Akıncı Özyürek B; Savaş Bozbaş Ş; Aydınalp A; Bozbaş H; Ulubay G;

Tuberkuloz Ve Toraks [Tuberk Toraks] 2019 Jun; Vol. 67 (2), pp. 102-107.

Introduction: Respiratory and cardiac functions in association with skeletal and neurophysiologic systems can be evaluated with cardiopulmonary exercise testing (CPET). Compared to treadmill exercise test, CPET provides more comprehensive data about the hemodynamic response to exercise.
Materials and Methods: We aimed to evaluate the relationship with CPET findings and coronary lesions identified on angiography in patients with angina pectoris who underwent teradmill exercise, CPET and coronary angiography (CAG). By this way we sought to examine the CPET parameters that might be predictive for coronary artery disease (CAD) before diagnostic exercise test results and ischemia symptoms develop. Thirty patients in whom CAG was planned because of symptoms and exercise test results were enrolled in the study. Oxygen consumption (VO2), carbondioxide production (VCO2), minute ventilation (VE), maximum work rate (WR), DVO2/DWR and O2 pulse (VO2/HR) values were calculated. Significant CAD was defined as ≥ 50% narrowing in at least one of the coronary arteries.
Result: The mean age was 60.4 ± 8.9 years ve 21 (65.6%) of subjects were male. On CAG, CAD was detected in 19 (59.4%) patients. Maximum heart rate, heart rate reserve (HRR), VE/VCO2 measured at anaerobic threshold (AT) and VO2(mL/kg/min) were significantly differed in patients with CAD than those without (p= 0.031; p= 0.041; p= 0.028; p= 0.03 respectively). Peak VO2, VO2/WR and O2 pulse values were higher in patients with normal angiographic results than those with CAD but the difference did not reach to statistical significance.
Conclusions: The findings of our study indicate that among CPET parameters AT VE/VCO2, ATVO2 (mL/kg/dk) and HRR can have predictive value in the diagnosis of CAD. We think that these parameters might be used in the evaluation of patients with angina and dyspnea suspected of CAD. In conclusion parameters obtained during the test that are not influenced by patient’s effort might increase the value of CPET in the diagnosis CAD.

Woodfield JC; Baldi C; Clifford K;

Scandinavian Journal Of Medicine & Science In Sports [Scand J Med Sci Sports] 2019 Aug 13. Date of Electronic Publication: 2019 Aug 13.

We read with interest the article by Boereboom et al. in the Scandinavian Journal of Medicine Science in Sport1 . This well-performed study showed that a short (8 sessions over 19 days) pre-operative exercise training program increased exercise time and work-load in the second cardiopulmonary exercise test (CPET), but did not lead to a change in participants’ peak VO2. We agree with the statement in the discussion that “Further work should be undertaken to explore exercise modality, training intensity, interval length and session frequency to try and determine an optimal HIIT protocol to improve the cardiorespiratory fitness (CRF) of preoperative patients in the short time-frame available”.

Lamotte MX, Chimenti S, Deboeck G, Gillet A, Kacelenenbogen R,
Strapart J, Vandeneynde F, Van Nooten G, Antoine M.

Acta Cardiol. 2018 Jun;73(3):248-255. doi: 10.1080/00015385.2017.1368947. Epub
2017 Aug 28.

BACKGROUND: With more than 15,000 implanted patients worldwide and a survival
rate of 80% at 1-year and 59% at 5-years, left ventricular assist device (LVAD)
implantation has become an interesting strategy in the management of heart
failure patients who are resistant to other kinds of treatment. There are limited
data in the literature on the change over time of exercise capacity in LVAD
patients, as well as limited knowledge about the beneficial effects that
rehabilitation might have on these patients. Therefore, the aim of our study was
to evaluate the evolution of exercise capacity on a cohort of patients implanted
with the same device (HeartWare©) and to analyse the potential impact of
rehabilitation.
METHODS: Sixty-two patients implanted with a LVAD between June 2011 and June 2015
were screened. Exercise capacity was evaluated by cardiopulmonary exercise
testing at 6 weeks, 6 and 12 months after implantation.
RESULTS: We have observed significant differences in the exercise capacity and
evolution between the trained and non-trained patients. Some of the trained
patients nearly normalised their exercise capacity at the end of the
rehabilitation programme.
CONCLUSIONS: Exercise capacity of patient implanted with a HeartWare© LVAD
increased in the early period after implantation. Rehabilitation allowed
implanted patients to have a significantly better evolution compared to
non-rehabilitated patients.

Duminda N Wijeysundera, Rupert M Pearse, Mark A Shulman, Tom E F Abbott, Elizabeth Torres, Althea Ambosta, Bernard L Croal, John T Granton, Kevin E Thorpe, Michael P W Grocott, Catherine Farrington, Paul S Myles, Brian H Cuthbertson, on behalf of the METS study investigators

www.thelancet.com Vol 391 June 30, 2018

Summary
Background Functional capacity is an important component of risk assessment for major surgery. Doctors’ clinical
subjective assessment of patients’ functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery.
Methods We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (<4 ), moderate (4–10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification.
Findings Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2–25) and 94·7% specificity (93·2–95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83–0·99; p=0·03).
Interpretation Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment.

Simpson SJ; Champion Z; Hall GL; French N; Reynolds V;

The Journal Of Pediatrics [J Pediatr] 2019 Aug 08. Date of Electronic Publication: 2019 Aug 08.

Objective: To evaluate the role of upper airway dysfunction, indicated by altered vocal quality (dysphonia), on the respiratory symptoms of children surviving very preterm birth.
Study Design: Children born <32 weeks of gestation participated in 2 separate assessments during midchildhood. The first visit assessed voice quality by a subjective evaluation using the Consensus Auditory-Perceptual Evaluation of Voice and a computerized analysis of the properties of the voice via the Acoustic Voice Quality Index. The second assessment recorded parentally reported respiratory symptoms and measures of lung function, including spirometry, lung volumes, oscillatory mechanics, and a cardiopulmonary exercise test.
Results: Preterm children (n = 35; median gestation 24.3 weeks) underwent paired voice and lung assessments at approximately 11 years of age. Preterm children with dysphonia (n = 25) reported significantly more respiratory symptoms than those with normal voices (n = 10) including wheeze (92% vs 40%; P = .001) and asthma diagnosed by a physician (60% vs 10%; P = .007). Lung function outcomes were generally not different between the dysphonic group and the group with normal voice (P > .05), except for the oscillatory mechanics measures, which were all at least 0.5 z score lower in the dysphonic group (Xrs8 mean difference = -0.91 z scores, P = .003; fres = 1.06 z scores, P = .019; AX = -0.87 z scores, P = .010; Rrs8 = 0.63 z scores, P = .068).
Conclusions: The upper airway may play a role in the respiratory symptoms experienced by some very preterm children and should be considered by clinicians, especially when symptoms are in the presence of normal lung function and are refractory to treatment.

Nemoto S; Kasahara Y; Izawa KP; Watanabe S; Yoshizawa K; Takeichi N; Kamiya K; Suzuki N; Omiya K; Matsunaga A; Akashi YJ;

International Journal Of Environmental Research And Public Health [Int J Environ Res Public Health] 2019 Aug 08; Vol. 16 (16). Date of Electronic Publication: 2019 Aug 08.

A simplified substitute for heart rate (HR) at the anaerobic threshold (AT), i.e., resting HR plus 30 beats per minute or a percentage of predicted maximum HR, is used as a way to determine exercise intensity without cardiopulmonary exercise testing (CPX) data. However, difficulties arise when using this method in subacute myocardial infarction (MI) patients undergoing beta-blocker therapy. This study compared the effects of αβ-blocker and β1-blocker treatment to clarify how different beta blockers affect HR response during incremental exercise. MI patients were divided into αβ-blocker (n = 67), β1-blocker (n = 17), and no-β-blocker (n = 47) groups. All patients underwent CPX one month after MI onset. The metabolic chronotropic relationship (MCR) was calculated as an indicator of HR response from the ratio of estimated HR to measured HR at AT (MCR-AT) and peak exercise (MCR-peak). MCR-AT and MCR-peak were significantly higher in the αβ-blocker group than in the β1-blocker group (p < 0.001, respectively). Multiple regression analysis revealed that β1-blocker but not αβ-blocker treatment significantly predicted lower MCR-AT and MCR-peak (β = -0.432, p < 0.001; β = -0.473, p < 0.001, respectively). Based on these results, when using the simplified method, exercise intensity should be prescribed according to the type of beta blocker used.

Forton K; Motoji Y; Pezzuto B; Caravita S; Delbaere A; Naeije R;Faoro V;

Human Reproduction (Oxford, England) [Hum Reprod] 2019 Aug 13. Date of Electronic Publication: 2019 Aug

13.Study Question: What is the functional relevance of decreased pulmonary vascular distensibility in adolescents conceived by IVF?
Summary Answer: Children born by IVF have a slight decrease in pulmonary vascular distensibility observed during normoxic exercise that is not associated with altered right ventricular function and aerobic exercise capacity.
What Is Known Already: General vascular dysfunction and increased hypoxic pulmonary hypertension have been reported in ART children as compared to controls. Pulmonary hypertension or decreased pulmonary vascular distensibility may affect right ventricular function and thereby possibly limit maximal cardiac output and aerobic exercise capacity.
Study Design, Size, Duration: This prospective case-control study enrolled 15 apparently healthy adolescents conceived by IVF/ICSI after fresh embryo transfer paired in a 2 to 1 ratio to 30 naturally conceived adolescents between March 2015 and May 2018.
Participants/materials, Setting, Methods: Fifteen IVF/ICSI adolescents and 30 controls from singleton gestations matched by age, gender, weight, height and physical activity underwent exercise echocardiography, lung diffusion capacity measurements and a cycloergometer cardiopulmonary exercise test. A pulmonary vascular distensibility coefficient α was determined from the pulmonary arterial pressure (PAP) versus cardiac output (Q) relationships. Pulmonary capillary volume (Vc) was calculated from single breath nitric oxide and carbon monoxide lung diffusion capacity measurements (DLCO and DLNO) at rest and during exercise (100 W). Eight of the IVF subjects and eight controls underwent a 30 min hypoxic challenge at rest with a fraction of inspired oxygen of 0.12 to assess hypoxic pulmonary vasoconstriction.
Main Results and the Role Of Chance: In normoxia, oxygen uptake (VO2), blood pressure, DLCO, DLNO, echocardiographic indices of right ventricular function, Q and PAP at rest and during exercise were similar in both groups. However, IVF children had a lower pulmonary vascular distensibility coefficient α (1.2 ± 0.3 versus 1.5 ± 0.3%/mmHg, P = 0.02) and a blunted exercise-induced increase in Vc (24 versus 32%, P < 0.05). Hypoxic-induced increase in pulmonary vascular resistance in eight IVF subjects versus eight controls was similar.
Limitations, Reasons For Caution: The IVF cohort was small, and thus type I or II errors could have occurred in spite of careful matching of each case with two controls. ART evolved over the years, so that it is not certain that the presently reported subtle changes will be reproducible in the future. As the study was limited to singletons born after fresh embryo transfers, our observations cannot be extrapolated to singletons born after frozen embryo transfer.
Wider Implications Of the Findings: The present study suggests that adolescents conceived by IVF have preserved right ventricular function and aerobic exercise capacity despite a slight alteration in pulmonary vascular distensibility as assessed by two entirely different methods, i.e. exercise echocardiography and lung diffusing capacity measurements. However, the long-term prognostic relevance of this slight decrease in pulmonary vascular distensibility needs to be evaluated in prospective large scale and long-term outcome studies.

Santana S; Gidding SS; Xie S; Jiang T; Kharouf R; Robinson BW;

Pediatric Cardiology [Pediatr Cardiol] 2019 Aug 07. Date of Electronic Publication: 2019 Aug 07.

Previous pediatric exercise test criteria for aortic stenosis severity were based on cardiac catheterization assessment, whereas current criteria are based on echocardiographic valve gradients. We sought to correlate exercise test criteria with echocardiographic assessment of severity. We report 65 studies, 51 patients (mean age of 13 ± 4 years; 75% males), with aortic stenosis (AS) who had a maximal exercise test between 2005 and 2016. We defined three groups based on resting mean Doppler gradient across their aortic valve: severe AS (n = 10; gradient of ≥ 40 mmHg), moderate AS (n = 20; gradient 25-39 mmHg), and mild AS (n = 35; gradient ≤ 24 mmHg). We studied symptoms (chest pain) during exercise, resting electrocardiogram changes (left ventricular hypertrophy [LVH]), complex arrhythmias during exercise, change in exercise systolic blood pressure (SBP; delta SBP = peak SBP-resting SBP), exercise duration, work, echocardiogram parameters (LVH), and ST-T wave changes with exercise. Additionally, we compared work and delta SBP during exercise with 117 control males and females without heart disease. Severe AS patients have statistically significant differences when compared with mild AS in ST-T wave depression during exercise, LVH on resting electrocardiogram, and echocardiogram. There was a significant difference in delta SBP between severe AS and normal controls (delta SBP 21.6 vs. 46.2 mmHg), and between moderate AS and normal controls (delta SBP 32 vs. 46.2 mmHg). There were no significant complications during maximal exercise testing. Children with echocardiographic severe and moderate AS have exercise testing abnormalities. Exercise test criteria for severity of AS were validated for echocardiographic criteria for AS severity.

Agnoletti G, Gala S, Ferroni F, Bordese R, Appendini L, Pace, Napoleone C, Bergamasco L;

J Thorac Cardiovasc Surg. 2017 Jun;153(6):1468-1475. doi:
10.1016/j.jtcvs.2017.01.051. Epub 2017 Feb 10.

Comment in
J Thorac Cardiovasc Surg. 2017 Jun;153(6):1476-1478.
J Thorac Cardiovasc Surg. 2017 Jun;153(6):1466-1467.

OBJECTIVES: To evaluate the effects of endothelin inhibitors (ERAs) on
hemodynamic and functional parameters in patients post-Fontan procedure with high
pulmonary vascular resistance (PVR).
METHODS: Among our cohort of patients with Fontan circulation, 8 children, 8
adolescents, and 8 adults had PVR ≥2 WU*m2. These patients were treated with ERAs
(minors with bosentan, adults with macitentan) and reevaluated after 6 months.
Pre- and posttreatment hemodynamic variables were assessed by cardiac
catheterization. Functional capacity was evaluated by cardiopulmonary exercise
testing (CPET). Our primary endpoint was to obtain a reduction of PVR; the
secondary endpoint was to obtain an improvement of functional capacity.
RESULTS: Under treatment, New York Heart Association class improved for
adolescents and adults. PVR decreased (P = .01) in all groups: in children from
the median value 2.3 (interquartile range 2.0-3.1) to 1.9 (1.4-2.3) WU*m2, in
adolescents from 2.3 (2.1-2.4) to 1.7 (1.4-1.8) WU*m2, and in adults from 2.8
(2.0-4.7) to 2.1 (1.8-2.8)WU*m2. In 71% of patients, PVR fell to less than 2
WU*m2. Cardiac index increased in adolescents from 2.6 (2.4-3.3) to 3.6 (3.4-4.3)
L/min/m2, P = .04, and in adults from 2.1 (2.0-2.3) to 2.8 (2.3-4.7) L/min/m2,
P = .03. CPET showed that only adolescents displayed a significant functional
improvement. Anaerobic threshold improved from 17 (13-19) to 18 (13-20)
mL/kg/min, P = .03; oxygen consumption and VO2 max increased from 1.3 (1.0-1.6)
to 1.7 (1.1-1.9) L/min, P = .02 and from 25 (21-28) to 28 (26-31) L/min, P = .02,
respectively. Oxygen pulse increased from 7.9 (5.7-10.4) to 11.2 (8.2-13.0)
L/beat, P = .01.
CONCLUSIONS: This is the first study that assesses by cardiac catheterization and
CPET the effects of ERA in patients with Fontan circulation with increased PVR.
These results suggest that ERAs might provide most pronounced hemodynamic and
functional improvement in adults and adolescents.

Fisher O, Gates Z, Parkes E, Shakespeare J, Goodyear SJ, Imray CHE, Benson RA;

Ann Vasc Surg. 2019 Aug 5. pii: S0890-5096(19)30542-4. doi:
10.1016/j.avsg.2019.05.047. [Epub ahead of print]

INTRODUCTION: Cardiopulmonary exercise testing (CPET) provides an objective
assessment of functional capacity and fitness. It can be used to guide decision
making prior to major vascular surgery. The EVAR-2 trial suggested endovascular
aneurysm repair (EVAR) in patients unfit for open repair failed to provide a
significant survival advantage over non surgical management. The aim of this
study was to assess contemporary survival differences between patients with poor
CPET measures who underwent EVAR or were not offered surgical intervention.
METHODS: A prospectively maintained database of CPET results of patients
considered for elective infrarenal aortic aneurysm repair was interrogated.
Anaerobic threshold (AT) of <11ml/min/kg was used to indicate poor physical
fitness. Hospital electronic records were then reviewed for peri-operative,
re-intervention and long term outcomes.
RESULTS: Between November 2007 and October 2017 532 aortic aneurysm repairs were
undertaken, of which 376 underwent pre-operative CPET. 70 patients were
identified as having an AT<11ml/min/kg. 37 patients underwent EVAR and 33 were
managed non surgically. All cause survival at 1, 3 and 5 years for those patients
who underwent EVAR was 97% 92% and 81% respectively. For those not offered
surgical intervention survival at the same points was 72%, 48% and 24% HR=5.13
(1.67-15.82) p=0.004. Aneurysm specific survival at 1, 3 and 5 years for those
patients who underwent EVAR was 97% 94% and 94% respectively. Survival at the
same time points for those not offered surgical intervention was 90% 69% 39%.
HR=7.48 (1.37-40.82) p=0.02.
CONCLUSIONS: In this small, retrospective, single centre, non-randomised cohort
EVAR may provide a survival advantage in patients with poor physical fitness
identified via CPET. Randomised studies with current generation EVAR are required
to validate the results shown here. Risk prediction, CPET, Survival.