Lauricella, Leticia Leone;  Universidade de São Paulo,  SP, Brazil.
Terra, Ricardo Mingarini.

Journal of thoracic disease [J Thorac Dis] 2026 Oct 30; Vol. 18 (10), pp. 1153.
Date of Electronic Publication: 2026 Oct 10.

• Background and Objective: Anatomical lung resection remains the cornerstone of curative treatment for early-stage non-small cell lung cancer, and patient selection is a major determinant of postoperative outcome. For more than a decade, preoperative assessment relied on three guidelines-American College of Chest Physicians (ACCP) (2013), European Respiratory Society/European Society of Thoracic Surgeons (ERS/ESTS) (2009) and British Thoracic Society/Society for Cardiothoracic Surgery (BTS/SCTS) (2010)-sharing a sequential approach of cardiac assessment, pulmonary function testing and, in selected patients, cardiopulmonary exercise testing (CPET). Since then, minimally invasive surgery became standard, randomised trials validated sublobar resection, and evidence accumulated for new predictors, particularly the minute ventilation-to-carbon dioxide output (VE/VCO₂ ) slope, frailty and sarcopenia. This review synthesises current preoperative risk stratification in light of the 2025 ERS/ESTS guideline and the 2021 American Association for Thoracic Surgery (AATS) expert consensus.
• Methods: We searched PubMed/MEDLINE for English-language literature on preoperative risk stratification and patient selection for anatomical lung resection, supplemented by hand-searching of reference lists and prioritising guidelines, randomised trials, systematic reviews and multicentre cohort studies. All numerical data were verified against the original publications.
• Key Content and Findings: The 2025 ERS/ESTS guideline introduces formal assessment of frailty and nutritional status, endorses prehabilitation, and repositions risk-prediction models as tools for benchmarking rather than individual selection. Its exercise-testing algorithm considers peak oxygen consumption and the VE/VCO₂ slope together in three risk categories (peak VO₂ ≥15, 12-15 and <12 mL/kg/min; slope <35, 35-40 and >40). The graded recommendation itself is confined to the use of CPET and does not endorse any specific parameter or cut-off, identifying only a peak VO₂ below 12 mL/kg/min or a VE/VCO₂ slope above 40 as suggestive of high surgical risk. The AATS consensus independently ranks frailty and functional status above chronological age. Together, these developments support a shift from a binary judgement of operability to a structured process that also determines how to operate, adapting the extent of resection and the surgical approach to the patient’s physiological reserve.
• Conclusions: Contemporary risk stratification integrates cardiopulmonary physiology, ventilatory efficiency, frailty and nutrition with the configuration of the operation itself. Threshold calibration in the minimally invasive era, the optimal VE/VCO₂ slope threshold and standardised frailty measurement remain unresolved.

Craciun, Maria-Laura; Faculty of Medicine,  Timișoara, Romania.
Avram, Cristiana Adina; Pah, Ana-Maria, et al.

Frontiers in cardiovascular medicine,2026 Oct 21

Pulmonary embolism (PE) is increasingly recognized as an episode of care that extends well beyond hospital discharge. Current guidance is distributed across several documents: the 2019 European Society of Cardiology (ESC) guidelines; the 2026 American Heart Association/American College of Cardiology (AHA/ACC) multisociety guideline, which replaced the massive/submassive terminology with clinical categories A-E; and separate position papers on catheter-directed intervention (CDI) and on follow-up. This narrative review (i) provides a side-by-side comparison of the ESC and AHA/ACC risk frameworks and their therapeutic implications; (ii) updates the evidence on reperfusion, including the recent randomized trials HI-PEITHO, PEERLESS and STORM-PE; and (iii) focuses on transitions of care and long-term follow-up, which guidelines address less comprehensively. Anticoagulation, preferably with a direct oral anticoagulant, remains the treatment for most patients. Systemic thrombolysis is reserved for high-risk (ESC) or category E (AHA/ACC) PE, because in intermediate-risk disease it halves hemodynamic decompensation at the cost of a several-fold increase in major and intracranial bleeding, without long-term functional benefit. In HI-PEITHO, ultrasound-facilitated catheter-directed thrombolysis reduced a 7-day composite outcome driven by cardiorespiratory decompensation (4.0% vs. 10.3%) in intermediate-high-risk patients with additional markers of physiological stress, without intracranial hemorrhage; a survival benefit of CDI has not been demonstrated. At discharge, a minimum bundle should specify the drug, dose, anticipated duration, provoking context, bleeding mitigation and follow-up ownership, followed by early contact within one week and a structured review at approximately three months. Up to half of survivors report persistent dyspnea or exercise limitation, whereas chronic thromboembolic pulmonary hypertension (CTEPH) develops in approximately 2%-3%. Persistent symptoms should prompt phenotype-directed evaluation with echocardiography, ventilation/perfusion scintigraphy, cardiopulmonary exercise testing and, when indicated, right-heart catheterization interpreted with the 2022 hemodynamic definitions, followed by early referral to an expert center where pulmonary endarterectomy, balloon pulmonary angioplasty and medical therapy can be combined. We state the type of evidence underpinning each key recommendation, propose a discharge bundle, a structured follow-up algorithm and episode-wide quality indicators, and identify the evidence gaps that should guide future trials.

Larsson, Jonas; Lund University, Lund, Sweden.
Dencker, Magnus; Bremander, Ann, et al

Frontiers in physiology. Oct 20, 2026

• Introduction: This study aimed to determine how combat gear and body armor (CB) affect the relationship between treadmill setting and internal physiological responses at ventilatory transitions, and to characterize right vastus lateralis muscle oxygen saturation (SmO₂ ) and exploratory early reoxygenation in female and male soldiers.
• Methods: Nine female and nine male soldiers completed randomized no-load (NL) and CB graded treadmill tests to volitional exhaustion. Heart rate and pulmonary gas exchange were measured, and right vastus lateralis SmO₂ was assessed using near-infrared spectroscopy. VT1 was identified using the V-slope method and VT2 using ventilatory-equivalent criteria. SmO₂ outcomes were referenced to a 30-s standing value.
• Results: VT1 was identified at a lower treadmill stage in CB than in NL in men (5.2 ± 0.8 vs. 6.4 ± 1.7; p = 0.02) and women (5.1 ± 0.6 vs. 7.1 ± 1.5; p <0.01). Absolute V̇O₂ at VT1 changed little, whereas HR was higher in CB in men (p <0.01) and women (p = 0.04). VT2 was also identified at a lower stage in CB in both groups (p <0.01). Baseline-referenced right vastus lateralis desaturation amplitude during CB was greater in men than women (39.0% ± 23.9% vs. 17.1 ± 14.5%; p <0.01), although adipose-tissue thickness at the sensor site was not measured. No statistically significant effects were detected for the early post-exercise indices.
• Discussion: CB altered the treadmill setting at which ventilatory transitions were observed and increased cardiovascular demand at VT1 without essentially changing absolute V̇O₂ at VT1. This indicates a changed relationship between treadmill task, transported mass, and internal physiological response rather than demonstrated displacement of the underlying metabolic threshold. The site-specific SmO₂ and early reoxygenation findings were exploratory, and between-sex interpretation was limited by the small sample and unmeasured adipose-tissue thickness.

Takino K; Gifu Heart Center, Gifu. Japan
Kuze Y; Nagai T; Hori M; Nakazawa Y; et al

Archives of Physical Medicine & Rehabilitation.
107(11):3257-3264, 2026 Nov.

OBJECTIVE: To develop and validate a machine learning (ML) model for
predicting reduced exercise capacity at 3 months postoperatively using
clinical parameters available at hospital discharge in patients undergoing
cardiovascular surgery, as the prediction of patient-centered functional
outcomes remains unexplored in patients with cardiac disease.

DESIGN: Retrospective cohort study conducted in accordance with the
Strengthening the Reporting of Observational Studies in Epidemiology
statement.

SETTING: A single cardiac center.

PARTICIPANTS: Patients (N=590) aged <=75 years who underwent
cardiovascular surgery between April 2015 and January 2025 and completed
cardiopulmonary exercise testing at 3 months postoperatively.

INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURES: Reduced exercise tolerance was defined as a peak
oxygen uptake <14 mL/min/kg at 3 months postoperatively. The model
performance was assessed using the area under the receiver operating
characteristic curve, sensitivity, and specificity.

RESULTS: Of the 590 patients analyzed, 139 (23.6 %) demonstrated reduced
exercise tolerance (peak oxygen uptake <14 mL/min/kg) at 3 months
postoperatively. Following multicollinearity assessment, forward feature
selection identified 9 predictors from the 43 candidate variables. Among
the 5 ML algorithms evaluated using 5-fold cross-validation, the random
forest model achieved the highest area under the receiver operating
characteristic curve (0.855), with a sensitivity of 0.643 and specificity
of 0.867. The SHapley Additive exPlanations analysis identified the
percentage of isometric knee extension strength, ratio of early mitral
inflow velocity to early diastolic mitral annular velocity, and
high-density lipoprotein cholesterol level as the primary predictive
factors.

CONCLUSIONS: An ML model using clinical parameters at hospital discharge
can effectively predict postoperative exercise intolerance during the
recovery phase. This model enables early risk stratification and might
facilitate targeted rehabilitation interventions in patients undergoing
cardiovascular surgery.

De Biase N; University of Pisa, Pisa, Italy.
Del Punta L; Moura-Ferreira S; De Schutter S; et al

Journal of Hypertension. 44(12):2227-2237, 2026 Dec 01.

OBJECTIVES: Conventional definitions of hypertensive response to exercise
(HRE) rely on absolute systolic blood pressure (SBP) thresholds, which do
not account for the metabolic demand driving the pressor response and show
inconsistent association with pathophysiology and prognosis. Whether
indexing SBP to oxygen consumption (VO 2 ) provides independent
pathophysiological information along the continuum from arterial
hypertension (AH) to heart failure (HF) remains unclear. We investigated
the haemodynamic and prognostic implications of the SBP/VO 2 slope in
patients with AH and preserved left ventricular ejection fraction.

METHODS: We enrolled 970 participants with AH, including 34% with
established HF. All subjects underwent baseline echocardiography and
cardiopulmonary exercise testing with stress echocardiography. We
categorized patients into tertiles of the slope of SBP relative to peak VO
2 from rest to peak exercise; the highest tertile was used to define HRE
for descriptive analyses. Patients were followed for all-cause mortality
or HF-related hospitalisation.

RESULTS: Patients with HRE (SBP/VO 2 slope >5.7 mmHg/ml/kg/min) displayed
adverse cardiac remodelling (higher left ventricular mass index, left
atrium dilation), systemic exercise-induced vascular dysfunction (elevated
peak systemic vascular resistance, reduced total arterial compliance), and
reduced peripheral oxygen extraction (lower peak arteriovenous oxygen
difference), despite well controlled resting BP. Over a 24-month median
follow-up, a steeper SBP/VO 2 slope was associated with a higher risk of
death or HF-related hospitalisation, independent of peak VO 2 (hazard
ratio per 1-standard deviation increase: 1.21; P = 0.041).

CONCLUSIONS: In patients with AH, a steeper SBP/VO 2 slope identifies a
high-risk haemodynamic phenotype and may repre

Zachwyc J; Wroclaw Medical University, Wroclaw, Poland.
Sharman JE; Kosowski W; Przewlocka-Kosmala M; et al

Journal of Hypertension. 44(11):2018-2026, 2026 Nov 01.

OBJECTIVES: Exercise blood pressure response (EBPR) is influenced by
arterial stiffness, reflected by pulse wave velocity (PWV). Adjustment for
cardiorespiratory fitness may refine its interpretation. Brachial
waveform-derived PWV remains underused due to concerns about age and SBP
dependence, and single-point office PWV may inadequately represent the
dynamic vascular load driving EBPR. We hypothesized that 24-h PWV would
outperform office PWV in predicting EBPR, and that indexing exercise SBP
to aerobic fitness would strengthen these associations.

METHODS: We studied 228 adults (46% men; age 53 +/- 12 years) with
adequately controlled blood pressure, irrespective of hypertension
diagnosis. Individuals with coronary artery disease, valvular disease, or
heart failure were excluded. All participants underwent office and 24-h
blood pressure monitoring with integrated pulse wave analysis
(Mobil-O-Graph), cardiopulmonary exercise testing, and echocardiography.
Exercise SBP at submaximal and peak workloads was normalized to peak
oxygen uptake (VO2).

RESULTS: Fitness-corrected SBP showed stronger associations with PWV than
uncorrected values (r = 0.64 vs. 0.15; P < 0.001). Both submaximal and
peak SBP indexed to peak VO2 increased stepwise across 24-h PWV tertiles;
this gradient was attenuated without fitness correction. After adjustment
for age, sex, SBP, BMI, and left ventricular hypertrophy and diastolic
dysfunction, 24-h PWV remained an independent predictor of
fitness-corrected EBPR, whereas office PWV was not statistically
significant.

CONCLUSION: Brachial BP-waveform-derived PWV independently predicts EBPR.
Ambulatory 24-h PWV demonstrates stronger associations with exercise BP
behaviour compared with single-time-point office PWV, and
fitness-corrected SBP outperforms conventional uncorrected measures.

Harada T; Mayo Clinic, Minnesota, USA.
Naser JA; Ghanbari F; Borlaug BA

Jacc: Cardiovascular Imaging. 19(11):1381-1403, 2026

Heart failure with preserved ejection fraction (HFpEF) is a clinical
syndrome characterized by dyspnea caused by hemodynamic congestion, which
develops at rest or with exercise. Noninvasive diagnosis remains
challenging, because resting diastolic pressures may be normal, and even
when abnormal, currently applied noninvasive indices lack sensitivity. The
pathophysiology of HFpEF extends far beyond diastolic dysfunction, and
such complexity can be better understood through imaging. This
State-of-the-Art Review emphasizes echocardiography and other noninvasive
imaging approaches as the first-line tools for HFpEF evaluation, while
linking multimodality imaging to invasive hemodynamics as a physiologic
reference standard. The authors emphasize evidence-based, multiparametric
assessment, where combined cardiopulmonary exercise testing with exercise
stress echocardiography can quantify the diverse reserve limitations that
characterize HFpEF, including cardiac and extracardiac contributors,
atrial and right heart dysfunction, pulmonary vascular and ventilatory
limitation, dynamic atrioventricular regurgitation, extrinsic restraint,
pulmonary congestion, and peripheral impairments, acknowledging that such
phenotyping must be anchored to actionable findings and evidence-based
interventions. The authors describe the potential role of exercise cardiac
magnetic resonance and artificial intelligence-enabled imaging analysis
for phenotyping and risk stratification. Finally, the authors propose an
echo-first Bayesian pathway that updates pretest to posttest probability
and supports identification of patients in whom invasive hemodynamic
exercise testing may be required to confirm the diagnosis and validate
imaging markers against invasively measured congestion.

Howden EJ; Baker Heart and Diabetes Institute, Australia
Sesa-Ashton G; Foulkes SJ; Wallace I; et al

American Journal of Physiology – Heart & Circulatory Physiology.
331(6):H2028-H2038, 2026 Dec 01

Postacute sequelae of COVID-19 syndrome (PASC) is widely attributed to
dysautonomia, although sympathetic outflow has rarely been measured
directly. We tested whether exercise and orthostatic intolerance in PASC
reflect impaired cardiac reserve or abnormal muscle sympathetic nerve
activity (MSNA) and its reflex control. Adults with PASC (n = 35; symptoms
>3 mo, no significant comorbidity) and age- and sex-matched recovered
controls (n = 12) underwent cardiopulmonary exercise testing (CPET),
echocardiogram, resting and exercise cardiac MRI, and peroneal
microneurography recordings of MSNA in supine position and during graded
head-up tilt to 60degree. Participants with PASC had lower peak oxygen
uptake ([Formula: see text]) indexed to lean mass (43.0 +/- 7.8 vs. 52.2
+/- 8.2 mL/lean body mass kg/min, P = 0.009) and whole body mass (26.1 +/-
7.5 vs. 34.9 +/- 10.2 mL/kg/min, P = 0.006), lower heart rate reserve (84
+/- 25 vs. 98 +/- 13 beats/min, P = 0.019), and impaired ventilatory
efficiency. Cardiac structure and biventricular contractile reserve were
normal. Supine MSNA burst frequency, burst incidence, sympathetic
baroreflex gain, and neurovascular transduction did not differ between
groups, and MSNA and mean arterial pressure increased similarly during
tilt (time P < 0.0001; group x time P = 0.78). Despite these findings, 12
of 29 participants with PASC (41%) terminated the tilt protocol due to
orthostatic symptoms or presyncope (Kaplan-Meier P = 0.0178). Eight
participants (27%) met postural orthostatic tachycardia syndrome (POTS)
criteria and had lower MSNA than non-POTS participants (P = 0.045).
Orthostatic intolerance occurred despite normal recruitment of MSNA and
maintained arterial pressure and exercise intolerance despite preserved
contractile reserve. Symptoms are therefore unlikely to originate in the
efferent sympathetic limb or myocardium and more likely reflect afferent
reflex dysregulation or impaired cerebral perfusion. NEW & NOTEWORTHY
Muscle sympathetic nerve activity (MSNA), sympathetic baroreflex gain, and
neurovascular transduction were intact in people with postacute sequelae
of COVID-19 syndrome (PASC), and MSNA was recruited normally during
head-up tilt. However, 41% of participants could not complete the tilt.
Biventricular contractile reserve was likewise preserved. Symptoms that
track neither sympathetic outflow nor systemic pressure localize the
disturbance upstream, to afferent reflex control, or downstream to the
cerebral circulation.

Ikeda M; Kyushu University, Fukuoka, Japan.
Hieda M; Yoshida K; Imabayashi M;

Physiological Reports. 14(21), 2026 Nov.

Exercise cardiovascular magnetic resonance imaging (exCMR) enables
quantitative assessment of biventricular responses during physiological
stress. We aimed to characterize right ventricular (RV)-left ventricular
(LV) volumetric relationships in healthy adults using exCMR. Eighteen
healthy adults (9 males, 9 females) underwent exCMR.
Electrocardiography-gated short-axis cine and phase-contrast flow images
were obtained at rest, at a target heart rate of 100 beats/min (Ex1), and
at 40% of peak work rate determined by cardiopulmonary exercise testing
(Ex2). The RV-LV volumetric relationship was operationally represented by
the RV/LV end-diastolic and end-systolic volume ratios derived from
simultaneous cine volumetry. All participants completed the protocol, and
all cine and phase-contrast datasets were analyzed. During exercise,
stroke volume increased in both ventricles predominantly through a
reduction in end-systolic volume (ESV), whereas end-diastolic volume (EDV)
changed little. Cine-derived LV and RV stroke volumes showed internal
concordance with phase-contrast flow-derived measurements. The RV/LV EDV
ratio (1.03, 1.03, and 1.03 at rest, Ex1, and Ex2, respectively) and RV/LV
ESV ratio (1.09, 1.09, and 1.08 at rest, Ex1, and Ex2, respectively)
remained stable across stages. Healthy adults maintained a stable relative
RV-LV volumetric relationship during low-to-moderate intensity supine
exercise. These findings provide quantitative physiological reference data
for future disease-focused studies.

Suzuki S(1), Division of Thoracic Surgery,  Keio University School of Medicine, Tokyo, Japan.
Asakura K, Chaudhuri N, Lodhia J, Milton R, et al

Interdiscip Cardiovasc Thorac Surg. 2026 Oct 30:ivag297. doi: 10.1093/icvts/ivag297. Online ahead of print.

OBJECTIVES: We compared major morbidity and exploratory oncological outcomes after wedge resection and segmentectomy in physiologically vulnerable patients with stage IA non-small cell lung cancer.
METHODS: This single-centre retrospective cohort included consecutive patients with clinical stage IA1-IA2 non-small cell lung cancer who underwent curative-intent wedge resection or segmentectomy between January 2017 and December 2024 and met cardiopulmonary exercise testing vulnerability criteria (peak oxygen uptake <15 mL/kg/min and/or minute ventilation-to-carbon dioxide output slope >35). The primary endpoint was 90-day major morbidity. Analyses adjusted for tumour location and radiological size; inverse probability of treatment weighting was exploratory. Median follow-up was estimated by reverse Kaplan-Meier, with administrative censoring on 23 February 2026.
RESULTS: Among 103 patients (47 wedge resection; 56 segmentectomy), median follow-up was 40.2 months. Major morbidity occurred in 6.4% and 12.5%, respectively (relative risk 1.96, 95% confidence interval 0.54-7.16); locoregional recurrence occurred in 14.9% and 7.1% (relative risk 0.48, 95% confidence interval 0.15-1.54). Neither comparison was statistically significant. Adjusted and weighted estimates were imprecise and did not show significant differences in major morbidity, event-free survival, overall survival, or locoregional recurrence.
CONCLUSIONS: No statistically significant difference in major morbidity was observed. Locoregional recurrence was 14.9% after wedge resection and 7.1% after segmentectomy (relative risk 0.48, 95% confidence interval 0.15-1.54); this exploratory estimate was imprecise.