Lundgaard E; Oslo Metropolitan University, Oslo, Norway;
Kraggerud H; Hamre C; Wouda M

Journal of Rehabilitation Medicine. 58:jrm44817, 2026 Jul 23.

OBJECTIVE: To investigate lung function and ventilatory response during
cardiopulmonary exercise testing in adults with cerebral palsy and assess
the relationship between perceived breathlessness and breathing reserve at
maximal exertion.

DESIGN: Prospective, cross-sectional study. Inclusion period October
2023-June 2024.

SUBJECTS: Adults with spastic cerebral palsy, Gross Motor Function
Classification Score (GMFCS) I-III (n = 100).

METHODS: Spirometry and cardiopulmonary exercise testing were conducted.
Ventilatory response during exercise was assessed via tidal volume and
respiratory rate. Perceived breathlessness was compared with breathing
reserve at maximal exertion.

RESULTS: 89 participants completed all tests (GMFCS I = 62, GMFCS II =
20, GMFCS III = 7); 90% had lung function within normal limits. Age- and
sex-adjusted maximal oxygen uptake was lowest in group III (p < 0.01). At
maximal exertion, 70% had breathing reserve < 20%, indicating ventilatory
limitation. Breathing reserve did not significantly differ between those
who did and did not report breathlessness as the limiting factor at
maximal exertion. Tidal volume and respiratory rate showed expected values
at maximal exertion.

CONCLUSION: Lung function was normal in most participants, yet
ventilatory limitations were common during maximal exercise. Perceived
breathlessness was not related to breathing reserve at maximal exertion.

Aucoin R; Dalhousie University, Halifax, Nova Scotia, Canada.
Jensen D; Stickland M; Brotto A et al

Clinical Physiology & Functional Imaging. 46(4):e70083, 2026 Jul.

BACKGROUND: Leg discomfort, assessed with the Borg category-ratio 0-10
(Borg CR10) scale, is a primary reason for exercise cessation in both
health and disease. However, interpretation during cardiopulmonary
exercise testing (CPET) is limited by the absence of normative reference
equations.

PURPOSE: Develop normative reference equations for leg discomfort during
CPET in relation to absolute and relative power output (W) and rate of
oxygen uptake (V’O2).

METHODS: This was a retrospective analysis of the Canadian Cohort
Obstructive Lung Disease (CanCOLD) study. We included healthy males and
females aged >=40 years who completed symptom limited incremental cycle
CPET. The probability of each Borg CR10 leg discomfort rating by W or V’O2
was predicted using multinomial logistic regression. Model performance was
evaluated by fit, calibration, discrimination (c-statistic), and
externally validated in an independent sample (n = 86) of healthy Canadian
adults.

RESULTS: In total, 156 participants (43% female) were included (mean age
64.8 years). The models demonstrated good discrimination in both internal
and external validation (AUC 0.85-0.90), with similar performance across
absolute and relative W and V’O2. An upper limit of normal ([ULN]; 95th
percentile) could not be defined, as leg discomfort responses were highly
clustered within the predicted normal range across exercise intensities.

CONCLUSIONS: We present normative reference equations for leg discomfort
during CPET. Although an ULN could not be established, these models enable
grading and interpretation of leg discomfort relative to the predicted
normal responses and facilitate comparisons across individuals and groups
in both clinical and research settings.

Cumitini L; Maggiore della Carita Hospital, Novara, Italy.
Giubertoni A; Mennuni M; Degiovanni A; Patti G

American Journal of Cardiology. 272:54-59, 2026 Aug 01.

Transcatheter tricuspid valve interventions have recently emerged as
effective therapeutic options for patients with severe tricuspid
regurgitation (TR) and heart failure at high surgical risk. Despite
evidence of post-procedural clinical improvement, data regarding changes
in functional capacity remain limited. In this prospective, observational
study, we enrolled high-risk patients with at least severe TR and heart
failure undergoing transcatheter tricuspid valve repair by the PASCAL
device or replacement with the EVOQUE system. Functional capacity was
evaluated by cardiopulmonary exercise testing (CPET), in addition to
clinical, laboratory, and echocardiographic parameters, at baseline and 3
months postprocedure. The primary endpoint was the change in peak oxygen
consumption (VO2) by CPET at 3 months versus baseline. Secondary endpoints
included changes in other CPET parameters, TR severity by transthoracic
echocardiography, New York Heart Association (NYHA) class, daily
furosemide dose, and pro-brain natriuretic peptide (pro-BNP) levels. A
total of 10 patients were enrolled, with successful device implantation
obtained in all cases. Peak VO2 improved significantly from 14.7 +/- 3.7
at baseline to 16.4 +/- 2.9 ml/kg/min at 3 months (p = 0.009). Peak oxygen
pulse increased from 85.1 +/- 20.2% to 103.7 +/- 23.3% (p = 0.022), and
ventilation maximum rose from 39.9 +/- 10.3 L/min to 45.7 +/- 10.9 L/min
(p = 0.035). TR severity was reduced (p = 0.002), NYHA class improved (p =
0.016), and daily furosemide dose decreased (p = 0.016). Although pro-BNP
levels declined, this reduction was not statistically significant. No
adverse event occurred during follow-up. In conclusion, among patients
with severe TR and heart failure, TR reduction by transcatheter tricuspid
valve interventions was associated with improved CPET-derived functional
capacity, better functional class, and reduced diuretic requirement during
short-term follow-up.

Oh C; Department of Anesthesiology Daejeon, 35015, Korea.
Park S; Lee S; Chong Y;et al

BMC Anesthesiology. 26(1), 2026 May 14.

BACKGROUND: Oxygen consumption (VO2) is a core element of hemodynamic
physiology and the metabolic counterpart to oxygen delivery. Modern
anesthesia machines enable real-time intraoperative VO2 estimation, yet
its relationship with preoperative metabolic capacity, as characterized by
cardiopulmonary exercise testing (CPET), has not been directly examined.

METHODS: This study analyzed preoperative CPET and intraoperative data
from adult patients >= 20 undergoing lung resection under general
anesthesia. Intraoperative VO2 was estimated from minute ventilation and
inspired and end-tidal oxygen fractions. Preoperative and intraoperative
VO2 were summarized, and associations between baseline VO2 and
intraoperative suppression were assessed.

RESULTS: Data from 32 patients were analyzed. Preoperative VO2 at rest,
anaerobic threshold, and peak exercise were 1.6 +/- 0.4, 5.1 +/- 1.9, and
6.1 +/- 1.7 metabolic equivalents (METs), respectively. The reduction from
resting to intraoperative VO2 (-29.0 +/- 19.4%) showed a strong
correlation with resting VO2 (r = 0.770, p < 0.001). Consequently,
regardless of preoperative resting VO2, intraoperative VO2 converged to a
relatively narrow range, averaging 1.1 +/- 0.2 METs.

CONCLUSIONS: In patients undergoing lung resection, intraoperative VO2
converged to approximately 1 MET under general anesthesia, largely
independent of preoperative resting metabolism. The clinical implications
of this observation remain unclear and warrant investigation in larger
prospective studies incorporating concurrent measurements of oxygen
delivery and clinical outcomes.

Vanhentenrijk S; Vascular and Thoracic Institute, Cleveland Clinic,
Cleveland, Ohio. USA
Chaikijurajai T; Engelman T; Grodin JL;et al

American Journal of Cardiology. 272:103-109, 2026 Aug 01.

Hemodynamic gain index (HGI) is a novel, simple parameter calculated from
resting and peak systolic blood pressure and heart rate (HR) during
exercise, however, its prognostic value in patients with hypertrophic
cardiomyopathy (HCM) is unknown. We investigate the prognostic value of
alternative nonmetabolic exercise testing parameters in a contemporary HCM
cohort. HGI was calculated from systolic blood pressure at rest and peak
/HR data from consecutive HCM patients who underwent cardiopulmonary
exercise testing for symptom evaluation. Multivariable Cox regression
analysis was performed with the primary outcome of all-cause mortality
and/or heart transplantation. Logistic regression models were used for HGI
to predict the need for future myectomy or alcohol septal ablation. In our
cohort of 905 patients with HCM, HGI correlated well with circulatory
power (CP, r = 0.71, p <0.001) and peak VO2 (r = 0.64, p <0.001). HGI
(Area Under Curve (AUC) 0.87, 95% CI 0.81-0.92) demonstrated comparable
accuracies to CP (AUC 0.88, 95% CI 0.83-0.92) and peak VO2 (AUC 0.81, 95%
CI 0.75-0.87) in predicting transplant-free survival. Higher HGI was
independently associated with a lower risk of primary endpoint (adjusted
HR 0.25, 95% CI 0.15-0.42, p <0.001), all-cause mortality (adjusted HR
0.31,95% CI 0.17-0.56, p <0.001), and was associated with lower risk for
future myectomy or alcohol septal ablation (OR 0.78, 95% CI 0.67-0.91, p =
0.002). HGI may serve as an independent predictor for adverse outcomes in
patients with HCM with comparable prognostic value to peak VO2 and CP. In
addition, HGI may identify those who would likely need myectomy or alcohol
septal ablation, independent of pVO2 evaluation.

Chumpagern W; University Faculty of Medicine, Khon Kaen, Thailand.
Spagnolo P; Ratanawatkul P; Mohning MP; Fernandez Perez ER

BMJ open respiratory research. 13(1), 2026 Jul 09.

BACKGROUND: Ventilatory efficiency (VE) from cardiopulmonary exercise
testing (CPET) is a valuable prognostic metric for evaluating
cardiopulmonary diseases. However, its relationship with clinical outcomes
in hypersensitivity pneumonitis (HP) remains unclear. We aimed to
determine whether VE correlates with disease severity and predicts
mortality in HP.

RESEARCH QUESTION: In patients with HP, does VE correlate with disease
severity and predict mortality?

METHODS: This retrospective cohort study (2009-2019) included patients
with non-fibrotic (nfHP) and fibrotic HP (fHP) and idiopathic pulmonary
fibrosis (IPF), which served as the comparison group. CPET variables,
including VE/carbon dioxide (VE/VCO2), were assessed across various forced
vital capacity (FVC%) and diffusing capacity for carbon monoxide (DLCO%)
ranges. Multivariate logistic regression identified predictors of 5-year
mortality and survival was assessed with Kaplan-Meier plots.

RESULTS: 164 patients were analysed (mean age of 65.6+/-12.0 years, 54.3%
male). 25 had nfHP, 66 fHP and 73 IPF. Overall, an increase in the VE/VCO2
slope and nadir was observed as the DLCO% decreased, but not with a
decrease in FVC%, while the intercept remained unchanged. Patients with
pulmonary hypertension (35%, 57/164) and fHP or IPF had significantly
higher VE/VCO2 slope and nadir when compared with patients without
pulmonary hypertension or nfHP, respectively. A VE/VCO2 slope >=42
predicted survival (HR 3.65; 95% CI 1.04 to 12.80). Restricting the
analysis to patients with HP showed similar results (HR 5.49; 95% CI 1.19
to 33.54).

INTERPRETATION: In patients with HP, elevated VE/VCO2 is associated with
the presence of pulmonary fibrosis, PH, reduced DLCO and a higher
mortality risk. A VE/VCO2 slope threshold of 42 may serve as a practical
prognostic marker for stratification.

Schmid V; School of Medicine and Health, TUM University Hospital, Munich, Germany.
Paterson S; Weinkauf C; Wang J; et al

GeroScience. 48(3):4827-4845, 2026 Jun.

Reduced peak oxygen uptake (VO2peak) is a hallmark of heart failure (HF)
and aging, but studies on VO2peak in older HF patients are limited. We
compared VO2peak in older HF patients versus controls and investigated
differences across the age continuum: young-old (YO, 60-69 years),
middle-old (MO, 70-79 years), and oldest-old (OO, >= 80 years). PubMed was
searched (1967 May 2024) for studies meeting the following inclusion
criteria: (1) HF patients with mean age >= 65 years; (2) VO2peak measured
via maximal cardiopulmonary exercise testing, and (3) control group for
aim 1. For aim 2, studies had to compare VO2peak within the age-subgroups.
Random-effects meta-analysis was conducted, comparing VO2peak (primary
aim, and Fick determinants when reported) between HF and controls (aim 1),
and VO2peak between older age-subgroups (aim 2). Results are presented as
weighted mean differences (WMD) with 95% confidence intervals. From 2788
screened articles, 38 studies were included. For aim 1, 30 studies (HF: n
= 1093, mean age 70 years, 46% female; controls: n = 942, mean age 69
years, 52% female) demonstrated a significantly lower VO2peak in HF (WMD –
8.8 mL/kg/min, [95% CI] – 10.3 to – 7.3 mL/kg/min). In the subset of
patients where Fick determinants were measured, peak cardiac output and
heart rate were lower in HF versus controls. For aim 2, eight studies
showed progressively lower VO2peak with age: MO vs. YO (- 1.5 mL/kg/min)
and OO vs. MO (- 1.2 mL/kg/min). Older HF patients exhibit significant
VO2peak reductions compared to controls, with progressively lower VO2peak
values observed across the older age continuum.

Rodo-Pin A; Pulmonology Department, Hospital del Mar- Barcelona,Spain.
Martin-Ontiyuelo C; Rodriguez-Fuster A;et al

Respiration. 105(8):864-872, 2026.

INTRODUCTION: To determine whether peak workload (Wpeak), expressed as a
percentage of predicted value during a cardiopulmonary exercise test
(CPET), can predict postoperative cardiopulmonary complications in
high-risk patients undergoing lung cancer resection.

METHODS: A retrospective cohort study was conducted on 226 consecutive
patients who underwent anatomical lung resection (lobectomy or
segmentectomy) for non-small cell lung cancer between 2013 and 2017. All
patients were considered high risk, with preoperative FEV1 and DLco <80%
predicted and underwent full CPET within 30 days prior to surgery. The
main endpoint was the occurrence of cardiopulmonary complications within
30 days postoperatively. The predictive ability of Wpeak (% predicted) for
complications was evaluated using ROC analysis and optimal cutoff was
identified. Outcomes were compared above and below this threshold.

RESULTS: A Wpeak threshold of 52% predicted was identified as the optimal
cutoff, with an area under the ROC curve of 0.59 (95% CI: 0.51-0.67; p =
0.015). Patients with Wpeak <=52% had a significantly higher rate of
postoperative complications (58% vs. 33%, p = 0.001), particularly
respiratory complications (47% vs. 28%, p = 0.008), and longer hospital
stays (mean 24 vs. 15 days, p = 0.002). They also had lower FEV1, DLco,
VO2peak, and heart rate responses compared to patients with Wpeak >52%.

CONCLUSIONS: Wpeak <=52% of predicted was associated with increased risk
of postoperative complications and longer hospitalization. Although the
discriminatory ability was modest (AUC 0.59), Wpeak <=52% predicted was
associated with higher postoperative complications and may serve as a
complementary tool for risk stratification, especially in resource-limited
settings. Further prospective validation is warranted.

Beg MA; The Royal Marsden Hospital, NHS Foundation Trust, London, UK.
Frountzas M; Oliver A; Plete NK; Akhbari AR;et al

Surgery. 196:110283, 2026 Aug.

BACKGROUND: Locally advanced rectal cancers may require beyond total
mesorectal excision, including extensive procedures, such as total pelvic
exenteration. These operations carry significant morbidity.
Cardiopulmonary exercise testing is utilized to assess physiological
fitness before major surgery. However, limited evidence exists regarding
its predictive value in beyond total mesorectal excision. This study aimed
to determine whether preoperative cardiopulmonary exercise testing
parameters are associated with postoperative morbidity following beyond
total mesorectal excision, with subgroup analysis of patients undergoing
total pelvic exenteration.

METHODS: A retrospective cohort study was conducted at a tertiary center,
including consecutive patients who underwent cardiopulmonary exercise
testing prior to beyond total mesorectal excision between 2014 and 2021.
Associations between anaerobic threshold (AT VO2) and peak oxygen
consumption (VO2 peak) with major perioperative morbidity (Clavien-Dindo
>=3) were investigated. Receiver operating characteristic analysis
identified optimal cutoff values, which were used to dichotomize patients
into low- and high-risk groups. Groups were compared using chi2 and
Mann-Whitney U tests.

RESULTS: A total of 116 patients were included, of whom 62 underwent
total pelvic exenteration. In the overall beyond total mesorectal excision
cohort, cardiopulmonary exercise testing parameters could not demonstrate
any significant correlation with postoperative outcomes. However, in the
total pelvic exenteration subgroup, both AT VO2 (area under the curve
0.68; P = .035) and VO2 peak (area under the curve 0.73; P = .013) were
associated with significant morbidity. Receiver operating
characteristic-derived thresholds (AT VO2 <11.45 mL/kg/min; VO2 peak
<19.15 mL/kg/min) identified higher complication rates (30-31% vs 6-7%)
and longer hospital stay.

CONCLUSION: Cardiopulmonary exercise testing seems to present an
exploratory association with perioperative morbidity in patients
undergoing total pelvic exenteration but did not show any significant
association across the broader beyond total mesorectal excision cohort.
Incorporating cardiopulmonary exercise testing into preoperative
assessment may support risk stratification and targeted optimization
before complex rectal cancer surgery.

Hildebrand ND; Department of Surgery, Maastricht University,
Maastricht, the Netherlands;
Alhulaili ZM; Driessens H; Hoeijmakers LSM; Bongers BC; et al

European Journal of Surgical Oncology. 52(8):111913, 2026 Aug.

INTRODUCTION: Major complication rates after pancreatoduodenectomy (PD)
are high. Cardiorespiratory fitness and body composition are considered
important determinants of postoperative outcomes. This study evaluated the
association between a multimodal preoperative assessment of
cardiorespiratory fitness and body composition as core patient phenotypes
and the occurrence of major complications following PD.

METHODS: In this two-center retrospective cohort study (2022-2024),
patients undergoing PD were included. Preoperative cardiorespiratory
fitness was assessed using cardiopulmonary exercise testing (CPET) or the
modified steep ramp test (mSRT). Poor cardiorespiratory fitness was
defined as an oxygen uptake (VO2) at the ventilatory anaerobic threshold
(AT) < 11.0 mL/kg/min or VO2 at peak exercise (VO2peak) < 18.0 mL/kg/min
during CPET, or a work rate at peak exercise <2.1W/kg at the mSRT.
Preoperative body composition parameters were derived from abdominal
computed tomography scans. Low muscle mass based on skeletal muscle index
(SMI) and myosteatosis (defined as low skeletal muscle radiation
attenuation, SM-RA) were assessed. The primary outcome was 30-day major
complications (Clavien-Dindo >= III). Logistic regression analyses
identified predictors.

RESULTS: Among 175 eligible patients (mean +/- SD age 69.1 +/- 8.2 years,
44.6% female), 34.9% were unfit; 54.9% had low muscle mass and 35.4% had
myosteatosis. Major complications occurred in 37.7% and 8.0% required
unplanned intensive care unit (ICU) admission. Preoperative
cardiorespiratory fitness correlated moderately with SM-RA (rho =
0.36-0.47; all p < 0.001). Poor cardiorespiratory fitness was associated
with major complications in multivariable analysis (adjusted odds ratio
[aOR] 2.54, 95% CI 1.17-5.54, p=0.02). Combined myosteatosis and poor
cardiorespiratory fitness (n = 28, 16.0%) was associated with both major
complications (aOR 3.40, 95% CI 1.25-9.28, p = 0.02) and unplanned ICU
admission (aOR 4.62, 95% CI 1.06-20.16, p = 0.04).

CONCLUSION: Myosteatosis correlates with lower cardiorespiratory fitness.
The combination of preoperative myosteatosis and poor cardiorespiratory
fitness is associated with major complications and postoperative ICU
admission. In future preoperative assessment, these patient phenotypes may
help to refine personalized risk assessment and guide inclusions for
trials on targeted preventive interventions.