Mazur A; Brat K; Homolka P; Merta Z; Svoboda M; Bratova M; Sramek V; Republic.; Olson LJ; Cundrle I;

PloS one [PLoS One] 2022 Aug 12; Vol. 17 (8), pp. e0272984.
Date of Electronic Publication: 2022 Aug 12 (Print Publication: 2022).

Introduction: Ventilatory efficiency (VE/VCO2 slope) has been shown superior to peak oxygen consumption (VO2) for prediction of post-operative pulmonary complications in patients undergoing thoracotomy. VE/VCO2 slope is determined by ventilatory drive and ventilation/perfusion mismatch whereas VO2 is related to cardiac output and arteriovenous oxygen difference. We hypothesized pre-operative VO2 predicts post-operative cardiovascular complications in patients undergoing lung resection.
Methods: Lung resection candidates from a published study were evaluated by post-hoc analysis. All of the patients underwent preoperative cardiopulmonary exercise testing. Post-operative cardiovascular complications were assessed during the first 30 post-operative days or hospital stay. One-way analysis of variance or the Kruskal-Wallis test, and multivariate logistic regression were used for statistical analysis and data summarized as median (IQR).
Results: Of 353 subjects, 30 (9%) developed pulmonary complications only (excluded from further analysis), while 78 subjects (22%) developed cardiovascular complications and were divided into two groups for analysis: cardiovascular only (n = 49) and cardiovascular with pulmonary complications (n = 29). Compared to patients without complications (n = 245), peak VO2 was significantly lower in the cardiovascular with pulmonary complications group [19.9 ml/kg/min (16.5-25) vs. 16.3 ml/kg/min (15-20.3); P<0.01] but not in the cardiovascular only complications group [19.9 ml/kg/min (16.5-25) vs 19.0 ml/kg/min (16-23.1); P = 0.18]. In contrast, VE/VCO2 slope was significantly higher in both cardiovascular only [29 (25-33) vs. 31 (27-37); P = 0.05] and cardiovascular with pulmonary complication groups [29 (25-33) vs. 37 (34-42); P<0.01)]. Logistic regression analysis showed VE/VCO2 slope [OR = 1.06; 95%CI (1.01-1.11); P = 0.01; AUC = 0.74], but not peak VO2 to be independently associated with post-operative cardiovascular complications.
Conclusion: VE/VCO2 slope is superior to peak VO2 for prediction of post-operative cardiovascular complications in lung resection candidates.

Nir V; Bentur L; Zucker-Toledano M; Gur M; Adler Z; Hanna M; Toukan Y; Masarweh K; Hakim F; Bar-Yoseph R

Pediatric pulmonology [Pediatr Pulmonol] 2022 Aug 15.
Date of Electronic Publication: 2022 Aug 15.

Background: Vascular rings are congenital anomalies of the aortic arch that compress the trachea and esophagus and may require corrective surgery. Data about the long-term effects of vascular rings are scarce. We aimed to evaluate the long-term cardiorespiratory, exercise capacity and quality of life of vascular ring patients.
Methods: A single center prospective study evaluating spirometry, echocardiography, six-minute walk test (6MWT), cardiopulmonary exercise testing (CPET) and quality of life questionnaire (SF36) in patients with a diagnosis of vascular ring, with or without corrective surgery.
Results: Twenty-seven patients participated (11.9±6 years, 52% males). The most common diagnosis was double aortic arch (16 patients, 59%). Nineteen patients had corrective surgery (O) and eight did not (NO). Pulmonary function tests were within normal range in both groups (FEV ₁ % predicted O=87.6±16.5, NO=83±10.8%). However, 11/27 had abnormal FEV ₁ , five had abnormal FVC and 13 (48%) had flattening of the expiratory curve. 6MWD and oxygen uptake were similarly mildly reduced in both groups; (6MWD O=80.1±10.7% predicted, NO=74.1±10.9% and oxygen uptake O=78.5±23.2% predicted, NO=73.4±14.3%). Peak O ₂ pulse (V̇O ₂ /HR% predicted) was mildly reduced in the NO group (O=88.4±17.3%, NO=75.8±16.2%). Echocardiogram and SF36 scores were normal in all patients.
Conclusions: Long-term evaluation of patients born with vascular rings revealed mild pulmonary impairment, reduction in 6MWD and oxygen uptake. The NO group had also mild reduced peak O ₂ pulse. Larger, long-term studies assessing functional parameters in operated and non-operated patients are needed to assess disease/surgery limitation in patients with vascular rings.

Aparisi Á; Ladrón R;Ybarra-Falcón C; Tobar J; San Román JA;

Frontiers in medicine [Front Med (Lausanne)] 2022 Jul 22; Vol. 9, pp. 924819.
Date of Electronic Publication: 2022 Jul 22 (Print Publication: 2022).

Coronavirus disease (COVID-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), with systemic organ damage in the most severe forms. Long-term complications of SARS-CoV-2 appear to be restricted to severe presentations of COVID-19, but many patients with persistent symptoms have never been hospitalized. Post-acute sequelae of COVID-19 (PASC) represents a heterogeneous group of symptoms characterized by cardiovascular, general, respiratory, and neuropsychiatric sequelae. The pace of evidence acquisition with PASC has been rapid, but the mechanisms behind it are complex and not yet fully understood. In particular, exercise intolerance shares some features with other classic respiratory and cardiac disorders. However, cardiopulmonary exercise testing (CPET) provides a comprehensive assessment and can unmask the pathophysiological mechanism behind exercise intolerance in gray-zone PASC. This mini-review explores the utility of CPET and aims to provide a comprehensive assessment of PASC by summarizing the current evidence.

Kunutsor SK; Khan H; Seidu S; Laukkanen JA

Journal of cardiopulmonary rehabilitation and prevention [J Cardiopulm Rehabil Prev] 2022 Aug 04.
Date of Electronic Publication: 2022 Aug 04.

Purpose: There are inverse and independent associations between cardiorespiratory fitness (CRF) and several adverse cardiometabolic outcomes. The percentage of age-predicted CRF (%age-predicted CRF) is comparable to absolute CRF as a risk indicator for some of these outcomes, but the association between %age-predicted CRF and risk of type 2 diabetes (T2D) has not been previously investigated. We aimed to assess the association between %age-predicted CRF and T2D in a prospective cohort study.
Methods: Cardiorespiratory fitness, as measured directly by peak oxygen uptake, was assessed in 1901 men aged 42-60 yr who underwent cardiopulmonary exercise testing. The age-predicted CRF estimated from a regression equation for age was converted to %age-predicted CRF using (achieved CRF/age-predicted CRF) × 100. Hazard ratios (95% CI) were estimated for T2D.
Results: During a median follow-up of 26.8 yr, 227 T2D cases were recorded. The risk of T2D decreased continuously with increasing %age-predicted CRF (P value for nonlinearity = .30). A 1-SD increase in %age-predicted CRF was associated with a decreased risk of T2D in analysis adjusted for established risk factors (HR = 0.68: 95% CI, 0.59-0.79). The corresponding adjusted risk was (HR = 0.51: 95% CI, 0.35-0.75) comparing extreme tertiles of %age-predicted CRF. The respective estimates for the association between absolute CRF and T2D were-HR (95% CI)-0.71 (0.60-0.83) and 0.64 (0.44-0.95).
Conclusions: Percentage of age-predicted CRF is linearly, inversely, and independently associated with the risk of incident T2D and may be a stronger risk indicator for T2D compared to absolute CRF in a general population of middle-aged and older men.

de Almeida VR; di Paschoale Ostolin TLV; de Barros Gonze B; de Almeida FR; Romiti M; Arantes RL; Dourado VZ;

International journal of cardiology [Int J Cardiol] 2022 Aug 06.
Date of Electronic Publication: 2022 Aug 06.

Background: Individuals with cardiovascular exercise limitations present oxygen pulse morphology with early flattening (plateau) during the cardiopulmonary exercise test (CPET). Although this oxygen pulse response is well known in cardiac patients, these changes’ prevalence and clinical relevance in asymptomatic individuals are not known. We aimed to quantify the proportion of asymptomatic adults with an early flattening of the oxygen pulse and investigate its association with classical cardiovascular risk factors.
Methods: We carried out a cross-sectional study with a sample of 824 adults aged between 18 and 80 years. We assessed anthropometry, body composition, and cardiovascular risk. In addition, we obtained cardiorespiratory and metabolic responses during a ramp protocol treadmill CPET.
Results: The prevalence of early flattening of the oxygen pulse was 36.8%. These participants were predominantly females, older, less educated, with a higher body mass and percentage of fat and a lower percentage of lean body mass. After a multinominal multiple logistic regression analysis, we identified female sex (odds ratio, 5.46: 95% confidence interval, 3.73-7.99), low education (2.24: 1.47-3.42), dyslipidemia (1.67: 1.14-2.45), smoking (1.64: 1.00-2.69), and physical inactivity (1.39: 1.02-1.96) as the leading independent predictors of the early flattening of oxygen pulse.
Conclusion: The early flattening of oxygen pulse is common in asymptomatic adults and is highly determined by modifiable cardiovascular risk factors. These results suggest that identifying the early flattening of oxygen pulse may be helpful in the prevention of cardiovascular diseases.

Carlen A; Eklund G; Andersson A; Carlhall C: Ekstrom M; Hedman K

Journal of Cardiovascular Development and Disease: Volume 9. Issue 7. 2022

Work rate has a direct impact on the systolic blood pressure (SBP) during aerobic exercise, which may be challenging in the evaluation of the SBP response in athletes reaching high work rates. We aimed to investigate the exercise SBP response in endurance athletes in relation to oxygen uptake (VO₂), work rate and to recent reference equations for exercise SBP in the general population. Endurance athletes with a left-ventricular end-diastolic diameter above the reference one performed a maximal bicycle cardiopulmonary exercise test. The increase in SBP during exercise was divided by the increase in VO₂ (SBP/VO₂ slope) and in Watts, respectively (SBP/W slope). The maximum SBP (SBP_max) and the SBP/W slope were compared to the predicted values. In total, 27 athletes (59% men) were included; mean age, 40 ± 10 years; mean VO_2max, 50 ± 5 mL/kg/min. The mean SBP/VO₂ slope was 29.8 ± 10.2 mm Hg/L/min, and the mean SBP/W slope was 0.27 ± 0.08 mm Hg/W. Compared to the predicted normative values, athletes had, on average, a 12.2 ± 17.6 mm Hg higher SBP_max and a 0.12 ± 0.08 mm Hg/W less steep SBP/W slope (p < 0.01 and p < 0.001, respectively). In conclusion, the higher SBP_max values and the less steep SBP/W slope highlight the importance of considering work rate when interpreting the SBP response in endurance athletes and suggest a need for specific normative values in athletes to help clinicians distinguish physiologically high maximal blood pressure from a pathological blood pressure response.

Hedman K; Hylander J; Mikios B; Fyrenius A

Journal of Thoracic & Cardiovascular Surgery: July 1 2022

Objective
We aimed to evaluate whether or not using the slope of the increase in minute ventilation in relation to carbon dioxide (VE/VCo2-slope), with a cutoff value of 35, could improve risk stratification for major pulmonary complications or death following lobectomy in lung cancer patients at moderate risk (Vo2peak = 10-20 mL/kg/min).
Methods
Single center, retrospective analysis of 146 patients with lung cancer who underwent lobectomy and preoperative cardiopulmonary exercise testing in 2008-2020. The main outcome was any major pulmonary complication or death within 30 days of surgery. Patients were categorized based on their preoperative cardiopulmonary exercise testing as: low-risk group, peak oxygen uptake >20 mL/kg/min; low-moderate risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope <35; and moderate-high risk, peak oxygen uptake 10 to 20 mL/kg/min and VE/VCo2-slope ≥35. The frequency of complications between groups was compared using χ2 test. Logistic regression was used to calculate the odds ratio with 95% CI for the main outcome based on the cardiopulmonary exercise testing group.
Results
Overall, 25 patients (17%) experienced a major pulmonary complication or died (2 deaths). The frequency of complications differed between the cardiopulmonary exercise testing groups: 29%, 13%, and 8% in the moderate-high, low-moderate, and low-risk group, respectively (P = .023). Using the low-risk group as reference, the adjusted odds ratio for the low-moderate risk group was 3.44 (95% CI, 0.66-17.90), whereas the odds ratio for the moderate-high risk group was 8.87 (95% CI, 1.86-42.39).
Conclusions
Using the VE/VCo2-slope with a cutoff value of 35 improved risk stratification for major pulmonary complications following lobectomy in lung cancer patients with moderate risk based on a peak oxygen uptake of 10 to 20 mL/kg/min. This suggests that the VE/VCo2-slope can be used for preoperative risk evaluation in lung cancer lobectomy.

• Silvapulle E; Darvall J;

R. F. W. Franssen; A. J. J. Eversdijk; M. Kuikhoven; J. M. Klaase; F. J. Vogelaar; M. L. G. Janssen-Heijnen;

BMC Anesthesiol 2022 Vol. 22 Issue 1 Pages 131

BACKGROUND: Accurate determination of cardiopulmonary exercise test (CPET) derived parameters is essential to allow for uniform preoperative risk assessment. The objective of this prospective observational study was to evaluate the inter-observer agreement of preoperative CPET-derived variables by comparing a self-preferred approach with a systematic guideline-based approach.
METHODS: Twenty-six professionals from multiple centers across the Netherlands interpreted 12 preoperative CPETs of patients scheduled for hepatopancreatobiliary surgery. Outcome parameters of interest were oxygen uptake at the ventilatory anaerobic threshold (VO2VAT) and at peak exercise (VO2peak), the slope of the relationship between the minute ventilation and carbon dioxide production (VE/VCO2-slope), and the oxygen uptake efficiency slope (OUES). Inter-observer agreement of the self-preferred approach and the guideline-based approach was quantified by means of the intra-class correlation coefficient.
RESULTS: Across the complete cohort, inter-observer agreement intraclass correlation coefficient (ICC) was 0.76 (95% confidence interval (CI) 0.57-0.93) for VO2VAT, 0.98 (95% CI 0.95-0.99) for VO2peak, and 0.86 (95% CI 0.75-0.95) for the VE/VCO2-slope when using the self-preferred approach. By using a systematic guideline-based approach, ICCs were 0.88 (95% CI 0.74-0.97) for VO2VAT, 0.99 (95% CI 0.99-1.00) for VO2peak, 0.97 (95% CI 0.94-0.99) for the VE/VCO2-slope, and 0.98 (95% CI 0.96-0.99) for the OUES.
CONCLUSIONS: Inter-observer agreement of numerical values of CPET-derived parameters can be improved by using a systematic guideline-based approach. Effort-independent variables such as the VE/VCO2-slope and the OUES might be useful to further improve uniformity in preoperative risk assessment in addition to, or in case VO2VAT and VO2peak are not determinable.

Chao WH; Tuan SH; Tang EK; Tsai YJ; Chung JH; Chen GB; Lin KL;

Frontiers in medicine [Front Med (Lausanne)] 2022 Jun 15; Vol. 9, pp. 900165.
Date of Electronic Publication: 2022 Jun 15 (Print Publication: 2022).

Objectives: Patients with lung cancer pose a high risk of morbidity and mortality after lung resection. Those who receive perioperative cardiopulmonary rehabilitation (PRCR) have better prognosis. Peak oxygen consumption (peak VO ₂ ), VO ₂ at the ventilatory threshold (VO ₂ at VT), and slope of minute ventilation to carbon dioxide production (V _E /V _CO2 slope) measured during pre-surgical cardiopulmonary exercise testing (CPET) have prognostic values after lung resection. We aimed to investigate the influence of individualized PRCR on postoperative complications in patients undergoing video-assisted thoracic surgery (VATS) for lung cancer with different pre-surgical risks.
Methods: This was a retrospective study. We recruited 125 patients who underwent VATS for lung cancer between 2017 and 2021. CPET was administered before surgery to evaluate the risk level and PRCR was performed based on the individual risk level defined by peak VO2, VO2 at VT, and VE/VCO2 slope, respectively. The primary outcomes were intensive care unit (ICU) and hospital lengths of stay, endotracheal intubation time (ETT), and chest tube insertion time (CTT). The secondary outcomes were postoperative complications (PPCs), including subcutaneous emphysema, pneumothorax, pleural effusion, atelectasis, infection, and empyema.
Results: Three intergroup comparisons based on the risk level by peak VO2 (3 groups), VO2 at VT (2 groups), and VE/VCO2 slope (3 groups) were done. All of the comparisons showed no significant differences in both the primary and secondary outcomes ( p = 0.061-0.910).
Conclusion: Patients with different risk levels showed comparable prognosis and PPCs after undergoing CPET-guided PRCR. PRCR should be encouraged in patients undergoing VATS for lung cancer.