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Pubblicazioni recenti - cardiopulmonary exercise
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The effect of cardiac rehabilitation at 4 weeks postoperatively on quality of life in patients treated with totally thoracoscopic ablation.
J Exerc Rehabil2019 Aug;15(4):610-615. doi: 10.12965/jer.1938340.170.
Seo Yong-Gon, Sung Jidong, Shin Mal-Soon, Park Yun-Jin, Min Kyoung-Bin, Kang Gyu-Min, Lee Jong-Min, Kim Myung-Ki,
Abstract
There is a lack of evidence on the effect of exercise-based cardiac rehabilitation (EBCR) in patients treated with total thoracoscopic ablation (TTA) for atrial fibrillation (AF). Our study investigated the efficacy and safety of postoperative exercise intervention in patients recovering from TTA. Twenty-four patients participated in the study, and were divided into the two groups, exercise group (EG) (n=12) and control group (n= 12). Patients in EG performed the exercise intervention including the aerobic and resistance exercise program twice a week for 8 weeks, which was used as a hospital-based cardiac rehabilitation for the out-patient. A cardiopulmonary exercise test was administered to evaluate aerobic exercise capacity, and qualitative aspect of patient's life was assessed using the Short Form 36 questionnaires to compare pre and postoperative wellness of patient's life. Although there was an increase of VO (peak oxygen uptake) after exercise intervention, no significant improvement was found (=0.055). Two of 4 physical health scores (role-physical, =0.013 and general health, =0.05) and three of four mental health scores (vitality, =0.027, social function, =0.016, and mental health, =0.003) were significantly improved after 8 weeks of EBCR. Each summarized scale in the physical (=0.022) and mental (= 0.004) survey section was also significantly improved in postoperative assessment compared to the preoperative one. In this context, we concluded that EBCR initiated at the time point of 4th week after TTA operation can guarantee the secure postoperative physical activity, and the 8 weeks of EBCR can effectively improve the quality of life in AF Patients.
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Effects of lung deflation induced by tiotropium/olodaterol on the cardiocirculatory responses to exertion in COPD.
Respir Med2019 Sep;157():59-68. doi: S0954-6111(19)30286-0.
Berton Danilo C, Marques Renata D, Palmer Brandon, O'Donnell Denis E, Neder J Alberto,
Abstract
BACKGROUND:
Hyperinflation has been associated with negative cardiocirculatory consequences in patients with chronic obstructive pulmonary disease (COPD). These abnormalities are likely to worsen when the demands for O increase, e.g., under the stress of exercise. Thus, pharmacologically-induced lung deflation may improve cardiopulmonary interactions and exertional cardiac output leading to higher limb muscle blood flow and oxygenation in hyperinflated patients with COPD.
METHODS:
20 patients (residual volume?=?201.6?±?63.6% predicted) performed endurance cardiopulmonary exercise tests (75% peak) 1?h after placebo or tiotropium/olodaterol 5/5??g via the Respimat® inhaler (Boehringer Ingelheim, Ingelheim am Rhein, Germany). Cardiac output was assessed by signal-morphology impedance cardiography. Near-infrared spectroscopy determined quadriceps blood flow (indocyanine green dye) and intra-muscular oxygenation.
RESULTS:
Tiotropium/olodaterol was associated with marked lung deflation (p?
CONCLUSIONS:
The beneficial effects of tiotropium/olodaterol on resting and operating lung volumes are not translated into enhanced cardiocirculatory responses to exertion in hyperinflated patients with COPD. Improvement in exercise tolerance after dual bronchodilation is unlikely to be mechanistically linked to higher muscle blood flow and/or O delivery.
Copyright © 2019. Published by Elsevier Ltd.
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Myocardial work is a predictor of exercise tolerance in patients with dilated cardiomyopathy and left ventricular dyssynchrony.
Int J Cardiovasc Imaging2019 Sep;():. doi: 10.1007/s10554-019-01689-4.
Schrub Florian, Schnell Frédéric, Donal Erwan, Galli Elena,
Abstract
The assessment of myocardial work (MW) by pressure-strain loops is a recently introduced tool for the assessment of myocardial performance. Aim of the present study is to evaluate the relationship between myocardial work and exercise tolerance in patients with dilated cardiomyopathy (DCM). 51 patients with DCM (mean age 57?±?13 years, left ventricular ejection fraction: 32?±?9%) underwent cardiopulmonary exercise test (CPET) to assess exercise performance. 22 patients (43%) had left or right bundle branch block with QRS duration?>?120 ms. Trans-thoracic echocardiography (TTE) was performed before CPET. The following indices of myocardial work (MW) were measured regionally and globally: constructive work (CW), wasted work (WW), and work efficiency (WE). Left ventricular dyssynchrony (LV-DYS) was defined by the presence of septal flash or apical rocking at TTE. LV-DYS was observed in 16 (31%) patients and associated with lower LV ejection fraction (LVEF), lower global and septal WE, and higher global and septal WW. In patients with LV-DYS, septal WE was the only predictor of exercise capacity at multivariable analysis (??=?0.68, p?=?0.03), whereas LVEF (??=?0.47, p?=?0.05) and age (? =?-?0.42, p?=?0.04) were predictors of exercise capacity in patients without LV-DYS. In patients with DCM, LV-DYS is associated with an heterogeneous distribution of myocardial work. Septal WE is the best predictor of exercise performance in these patients.
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Impaired right ventricular lusitropy is associated with ventilatory inefficiency in PAH.
Eur Respir J2019 Sep;():. doi: 1900342.
Tello Khodr, Dalmer Antonia, Vanderpool Rebecca, Ghofrani Hossein A, Naeije Robert, Roller Fritz, Seeger Werner, Dumitrescu Daniel, Sommer Natascha, Brunst Anne, Gall Henning, Richter Manuel J,
Abstract
Cardiopulmonary exercise testing (CPET) is an important tool to assess functional capacity and prognosis in pulmonary arterial hypertension (PAH). However, the association of CPET parameters with the adaptation of right ventricular (RV) function to afterload remains incompletely understood.Thirty-seven patients with PAH (idiopathic in 31 cases) underwent single-beat pressure-volume loop measurements of RV end-systolic elastance (Ees), arterial elastance (Ea) and diastolic elastance (Eed). They also underwent magnetic resonance imaging of pulmonary arterial stiffness. The results were correlated to CPET variables. Predictive relevance of RV function parameters for clinically relevant ventilatory inefficiency, defined as minute ventilation/carbon dioxide production (V/VCO) slope >48, was evaluated using logistic regression analysis.Median [interquartile range] of V/VCO slope was 42 [32-52], of V/VCO nadir was 40 [31-44], and mean±sd of peak end-tidal CO tension (PCO) was 23±8?mmHg. Ea, Eed and parameters reflecting pulmonary arterial stiffness (capacitance and distensibility) were correlated to V/VCO slope, V/VCO nadir, PCO and peak oxygen pulse. RV Ees and RV-arterial coupling as assessed by the Ees/Ea ratio showed no correlations with CPET parameters. Ea (univariate odds ratio: 7.28; 95% confidence interval: 1.20-44.04) and Eed (univariate odds ratio: 2.21; 95% confidence interval: 0.93-5.26) were significantly associated with ventilatory inefficiency (p<0.10).Our data suggest that impaired RV lusitropy and increased afterload are associated with ventilatory inefficiency in PAH.
Copyright ©ERS 2019.
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The neurohormonal basis of pulmonary hypertension in heart failure with preserved ejection fraction.
Eur Heart J2019 Sep;():. doi: ehz626.
Obokata Masaru, Kane Garvan C, Reddy Yogesh N V, Melenovsky Vojtech, Olson Thomas P, Jarolim Petr, Borlaug Barry A,
Abstract
AIMS:
Pulmonary hypertension (PH) represents an important phenotype among the broader spectrum of patients with heart failure with preserved ejection fraction (HFpEF), but its mechanistic basis remains unclear. We hypothesized that activation of endothelin and adrenomedullin, two counterregulatory pathways important in the pathophysiology of PH, would be greater in HFpEF patients with worsening PH, and would correlate with the severity of haemodynamic derangements and limitations in aerobic capacity and cardiopulmonary reserve.
METHODS AND RESULTS:
Plasma levels of C-terminal pro-endothelin-1 (CT-proET-1) and mid-regional pro-adrenomedullin (MR-proADM), central haemodynamics, echocardiography, and oxygen consumption (VO2) were measured at rest and during exercise in subjects with invasively-verified HFpEF (n?=?38) and controls free of HF (n?=?20) as part of a prospective study. Plasma levels of CT-proET-1 and MR-proADM were highly correlated with one another (r?=?0.89, P?
CONCLUSION:
Subjects with HFpEF display activation of the endothelin and adrenomedullin neurohormonal pathways, the magnitude of which is associated with pulmonary haemodynamic derangements, limitations in RV functional reserve, reduced cardiac output, and more profoundly impaired exercise capacity in HFpEF. Further study is required to evaluate for causal relationships and determine if therapies targeting these counterregulatory pathways can improve outcomes in patients with the HFpEF-PH phenotype.
CLINICAL TRIAL REGISTRATION:
NCT01418248; https://clinicaltrials.gov/ct2/results? term=NCT01418248&Search=Search.
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author(s) 2019. For permissions, please email: journals.permissions@oup.com.
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Arterial switch operation for transposition of the great arteries: A single-centre 32-year experience.
J Card Surg2019 Sep;():. doi: 10.1111/jocs.14045.
Vida Vladimiro L, Zanotto Lorenza, Zanotto Lucia, Triglia Laura T, Bellanti Ermanno, Castaldi Biagio, Padalino Massimo A, Gasperetti Andrea, Battista Francesca, Varnier Maurizio, Stellin Giovanni,
Abstract
OBJECTIVE:
Arterial switch operation (ASO) is nowadays the standard of care for neonates with D-transposition of the great arteries (D-TGA). We evaluated our early and late results with ASO for D-TGA.
MATERIALS AND METHODS:
We collected data on 267 patients with D-TGA, either with intact ventricular septum (D-TGA/IVS; n?=?182, 68%) and with other associated congenital heart malformations (complex D-TGA; n?=?85, 32%) that underwent ASO between January 1987 and July 2018.
RESULTS:
Median age at ASO was 8 days (interquartile range [IQR], 6-12 days). Fifteen patients (5.6%) died in hospital (6/182 with D-TGA/IVS, 3.3% and 9/85 with complex D-TGA, 11%; P?=?0.02). Median follow-up time was 10.2 years (IQR, 3.7-18 years). There were 2 (0.8%) late sudden deaths. Overall survival at 10 and 20 years was 94% and 93%, respectively. Thirty-five patients (14%) required either reoperations or reinterventions, mainly for right ventricular outflow tract obstruction (n?=?28, 11%). Freedom from reoperation/reintervention at 10 and 20 years was 87% and 78%, respectively. All patients were in NYHA I at latest clinical examination. Six over 173 patients (3.4%) who underwent a postoperative evaluation of their coronaries presented acquired anomalies. Forty-four patients (17%) who performed a cardiopulmonary exercise testing (CPET) have a predicted VO comparable to normal peers.
CONCLUSIONS:
The results of ASO for D-TGA are excellent, with a fairly low mortality and reoperation/reintervention rate. Functional capacity evaluated with CPET is comparable to normal peers. Continuous follow-up for detecting asymptomatic acquired coronary artery disease is mandatory. A reassessment of competitive sport eligibility criteria for specific D-TGA patients should be considered.
© 2019 Wiley Periodicals, Inc.
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Can we predict potentially dangerous coronary patterns in patients with transposition of the great arteries after an arterial switch operation?
Cardiol Young2019 Sep;():1-6. doi: 10.1017/S104795111900204X.
Michalak Krzysztof W, Sobczak-Budlewska Katarzyna, Moll Jacek J, Szymczyk Konrad, Moll Jadwiga A, Niwald Marek, Dry?ek Pawe?, Moll Maciej,
Abstract
INTRODUCTION:
Coronary artery complications are the main reason for early mortality after an arterial switch operation. Late complications are relatively rare, and there is no consensus regarding the need or indications for routine follow-up coronary artery evaluations or the best first-line assessment modality. The aim of this study was to present the long-term post-operative frequency of coronary abnormalities in asymptomatic patients with transposition of the great arteries discovered by coronary CT angiography and potential "red flags" revealed by other examinations.
PATIENTS AND METHODS:
A group of 50 consecutive asymptomatic patients who underwent routine long-term coronary artery evaluation after an arterial switch operation according to our institutional protocol were qualified for this study. This routine in-hospital visit included a detailed medical interview, electrocardiography, echocardiography, Holter electrocardiography examinations, and laboratory and cardiopulmonary exercise tests. Patients who showed significant abnormalities were qualified for perfusion scintigraphy.
RESULTS:
Unfavourable coronary abnormalities were detected in 30 patients (60%) and included ostial stenosis, muscular bridge, coronary fistula, interarterial course, proximal kinking, high ellipticity index, proximal acute angulation (<30 degree) of the left coronary artery, and proximal acute angulation of the right coronary artery. These features could not be predicted based on the medical interviews, surgical reports, or non-invasive screening test results.
CONCLUSION:
Complex coronary configurations with potentially dangerous coronary features are common in patients with transposition after an arterial switch operation. Such high-risk patients cannot be identified indirectly, and coronary CT angiography provides accurate information that is useful for post-operative management.
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Regression of Left Ventricular Mass in Athletes Undergoing Complete Detraining Is Mediated by Decrease in Intracellular but Not Extracellular Compartments.
Circ Cardiovasc Imaging2019 Sep;12(9):e009417. doi: 10.1161/CIRCIMAGING.119.009417.
Swoboda Peter P, Garg Pankaj, Levelt Eylem, Broadbent David A, Zolfaghari-Nia Ashkun, Foley A James R, Fent Graham J, Chew Pei G, Brown Louise A, Saunderson Christopher E, Dall'Armellina Erica, Greenwood John P, Plein Sven,
Abstract
BACKGROUND:
Athletic cardiac remodeling can occasionally be difficult to differentiate from pathological hypertrophy. Detraining is a commonly used diagnostic test to identify physiological hypertrophy, which can be diagnosed if hypertrophy regresses. We aimed to establish whether athletic cardiac remodeling assessed by cardiovascular magnetic resonance is mediated by changes in intracellular or extracellular compartments and whether this occurs by 1 or 3 months of detraining.
METHODS:
Twenty-eight athletes about to embark on a period of forced detraining due to incidental limb bone fracture underwent clinical assessment, ECG, and contrast-enhanced cardiovascular magnetic resonance within a week of their injury and then 1 month and 3 months later.
RESULTS:
After 1 month of detraining, there was reduction in left ventricular (LV) mass (130±28 to 121±25 g; <0.0001), increase in native T1 (1225±30 to 1239±30 ms; =0.02), and extracellular volume fraction (24.5±2.3% to 26.0±2.6%; =0.0007) with no further changes by 3 months. The decrease in LV mass was mediated by a decrease in intracellular compartment volume (94±22 to 85±19 mL; <0.0001) with no significant change in the extracellular compartment volume. High LV mass index, low native T1, and low extracellular volume fraction at baseline were all predictive of regression in LV mass in the first month.
CONCLUSIONS:
Regression of athletic LV hypertrophy can be detected after just 1 month of complete detraining and is mediated by a decrease in the intracellular myocardial compartment with no change in the extracellular compartment. Further studies are needed in athletes with overt and pathological hypertrophy to establish whether native T1 and extracellular volume fraction may complement electrocardiography, echocardiography, cardiopulmonary exercise testing, and genetic testing in predicting the outcome of detraining.
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Prolonged treadmill running in normobaric hypoxia causes gastrointestinal barrier permeability and elevates circulating levels of pro- and anti-inflammatory cytokines.
Appl Physiol Nutr Metab2019 Sep;():. doi: 10.1139/apnm-2019-0378.
Hill Garrett W, Gillum Trevor L, Lee Ben J, Romano Phebe A, Schall Zach J, Hamilton Ally M, Kuennen Matthew R,
Abstract
PURPOSE:
This study examined the impact of treadmill running in normobaric hypoxia on gastrointestinal barrier permeability and the systemic inflammatory response.
METHODS:
Ten recreationally-active participants completed two 1h bouts of matched-workload treadmill exercise(65% normoxic VO2max) in counterbalanced order. One bout was performed in normoxia(NORM: FIO2=20.9%) and the other in normobaric hypoxia(HYP: FIO2=13.5%). Minute ventilation(VE), respiratory rate(RR), tidal volume(VT), oxygen consumption(VO2), carbon dioxide production(VCO2), respiratory quotient(RQ), and heart rate(HR) were measured with a metabolic cart. Peripheral oxygen saturation(SpO2) was measured with pulse oximetry. Absolute tissue saturation(StO2) was measured with near-infrared spectroscopy. Fatty acid-binding protein(I-FABP) and circulating cytokine concentrations(IL-1Ra, IL-6, IL-10, TNF?) were assayed from plasma samples collected Pre, Post, 1h-Post, and 4h-Post exercise. Data were analyzed with 2-Way(Condition*Time) RM ANOVAs and Newman-Keuls post hocs were run where appropriate(p<0.05).
RESULTS:
As compared to NORM, 1h of treadmill exercise in HYP caused greater(p<0.05) changes in VE(+30%), RR(+16%), VT(+10%), VCO2(+18%), RQ(+16%), HR(+4%), SpO2(-16%) and StO2(-10%). Gut barrier permeability and circulating cytokine concentrations were also greater(p<0.05) following HYP exercise, where I-FABP was shown increased at Post(+68%) and IL-1Ra at 1h-Post(+266%). I-FABP and IL-1Ra did not change following NORM exercise. IL-6 and IL-10 increased with exercise in both study conditions but were increased more(p<0.05) following HYP exercise at Post(+705% and +127%; respectively) and 1h-Post(+400% and +128%; respectively).
KEY FINDINGS:
? Normobaric hypoxia caused significant desaturation and increased most cardiopulmonary responses by 10-30%. ? Significant gut barrier permeability and increased pro- and anti-inflammatory cytokine concentrations could promote an "open window" in the hours following HYP exercise.
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The 2-minute walk test is not a valid method to determine aerobic capacity in persons with multiple sclerosis.
NeuroRehabilitation2019 Sep;():. doi: 10.3233/NRE-192792.
Beckerman Heleen, Heine Martin, van den Akker Lizanne E, de Groot Vincent,
Abstract
BACKGROUND:
Walking tests, like the 2-minute fast walk test, are simple, inexpensive performance-based tests, and therefore seem attractive to estimate the aerobic fitness in people with chronic diseases.
OBJECTIVE:
To determine the criterion validity of the 2-minute fast walk test for estimating aerobic capacity in patients with Multiple Sclerosis (MS), by comparing it with the peak oxygen uptake (VO2peak in mL/kg/min) as measured by Cardiopulmonary Exercise Testing (CPET) on a cycle ergometer.
METHODS:
The 2?min fast walk test was performed on a marked indoor trajectory, using a static start protocol. Aerobic capacity (VO2peak, in mL/kg/min) was derived from CPET on a cycle ergometer. Criterion validity was tested by means of Pearson's correlation coefficient and should be at least 0.70 for a good criterion validity of the 2?min walk test. Linear regression analysis was applied to more precisely estimate VO2peak.
RESULTS:
In total 141 people with severe MS-related fatigue (mean age 47.0 years (range 23-68 years), 73% women, median disease duration 7.8 years (range 0.3 - 28.7 years)) performed both tests. The distance walked in two minutes ranged from 52.0 to 290.0?m (mean 175.1?m, sd 44.9?m), while the VO2peak varied between 11.31 and 40.28?mL/kg/min (mean 22.52?mL/kg/min, sd 6.07?mL/kg/min). The correlation between the 2?min walk test and VO2peak was 0.441 (95% CI: 0.309-0.570). The absolute residual error in estimated VO2peak was 5.47?mL/kg/min.
CONCLUSIONS:
Due to the poor correlation found between the 2?min walk test and VO2peak, the 2-min walk test cannot be recommended as a valid alternative for estimating aerobic capacity in persons with MS.
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Failing Homeostasis of Quadriceps Muscle Energy- and pH Balance During Bicycling in a Young Patient With a Fontan Circulation.
Front Cardiovasc Med2019 ;6():121. doi: 10.3389/fcvm.2019.00121.
Haarman Meindina G, Vos Johannes D L, Berger Rolf M F, Willems Tineke P, Jeneson Jeroen A L,
Abstract
Patients with a congenital heart condition palliated with a Fontan circulation generally present with decreased exercise capacity due to impaired cardiopulmonary function. Recently, a study in patients with a Fontan circulation reported evidence for abnormal vascular endothelial function in leg muscle. We investigated if abnormal skeletal muscle hemodynamics during exercise play a role in the limited exercise tolerance of Fontan patients. If so, abnormalities in intramuscular energy metabolism would be expected both during exercise as well as during post-exercise metabolic recovery. In a young patient with a Fontan circulation and his healthy twin brother we studied the dynamics of energy- and pH-balance in quadriceps muscle during and after a maximal in-magnet bicycling exercise challenge using 31-phosphorus magnetic resonance spectroscopy. An unrelated age-matched boy was also included as independent control. Quadriceps phosphocreatine (PCr) depletion during progressive exercise was more extensive in the Fontan patient than in both controls (95% vs. 80%, respectively). Importantly, it failed to reach an intermittent plateau phase observed in both controls. Quadriceps pH during exercise in the Fontan patient fell 0.3 units at low to moderate workloads, dropping to pH 6.6 at exhaustion. In both controls quadriceps acidification during exercise was absent but for the maximal workload in the twin brother (pH 6.8). Post-exercise, the rate of metabolic recovery in the Fontan patient and both controls was identical (time constant of PCr recovery 32 ± 4, 31 ± 2, and 28 ± 4 s, respectively). Homeostasis of quadriceps energy- and pH-balance during a maximal exercise test failed in the Fontan patient in comparison to his healthy twin brother and an age-matched independent control. Post-exercise metabolic recovery was normal which does not support the contribution of significant endothelial dysfunction affecting adequate delivery of oxidative substrates to the muscle to the lower exercise capacity in this particular Fontan patient. These results suggest that mitochondrial ATP synthetic capacity of the quadriceps muscle was intact but cardiac output to the leg muscles during exercise was insufficient to meet the muscular demand for oxygen. Therefore, improving cardiac output remains the main therapeutic target to improve exercise capacity in patients with a Fontan circulation.
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[Effect of trimetazidine on cardiac function and exercise tolerance in hypertension patients with diabetic].
Zhejiang Da Xue Xue Bao Yi Xue Ban2019 May;48(3):282-288.
Ye Pingxian, Ye Pingzhen, He Jinping,
Abstract
OBJECTIVE:
To determine the effect of trimetazidine on cardiac function and exercise tolerance in primary hypertension patients with type 2 diabetic.
METHODS:
In this randomized, double-blind, placebo-controlled prospective study, 60 primary hypertensive patients with diabetic were equally assigned into two groups, patients received trimetazidine (20 mg, 3 times a day) or placebo for 1 year. Echocardiography, cardiopulmonary exercise testing were performed; and the plasma N terminal pro B type natriuretic peptide (NT-ProBNP), hr-CRP, TNF-?, angiotensin ? and endothelin concentration were determined before and after treatment.
RESULTS:
In trimetazidine group, the left ventricular mass index, the mitral flow velocity E wave to A wave ratio (E/A), the peak early diastolic velocity (V) to late diastolic velocity (V) ratio (V/V) and the peak systolic velocity (Vs) were significantly improved, the plasma NT-ProBNP level was significantly decreased, and the exercise time, metabolic equivalent, maximal oxygen uptake and anaerobic threshold were significantly increased (all <0.05); plasma concentration of hr-CRP, TNF-?, angiotensin ? and endothelin were significantly reduced after trimetazidine treatment, compared with baseline (all <0.05) and with placebo (all <0.05). There were no significant differences in any of above parameters after treatment in placebo group (all >0.05). No severe adverse reaction was observed in both groups.
CONCLUSIONS:
For patients with both hypertension and diabetes, trimetazidine can improve cardiac function and increase exercise tolerance.
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Unexplained exertional intolerance associated with impaired systemic oxygen extraction.
Eur J Appl Physiol2019 Sep;():. doi: 10.1007/s00421-019-04222-6.
Melamed Kathryn H, Santos Mário, Oliveira Rudolf K F, Urbina Mariana Faria, Felsenstein Donna, Opotowsky Alexander R, Waxman Aaron B, Systrom David M,
Abstract
PURPOSE:
The clinical investigation of exertional intolerance generally focuses on cardiopulmonary diseases, while peripheral factors are often overlooked. We hypothesize that a subset of patients exists whose predominant exercise limitation is due to abnormal systemic oxygen extraction (SOE).
METHODS:
We reviewed invasive cardiopulmonary exercise test (iCPET) results of 313 consecutive patients presenting with unexplained exertional intolerance. An exercise limit due to poor SOE was defined as peak exercise (Ca-vO)/[Hb]???0.8 and VO??0.8, VO???80%, and no cardiac or pulmonary limit were considered otherwise normal. The otherwise normal group was divided into hyperventilators (HV) and normals (NL). Hyperventilation was defined as peak PaCO?
RESULTS:
Prevalence of impaired SOE as the sole cause of exertional intolerance was 12.5% (32/257). At peak exercise, poor SOE and HV had less acidemic arterial blood compared to NL (pHa?=?7.39?±?0.05 vs. 7.38?±?0.05 vs. 7.32?±?0.02, p?
CONCLUSIONS:
We identified a cohort of patients whose exercise limitation is due only to systemic oxygen extraction, due to either an intrinsic abnormality of skeletal muscle mitochondrion, limb muscle microcirculatory dysregulation, or hyperventilation and left shift the oxyhemoglobin dissociation curve.
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Pulmonary artery size is associated with functional clinical status in the Fontan circulation.
Heart2019 Sep;():. doi: heartjnl-2019-314972.
Ridderbos Floris-Jan S, Bonenkamp Bregje E, Meyer Sophie L, Eshuis Graziella, Ebels Tjark, van Melle Joost P, Willems Tineke P, Berger Rolf M F,
Abstract
OBJECTIVE:
In the Fontan circulation, non-pulsatile pulmonary blood flow is suggested to negatively affect pulmonary artery growth. The pulmonary vasculature is regarded a key determinant of outcome after Fontan completion. We hypothesised that in Fontan patients pulmonary artery size correlates with follow-up and functional clinical status.
METHODS:
This is a single-centre, cross-sectional cohort study. Thirty-nine paediatric and adult Fontan patients with a concomitant cardiac magnetic resonance (CMR) scan and a cardiopulmonary exercise test between 2012 and 2013 were included. CMR-derived left and right pulmonary artery cross-sectional areas were expressed as Nakata index. Functional status was defined as peak oxygen consumption (pVO) indexed for weight, as percentage of predicted (pred) and as New York Heart Association Functional Class (NYHA-FC).
RESULTS:
Age at CMR was 18±7.2 years. Time since Fontan completion was 11.9±7.4 years. Nakata index was lower versus the reference values (238.6±78.5 vs 330±30?mm/m, p<0.001). Nakata index correlated negatively with age at CMR (r=-0.393, p=0.013) and time since Fontan completion (r=-0.341, p=0.034). pVO was 27.9±8.9?mL/min/kg and pVOpred was 58.1%±14.1%. Nakata index correlated positively with pVO (r=0.468, p=0.003) and pVOpred (r=0.353, p=0.028). Nakata index correlated negatively with NYHA-FC (r=-0.450, p=0.004). Nakata index was an independent predictor (?=0.359, p=0.007) for pVO (adjusted R=0.442, with maximum heart rate and oxygen pulse at peak exercise).
CONCLUSIONS:
Pulmonary artery size expressed as Nakata index is a novel independent predictor for functional clinical status. Nakata index negatively correlated with follow-up duration, suggesting that chronic abnormal non-pulsatile pulmonary blood flow plays a role in lagging pulmonary arterial growth in the Fontan circulation.
© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.
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Acquired loss of cardiac vagal activity is associated with myocardial injury in patients undergoing noncardiac surgery: prospective observational mechanistic cohort study.
Br J Anaesth2019 Sep;():. doi: S0007-0912(19)30600-2.
May Shaun M, Reyes Anna, Martir Gladys, Reynolds Joseph, Paredes Laura Gallego, Karmali Shamir, Stephens Robert C M, Brealey David, Ackland Gareth L,
Abstract
BACKGROUND:
Myocardial injury is more frequent after noncardiac surgery in patients with preoperative cardiac vagal dysfunction, as quantified by delayed heart rate (HR) recovery after cessation of cardiopulmonary exercise testing. We hypothesised that serial and dynamic measures of cardiac vagal activity are also associated with myocardial injury after noncardiac surgery.
METHODS:
Serial autonomic measurements were made before and after surgery in patients undergoing elective noncardiac surgery. Cardiac vagal activity was quantified by HR variability and HR recovery after orthostatic challenge (supine to sitting). Revised cardiac risk index (RCRI) was calculated for each patient. The primary outcome was myocardial injury (high-sensitivity troponin ?15 ng L) within 48 h of surgery, masked to investigators. The exposure of interest was cardiac vagal activity (high-frequency power spectral analysis [HF]) and HR recovery 90 s from peak HR after the orthostatic challenge.
RESULTS:
Myocardial injury occurred in 48/189 (25%) patients, in whom 41/48 (85%) RCRI was <2. In patients with myocardial injury, vagal activity (HF) declined from 5.15 (95% confidence interval [CI]: 4.58-5.72) before surgery to 4.33 (95% CI: 3.76-4.90; P<0.001) 24 h after surgery. In patients who remained free of myocardial injury, HF did not change (4.95 [95% CI: 4.64-5.26] before surgery vs 4.76 [95% CI: 4.44-5.08] after surgery). Before and after surgery, the orthostatic HR recovery was slower in patients with myocardial injury (5 beats min [95% CI: 3-7]), compared with HR recovery in patients who remained free of myocardial injury (10 beats min [95% CI: 7-12]; P=0.02).
CONCLUSIONS:
Serial HR measures indicating loss of cardiac vagal activity are associated with perioperative myocardial injury in lower-risk patients undergoing noncardiac surgery.
Copyright © 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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Effect of pre-discharge cardiopulmonary fitness on outcomes in patients with ST-elevation myocardial infarction after percutaneous coronary intervention.
BMC Cardiovasc Disord2019 Sep;19(1):210. doi: 10.1186/s12872-019-1189-x.
Cai He, Zheng Yang, Liu Zhaoxi, Zhang Xinying, Li Rongyu, Shao Wangshu, Wang Lin, Zou Lin, Cao Pengyu,
Abstract
BACKGROUND:
The purpose of this study was to analyze cardiopulmonary fitness in Phase I cardiac rehabilitation on the prognosis of patients with ST-Elevation Myocardial Infarction (STEMI) after percutaneous coronary intervention (PCI).
METHODS:
The study enrolled a total of 499 STEMI patients treated with PCI between January 2015 and December 2015. Patients were assigned to individualized exercise prescriptions (IEP) group and non-individualized exercise prescriptions (NIEP) group according to whether they accept or refuse individualized exercise prescriptions. We compared the incidence of major cardiovascular events between the two groups. IEP group were further divided into two subgroups based on prognosis status, namely good prognosis (GP) group and poor prognosis (PP) group. Key cardio-pulmonary exercise testing (CPX) variables that may affect the prognosis of patients were identified through comparison of the cardio-respiratory fitness (CRF).
RESULTS:
There is no significant difference in the incidence of cardio-genetic death, re-hospitalization, heart failure, stroke, or atrial fibrillation between the IEP and the NIEP group. But the incidence of total major adverse cardiac events (MACE) was significantly lower in the IEP group than in the NIEP group (P?=?0.039). The oxygen consumption (VO) at ventilation threshold (VT), minute CO ventilation (E-VCO), margin of minute ventilation carbon dioxide production (?CO) rest partial pressure of end-tidal carbon dioxide(R-PCO), exercise partial pressure of end-tidal carbon dioxide(E-PCO) and margin of partial pressure of end-tidal carbon dioxide(?PCO) were significantly higher in the GP subgroup than in the PP subgroup; and the slope for minute ventilation/carbon dioxide production (V/VCO) was significantly lower in GP subgroup than in PP subgroup (P?=?0.010). The VO at VT, V/VCO slope, E-VCO, ?CO, R-PCO, E-PCO and margin of partial pressure of end-tidal carbon dioxide CO (?PCO) were predictive of adverse events. The VO at VT was an independent risk factor for cardiovascular disease prognosis.
CONCLUSIONS:
Individualized exercise prescription of Phase I cardiac rehabilitation reduced the incidence of cardiovascular events in patients with STEMI after PCI. VO at VT is an independent risk factor for cardiovascular disease prognosis, and could be used as an important evaluating indicator for Phase I cardiac rehabilitation.
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32 year follow up of patients following atrial redirection surgery for transposition of the great arteries.
Congenit Heart Dis2019 Sep;():. doi: 10.1111/chd.12822.
Morrison M Louise, Grant Brian, McCrossan Brian A, Sands Andrew J, Owens Colum G, Spence Mark S, Casey Frank A, Craig Brian G, Lockhart Christopher J,
Abstract
OBJECTIVE:
A significant body of patients who have undergone Mustard or Senning procedure require lifelong follow up. In this retrospective review, we examined the cohort of such patients currently attending our center.
DESIGN:
Patients who had undergone either Mustard or Senning procedure were identified. We retrospectively reviewed medical records, recorded demographic information and data regarding the clinical state, NHYA class, cardiopulmonary exercise testing, NT-proBNP measurement, and recent cardiac MRI findings.
RESULTS:
Forty-six patients were identified, the mean age was 32.2 years (± 6.1 years), 67.4% were male. Thirty-two patients (69.6%) had undergone a Senning procedure. The median length of the follow-up was 32 years. Thirty-two patients (69.6%) were NHYA class 1. The mean VO achieved was 24.2 ± 5.8 mL/min/kg. The mean NT-proBNP was 266.4 pg/mL (± 259.9 pg/mL). The mean right ventricular end-diastolic volume (RVEDV) was 212.4 mL ± 73.1 mL (indexed 114.2 mL/m ± 34.4 mL/m ). The mean right ventricular ejection fraction (RVEF) was 53.7% ± 7.9%. The mean left ventricular end-diastolic volume (LVEDV) was 161.5 mL ± 73.7 mL (indexed 87.8 mL/m ± 41.1 mL/m ). The mean left ventricular ejection fraction (LVEF) was 59.8% ± 5.7%. There was a significant correlation between right ventricular (RV) size on MRI and NT-proBNP level.
CONCLUSIONS:
We present a relatively well cohort of patients with overall favorable long-term outcome. The majority of patients are NHYA class 1 and the systemic right ventricular function appears to be well preserved as assessed by MRI. The exercise tolerance is reduced, with the majority of patients achieving around 60% of the estimated VO . Regular specialist follow-up and assessment with advanced imaging at regular intervals remain important for this group.
© 2019 Wiley Periodicals, Inc.
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Skeletal myofiber VEGF deficiency leads to mitochondrial, structural and contractile alterations in mouse diaphragm.
J Appl Physiol (1985)2019 Sep;():. doi: 10.1152/japplphysiol.00779.2018.
Cannon Daniel T, Rodewohl Lukas, Adams Volker, Breen Ellen C, Bowen T Scott,
Abstract
Diaphragm dysfunction accompanies cardiopulmonary disease and impaired oxygen delivery. Vascular endothelial growth factor (VEGF) regulates oxygen delivery through angiogenesis, capillary maintenance, and contraction-induced perfusion. We hypothesized that myofiber-specific VEGF deficiency contributes to diaphragm weakness and fatigability. Diaphragm protein expression, capillarity and fiber morphology, mitochondrial respiration and hydrogen peroxide (HO) generation, and contractile function were compared between adult mice with conditional gene ablation of skeletal myofiber VEGF (SkmVEGF; n=12) and littermate controls (n=13). Diaphragm VEGF protein was ~50 % lower in SkmVEGF than littermate controls (1.45±0.65 vs. 3.04±1.41 pg/total protein; P=0.001). This was accompanied by an ~15% impairment in maximal isometric specific force (F[1,23] = 15.01, P=0.001) and a trend for improved fatigue resistance (P=0.053). Mean fiber cross-sectional area and type I fiber cross-sectional area were lower in SkmVEGF by ~40 % and ~25% (P<0.05). Capillary-to-fiber ratio was also lower in SkmVEGF by ~40% (P<0.05), thus capillary density was not different. Sarcomeric actin expression was ~30% lower in SkmVEGF (P<0.05), while myosin heavy chain and MAFbx were similar (measured via immunoblot). Mitochondrial respiration, citrate synthase activity, PGC-1?, and HIF-1? were not different in SkmVEGF (P>0.05). However mitochondrial-derived reactive oxygen species (ROS) flux was lower in SkmVEGF (P=0.0003). In conclusion, myofiber-specific VEGF gene deletion resulted in a lower capillary-to-fiber ratio, type I fiber atrophy, actin loss, and contractile dysfunction in the diaphragm. In contrast, mitochondrial respiratory function was preserved alongside lower ROS generation, which may play a compensatory role to preserve fatigue resistance in the diaphragm.
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How should the cardiopulmonary exercise test be interpreted in heart failure?
Turk Kardiyol Dern Ars -
Validation of the two-minute step test in obese with comorbibities and morbidly obese patients.
Braz J Med Biol Res2019 ;52(9):e8402. doi: S0100-879X2019000900605.
Ricci P A, Cabiddu R, Jürgensen S P, André L D, Oliveira C R, Di Thommazo-Luporini L, Ortega F P, Borghi-Silva A,
Abstract
Cardiopulmonary fitness assessment is a valuable resource to obtain quantitative indicators of an individual's physical performance. The cardiopulmonary exercise test (CPX), considered the gold standard test for this evaluation, is costly and difficult to be accessed by the general population. In order to make this evaluation more accessible, and to better reflect the performance of daily life activities, alternative tests were proposed. Morbidly obese patients present limitations that impair physical performance assessment and could benefit from a test of shorter duration, provided it is validated. This observational study aimed to validate the two-minute step test (2MST) as a tool to evaluate functional capacity (FC) in obese with comorbidities and morbidly obese patients, compared the 2MST with CPX as a measure of physical performance, and developed a predictive equation to estimate peak oxygen uptake (VO2) in the 2MST. The CPX and the 2MST were performed and metabolic and ventilatory parameters were recorded in 31 obese individuals (BMI>35 kg/m2). Pearson correlation and multiple linear regression analyses were performed to evaluate the peak VO2 best predictors. Bland-Altman analysis was performed to assess the agreement between the two methods. Peak VO2 measured by CPX and 2MST showed a strong correlation (r=0.70, P<0.001) and there was a moderate correlation between peak VO2 of the 2MST and the number of up-and-down step cycles (UDS) (r=0.55; P=0.01). The reference equation obtained was: VO2 (mL·kg-1·min-1) = 13.341 + 0.138 × total UDS - (0.183 × BMI), with an estimated standard error of 1.3 mL·kg-1·min-1. The 2MST is a viable, practical, and easily accessible test for FC. UDS and BMI can predict peak VO2 satisfactorily.
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