Zhang LY, Liu ZJ, Shen L, Huang YG

快速康复外科(ERAS)旨在通过多种优化措施减少患者的围术期应激反应,加速患者术后康复过程。随着ERAS理念的推广,如何更有效地实施ERAS方案成为新的挑战。心肺
运动试验在ERAS术前评估、制定优化措施和术后康复环节都具有良好的应用价值。本文主要综述心肺运动试验在ERAS中的应用进展,为制定更细致、更全面的ERAS方案提供
依据。.

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.

Kurpaska M – mkurpaska@wim.mil.pl. – Krzesiński P; Gielerak G; Uziębło-Życzkowska B; Banak M; Stańczyk A;Piotrowicz K;

Hypertension Research: Official Journal Of The Japanese Society Of Hypertension [Hypertens Res] 2018 Nov 30. Date of Electronic Publication: 2018 Nov 30.

Patients with arterial hypertension (AH), especially women, often report exercise intolerance and dyspnea. However, these symptoms are not frequently reflected in standard assessments. The aim of the study was to evaluate the clinical value of impedance cardiography (ICG) in the hemodynamic assessment of patients with AH during exercise, particularly the differences between subgroups based on sex and the presence of dyspnea. Ninety-eight patients with AH (52 women; 54.5 ± 8.2 years of age) were evaluated for levels of N-terminal pro-B-type brain natriuretic peptide (NT-proBNP), exercise capacity (cardiopulmonary exercise testing (CPET) and the 6-min walk test (6MWT)), and exercise ICG. Patients with AH were stratified into the following four subgroups: males without dyspnea (MnD, n = 38); males with dyspnea (MD, n = 8); females without dyspnea (FnD, n = 27); and females with dyspnea (FD, n = 25). In comparison with the MnD subgroup, the FnD subgroup demonstrated significantly higher NT-proBNP levels; lower exercise capacity (shorter 6MWT distance, lower peak oxygen uptake (VO2), lower O2 pulse); higher peak stroke volume index (SVI); and higher SVI at the anaerobic threshold (AT). In comparison with the other subgroups, the FD subgroup walked a shorter distance during the 6MWT distance; had a steeper VE/VCO2 slope; had lower values of peak stroke volume (SV) and peak cardiac output (CO); and had a smaller change in CO from rest to peak. However, no other differences were identified (NT-proBNP, left ventricular diastolic dysfunction, or CPET parameters). Exercise impedance cardiography revealed an impaired hemodynamic response to exercise in hypertensive females with dyspnea. In patients with unexplained exercise intolerance, impedance cardiography may complement traditional exercise tests.

Berntsen KS; Edvardsen E; Hansen BH; Flatø B; Sjaastad I; Sanner H;

Rheumatology (Oxford, England) [Rheumatology (Oxford)] 2018 Nov 30. Date of Electronic Publication: 2018 Nov 30.

Objectives: To compare cardiorespiratory fitness (CRF) expressed as maximal oxygen uptake (VO2max) between patients with long-term JDM and controls and between patients with active and inactive disease, as well as to explore exercise limiting factors and associations between CRF and disease variables.
Methods: JDM patients (n = 45) and age- and gender-matched controls (n = 45) performed a cardiopulmonary exercise test (CPET) on a treadmill until exhaustion. Physical activity was measured by accelerometers. Disease activity, damage and muscle strength/function were assessed by validated tools. Clinically inactive disease was defined according to PRINTO criteria.
Results: The mean disease duration was 20.8 (s.d. 11.9) years and 29/45 (64%) patients had inactive disease. A low VO2max was found in 27% of patients vs 4% of controls (P = 0.006). The mean VO2max and maximal ventilation (VEmax) were lower in patients with active and inactive disease compared with controls. Patients with active disease also had lower maximal voluntary ventilation (MVV) compared with controls and lower VEmax and MVV compared with those with inactive disease. Patients with inactive disease had lower physical activity levels compared with controls. VO2max correlated negatively with disease damage in patients with inactive disease and positively with muscle strength/function in patients with active disease.
Conclusion: CRF was lower in JDM patients, both with active and inactive disease, compared with controls after a mean 20 years disease duration. Cardiopulmonary exercise test results suggested different limiting factors contributing to the reduced CRF according to disease activity, including deconditioning in inactive disease and reduced ventilatory capacity in active disease. Further research is needed to verify this.

Muller PT; Utida KAM; Augusto TRL; Spreafico MVP; Mustafa RC; Xavier AW; Saraiva EF;

Respiratory Medicine [Respir Med] 2018 Dec; Vol. 145, pp. 101-109. Date of Electronic Publication: 2018 Oct 30.

Background: Left ventricular diastolic dysfunction (LVDD) is highly prevalent in COPD and conflicting results have emerged regarding the consequences on exercise capacity in the 6MWT. We sought to examine the ventilatory efficiency and variability metrics as the primary endpoint and aerobic capacity (V’O2) as the secondary endpoint.
Methods: Forty subjects were included and submitted to comprehensive lung function tests, detailed pulsed-Doppler echocardiography, and cardiopulmonary exercise testing. Four subjects were excluded due to concomitant cardiac disease and two owing to COPD exacerbation.
Results: Seventeen COPD/LVDD+ and seventeen COPD/LVDD-individuals were closely matched for baseline characteristics. Throughout the exercise, there was no difference between-groups for primary (V’E/V’CO2slope and V’E/V’CO2nadir, p > 0.05 for both) or secondary endpoints (V’O2peak%pred, p > 0.05). Ventilatory variability remained unchanged. However, after very well age- and sex-matched subgroup analysis, five-moderate and three-mild COPD/LVDD + subjects with elevated left ventricular filling pressure (E/e’>13, n = 8), presented a downward-shifted V’E/V’CO2slope (25.7 ± 5.1 vs 33.4 ± 7.1, p = 0.031) and V’E/V’CO2nadir reduction (29.7 ± 3.9 vs 36.3 ± 7.2, p = 0.042) besides significantly better V’O2peak%pred (92.1 ± 21.6% vs 75.8 ± 13.1%, p = 0.045) compared to 8 COPD/LVDD-controls. Ventilatory variability remained once again unchanged.
Conclusions: COPD/LVDD overlap is not associated with worse exercise tolerance and/or wasted ventilation in excess compared to controls, even when suspected for elevated left ventricular filling pressure. Further studies are warranted to study specifically if augmented pulmonary blood transit time can allow better gas-exchange, thus preserving exercise capacity under specific conditions in COPD patients without heart failure.

Hamazaki N; Masuda T; Kamiya K; Matsuzawa R; Nozaki K; Maekawa E; Noda C; Yamaoka-Tojo M; Ako J;

Respirology (Carlton, Vic.) [Respirology] 2018 Nov 14. Date of Electronic Publication: 2018 Nov 14.

Background and Objective: Respiratory muscle weakness causes fatigue in these muscles during exercise and thereby increases dead-space ventilation ratio with decreased tidal volume. However, it remains unclear whether respiratory muscle weakness aggravates ventilation-perfusion mismatch through the increased dead-space ventilation ratio. In ventilation-perfusion mismatch during exercise, minute ventilation versus carbon dioxide production (VE/VCO2 ) slope > 34 is an indicator of poor prognosis in patients with chronic heart failure (CHF). We examined the relationship of respiratory muscle weakness with dead-space ventilation ratio and ventilation-perfusion mismatch during exercise and clarified whether respiratory muscle weakness was a clinical predictor of VE/VCO2 slope > 34 in patients with CHF.
Methods: Maximal inspiratory pressure (PImax ) was measured as respiratory muscle strength 2 months after hospital discharge in 256 compensated patients with CHF. During cardiopulmonary exercise test, we assessed minute dead-space ventilation versus VE (VD/VE ratio) as dead-space ventilation ratio and VE/VCO2 slope as ventilation-perfusion mismatch. Patients were divided into low, moderate and high PImax groups based on the PImax tertile. We investigated determinants of VE/VCO2 slope > 34 among these groups.
Results: The low PImax group showed significantly higher VD/VE ratios at 50% of peak workload and at peak workload and higher VE/VCO2 slope than the other two groups (P < 0.001, respectively). PImax was a significant independent determinant of VE/VCO2 slope > 34 (odds ratio (OR): 0.67, 95% CI: 0.54-0.82) with area under the receiver operating characteristic curve of 0.812 (95% CI: 0.750-0.874).
Conclusion: Respiratory muscle weakness was associated with an increased dead-space ventilation ratio aggravating ventilation-perfusion mismatch during exercise in patients with CHF.

Miyazaki T; Callister MEJ; Franks K; Dinesh P; Nagayasu T; Brunelli A;

Lung Cancer (Amsterdam, Netherlands) [Lung Cancer] 2018 Nov; Vol. 125, pp. 218-222. Date of Electronic Publication: 2018 Oct 04.

Objectives: The aim of the study was to identify whether ventilation-to-carbon dioxide output (VE/V CO2) slope obtained from cardiopulmonary exercise test (CPET) as part of the preoperative functional workup was an independent prognostic factor for short and long-term survival after major lung resection.
Patients and Methods: 974 consecutive patients undergoing lobectomy (n = 887) or segmentectomy (n = 87) between April 2014 to March 2018 were included. 209 (22%) underwent CPET, and pulmonary function tests and several clinical factors including age, sex, performance status and comorbidities were retrospectively investigated to identify the prognostic factors with a multivariable Cox regression analysis.
Results: Among the patients with measured VE/V CO2, the incidence of cardiopulmonary complications in patients with high VE/V CO2 slope (>40) was 37% (19 of 51) vs. 27% (33 of 121) in those with lower slope values (p = 0.19). The 90-day mortality in patients with high VE/V CO2 slope (n = 8) was 16% vs. 5% (n = 6) in those with lower slope values (p = 0.03). No overall difference in 2-year mortality was identified between the two groups (VE/VCO2 > 40: 70% (54-80) vs. VE/VCO2 ≤ 40: 72% (63-80), log-rank test, p = 0.39). In a Cox regression analysis VE/VCO2 values were associated with poorer 2-year survival (HR 1.05, 95% CI 1.01-1.10, p = 0.030).
Conclusions: We found that VE/V CO2 slope was an independent prognostic factor for the 90-day mortality and 2-year survival after anatomic pulmonary resection. This finding may assist during the multidisciplinary treatment decision-making process in high-risk patients with lung cancer.

Letnes JM; Dalen H; Vesterbekkmo EK; Wisløff U; Nes BM;

European Heart Journal [Eur Heart J] 2018 Nov 29. Date of Electronic Publication: 2018 Nov 29.

Aims: The majority of previous research on the association between cardiorespiratory fitness (CRF) and cardiovascular disease (CVD) is based on indirect assessment of CRF in clinically referred predominantly male populations. Therefore, our aim was to examine the associations between VO2peak measured by the gold-standard method of cardiopulmonary exercise testing and fatal and non-fatal coronary heart disease (CHD) in a healthy and fit population.
Methods and results: Data on VO2peak from 4527 adults (51% women) with no previous history of cardiovascular or lung disease, cancer, and hypertension or use of antihypertensive medications participating in a large population-based health-study (The HUNT3 Study), were linked to hospital registries and the cause of death registry. Average VO2peak was 36.0 mL/kg/min and 44.4 mL/kg/min among women and men, and 83.5% had low 10-year risk of CVD at baseline. Average follow-up was 8.8 years, and 147 participants reached the primary endpoint. Multi-adjusted Cox-regression showed 15% lower risk for the primary endpoint per one-MET (metabolic equivalent task) higher VO2peak [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.77-0.93], with similar results across sex. The highest quartile of VO2peak had 48% lower risk of event compared with the lowest quartile (multi-adjusted HR 0.52, 95% CI 0.33-0.82). Oxygen pulse and ventilatory equivalents of oxygen and carbon dioxide also showed significant predictive value for the primary endpoint.
Conclusion: VO2peak was strongly and inversely associated with CHD across the whole fitness continuum in a low-risk population sample. Increasing VO2peak may have substantial benefits in reducing the burden of CHD.

Mediano MFF; Leifer ES; Cooper LS; Keteyian SJ; Kraus WE; Mentz RJ; Fleg JL;

JACC. Heart Failure [JACC Heart Fail] 2018 Dec; Vol. 6 (12), pp. 1011-1019.

Objectives: This study sought to evaluate the influence of baseline physical activity (PA) on responses to aerobic exercise training and clinical events in outpatients with chronic systolic heart failure (HF) from the multicenter HF-ACTION (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure) trial.
Background: The influence of baseline PA on exercise capacity, responses to exercise training and clinical outcomes in patients with chronic HF is unclear.
Methods: Of 2,130 participants who provided consent for this analysis, 1,494 patients (64%) had complete baseline PA data, using a modified version of the International Physical Activity Questionnaire-Short Form questionnaire and were included in the analysis; 742 received usual care and 752 were allocated to the exercise training group. Changes in exercise capacity, all-cause mortality and hospitalization, cardiovascular (CV) mortality and hospitalization, and CV mortality and HF hospitalization were evaluated as a function of baseline PA tertile.
Results: At baseline, the highest PA tertile showed greater peak oxygen uptake, cardiopulmonary exercise test duration, and 6-min walk test distance than the other 2 PA tertiles, as well as lower New York Heart Association functional class, lower Beck depression score, and lower atrial fibrillation prevalence than the lowest PA tertile. Compared to the lowest PA tertile, the middle tertile had 18% lower risk of CV death/CV hospitalizations, and the upper tertile showed 23% lower risk of CV death/HF hospitalizations. Exercise capacity and clinical outcome responses to training were similar and largely nonsignificant across baseline PA tertiles with significant benefit of training on exercise test duration for all tertiles.
Conclusions: In patients with chronic systolic HF, aerobic exercise training significantly improves exercise test duration to a similar extent across baseline PA tertiles. Although higher baseline PA was associated with lower risk of clinical events, no significant differences in event rates within each PA tertile were seen between subgroups randomized to exercise training versus usual care. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure [HF-ACTION]; NCT00047437).

Powell AW, Mays WA, Knecht SK, Chin C;

Cardiol Young. 2018 Nov 26:1-7. doi: 10.1017/S1047951118001920. [Epub ahead of
print]

BACKGROUND: A transannular patch is often used in the contemporary surgical
repair of tetralogy of Fallot. This can lead to significant pulmonary
insufficiency and increased right ventricular volumes and ultimately pulmonary
valve replacement. Cardiopulmonary exercise testing is used to assess exercise
capacity in tetralogy of Fallot patients before pulmonary valve replacement.
There is only few published literatures on how lung function affects functional
capacity in tetralogy of Fallot patients repaired with a transannular patch.
METHODS: A retrospective chart review was done from 2015 to 2017 on patients with
tetralogy of Fallot who underwent maximal effort cardiopulmonary exercise testing
with cycle ergometry and with concurrent pulmonary function testing. Tetralogy of
Fallot patients repaired with a transannular patch without pulmonary valve
replacement were compared with age, gender, and size-matched normal controls.
RESULTS: In the tetralogy of Fallot group, 24 out of 57 patients underwent
primary repair with a transannular patch. When compared to the normal controls,
they demonstrated abnormal predicted forced expiratory volume in one second (79 ±
23.1% versus 90.7 ± 14.1%, p<0.05), predicted maximal voluntary ventilation (74 ±
18% versus 90.5 ± 16.2%, p<0.05) while having low-normal predicted forced vital
capacity (80.5 ± 17.2% versus 90.2 ± 12.4%, p<0.05) and normal breathing reserve
percentage (50.3 ± 11.3% versus 47.5 ± 17.3%, p = 0.52). Cardiopulmonary exercise
testing abnormalities included significantly lower percent predicted oxygen
consumption (63.2 ± 12.2% versus 87 ± 12.1%, p<0.05), maximal heart rate (171.8 ±
18.9 versus 184.6 ± 13.6, p<0.05), and percent predicted maximum workload (61.7 ±
15.9% versus 88.3 ± 21.5%, p<0.05).
CONCLUSIONS: Tetralogy of Fallot patients repaired with a transannular patch can
have abnormal pulmonary function testing with poor exercise capacity in addition
to chronotropic incompetence and impaired muscular power.

Otto JM, Plumb JOM, Wakeham D, Clissold E, Loughney L, Schmidt W, Montgomery HE, Grocott MPW, Richards

Br J Anaesth. 2017 May 1;118(5):747-754. doi: 10.1093/bja/aew445.
Comment in Br J Anaesth. 2017 May 1;118(5):655-657.
Comment on Eur J Appl Physiol. 2013 May;113(5):1181-8.

Background: Cardiopulmonary exercise testing (CPET) measures peak exertional
oxygen consumption ( V˙O2peak ) and that at the anaerobic threshold ( V˙O2 at AT,
i.e. the point at which anaerobic metabolism contributes substantially to overall
metabolism). Lower values are associated with excess postoperative morbidity and
mortality. A reduced haemoglobin concentration ([Hb]) results from a reduction in
total haemoglobin mass (tHb-mass) or an increase in plasma volume. Thus, tHb-mass
might be a more useful measure of oxygen-carrying capacity and might correlate
better with CPET-derived fitness measures in preoperative patients than does
circulating [Hb].
Methods: Before major elective surgery, CPET was performed, and both tHb-mass
(optimized carbon monoxide rebreathing method) and circulating [Hb] were
determined.
Results: In 42 patients (83% male), [Hb] was unrelated to V˙O2 at AT and V˙O2peak
( r =0.02, P =0.89 and r =0.04, P =0.80, respectively) and explained none of the
variance in either measure. In contrast, tHb-mass was related to both ( r =0.661,
P <0.0001 and r =0.483, P =0.001 for V˙O2 at AT and V˙O2peak , respectively). The
tHb-mass explained 44% of variance in V˙O2 at AT ( P <0.0001) and 23% in V˙O2peak
( P =0.001).
Conclusions: In contrast to [Hb], tHb-mass is an important determinant of
physical fitness before major elective surgery. Further studies should determine
whether low tHb-mass is predictive of poor outcome and whether targeted increases
in tHb-mass might thus improve outcome.