Meierhofer C; Kühn A; Müller J; Shehu N; Hager A; Martinoff S; Stern H; Ewert P; Vogt M;

Pediatric Cardiology [Pediatr Cardiol] 2019 Feb 06. Date of Electronic Publication: 2019 Feb 06.

Background: Exercise capacity is a well-defined marker of outcome in congenital heart disease. We analyzed seventeen cardiovascular magnetic resonance (CMR) derived parameters and their correlation to exercise capacity in patients with Ebstein’s anomaly (EA).
Methods: Fifty-four surgery free patients, age 5 to 69 years (median 30 years) prospectively underwent CMR examination and cardiopulmonary exercise testing (CPET). The following volume/flow parameters were compared with peak oxygen uptake as the percentage of normal (peakVO2%) using univariate and multivariate analysis: right and left ventricular ejection fraction (RVEF and LVEF), the indexed end-diastolic and end-systolic volumes (RVEDVi, RVESVi, LVEDVi, and LVESVi), the indexed stroke volumes (RVSVi and LVSVi), the total normalized right and left heart volumes; the total right to left heart volume ratio (R/L-ratio). The indexed antegrade flow (ante), indexed net flow (net) as well as cardiac index (CI) in the aorta (Ao) and pulmonary artery (PA) were used.
Results: RVEF (R2 0.2788), indexed flow PA net (R2 0.2330), and PA ante (R2 0.1912) showed the best correlation with peakVO2% (all p < 0.001) in the univariate model. Further significant correlation could also be demonstrated with CI-PA, LVEF, LVSVi, Aorta net, RVESVi, and Aorta ante. Multivariate analysis for RVEF and indexed net flow PA revealed a R2 of 0.4350.
Conclusion: Functional CMR parameters as RVEF and LVEF and flow data of cardiac forward flow correlate to peakVO2%. Evaluation of the indexed net flow in the pulmonary artery and the overall function of the right ventricle best predicts the maximal exercise capacity in patients with EA.

Carriere C; Corrà U; Piepoli M; Bonomi A; Salvioni E; Binno S; Magini A; Sciomer S; Pezzuto B;
Gentile P; Schina M; Sinagra G; Agostoni P

European Journal Of Preventive Cardiology [Eur J Prev Cardiol] 2019 Feb 12, pp. 2047487319829950. Date of Electronic Publication: 2019 Feb 12.

Background: During cardiopulmonary exercise test, the isocapnic buffering period ranges between anaerobic threshold (AT) and respiratory compensation point (RCP). We investigated whether oxygen uptake (VO2) increase during the isocapnic buffering period (ΔVO2AT-RCP) is related to heart failure severity and prognosis.
Methods: We retrospectively analysed reduced ejection fraction heart failure patients who attained RCP at cardiopulmonary exercise test. The study endpoint was the composite of cardiovascular mortality and urgent heart transplantation/left ventricular assist device implantation. Hazard ratio was assessed to identify the increase of risk associated with ΔVO2AT-RCP (below and above the median of ΔVO2AT-RCP).
Results: AT and RCP were both identified in 782 (39.2%) out of 1995 reduced ejection fraction heart failure cases. Left ventricular ejection fraction and peak VO2 were 33 ± 9% and 16.5 ± 4.5 mL/kg per min (61 ± 16% of predicted value), suggesting moderate heart failure. At five years, endpoint did not vary between patients below and above the median ΔVO2AT-RCP (3.85 mL/min per kg (25-75th interquartile range = 2.69-5.46)). ΔVO2AT-RCP correlated with several parameters associated to heart failure prognosis, such as peak VO2, VE/VCO2 slope, brain natriuretic peptide and left ventricular ejection fraction. The ΔVO2AT-RCP value was associated with prognosis at univariate but not at multivariable analysis, where only VE/VCO2 slope endured.
Conclusion: ΔVO2AT-RCP correlates with several parameters linked to heart failure severity. Isocapnic buffering period stratifies heart failure patients, but not more than other prognostic indices.

Van Iterson EH

European Journal Of Preventive Cardiology [Eur J Prev Cardiol] 2019 Feb 20, pp. 2047487319832747. Date of Electronic Publication: 2019 Feb 20.

NO ABSTRACT AVAILABLE

Smolis-Bąk E; Chwyczko T; Kowalik I; Borowiec A; Maciąg A; Szwed H; Dąbrowski R

Advances In Medical Sciences [Adv Med Sci], ISSN: 1898-4002, 2019 Feb 26; Vol. 64 (2), pp. 241-245

Purpose: The aim of this study was to assess exercise capacity and echocardiographic parameters in patients with heart failure with reduced ejection fraction (HFrEF) in NYHA III functional class, after cardiac resynchronization therapy (CRT) or implantable cardioverter-defibrillator (ICD) implantation followed by 6 months of supervised rehabilitation in ICD patients.
Materials and Methods: The study included patients with HFrEF and impaired left ventricle systolic function (LVEF ≤ 35%), divided into two groups: CRT group – patients after CRT-D implantation > six weeks, and ICD-rehab group – patients after ICD implantation > six weeks, followed by 6 months of supervised aerobic interval training and the conditioning exercises. At baseline and after 6 months in all the patients cardiopulmonary exercise tests (CPX) and standard echocardiographic examinations were performed.
Results: The study included 61 patients (49-77 years) with HFrEF. At baseline, the values of CPX parameters were similar in both groups. After completing training almost all CPX parameters in the ICD-rehab group significantly improved, except for anaerobic threshold (AT). In the CRT group significant improvements were found in 2 parameters: peak oxygen uptake (VO2) and exercise tolerance (metabolic equivalents, METs). Significant reductions in left and right ventricle diameters and an increase in LVEF were observed in both groups after 6 months.
Conclusions: Significant improvement in exercise tolerance capacity and increase of LVEF were observed in similar extent both in heart failure patients with CRT and with ICD undergoing the rehabilitation program. Regular, controlled exercise trainings provided additional, safe and easy to conduct therapeutic option for heart failure patients with no indications for CRT.

Williams CA; Wedgwood KCA; Mohammadi H; Prouse K; Tomlinson OW; Tsaneva-Atanasova K

Plos One [PLoS One], ISSN: 1932-6203, 2019 Feb 13; Vol. 14 (2), pp. e0211219; Publisher: Public Library of Science; PMID: 30759119;

Cystic fibrosis (CF) is a debilitating chronic condition, which requires complex and expensive disease management. Exercise has now been recognised as a critical factor in improving health and quality of life in patients with CF. Hence, cardiopulmonary exercise testing (CPET) is used to determine aerobic fitness of young patients as part of the clinical management of CF. However, at present there is a lack of conclusive evidence for one limiting system of aerobic fitness for CF patients at individual patient level. Here, we perform detailed data analysis that allows us to identify important systems-level factors that affect aerobic fitness. We use patients’ data and principal component analysis to confirm the dependence of CPET performance on variables associated with ventilation and metabolic rates of oxygen consumption. We find that the time at which participants cross the gas exchange threshold (GET) is well correlated with their overall performance. Furthermore, we propose a predictive modelling framework that captures the relationship between ventilatory dynamics, lung capacity and function and performance in CPET within a group of children and adolescents with CF. Specifically, we show that using Gaussian processes (GP) we can predict GET at the individual patient level with reasonable accuracy given the small sample size of the available group of patients. We conclude by presenting an example and future perspectives for improving and extending the proposed framework. The modelling and analysis have the potential to pave the way to designing personalised exercise programmes that are tailored to specific individual needs relative to patient’s treatment therapies.

Menachem JN; Reza N; Mazurek JA; Burstein D; Birati EY; Fox A; Kim YY; Molina M; Partington SL; Tanna M; Tobin L; Wald J; Goldberg LR

World Journal For Pediatric & Congenital Heart Surgery [World J Pediatr Congenit Heart Surg], ISSN: 2150-136X, 2019 Mar 04

Introduction:: Treatment of patients with adult congenital heart disease (ACHD) with advanced therapies including heart transplant (HT) is often delayed due to paucity of objective prognostic markers for the severity of heart failure (HF). While the utility of Cardiopulmonary Exercise Testing (CPET) in non-ACHD patients has been well-defined as it relates to prognosis, CPET for this purpose in ACHD is still under investigation.
Methods:: We performed a retrospective cohort study of 20 consecutive patients with ACHD who underwent HT between March 2010 and February 2016. Only 12 of 20 patients underwent CPET prior to transplantation. Demographics, standard measures of CPET interpretation, and 30-day and 1-year post transplantation outcomes were collected.
Results:: Patient Characteristics. Twenty patients with ACHD were transplanted at a median of 40 years of age (range: 23-57 years). Of the 12 patients who underwent CPET, 4 had undergone Fontan procedures, 4 had tetralogy of Fallot, 3 had d-transposition of the great arteries, and 1 had Ebstein anomaly. Thirty-day and one-year survival was 100%. All tests included in the analysis had a peak respiratory quotient _1.0. The median peak oxygen consumption per unit time (_VO2) for all diagnoses was 18.2 mL/kg/min (46% predicted), ranging from 12.2 to 22.6.
Conclusion:: There is a paucity of data to support best practices for patients with ACHD requiring transplantation. While it cannot be proven based on available data, it could be inferred that outcomes would have been worse or perhaps life sustaining options unavailable if providers delayed referral because of the lack of attainment of CPET-specific thresholds.

Abbott TEF; Pearse RM; Cuthbertson BH; Wijeysundera DN; Ackland GL; METS study investigators

British Journal Of Anaesthesia [Br J Anaesth], ISSN: 1471-6771, 2019 Feb; Vol. 122 (2), pp. 188-197

Background: The aetiology of perioperative myocardial injury is poorly understood and not clearly linked to pre-existing cardiovascular disease. We hypothesised that loss of cardioprotective vagal tone [defined by impaired heart rate recovery ≤12 beats min-1 (HRR ≤12) 1 min after cessation of preoperative cardiopulmonary exercise testing] was associated with perioperative myocardial injury.
Methods: We conducted a pre-defined, secondary analysis of a multi-centre prospective cohort study of preoperative cardiopulmonary exercise testing. Participants were aged ≥40 yr undergoing non-cardiac surgery. The exposure was impaired HRR (HRR≤12). The primary outcome was postoperative myocardial injury, defined by serum troponin concentration within 72 h after surgery. The analysis accounted for established markers of cardiac risk [Revised Cardiac Risk Index (RCRI), N-terminal pro-brain natriuretic peptide (NT pro-BNP)].
Results: A total of 1326 participants were included [mean age (standard deviation), 64 (10) yr], of whom 816 (61.5%) were male. HRR≤12 occurred in 548 patients (41.3%). Myocardial injury was more frequent amongst patients with HRR≤12 [85/548 (15.5%) vs HRR>12: 83/778 (10.7%); odds ratio (OR), 1.50 (1.08-2.08); P=0.016, adjusted for RCRI). HRR declined progressively in patients with increasing numbers of RCRI factors. Patients with ≥3 RCRI factors were more likely to have HRR≤12 [26/36 (72.2%) vs 0 factors: 167/419 (39.9%); OR, 3.92 (1.84-8.34); P<0.001]. NT pro-BNP greater than a standard prognostic threshold (>300 pg ml-1) was more frequent in patients with HRR≤12 [96/529 (18.1%) vs HRR>12 59/745 (7.9%); OR, 2.58 (1.82-3.64); P<0.001].
Conclusions: Impaired HRR is associated with an increased risk of perioperative cardiac injury. These data suggest a mechanistic role for cardiac vagal dysfunction in promoting perioperative myocardial injury.

Herth FJF, Slebos DJ, Criner GJ, Valipour A, Sciurba F, Shah PL

Respiration. 2019 Mar 5:1-10. doi: 10.1159/000496122. [Epub ahead of print]

Endoscopic lung volume reduction (ELVR) therapies are gaining prominence as a
treatment option with guideline recommendations by COPD GOLD and NICE and the
recent FDA approval for endobronchial valves. The transition from an
experiment-based therapy only to clinical care comes with new challenges. A
significant volume of evidence-based data has been published; all data
demonstrate consistent improvements in several aspects of patient outcomes.
Patients suffering from severe air trapping and thoracic hyperinflation seem to
benefit the most from ELVR. In addition to lung function, baseline assessment
should ideally include cardiopulmonary exercise testing, high-resolution computer
tomography scan, perfusion scintigraphy, and echocardiography. This expert ELVR
statement updates best practice recommendations from 2017 regarding patient
selection and utilization of these various techniques for treating patients with
advanced emphysema.

Arena R; Ozemek C,

Expert Review Of Cardiovascular Therapy [Expert Rev Cardiovasc Ther], ISSN: 1744-8344, 2019 Feb 21;

No abstract available

Guo DC; Li YD; Yang YH; Zhu WW; Sun LL; Jiang W; Ye XG; Cai QZ; Lu XZ

Echocardiography (Mount Kisco, N.Y.) [Echocardiography] 2019 Feb 22. Date of Electronic Publication: 2019 Feb 22.

Objectives: Right ventricular (RV) contractile reserve reflects the ability of RV to accommodate the increased afterload and may play an essential role in the evaluation of precapillary pulmonary hypertension (PH). This study aimed to assess RV contractile reserve based on exercise stress echocardiography (ESE) and to determine the echocardiographic determinants of exercise capacity in patients with precapillary PH.
Methods: A total of 31 patients with precapillary PH and 15 age- and sex-matched healthy control subjects were prospectively recruited. All subjects underwent ESE to assess RV function at rest and under peak exercise. Changes in these parameters during exercise were calculated to quantify the RV contractile reserve. Patients with precapillary PH also underwent cardiopulmonary exercise test (CPET), and data pertaining to peak oxygen uptake (peak VO2 ) and minute ventilation/carbon dioxide production (VE/VCO2 ) were collected.
Results: Right ventricular contractile reserve including change in tricuspid annular plane systolic excursion (∆TAPSE), change in RV fractional area change (∆RVFAC), and change in Doppler-derived tricuspid lateral annular peak systolic velocity (∆S’) was significantly depressed in precapillary PH patients compared with control subjects (P < 0.05). Parameters of RV function and RV contractile reserve were markedly associated with maximal exercise capacity (P < 0.05). ∆RVFAC was an independent predictor of peak VO2 (r2  = 0.601, P < 0.05).
Conclusions: Assessment of RV contractile reserve facilitates identification of subclinical dysfunction and evaluation of clinical status and severity of precapillary PH. ESE as a noninvasive method may provide a comprehensive clinical assessment and facilitate therapeutic decision-making for these patients.