Sietsema, Kathy E; David Geffen School of Medicine at UCLA, Torrance, California.
Rossiter, Harry B.

Seminars in Respiratory & Critical Care Medicine. 44(5):661-680, 2023 Oct.

Aerobic, or endurance, exercise is an energy requiring process supported
primarily by energy from oxidative adenosine triphosphate synthesis. The
consumption of oxygen and production of carbon dioxide in muscle cells are
dynamically linked to oxygen uptake (VO2) and carbon dioxide output (VCO2)
at the lung by integrated functions of cardiovascular, pulmonary,
hematologic, and neurohumoral systems. Maximum oxygen uptake (VO2max) is
the standard expression of aerobic capacity and a predictor of outcomes in
diverse populations. While commonly limited in young fit individuals by
the capacity to deliver oxygen to exercising muscle, (VO2max) may become
limited by impairment within any of the multiple systems supporting
cellular or atmospheric gas exchange. In the range of available power
outputs, endurance exercise can be partitioned into different intensity
domains representing distinct metabolic profiles and tolerances for
sustained activity. Estimates of both VO2max and the lactate threshold,
which marks the upper limit of moderate-intensity exercise, can be
determined from measures of gas exchange from respired breath during
whole-body exercise. Cardiopulmonary exercise testing (CPET) includes
measurement of VO2 and VCO2 along with heart rate and other variables
reflecting cardiac and pulmonary responses to exercise. Clinical CPET is
conducted for persons with known medical conditions to quantify
impairment, contribute to prognostic assessments, and help discriminate
among proximal causes of symptoms or limitations for an individual. CPET
is also conducted in persons without known disease as part of the
diagnostic evaluation of unexplained symptoms. Although CPET quantifies a
limited sample of the complex functions and interactions underlying
exercise performance, both its specific and global findings are uniquely
valuable. Some specific findings can aid in individualized diagnosis and
treatment decisions. At the same time, CPET provides a holistic summary of
an individual’s exercise function, including effects not only of the
primary diagnosis, but also of secondary and coexisting conditions.

Goulart CDL; Federal University of Sao Carlos, UFSCar, Sao Carlos, SP, Brazil.
& several oher institutions
Silva RN; Agostoni P; Franssen FME; Myers J; Arena R;
Borghi-Silva A

Respiratory Medicine. 217:107332, 2023 Oct.

BACKGROUND: Exercise oscillatory ventilation (EOV) is considered an
important variable for predicting poor prognosis in patients with heart
failure (HF) with reduced left ventricular ejection fraction (HFrEF).
However, there are no studies evaluating EOV presence in the coexistence
chronic obstructive pulmonary disease (COPD) and HFrEF.

AIMS: I) To compare the clinical characteristics of participants with
coexisting HFrEF-COPD with and without EOV during cardiopulmonary exercise
testing (CPET); and II) to identify the impact of EOV on mortality during
follow-up for 35 months.

METHODS: 50 stable HFrEF-COPD (EF<50%) participants underwent CPET and
were followed for 35 months. The parametric Student’s t-test, chi-square
tests, linear regression model and Kaplan-Meier analysis were applied.

RESULTS: We identified 13 (26%) participants with EOV and 37 (74%)
without EOV (N-EOV) during exercise. The EOV group had worse cardiac
function (LVEF: 30 +/- 6% vs. N-EOV 40 +/- 9%, p = 0.007), worse pulmonary
function (FEV1: 1.04 +/- 0.7 L vs. N-EOV 1.88 +/- 0.7 L, p = 0.007), a
higher mortality rate [7 (54%) vs. N-EOV 8 (27%), p = 0.02], higher minute
ventilation/carbon dioxide production (VE/ V CO2) slope (42 +/- 7 vs.
N-EOV 36 +/- 8, p = 0.04), reduced peak ventilation (L/min) (26.2 +/- 16.7
vs. N-EOV 40.3 +/- 16.4, p = 0.01) and peak oxygen uptake (mlO2 kg-1
min-1) (11.0 +/- 4.0 vs. N-EOV 13.5 +/- 3.4 mlkg-1min-1, p = 0.04) when
compared with N-EOV group. We found that EOV group had a higher risk of
mortality during follow-up (long-rank p = 0.001) than patients with N-EOV
group.

CONCLUSION: The presence of EOV is associated with greater severity of
coexisting HFrEF and COPD and a reduced prognosis. Assessment of EOV in
participants with coexisting HFrEF-COPD, as a biomarker for both clinical
status and prognosis may therefore be warranted.

Martin de Miguel I; Hospital Universitario 12 de Octubre, Madrid, Spain;
Jimenez Lopez-Guarch C; Segura de La Cal T; Huertas
Nieto S; Sarnago Cebada F; Velazquez Martin M; Maneiro Melon N; Cruz
Utrilla A; Biscotti Rodil B; Gutierrez-Ortiz E; Arribas Ynsaurriaga F;
Escribano Subias P

Chest. 169(3):769-783, 2026 Mar.

BACKGROUND: Chronic thromboembolic pulmonary disease corresponds to
exercise impairment after a pulmonary embolism due to persistent chronic
thrombi and exercise pulmonary hypertension (PH). Diagnosis requires
exercise right heart catheterization (RHC), whereas data on noninvasive
diagnosis are scarce.

RESEARCH QUESTION: Is there an association between noninvasive parameters
and exercise PH among symptomatic patients with chronic thromboembolism?

STUDY DESIGN AND METHODS: Data come from a prospective cohort of 92
patients with chronic thrombi and absence/only mild resting PH undergoing
cardiopulmonary exercise testing and exercise RHC with concomitant
echocardiography. Clinical, functional, imaging, and hemodynamic data were
documented. Exercise PH was defined as mean pulmonary artery
pressure/cardiac output slope > 3 mm Hg/L/min.

RESULTS: The mean age of the patients was 52.7 +/- 14.3 years, and 62.0%
were male. A total of 37 patients (40.2%) developed exercise PH. Patients
with exercise PH had lower peak oxygen consumption, lower peak exercise
oxygen saturation, and higher ventilatory inefficiency. At rest and peak
exercise, they had higher tricuspid regurgitation peak velocity (TRPV),
lower tricuspid annular plane systolic excursion (TAPSE)/pulmonary artery
systolic pressure (PASP) ratio, invasively higher pulmonary pulse
pressure, and lower pulmonary artery compliance. Peak exercise aortic
saturation, peak oxygen consumption, partial pressure of end-tidal CO2 at
first ventilatory threshold, TRPV, and TAPSE/PASP ratio were independent
predictors of exercise PH. Two weighted risk scores including age, partial
pressure of end-tidal CO2 at first ventilatory threshold, and peak TRPV or
peak TAPSE/PASP identified patients at low vs high risk of exercise PH.

INTERPRETATION: Our results show that symptomatic patients with chronic
thrombi and exercise PH had impaired right ventricular contractile reserve
and augmented afterload assessed by cardiopulmonary exercise testing,
exercise echocardiography, and exercise RHC. Two noninvasive
multiparametric scores aided stratification of low vs high risk of
exercise PH.

Maggio ABR; University Hospitals of Geneva, Geneva, Switzerland,
Perret I; Alramadina N; Perrin A; Barazzone C; Mornand A

Pulmonary Medicine. 2026(1):e5599011, 2026.

BACKGROUND: Post-COVID syndrome (PCS) in adolescents, marked by persistent
symptoms such as dyspnea and fatigue, remains poorly understood,
particularly in those referred for exercise intolerance.

OBJECTIVE: The objective of this study is to describe the clinical
presentation and cardiorespiratory fitness (CRF) of adolescents with PCS
and identify factors distinguishing those with normal versus reduced CRF.

STUDY DESIGN: In this cross-sectional study, 31 adolescents (90% female)
with PCS underwent cardiopulmonary exercise testing (CPET), pulmonary
function tests, and completed validated questionnaires assessing fatigue,
depression, hyperventilation, physical activity, and quality of life
(QoL). Patients were grouped by CRF status and compared.

RESULTS: Symptoms were more prevalent than in general PCS literature,
likely due to referral bias. Moderate depression risk was present in 35%,
and 75% reported QoL impairment comparable with chronic conditions. Nearly
half (48%) had reduced CRF. CRF was not associated with acute infection
severity but correlated with orthostatism, reduced O2 pulse, and increased
static air trapping (p < 0.05). Preinfection physical activity was
positively associated with CRF (p = 0.014), whereas postinfection activity
levels were similar across groups.

CONCLUSION: PCS significantly impacts CRF, QoL, and psychological
well-being in adolescents with exercise intolerance. Reduced CRF appears
multifactorial, involving autonomic dysfunction, pulmonary limitations,
and deconditioning. These findings underscore the need for comprehensive
evaluation and targeted management strategies in this vulnerable
population.

Hayiroglu MI; Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey.
Cinar T; Cilli Hayiroglu S; Saylik F; Uzun M; Tekkesin AI

Acta Cardiologica. 78(9):1000-1005, 2023 Nov.

BACKGROUND: This investigation aims to assess the influence of a mobile
application and smart devices on cardiopulmonary exercise testing (CPET)
over a one-year period in individuals who have high risk for
cardiovascular disease.

METHODS: This is a post-hoc subgroup analysis of Lifestyle Intervention
Using Mobile Technology in Patients with High Cardiovascular Risk: A
Pragmatic Randomised Clinical Trial (LIGHT). In the intervention plus
standard care standard standard care arms, 138 and 103 patients were
recruited, respectively. The 1-year VO2 measurements were adjusted to the
baseline VO2 measurements as the study’s endpoint. VO2 measurements were
taken for each subject during the randomisation and final CPET
examinations.

RESULTS: The intervention plus standard care improved VO2 measurements by
1.1 (adjusted treatment effect 1.1, 95% confidence interval (CI): 0.8,
1.4, p < 0.001) compared to standard care following 1-year follow-up.

CONCLUSION: At a 1-year follow-up, the smart device and mobile
application technologies increased VO2 measurements in individuals with
high cardiovascular risk compared to conventional treatment alone.
Publication Type

Campbell N; Department of Critical Care. Scottish Liver Transplant Unit, Royal Infirmary of
Edinburgh, Edinburgh, UK.
Beattie C; Gillies MA

Current Opinion in Critical Care. 32(2):179-186, 2026 Apr 01.

PURPOSE OF REVIEW: Survival rates following liver transplantation now
exceed 90% at one year. However, the patient group undergoing liver
transplantation is increasingly complex, requiring continued focus on
improving perioperative care to sustain these survival outcomes. This
review highlights recent advances in the postoperative care of the liver
transplantation patient.

RECENT FINDINGS: Modern care integrates Enhanced Recovery After Surgery
(ERAS) principles, which emphasise early mobilisation and device
minimisation. Risk stratification has become increasingly sophisticated,
with frailty and cardiopulmonary exercise testing providing powerful
prognostic information; emerging machine learning approaches may further
refine personalised risk prediction.Goal-directed haemodynamic management
is advocated, with restrictive fluid strategies and viscoelastic
haemostatic assays to minimise transfusion. Advances in graft optimisation
have expanded the donor pool: normothermic regional perfusion reduces
ischaemic cholangiopathy in donation after cardiac death grafts, while
machine perfusion systems show promise in improving early graft
function.Advanced organ support (extracorporeal membrane oxygenation)
requires careful graft-conscious management. Infection prevention
strategies include tailored prophylaxis approaches. Nutrition and
structured prehabilitation/rehabilitation programmes support recovery,
reduce complications and address persistent functional deficits.

SUMMARY: Collectively, these developments reflect a shift toward
personalised, multidisciplinary postoperative care, aimed at improving
both survival and quality of life for liver transplantation recipients.

Hashiba M; University of Copenhagen, Copenhagen,Denmark.
Hansen MT; Helge JW; Nielsen SK; Gustavsen PH; Mohamed AA; Holt
A; Elmegaard M; Petersen CS; Schou M; Lamberts MK; Wolsk E

International Journal of Cardiology. 451:134252, 2026 May 15.

BACKGROUND: Peak oxygen consumption (pVO2) is a key predictor of mortality
and morbidity in patients with heart failure with reduced ejection
fraction (HFrEF).

METHODS: From December 2022 to September 2023, patients with new-onset
HFrEF were prospectively enrolled from a heart failure outpatient clinic.
All patients underwent at least 12 weeks of guideline-directed medical
therapy (GDMT) initiation and management, including physical training and
education. Cardiopulmonary exercise testing (CPET), medication,
echocardiography, and clinical data were collected at baseline and after
12 weeks. Associations with pVO2 changes were examined using univariable
and multivariable regression analyses.

RESULTS: We included 48 patients (median age 73 years, 20.8% women) with
baseline left ventricular ejection fraction (LVEF) of 30% +/- 7 and pVO2
of 18.1 +/- 5.6 mL/min/kg. After 12 weeks, pVO2 increased by 2.2 mL/min/kg
(95% CI: 1.3-3.1, p < 0.001) and LVEF improved to 44% (+14% [95% CI:
12-17, p < 0.001]). In the multivariable model, reductions in N-terminal
pro-B-type natriuretic peptide (NT-proBNP) and body mass index (BMI) were
associated with higher pVO2 (beta = -1.11 [95% CI: -2.15 to -0.06, p =
0.039]; beta = -1.62 [95% CI: -2.99 to -0.25, p = 0.023]). Higher left
atrial end-systolic volume index (LAESVi) was also associated with
increased pVO2 (beta = 0.23 [95% CI: 0.10-0.35, p = 0.001]).

CONCLUSION: GDMT was associated with improvements in cardiorespiratory
fitness and LVEF in patients with new-onset HFrEF. Reductions in
NT-proBNP, decreases in BMI, and increases in LAESVi were independently
associated with pVO2 improvements after 12 weeks.

Lin TT; University College of Medicine and Hospital, Taipei,Taiwan.
Huang KC; Lin HH; Su MM; Lin LC; Lin LY; Wu CK

European Radiology. 36(2):1146-1157, 2026 Feb.

OBJECTIVES: To investigate the role of right ventricular (RV) maladaptive
response to increased afterload in the early diagnosis of heart failure
with preserved ejection fraction (HFpEF) using cardiac magnetic resonance
(CMR) and invasive cardiopulmonary exercise testing (iCPET). This study
evaluates biventricular function and its association with exercise
performance in HFpEF.

MATERIALS AND METHODS: We prospectively recruited 145 patients with
suspected HFpEF from two centers, of whom 113 underwent echocardiography,
iCPET, and CMR. Patients met the 2016 European Society of Cardiology HFpEF
criteria, with iCPET confirming HFpEF as a pulmonary capillary wedge
pressure (PCWP) > 15 mmHg at rest and > 25 mmHg at peak exercise. The
diagnostic performance of CMR parameters was assessed using the area under
the curve (AUC).

RESULTS: Among the 113 patients, 72 had HFpEF (68 +/- 10 years) and 41
were non-HFpEF (66 +/- 11 years). HFpEF patients exhibited significantly
reduced resting pulmonary artery compliance. CMR-derived RV longitudinal
strain and left atrial (LA) reservoir strain had the highest diagnostic
accuracy for HFpEF (AUC 0.805 and 0.776, respectively). A sex disparity
was observed in the LA reservoir strain’s diagnostic performance, with
higher accuracy in males (AUC 0.801) compared to females (AUC 0.559).
Additionally, impaired LA reservoir and booster strains, correlated with
reduced exercise capacity and increased PCWP during exercise, highlighting
their clinical relevance.

CONCLUSIONS: RV systolic dysfunction and impaired LA strain serve as
early HFpEF markers. The more pronounced LA dysfunction in males suggests
potential sex-specific differences, underscoring the need to integrate RV
and LA strain assessment into HFpEF diagnostics and personalized treatment
approaches.

KEY POINTS: Question Can cardiac MRI (CMR)-derived RV strain and LA
reservoir strain improve the early diagnosis of HFpEF in symptomatic
patients with preserved ejection fraction? Findings CMR-derived RV
longitudinal strain and LA reservoir strain effectively differentiate
early HFpEF; diagnostic accuracy of LA strain varies significantly by sex.
Clinical relevance CMR-based RV and LA strain measurements enhance early
HFpEF detection, with higher diagnostic accuracy in males, supporting
sex-specific diagnostic strategies for timely and personalized heart
failure care.

Houtkamp D; University of Physiotherapy, Amersfoort, The Netherlands.
Pool-Goudzwaard AL; Takken T; Chettouf S; Van de Wiel A;
Bautmans I; Bongers BC

European Journal of Applied Physiology. 126(2):1067-1077, 2026 Feb.

PURPOSE: Accurate interpretation of cardiorespiratory fitness (CRF)
requires reference values that account for sex, age, and body composition.
Existing reference values often lack these distinctions or exclude older
adults. This study aimed to establish sex- and age-specific reference
values for absolute and relative (body mass-corrected and lean body
mass-corrected) CRF parameters derived from cardiopulmonary exercise
testing (CPET) in Dutch community-dwelling 55- to 75-year-old adults.

METHODS: Cross-sectional data from 611 participants of the AMCOHF study
were analyzed. CRF was assessed via cycle ergometer CPET evaluating oxygen
uptake (VO2peak) and work rate (WRpeak) at peak exercise, oxygen uptake at
the ventilatory anaerobic threshold (VO2VAT), and oxygen uptake efficiency
slope (OUES). Body mass and lean body mass were measured using dual-energy
X-ray absorptiometry. Reference values stratified by sex and age were
developed using generalized additive models. Prediction equations were
generated using multiple linear regression. Correlations with VO2peak
assessed the usefulness of VO2VAT and OUES as submaximal and
effort-independent alternatives for CRF.

RESULTS: All CRF variables declined with age. VO2peak (L/min) declined
quasi-linearly (females: 1.3%/year; males: 2.5%/year). Significant sex
differences were observed between all CRF variables (absolute and body
mass-corrected values: p < 0.001; lean body mass-corrected values: p <
0.05). Significant correlations were found between VO2peak and WRpeak (rho
= 0.90), VO2VAT (rho = 0.78), and OUES (rho = 0.87).

CONCLUSION: This study provides reference values for VO2peak, WRpeak,
VO2VAT, and OUES in Dutch older adults aged 55-75 years during cycle
ergometer CPET, offering a unique dataset for assessing CRF and monitoring
intervention effects.

D’Ambrosio P; The University of Melbourne, Parkville, VIC, Australia & many other centres
De Paepe J; Spencer LW; Ohanian M; Janssens K; Mitchell AM;
Flannery MD; Bekhuis Y; Pauwels R; Delpire B; Dausin C; Rowe SJ; Van
Puyvelde T; Young PE; Soka MJ; Johnson R; Yu C; Morris GM; Robyns T;
Lacaze P; Giannoulatou E; Kistler PM; Kalman JM; Heidbuchel H; Willems R;
Claessen G; Fatkin D; La Gerche A

Circulation. 153(9):616-630, 2026 Mar 03.

METHODS: We phenotyped current and former elite endurance athletes in the
Pro@Heart cohort study using multimodal cardiac imaging, cardiopulmonary
exercise testing, and Holter monitoring. Genetic susceptibility to
bradycardia was assessed using a validated HR-associated polygenic risk
score (HR-PRS), in which lower scores are associated with a lower HR, and
compared with healthy nonathletic controls. Clinical and genetic features
of bradycardic endurance athletes with minimum HR <=40 bpm on a Holter
monitor (bradycardic athletes [BAs]) were compared with non-BAs). A
healthy cohort of nonathletes from the ASPREE study (Aspirin in Reducing
Events in the Elderly) were used for genetic comparisons.

RESULTS: Among 465 endurance athletes (median age, 23 [18-49] years, 75%
men), 175 (38%) had a minimum HR on a Holter monitor <=40 bpm, of whom 7
(2% of total) had a HR <=30bpm. Pauses >=2 s were observed in 115 (25%)
athletes, of whom 12 (3% of total) had pauses >=3 s. Mobitz I
second-degree atrioventricular block was observed in 15 (3% of total)
athletes. BAs were younger and fitter and exhibited greater athletic
cardiac remodeling than non-BAs. Mean HR-PRS was significantly lower in
all athletes compared with ASPREE nonathletes (P<0.001) and in BAs
compared with non-BAs (P=0.006). When the distribution of HR-PRS within
our athletic cohort was considered, athletes with scores in the bottom
quartile had a lower minimum HR (median HR, 41 [35-45] bpm versus 45
[40-49] bpm, P<0.001) and higher bradycardia burden (14 [2-37]% versus 2
[0%-25]%, P<0.001) than those with scores in the top quartile. After
adjusting for age, sex, fitness, and indexed right atrial volume, HR-PRS
was independently associated with lower minimum HR and increased the odds
of resting bradycardia by 2-fold (odds ratio [OR], 2.2 [95% CI, 1.3-3.9];
P=0.004). Neither bradycardia nor pauses were associated with increased
risk of adverse outcomes over 5.5 years.

CONCLUSIONS: Resting bradycardia (HR <=40 bpm) and pauses of 2 to 3 s are
present in a significant proportion of endurance athletes and are well
tolerated. Our data suggest that both fitness and genetic variation
contribute to sinus node function in endurance athletes. Intriguingly,
HR-PRS differed between athletes and nonathletes, raising the possibility
that genetics may be a determinant of athleticism.