Stöcker F; Neidenbach R; Fritz C; Oberhoffer RM; Ewert P; Hager A; Nagdyman N;

Frontiers In Pediatrics [Front Pediatr] 2019 Mar 26; Vol. 7, pp. 96. Date of Electronic Publication: 20190326 (Print Publication: 2019).

Introduction: As survival of previously considered as lethal congenital heart disease forms is the case in our days, issues regarding quality of life including sport and daily activities emerge. In patients with Fontan circulation, there is no pump to propel blood into the pulmonary arteries since the systemic veins are directly connected to the pulmonary arteries. The complex hemodynamics of Fontan circulation include atrial function, peripheral muscle pump, integrity of the atrioventricular valve, absence of restrictive, or obstructive pulmonary lung function. Therefore, thoracic mechanics are of particular importance within the complex hemodynamics of Fontan circulation.
Methods: To understand the physiology of respiratory muscles, the aim of this study was to examine the matching of auxiliary respiratory muscle oxygen delivery and utilization during incremental exercise in young male Fontan patients (n = 22, age = 12.04 ± 2.51) and healthy Controls (n = 10, age = 14.90 ± 2.23). All subjects underwent a cardiopulmonary exercise test (CPET) to exhaustion whereas respiratory muscle oxygenation was measured non-invasively using a near-infrared spectrometer (NIRS).
Results: CPET revealed significantly lower peak power output, oxygen uptake and breath activity in Fontan patients. The onset of respiratory muscle deoxygenation was significantly earlier. The matching of local muscle perfusion to oxygen demand was significantly worse in Fontans between 50 and 90% [Formula: see text] .
Findings: The results indicate that (a) there is high strain on respiratory muscles during incremental cycling exercise and (b) auxiliary respiratory muscles are worse perfused in patients who underwent a Fontan procedure compared to healthy Controls. This might be indicative of a more general skeletal muscle strain and worse perfusion in Fontan patients rather than a localized-limited to thoracic muscles phenomenon.

Mylius CF; Krijnen WP; van der Schans CP; Takken T;

ERJ Open Research [ERJ Open Res] 2019 Apr 01; Vol. 5 (2). Date of Electronic Publication: 20190401 (Print Publication: 2019).

Peak oxygen uptake (V’O2peak) is recognised as the best expression of aerobic fitness. Therefore, it is essential that V’O2peak reference values are accurate for interpreting a cardiopulmonary exercise test (CPET). These values are country specific and influenced by underlying biological ageing processes. They are normally stratified per paediatric and adult population, resulting in a discontinuity at the transition point between prediction equations. There are currently no age-related reference values available for the lifespan of individuals in the Dutch population. The aim of this study is to determine the best-fitting regression model for V’O2peak in the healthy Dutch paediatric and adult populations in relation to age. In this retrospective study, CPET cycle ergometry results of 4477 subjects without reported somatic diseases were included (907 females, age 7.9-65.0 years). Generalised additive models were employed to determine the best-fitting regression model. Cross-validation was performed against an independent dataset consisting of 3518 subjects (170 females, age 6.8-59.0 years). An additive model was the best fitting with the largest predictive accuracy in both the primary (adjusted R2=0.57, standard error of the estimate (see)=556.50 mL·min-1) and cross-validation (adjusted R2=0.57, see=473.15 mL·min-1) dataset. This study provides a robust additive regression model for V’O2peak in the Dutch population.

Bhatti YJ; Rice AJ; Kempny A; Dimopoulos K; Price LC; Ranu H; Wells A; Wort SJ; McCabe C;

Pulmonary Circulation [Pulm Circ] 2019 Apr-Jun; Vol. 9 (2), pp. 2045894019845615.

Early diagnosis of pulmonary artery hypertension (PAH) is diagnostically challenging given the extent of pulmonary vascular remodeling required to bring about clinical signs and symptoms. Exercise testing can be invaluable in this setting, as stressing the cardiopulmonary system may unmask early disease. This report describes a young patient with a positive family history of PAH in whom contemporaneous invasive cardiopulmonary exercise testing and surgical lung biopsy reveal the novel association between exercise pulmonary hypertension (ePH) and early histological changes of PAH. Exercise PH currently carries no pathological correlates which means the hemodynamic effects of early pulmonary vascular remodeling remain unknown. Following the recent proceedings from the World Symposium in Pulmonary Hypertension 2018, which broaden the hemodynamic definition of PAH, this report suggests an important association between ePH and early pulmonary vascular remodeling supporting a role for exercise hemodynamic evaluation in patients at increased familial risk of PAH.

Małek ŁA; Czajkowska A; Mróz A; Witek K; Barczuk-Falęcka M; Nowicki D; Postuła M; Werys K;

Both regular physical activity and hypertension may be related to increased myocardial thickness, but the interplay between these two factors in causing cardiac remodeling in athletes is still a matter of debate. The aim of this study was to analyze the relation between resting and peak exercise blood pressure (BP) and myocardial hypertrophy in healthy middle-aged amateur endurance athletes. The study included 30 male, long-term athletes (mean age 40.9±6.6 years) who underwent resting BP assessment, cardiopulmonary exercise testing with peak exercise BP measurement, and cardiac magnetic resonance. We found that interventricular septal diameter is increased in athletes with high-normal resting BP (n=11, 37%) – median 13 mm (interquartile range: 12-13.75 mm), but not in those with optimal or normal BP (n=19) – median 10 mm (10-11.75 mm), P=0.001. This finding is accompanied by significantly higher left and right ventricular mass index and larger left atrial area in the first group. These differences are even more pronounced in athletes in whom high-normal BP is accompanied by exaggerated blood pressure response (EBPR) to exercise, whereas isolated EBPR to exercise does not lead to hypertrophy or further left atrial enlargement. Prehypertension, isolated or combined with EBPR to exercise, affects cardiac remodeling in athletes. Identification of increased myocardial thickness in pure endurance middle-aged athletes should merit further investigation on masked hypertension.

Krol K; Morgan MA; Khurana S;

The Medical Clinics Of North America [Med Clin North Am] 2019 May; Vol. 103 (3), pp. 565-576.

Respiratory symptoms are common reasons for patients to seek care and contribute significantly to use of health care resources. Identifying the underlying etiology of a respiratory symptom is key to management; yet, pinpointing the cause can be a challenge. Familiarity with the tools available to help discern between the various contributing etiologies is crucial in guiding management. Assessment and quantification of pulmonary function can provide an objective measure to guide diagnosis and therapy. We review key points of pulmonary function evaluation, highlighting indications and contraindications, fundamentals of interpretation, and the limitations of each individual component.

Dirou S, Chambellan A, Chevallier P, Germaud P, Lamirault G, Gourraud PA, Perrot B, Delasalle B, Forestier B, Guillaume T, Peterlin P, Garnier A, Magnan A, Blanc FX, Lemarchand P.

Bone Marrow Transplant. 2018 Mar;53(3):281-290. doi: 10.1038/s41409-017-0057-5.
Epub 2017 Dec 21.

Long-term survivors after allogeneic hematopoietic stem cell transplantation
(allo-HSCT) are at high risk for treatment-related adverse events, that may
worsen physical capacity and may induce fatigue and disability. The aims of this
prospective study were to evaluate exercise capacity in allotransplant survivors
and its relationship with fatigue and disability. Patient-reported outcomes and
exercise capacity were evaluated in 71 non-relapse patients 1 year after
allo-HSCT, using validated questionnaires, cardiopulmonary exercise testing
(CPET) with measure of peak oxygen uptake (peakVO2) and deconditioning, pulmonary
function testing, echocardiography and 6-min walk test. A high proportion (75.4%)
of allo-HSCT survivors showed abnormal cardiopulmonary exercise testing
parameters as compared to predicted normal values, including 49.3% patients who
exhibited moderate to severe impairment in exercise capacity and 37.7% patients
with physical deconditioning. PeakVO2 values were not accurately predicted by
6-min walk distances (r = 0.53). Disability and fatigue were strongly associated
with decreased peakVO2 values (p = 0.002 and p = 0.008, respectively). Exercise
capacity was reduced in most allo-HSCT long-term survivors. Because reduced
exercise capacity was associated with fatigue, disability and a decrease in
quality of life, cardiopulmonary exercise testing should be performed in every
patient who reports fatigue and disability.

Brat K(, Stastna N, Merta Z, Olson LJ, Johnson BD, CundrleI Jr

PLoS One. 2019 Apr 23;14(4):e0215997. doi: 10.1371/journal.pone.0215997.
eCollection 2019

INTRODUCTION: Measurement of ventilatory efficiency, defined as minute
ventilation per unit carbon dioxide production (VE/VCO2), by cardiopulmonary
exercise testing (CPET) has been proposed as a screen for hyperventilation
syndrome (HVS). However, increased VE/VCO2 may be associated with other disorders
which need to be distinguished from HVS. A more specific marker of HVS by CPET
would be clinically useful. We hypothesized ventilatory control during exercise
is abnormal in patients with HVS.
METHODS: Patients who underwent CPET from years 2015 through 2017 were
retrospectively identified and formed the study group. HVS was defined as dyspnea
with respiratory alkalosis (pH >7.45) at peak exercise with absence of acute or
chronic respiratory, heart or psychiatric disease. Healthy patients were selected
as controls. For comparison the Student t-test or Mann-Whitney U test were used.
Data are summarized as mean ± SD or median (IQR); p<0.05 was considered
significant.
RESULTS: Twenty-nine patients with HVS were identified and 29 control subjects
were selected. At rest, end-tidal carbon dioxide (PETCO2) was 27 mmHg (25-30) for
HVS patients vs. 30 mmHg (28-32); in controls (p = 0.05). At peak exercise PETCO2
was also significantly lower (27 ± 4 mmHg vs. 35 ± 4 mmHg; p<0.01) and VE/VCO2
higher ((38 (35-43) vs. 31 (27-34); p<0.01)) in patients with HVS. In contrast to
controls, there were minimal changes of PETCO2 (0.50 ± 5.26 mmHg vs. 6.2 ± 4.6
mmHg; p<0.01) and VE/VCO2 ((0.17 (-4.24-6.02) vs. -6.6 (-11.4-(-2.8)); p<0.01))
during exercise in patients with HVS. The absence of VE/VCO2 and PETCO2 change
during exercise was specific for HVS (83% and 93%, respectively).
CONCLUSION: Absence of VE/VCO2 and PETCO2 change during exercise may identify
patients with HVS.

Lam S, Alexandre L, Hardwick G, Hart AR

Surgery. 2019 Apr 10. pii: S0039-6060(19)30058-3. doi:
10.1016/j.surg.2019.02.001. [Epub ahead of print]

BACKGROUND: Postoperative complications after esophagectomy are thought to be
associated with reduced fitness. This observational study explored the
associations between aerobic fitness, as determined objectively by preoperative
cardiopulmonary exercise testing (CPEX), and 30-day morbidity after
esophagectomy.
METHODS: We retrospectively identified 254 consecutive patients who underwent
esophagectomy at a single academic teaching hospital between September 2011 and
March 2017. Postoperative complication data were measured using the Esophageal
Complications Consensus Group definitions and graded using the Clavien-Dindo
classification system of severity (blinded to cardiopulmonary exercise testing
values). Associations between preoperative cardiopulmonary exercise testing
variables and postoperative outcomes were estimated using logistic regression.
RESULTS: A total of 206 patients (77% male) were included in the analyses, with a
mean age of 67 years (SD 9). The mean values for the maximal oxygen consumed at
the peak of exercise (VO2peak) and the anaerobic threshold were 21.1 mL/kg/min
(SD 4.5) and 12.4 mL/kg/min (SD 2.8), respectively. The vast majority of patients
(98.5%) had malignant disease-predominantly adenocarcinoma (84.5%), for which
most received neoadjuvant chemotherapy (79%) and underwent minimally invasive
Ivor Lewis esophagectomy (53%). Complications at postoperative day 30 occurred in
111 patients (54%), the majority of which were cardiopulmonary (72%). No
associations were found between preoperative cardiopulmonary exercise testing
variables and morbidity for either VO2peak (OR 1.00, 95% CI 0.94-1.07) or
anaerobic threshold (OR 0.98, 95% CI 0.89-1.09).
CONCLUSION: Preoperative cardiopulmonary exercise testing variables were not
associated with 30-day complications after esophagectomy. The findings do not
support the use of cardiopulmonary exercise testing as an isolated preoperative
screening tool to predict short-term morbidity after esophagectomy. This modestly
sized observational work highlights the need for larger studies examining
associations between preoperative cardiopulmonary exercise testing and outcomes
after esophagectomy to look for consistency in our findings.

Gravier FE, Bonnevie T, Boujibar F, Médrinal C, Prieur G, Combret Y, Muir JF, Cuvelier A, Baste JM, Debeaumont D

J Thorac Cardiovasc Surg. 2019 Feb 19. pii: S0022-5223(19)30448-9

OBJECTIVE: Cardiopulmonary exercise testing (CPET) for patients awaiting lung
resection for non-small cell lung cancer (NSCLC) has developed considerably in
recent years. Pulmonary rehabilitation before surgery (prehabilitation) improves
postoperative risk factors such as forced expiratory volume in 1 second and peak
oxygen consumption (VO2peak). Ventilatory inefficiency assessed according to the
linear regression of the ratio between the increase in minute ventilation and the
expired carbon dioxide flow during CPET (VE/VCO2 slope) >35, is a high-risk
factor for postoperative complications. Our objective was to assess the effect of
prehabilitation on VE/VCO2 slope, and its relationship with VO2peak.
METHODS: This retrospective cohort study was performed between January 1, 2014
and December 31, 2017 at Rouen University Hospital. One hundred fifty-two
patients with NSCLC awaiting lung surgery who underwent CPET were screened. A
total of 50 patients who underwent CPET before and after prehabilitation were
included.
RESULTS: VE/VCO2 slope did not change significantly after prehabilitation
(median, 37.1 [25th-75th percentile, 33.8-43.4] vs median, 35.4 [25th-75th
percentile, 31.1-40.5]; P = .09), whereas VO2peak increased significantly (from a
median of 13.2 [25th-75th percentile, 11.9-14.7] to a median of 14.8 [25th-75th
percentile, 13.1-16.4] mL/kg/min). The number of patients with a high risk of
postoperative complications (ie, VE/VCO2 slope >35) did not change significantly
after prehabilitation. Cardiorespiratory parameters improved significantly more
in patients who underwent at least 15 sessions of ambulatory prehabilitation.
CONCLUSIONS: VE/VCO2 slope, a known predictor of favorable surgical outcomes in
patients with NSCLC, did not change with the prehabilitation program used in this
study, despite clear improvements in VO2peak and other CPET measures. Larger,
prospective studies are needed to confirm the results of this study.

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

Heart And Vessels [Heart Vessels] 2019 Jan 02. Date of Electronic Publication: 2019 Jan 02.

Resting heart rate (HR) plus 20 or 30 beats per minute (bpm), i.e., a simplified substitute for HR at the anaerobic threshold (AT), is used as a tool for exercise prescription without cardiopulmonary exercise testing data. While resting HR plus 20 bpm is recommended for patients undergoing beta-blocker therapy, the effects of specific beta blockers on HR response to exercise up to the AT (ΔAT HR) in patients with subacute myocardial infarction (MI) are unclear. This study examined whether carvedilol treatment affects ΔAT HR in subacute MI patients. MI patients were divided into two age- and sex-matched groups [carvedilol (+), n = 66; carvedilol (-), n = 66]. All patients underwent cardiopulmonary exercise testing at 1 month after MI onset. ΔAT HR was calculated by subtracting resting HR from HR at AT. ΔAT HR did not differ significantly between the carvedilol (+) and carvedilol (-) groups (35.64 ± 9.65 vs. 34.67 ± 11.68, P = 0.604). Multiple regression analysis revealed that old age and heart failure after MI were significant predictors of lower ΔAT HR (P = 0.039 and P = 0.013, respectively), but not carvedilol treatment. Our results indicate that carvedilol treatment does not affect ΔAT HR in subacute MI patients. Therefore, exercise prescription based on HR plus 30 bpm may be feasible in this patient population, regardless of carvedilol use, without gas-exchange analysis data.