct
validation testing, these data suggest SVACET, SVECHO, and O2pulse demonstrate
moderate-to-strong concurrent validity for measuring/predicting exercise SV in
HFpEF.

Shiraishi Y; Katsumata Y; Sadahiro T; Azuma K; Akita K; Isobe S; Yashima F; Miyamoto K; Nishiyama T; Tamura Y; Kimura T; Nishiyama N; Aizawa Y; Fukuda K; Takatsuki S

Journal Of The American Heart Association [J Am Heart Assoc], ISSN: 2047-9980, 2018 Jan 07; Vol. 7

Background: It has never been possible to immediately evaluate heart rate variability (HRV) during exercise. We aimed to visualize the real-time changes in the power spectrum of HRV during exercise and to investigate its relationship to the ventilatory threshold (VT).
Methods and Results: Thirty healthy subjects (29.1±5.7 years of age) and 35 consecutive patients (59.0±13.2 years of age) with myocardial infarctions underwent cardiopulmonary exercise tests with an RAMP protocol ergometer. The HRV was continuously assessed with power spectral analyses using the maximum entropy method and projected on a screen without delay. During exercise, a significant decrease in the high frequency (HF) was followed by a drastic shift in the power spectrum of the HRV with a periodic augmentation in the low frequency/HF (L/H) and steady low HF. When the HRV threshold (HRVT) was defined as conversion from a predominant high frequency (HF) to a predominant low frequency/HF (L/H), the VO2 at the HRVT (HRVT-VO2) was substantially correlated with the VO2 at the lactate threshold and VT) in the healthy subjects (r=0.853 and 0.921, respectively). The mean difference between each threshold (0.65 mL/kg per minute for lactate threshold and HRVT, 0.53 mL/kg per minute for VT and HRVT) was nonsignificant (P>0.05). Furthermore, the HRVT-VO2 was also correlated with the VT-VO2 in these myocardial infarction patients (r=0.867), and the mean difference was -0.72 mL/kg per minute and was nonsignificant (P>0.05).
Conclusions: A HRV analysis with our method enabled real-time visualization of the changes in the power spectrum during exercise. This can provide additional information for detecting the VT.

Lam CS, Rienstra M, Tay WT, Liu LC, Hummel YM, van der Meer P,
de Boer RA, Van Gelder IC, van Veldhuisen DJ, Voors AA, Hoendermis
ES.

JACC Heart Fail. 2017 Feb;5(2):92-98. doi: 10.1016/j.jchf.2016.10.005. Epub 2016
Dec 21.

OBJECTIVES: This study sought to study the association of atrial fibrillation
(AF) with exercise capacity, left ventricular filling pressure, natriuretic
peptides, and left atrial size in heart failure with preserved ejection fraction
(HFpEF).
BACKGROUND: The diagnosis of HFpEF in patients with AF remains a challenge
because both contribute to impaired exercise capacity, and increased natriuretic
peptides and left atrial volume.
METHODS: We studied 94 patients with symptomatic heart failure and left
ventricular ejection fractions ≥45% using treadmill cardiopulmonary exercise
testing and right- and/or left-sided cardiac catheterization with simultaneous
echocardiography.
RESULTS: During catheterization, 62 patients were in sinus rhythm, and 32
patients had AF. There were no significant differences in age, sex, body size,
comorbidities, or medications between groups; however, patients with AF had lower
peak oxygen consumption (VO2) compared with those with sinus rhythm (10.8 ± 3.1
ml/min/kg vs. 13.5 ± 3.8 ml/min/kg; p = 0.002). Median (25th to 75th percentile)
N-terminal pro-B-type natriuretic peptide (NT-proBNP) was higher in AF versus
sinus rhythm (1,689; 851 to 2,637 pg/ml vs. 490; 272 to 1,019 pg/ml; p < 0.0001).
Left atrial volume index (LAVI) was higher in AF than sinus rhythm (57.8 ± 17.0
ml/m2 vs. 42.5 ± 15.1 ml/m2; p = 0.001). Invasive hemodynamics showed higher mean
pulmonary capillary wedge pressure (PCWP) (19.9 ± 3.7 vs. 15.2 ± 6.8) in AF
versus sinus rhythm (all p < 0.001), with a trend toward higher left ventricular
end-diastolic pressure (17.7 ± 3.0 mm Hg vs. 15.7 ± 6.9 mm Hg; p = 0.06). After
adjusting for clinical covariates and mean PCWP, AF remained associated with
reduced peak VO2 increased log NT-proBNP, and enlarged LAVI (all p ≤0.005).
CONCLUSIONS: AF is independently associated with greater exertional intolerance,
natriuretic peptide elevation, and left atrial remodeling in HFpEF. These data
support the application of different thresholds of NT-proBNP and LAVI for the
diagnosis of HFpEF in the presence of AF versus the absence of AF.

Rocco IS, Viceconte M, Pauletti HO, Matos-Garcia BC,
Marcondi NO, Bublitz C, Bolzan DW, Moreira RSL, Reis MS,
Hossne NA Jr, Gomes WJ, Arena R, Guizilini S.

Disabil Rehabil. 2017 Dec 26:1-7. doi: 10.1080/09638288.2017.1401673. [Epub ahead
of print]

PURPOSE: We aimed to investigate the ability of oxygen uptake kinetics to predict
short-term outcomes after off-pump coronary artery bypass grafting.
METHODS: Fifty-two patients aged 60.9 ± 7.8 years waiting for off-pump coronary
artery bypass surgery were evaluated. The 6-min walk test distance was performed
pre-operatively, while simultaneously using a portable cardiopulmonary testing
device. The transition of oxygen uptake kinetics from rest to exercise was
recorded to calculate oxygen uptake kinetics fitting a monoexponential regression
model. Oxygen uptake at steady state, constant time, and mean response time
corrected by work rate were analysed. Short-term clinical outcomes were evaluated
during the early post-operative of off-pump coronary artery bypass surgery.
RESULTS: Multivariate analysis showed body mass index, surgery time, and mean
response time corrected by work rate as independent predictors for short-term
outcomes. The optimal mean response time corrected by work rate cut-off to
estimate short-term clinical outcomes was 1.51 × 10-3 min2/ml. Patients with
slower mean response time corrected by work rate demonstrated higher rates of
hypertension, diabetes, EuroSCOREII, left ventricular dysfunction, and impaired
6-min walk test parameters. The per cent-predicted distance threshold of 66% in
the pre-operative was associated with delayed oxygen uptake kinetics.
CONCLUSIONS: Pre-operative oxygen uptake kinetics during 6-min walk test predicts
short-term clinical outcomes after off-pump coronary artery bypass surgery. From
a clinically applicable perspective, a threshold of 66% of pre-operative
predicted 6-min walk test distance indicated slower kinetics, which leads to
longer intensive care unit and post-surgery hospital length of stay. Implications
for rehabilitation Coronary artery bypass grafting is a treatment aimed to
improve expectancy of life and prevent disability due to the disease progression;
The use of pre-operative submaximal functional capacity test enabled the
identification of patients with high risk of complications, where patients with
delayed oxygen uptake kinetics exhibited worse short-term outcomes; Our findings
suggest the importance of the rehabilitation in the pre-operative in order to
“pre-habilitate” the patients to the surgical procedure; Faster oxygen uptake
on-kinetics could be achieved by improving the oxidative capacity of muscles and
cardiovascular conditioning through rehabilitation, adding better results
following cardiac surgery.

Sato Y; Yoshihisa A; Department of Cardiovascular Medicine, Fukushima Medical University, Fukushima, Japan. Electronic address: yoshihis@fmu.ac.jp.
Kimishima Y; Kiko T; Watanabe S; Fukushima; Kanno Y;
et al.

The Canadian Journal Of Cardiology [Can J Cardiol] 2018 Jan; Vol. 34 (1), pp. 80-87. Date of Electronic Publication: 2017 Nov 08.

Background: It is widely recognized that overt hyper- as well as hypothyroidism are potential causes of heart failure (HF). Additionally it has been recently reported that subclinical hypothyroidism (sub-hypo) is associated with atherosclerosis, development of HF, and cardiovascular death. We aimed to clarify the effect of sub-hypo on prognosis of HF, and underlying hemodynamics and exercise capacity.
Methods: We measured the serum levels of thyroid stimulating hormone (TSH) and free thyroxine (FT4) in 1100 consecutive HF patients. We divided these patients into 5 groups on the basis of plasma levels of TSH and FT4, and focused on euthyroidism (0.4 ≤ TSH ≤ 4 μIU/mL and 0.7 ≤ FT4 ≤ 1.9 ng/dL; n = 911; 82.8%) and sub-hypo groups (TSH > 4 μIU/mL and 0.7 ≤ FT4 ≤ 1.9 ng/dL; n = 132; 12.0%). We compared parameters of echocardiography, cardiopulmonary exercise testing, and cardiac catheterization, and followed up for cardiac event rate and all-cause mortality between the 2 groups.
Results: Although left ventricular ejection fraction did not differ between the 2 groups, the sub-hypo group had lower peak breath-by-breath oxygen consumption and higher mean pulmonary arterial pressure than the euthyroidism group (peak breath-by-breath oxygen consumption, 14.0 vs 15.9 mL/min/kg; P = 0.012; mean pulmonary arterial pressure, 26.8 vs 23.5 mm Hg, P = 0.020). In Kaplan-Meier analysis (mean 1098 days), the cardiac event rate and all-cause mortality were significantly higher in the sub-hypo group than those in the euthyroidism group (log rank, P < 0.01, respectively). In Cox proportional hazard analysis, sub-hypo was a predictor of cardiac event rate and all-cause mortality in HF patients (P < 0.05, respectively).
Conclusions: Sub-hypo might be associated with adverse prognosis, accompanied by impaired exercise capacity and higher pulmonary arterial pressure, in HF patients.

Richardson K; Levett DZH;  Jack S; Grocott MPW

British Journal Of Anaesthesia [Br J Anaesth] 2017 Dec 01; Vol. 119 (suppl_1), pp. i34-i43.

There is a consistent relationship between physical activity, physical fitness, and health across almost all clinical contexts, including the perioperative setting. Physiological measurements obtained during physical exercise may be used to infer the risk of adverse outcome after major surgery. In particular, data obtained from perioperative cardiopulmonary exercise testing have an expanding role in perioperative care. Such information may be used to inform a variety of changes in clinical practice, including interventions that may reduce the risk of perioperative adverse events. Specifically, for patients undergoing major cancer surgery there is a complex interplay between different cancer treatments, including neoadjuvant therapies (chemo- and chemo- plus radiotherapy), surgery, and physical fitness, and the modulation of these relationships by perioperative exercise interventions. Preoperative cardiopulmonary exercise testing provides an objective evaluation of physical fitness and has been used to provide an individualized risk profile in order to guide collaborative decision-making, inform the consent process, characterize and optimize co-morbidities, and to triage patients to perioperative care. Furthermore, studies evaluating exercise interventions aimed at increasing preoperative exercise capacity have established that training improves physical fitness. However, to date, this literature is largely composed of feasibility and pilot studies with small sample sizes, which are in general underpowered to assess clinical outcomes. Adequately powered prospective multicentre studies are needed to characterize the most effective means of improving patient fitness before surgery and to evaluate the impact of such improvements on surgical and disease-specific (e.g. cancer) outcomes.

Schaun GZ

Sports Med Open. 2017 Dec 8;3(1):44. doi: 10.1186/s40798-017-0112-1.

Commonly performed during an incremental test to exhaustion, maximal oxygen
uptake (V̇O2max) assessment has become a recurring practice in clinical and
experimental settings. To validate the test, several criteria were proposed. In
this context, the plateau in oxygen uptake (V̇O2) is inconsistent in its
frequency, reducing its usefulness as a robust method to determine “true”
V̇O2max. Moreover, secondary criteria previously suggested, such as expiratory
exchange ratios or percentages of maximal heart rate, are highly dependent on
protocol design and often are achieved at V̇O2 percentages well below V̇O2max.
Thus, an alternative method termed verification phase was proposed. Currently, it
is clear that the verification phase can be a practical and sensitive method to
confirm V̇O2max; however, procedures to conduct it are not standardized across
the literature and no previous research tried to summarize how it has been
employed. Therefore, in this review the knowledge on the verification phase was
updated, while suggestions on how it can be performed (e.g. intensity, duration,
recovery) were provided according to population and protocol design. Future
studies should focus to identify a verification protocol feasible for different
populations and to compare square-wave and multistage verification phases.
Additionally, studies assessing verification phases in different patient
populations are still warranted.