J. G. Kovoor, S. D. Nann, C. Chambers, K. Mishra, S. Goel, I. Thompson, Koh D; Litwin P; Bacchi S; Harford PJ; Stretton B; Gupta AK,

J Perioper Pract 2023 Pages 17504589231214395

Prehabilitation, or interventions before surgery aimed at improving preoperative health and postoperative outcomes, has various forms. Although it may confer benefit to patients undergoing general surgery, this is not certain. Furthermore, although it may yield a net monetary gain, it is also likely to require substantial monetary and non-monetary investment. The impact of prehabilitation is highly variable and dependent on multiple factors. Physical function and pulmonary outcomes are likely to be improved by most forms of prehabilitation involving physical and multimodal exercise programmes. However, other surgical outcomes have demonstrated mixed results from prehabilitation. Within this issue, the measures used for evaluating baseline patient biopsychosocial health are important, and collecting sufficient data to accurately inform patient-centred prehabilitation programmes is only possible through thorough clinical and laboratory investigation and synthesised metrics such as cardiopulmonary exercise testing. Although a multimodal approach to prehabilitation is the current gold standard, societal factors may affect engagement with programmes that require a significant in-person activity. However, this is weighed against the substantial financial and non-financial investment that accompanies many programmes. The overall effectiveness and optimal mode of intervention across the discipline of general surgery remains unclear, and further research is needed to prove prehabilitation’s full worth.

Brotto AR; Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.;
Phillips DB; Rowland SD; Moore LE; Wong E;Stickland MK;

BMJ open respiratory research [BMJ Open Respir Res] 2023 Dec 22; Vol. 10 (1).
Date of Electronic Publication: 2023 Dec 22.

Introduction: Individuals with asthma breathe at higher operating lung volumes during exercise compared with healthy individuals, which contributes to increased exertional dyspnoea. In health, females are more likely to develop exertional dyspnoea than males at a given workload or ventilation, and therefore, it is possible that females with asthma may develop disproportional dyspnoea on exertion. The purpose of this study was to compare operating lung volume and dyspnoea responses during exercise in females with and without asthma.
Methods: Sixteen female controls and 16 females with asthma were recruited for the study along with 16 male controls and 16 males with asthma as a comparison group. Asthma was confirmed using American Thoracic Society criteria. Participants completed a cycle ergometry cardiopulmonary exercise test to volitional exhaustion. Inspiratory capacity manoeuvres were performed to estimate inspiratory reserve volume (IRV) and dyspnoea was evaluated using the Modified Borg Scale.
Results: Females with asthma exhibited elevated dyspnoea during submaximal exercise compared with female controls (p<0.05). Females with asthma obtained a similar IRV and dyspnoea at peak exercise compared with healthy females despite lower ventilatory demand, suggesting mechanical constraint to tidal volume (V _T ) expansion. V _T -inflection point was observed at significantly lower ventilation and V̇ O ₂ in females with asthma compared with female controls. Forced expired volume in 1 s was significantly associated with V _T -inflection point in females with asthma (R ² =0.401; p<0.01) but not female controls (R ² =0.002; p=0.88).
Conclusion: These results suggest that females with asthma are more prone to experience exertional dyspnoea, secondary to dynamic mechanical constraints during submaximal exercise when compared with females without asthma.

Holt MF;  Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
Flø A;Ravnestad H; Bjørnø V; Gullestad L; Andreassen AK; DBroch K; Gude E

ESC heart failure [ESC Heart Fail] 2023 Dec 29.
Date of Electronic Publication: 2023 Dec 29.

Aims: Our aim was to investigate haemodynamics at rest and during exercise in patients with transthyretin cardiomyopathy (ATTR-CM) in light of the 2022 European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines on pulmonary hypertension (PH).
Methods and Results: We performed right heart catheterization (RHC) in 57 subjects with ATTR-CM. The proportion of patients with PH was 77% according to the 2022 guidelines versus 47% when applying the 2015 guidelines. Isolated post-capillary PH and combined pre- and post-capillary PH were most prevalent. Thirty-six patients underwent a supine bicycle cardiopulmonary exercise test during RHC. Exercise-induced PH was defined as an increase in mean pulmonary arterial pressure from rest to exercise per increase in cardiac output (ΔmPAP/ΔCO) of > 3 mmHg/L/min. An increase in pulmonary arterial wedge pressure per change in cardiac output (ΔPAWP/ΔCO) from rest to exercise >2 mmHg/L/min was considered suggestive of post-capillary exercise-induced PH. All but two patients who exercised during RHC developed exercise-induced PH. The median ΔmPAP/ΔCO was 7.2 mmHg/L/min and ΔPAWP/ΔCO was 5.1 mmHg/L/min. The median ΔRAP/ΔCO was 3.6 mmHg/L/min and ΔRAP/ΔPAWP was 0.6 mmHg/L/min.
Conclusions: Most patients with ATTR-CM have isolated post-capillary or combined pre- and post-capillary PH at rest, and almost all patients develop exercise-induced PH with a large post-capillary component. There was a pronounced, but balanced increase in atrial pressures on exercise.

Kristenson K; Linköping University, Linköping, Sweden.
Gerring E; Björnsson B; Sandström P; Hedman K;

Physiological reports [Physiol Rep] 2024 Jan; Vol. 12 (1), pp. e15904.

This pilot study aimed to evaluate if peak VO ₂ and ventilatory efficiency in combination would improve preoperative risk stratification beyond only relying on peak VO ₂ . This was a single-center retrospective cohort study including all patients who underwent cardiopulmonary exercise testing (CPET) as part of preoperative risk evaluation before major upper abdominal surgery during years 2008-2021. The primary outcome was any major cardiopulmonary complication during hospitalization. Forty-nine patients had a preoperative CPET before decision to pursue to surgery (cancer in esophagus [n = 18], stomach [6], pancreas [16], or liver [9]). Twenty-five were selected for operation. Patients who suffered any major cardiopulmonary complication had lower ventilatory efficiency (i.e., higher VE/VCO ₂ slope, 37.3 vs. 29.7, p = 0.031) compared to those without complications. In patients with a low aerobic capacity (i.e., peak VO ₂  < 20 mL/kg/min) and a VE/VCO ₂ slope ≥ 39, 80% developed a major cardiopulmonary complication. In this pilot study of patients with preoperative CPET before major upper abdominal surgery, patients who experienced a major cardiopulmonary complication had significantly lower ventilatory efficiency compared to those who did not. A low aerobic capacity in combination with low ventilatory efficiency was associated with a very high risk (80%) of having a major cardiopulmonary complication.

Slavich M; Cardiology, San Raffaele Scientific Institute, Milan Italy
Ricchetti G; Demarchi B; Cavalli G;Spoladore R;DFederico A; Federico F; Bezzi C; NMargonato A; Fragasso G

Journal of cardiovascular medicine (Hagerstown, Md.) [J Cardiovasc Med (Hagerstown)] 2024 Feb 01; Vol. 25 (2), pp. 141-148.
Date of Electronic Publication: 2023 Dec 22.

Background: Nearly two-thirds of patients with heart failure with reduced ejection fraction (HFrEF) have right ventricular dysfunction, previously identified as an independent predictor of reduced functional capacity and poor prognosis. Beta-blocker therapy (β-BT) reduces mortality and hospitalizations in patients with HFrEF and is approved as first-line therapy regardless of concomitant right ventricular function. However, the exact role of sympathetic nervous system activation in right ventricular dysfunction and the potential usefulness (or harmfulness) of β-BT in these patients are still unclear.
Objectives: The aim of the study is to evaluate the medium-term effect of β-BT discontinuation on functional capacity and right ventricular remodelling based on cardiopulmonary exercise testing (CPET), echocardiography and serum biomarkers in patients with clinically stable biventricular dysfunction.
Methods: In this single-centre, open-label, prospective trial, 16 patients were enrolled using the following criteria: patients were clinically stable without signs of peripheral congestion; NYHA II-III while on optimal medical therapy (including β-BT); LVEF 40% or less; echocardiographic criteria of right ventricular dysfunction. Patients were randomized 1 : 1 either to withdraw (group 0) or continue (group 1) β-BT. In group 0, optimal heart rate was obtained with alternative rate-control drugs. Echo and serum biomarkers were performed at baseline, after 3 and 6 months; CPET was performed at baseline and 6 months. Mann–Whitney U test was adopted to determine the relationships between β-BT discontinuation and effects on right ventricular dysfunction.
Results: At 6 months’ follow up, S’ DTI improved (ΔS’: 1.01 vs. -0.92 cm/s; P = 0.03), while estimated PAPs (ΔPAPs: 0.8 vs. -7.5 mmHg; P = 0.04) and echo left ventricular-remodelling (ΔEDVi: 19.55 vs. -0.96 ml/mq; P = 0.03) worsened in group 0. In absolute terms, the only variables significantly affected by β-BT withdrawal were left ventricular EDV and ESV, appearing worse in group 0 (mean EDVi 115 vs. 84 ml/mq; mean ESVi 79 vs. 53.9 ml/mq, P = 0.03). No significant changes in terms of functional capacity were observed after β-BT withdrawal.
Conclusion: In HFrEF patients with concomitant right ventricular dysfunction, β-BT discontinuation did not produce any beneficial effects. In addition, despite maintenance of optimal heart rate control, β-BT discontinuation induced worsening of left ventricular remodelling. Our study corroborates the hypothesis that improvement in left ventricular function may likewise be a major determinant for improvement in right ventricular function, reducing pulmonary wedge pressure and right ventricular afterload, with only a marginal action of its negative inotropic effect. In conclusion, β-BT appears beneficial also in heart failure patients with biventricular dysfunction.

Kristenson K; Linkoping University, Linkoping, Sweden
Gerring E; Bjornsson B; Sandstrom P; Hedman K

Physiological Reports. 12(1):e15904, 2024 Jan.

This pilot study aimed to evaluate if peak VO2 and ventilatory efficiency
in combination would improve preoperative risk stratification beyond only
relying on peak VO2 . This was a single-center retrospective cohort study
including all patients who underwent cardiopulmonary exercise testing
(CPET) as part of preoperative risk evaluation before major upper
abdominal surgery during years 2008-2021. The primary outcome was any
major cardiopulmonary complication during hospitalization. Forty-nine
patients had a preoperative CPET before decision to pursue to surgery
(cancer in esophagus [n = 18], stomach [6], pancreas [16], or liver [9]).
Twenty-five were selected for operation. Patients who suffered any major
cardiopulmonary complication had lower ventilatory efficiency (i.e.,
higher VE/VCO2 slope, 37.3 vs. 29.7, p = 0.031) compared to those without
complications. In patients with a low aerobic capacity (i.e., peak VO2 <
20 mL/kg/min) and a VE/VCO2 slope >= 39, 80% developed a major
cardiopulmonary complication. In this pilot study of patients with
preoperative CPET before major upper abdominal surgery, patients who
experienced a major cardiopulmonary complication had significantly lower
ventilatory efficiency compared to those who did not. A low aerobic
capacity in combination with low ventilatory efficiency was associated
with a very high risk (80%) of having a major cardiopulmonary
complication.

Moroni F; Many centres in USA and Italy
Golino M; Carbone S; Trankle C; Del Buono MG; Talasaz A; Arena
R; Canada JM; Biondi-Zoccai G; Van Tassel B; Abbate A

ESC heart failure. 10(5):3199-3202, 2023 Oct.

AIMS: Interleukin-1 (IL-1) blockade may improve exercise capacity in
patients with heart failure (HF) patients. The extent of the improvement
and its persistence beyond discontinuation of IL-1 blockade is unknown.
METHODS AND RESULTS: The primary objective was to determine changes in
cardiorespiratory fitness and cardiac function on-treatment with IL-1
blocker, anakinra, and off-treatment, after treatment cessation. We
performed cardiopulmonary exercise testing, Doppler echocardiography, and
biomarkers in 73 patients with HF, 37 (51%) females, 52 (71%)
Black-African-American, before and after treatment with anakinra 100 mg
daily. In a subset of 46 patients, testing was also repeated after
treatment cessation. Quality of life was assessed in each patient using
standardized questionnaires. Data are presented as median and
interquartile range. Treatment with anakinra for 4 [2-12] weeks was
associated with a significant improvement in high-sensitivity C-reactive
protein (from 6.2 [3.3-15.4] to 1.4 [0.8-3.4] mg/L, P < 0.001), peak
oxygen consumption (VO2peak , from 13.9 [11.6-16.6] to 15.2 [12.9-17.4]
mL/kg/min, P < 0.001). Ventilatory efficiency, exercise time,
Doppler-derived signs and biomarkers of elevated intracardiac pressures,
and quality-of-life measures also improved with anakinra. In the 46
patients in whom off-treatment data were available 12 [4-12] weeks later,
many of the favourable changes seen with anakinra were largely reversed
(from 1.5 [1.0-3.4] to 5.9 [1.8-13.1], P = 0.001 for C-reactive protein,
and from 16.2 [14.0-18.4] to 14.9 [11.5-17.8] mL/kg/min, P = 0.017, for
VO2peak ).
CONCLUSIONS: These data validate IL-1 as an active and dynamic modulator
of cardiac function and cardiorespiratory fitness in HF.

K. Kristenson, Linköping University, Sweden
E. Gerring, B. Bjornsson, P. Sandstrom and K. Hedman

Physiol Rep 2024 Vol. 12 Issue 1 Pages e15904

This pilot study aimed to evaluate if peak VO(2) and ventilatory efficiency in combination would improve preoperative risk stratification beyond only relying on peak VO(2) . This was a single-center retrospective cohort study including all patients who underwent cardiopulmonary exercise testing (CPET) as part of preoperative risk evaluation before major upper abdominal surgery during years 2008-2021. The primary outcome was any major cardiopulmonary complication during hospitalization. Forty-nine patients had a preoperative CPET before decision to pursue to surgery (cancer in esophagus [n = 18], stomach [6], pancreas [16], or liver [9]). Twenty-five were selected for operation. Patients who suffered any major cardiopulmonary complication had lower ventilatory efficiency (i.e., higher VE/VCO(2) slope, 37.3 vs. 29.7, p = 0.031) compared to those without complications. In patients with a low aerobic capacity (i.e., peak VO(2) < 20 mL/kg/min) and a VE/VCO(2) slope >/= 39, 80% developed a major cardiopulmonary complication. In this pilot study of patients with preoperative CPET before major upper abdominal surgery, patients who experienced a major cardiopulmonary complication had significantly lower ventilatory efficiency compared to those who did not. A low aerobic capacity in combination with low ventilatory efficiency was associated with a very high risk (80%) of having a major cardiopulmonary complication.

de Souza JAF; Physiotherapy Dept, Federal University of Pernambuco (UFPE) and Federal University of Sao Carlos (UFSCAR)Brazil.
Catai AM; Araújo BTS; Barros AEVR; de Aguiar MIR; Campos SL; de Andrade AD; Brandão DC;

Heart & lung : the journal of critical care [Heart Lung] 2023 Dec 12.
Date of Electronic Publication: 2023 Dec 12.

Background: Endothelial dysfunction and peak oxygen uptake (VO _2peak ) are also predictors of increased risk of cardiovascular events in heart transplantation (HTx) recipients. The preservation of endothelial function may contribute to exercise tolerance.
Objective: To investigate the correlation between peripheral endothelial function and exercise tolerance through VO _2peak and ventilation to carbon dioxide production slope (VE / VCO _{2 slope} ) in HTx recipients.
Methods: A pilot cross-sectional study was conducted with adult individuals aged 18-65 years, HTx ≥ six months after surgery, who had a stable medical condition and no changes over the last three months of immunosuppressive treatment. The patients underwent an assessment of endothelial function through PAT (EndoPAT-2000®) and performed a cardiopulmonary exercise test (CPET).
Results: A total of 41% of the studied population presented endothelial dysfunction. The individuals were divided into two groups: the endothelial dysfunction (GED; n=9) group and the normal endothelial function (GNEF; n=13) group according to the logarithm of the reactive hyperemia index (LnRHI). There was a positive and moderate correlation between the LnRHI and VO _{2 peak} (r=0.659, p=0.013) and a negative and moderate correlation between the LnRHI and VE/VCO _{2 slope} (r= -0.686, p= 0.009) in the GNEF. However, no significant correlations were found in the GED.
Conclusion: The results showed that the preservation of peripheral endothelial function is significantly correlated with an increase in exercise tolerance in individuals after HTx. These findings bring important considerations for cardiovascular risk prevention and emphasize that therapeutic strategies with physical training programs must be implemented early.

Franssen RFW;  Maastricht University, and other centres in the Netherlands.
Berkel AEM; Ten Cate DWG; van der Palen J; Vogelaar FJ; Slooter G; Klaase JM; Janssen-Heijnen Bongers BC

Publisher: Springer-Verlag Country of Publication: Germany NLM ID: 9808285 Publication Model: Electronic Cited Medium:
Internet ISSN: 1435-2451 (Electronic) Linking ISSN: 14352443 NLM ISO Abbreviation: Langenbecks Arch Surg Subsets: MEDLINE

Purpose: This study aimed to investigate the association of effort-independent variables derived from the preoperative cardiopulmonary exercise test (CPET) with 30-day postoperative complications after elective colorectal surgery.
Methods: A multicenter (n=4) retrospective explorative study was performed using data of patients who completed a preoperative CPET and underwent elective colorectal surgery. The preoperative slope of the relation between minute ventilation and carbon dioxide production (VE/VCO ₂ -slope) and the oxygen uptake efficiency slope (OUES), as well as 30-day postoperative complications, were assessed. Multivariable logistic regression analyses and receiver operating characteristic (ROC) curves were used to investigate the prognostic value of the relationship between these preoperative CPET-derived effort-independent variables and postoperative complications.
Results: Data from 102 patients (60.1% males) with a median age of 72.0 (interquartile range 67.8-77.4) years were analyzed. Forty-four patients (43.1%) had one or more postoperative complications (of which 52.3% general and 77.3% surgical complications). Merely 10 (9.8%) patients had a general complication only. In multivariate analysis adjusted for surgical approach (open versus minimally invasive surgery), the VE/VCO ₂ -slope (odds ratio (OR) 1.08, confidence interval (CI) 1.02-1.16) and OUES (OR 0.94, CI 0.89-1.00) were statistically significant associated with the occurrence of 30-day postoperative complications.
Conclusion: The effort-independent VE/VCO ₂ -slope and OUES might be used to assist in future preoperative risk assessment and could especially be of added value in patients who are unable or unwilling to deliver a maximal cardiorespiratory effort. Future research should reveal the predictive value of these variables individually and/or in combination with other prognostic (CPET-derived) variables for postoperative complications.
Trial Registration Number: ClinicalTrials.gov NCT05331196.