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PubMed1994

[Exercise capacity after heart valve replacement].

Exercise capacity following heart-valve replacement is dependent on how close to normal the artificial device can restore valve function, to what degree a preoperative impaired myocardial function and/or an increased pulmonary vascular resistance is normalized. The postoperative functional result can be determined by the subjective improvement of the patient, his functional capacity, exercise capacity, the central hemodynamics at rest and during exercise, and the systolic and diastolic function of the left and right ventricular myocardium. The subjective improvement of individual symptoms is obviously dependent on the degree of postoperative normalization of hemodynamics, especially of pressures in the pulmonary circulation. Subjective improvement can be objectified by comparing the functional capacities before and after surgery. Post-operative normalization of central hemodynamics and myocardial function does not happen immediately but within 3 to more than 12 months. A 12-month period can generally be expected in patients with mitral stenosis and increased pulmonary vascular resistance (> 400 dyn.sec.cm-5) prior to surgery. In patients with mitral and aortic regurgitation as well as with aortic stenosis and preoperative decrease of their left ventricular ejection fraction during exercise, continuous improvement of left ventricular pump function also may need up to 12 months. Physiological hemodynamic conditions generally are not restored by valve replacement. All prostheses are stenotic to forward blood flow because of the obstruction created by the narrowing of the valve area by sewing cuff and valve poppet. This may result in a hemodynamically important stenosis, especially after atrio-ventricular valve implantation, and may limit subjective and functional improvement. Exercise capacity after aortic valve replacement depends mainly on whether or not myocardial damage persists postoperatively. A workload of 1.5 w/kg body weight (BW) has been performed by 100% of patients aged 45 to 55 years with prostheses implanted for aortic stenosis. The significant lower exercise capacity all patients with valve replacement for aortic regurgitation have experienced (0.4 w/kg BW) indicates that a substantial number of these patients has irreversible myocardial damage prior to surgery. The workload experienced by patients with mitral valve prostheses varies between 0.4 and 2.0 w/kg BW (mitral stenosis) and 0.3-2.3 w/kg BW (mitral regurgitation), respectively. To objectify the functional result of heart-valve replacement, hemodynamic-metabolic measurements of functional improvement, determination of left, eventually also of right-ventricular function by echocardiography and additional invasive measurements of the central hemodynamics and myocardial pump function parameters at rest and during exercise might be necessary.

Adult↗
PubMed1989

Exercise capacity during the first year after cardiac transplantation.

Few data are available examining the influence of perioperative clinical parameters on exercise capacity after cardiac transplantation. Accordingly, 40 patients were studied by metabolic exercise testing early (1 to 3 months) and late (6 to 12 months) after cardiac transplantation. Various clinical parameters, including congestive heart failure class, length of hospital stay, age, cold ischemic time and histologic evidence of rejection were correlated with exercise capacity after transplantation. As expected, peak exercise capacity correlated inversely with both age and length of hospital stay. There was no correlation with preoperative congestive heart failure class or heart rate at rest. Interestingly, there was a statistically significant correlation between cold ischemic time and exercise capacity after transplantation. In addition, increased episodes of rejection during the first 6 months after transplantation resulted in statistically lower exercise capacity at 6 to 12 months after the operation. Thus, ischemic damage during transport of the donor organs and subclinical damage during early rejection may affect clinical status after heart transplantation and may only be apparent during increased physical demand such as exercise.

Adult↗
PubMed2005

Echocardiographic and hemodynamic characteristics of reconstructed bicuspid aortic valves at rest and exercise.

Repair of diseased bicuspid aortic valves has gained increasing interest as an alternative to conventional valve replacement. Hemodynamic data at exercise have not been reported before. The aim of this study was to investigate the clinical and echocardiographic status of patients after bicuspid aortic valve repair at rest and exercise. Between 03/94 and 09/02 a reconstruction of an incompetent bicuspid aortic valve was performed in 25 patients (mean age 35+/-12.1 years, group A, mean insufficiency 2.8 preoperatively). Patients were investigated clinically and echocardiographically after 2.1+/-2.4 (0.1-8.9) years at rest and exercise and compared to 20 controls (group B). Clinical followup was complete. There were no deaths, reoperations, thromboembolic or bleeding complications. At last examination 21 patients were in NYHA class I, n=4 in NYHA class II and mean aortic valve insufficiency (AI) was 1.0 with one patient having an AI>II degrees. Maximum and mean pressure gradient (dPmax/mean) across the aortic valve at rest were 14+/-5.5/7+/-2.6 mmHg for patients of group A and 7+/-2.5/3.6+/-1.1 mmHg in group B. Mean AVA at rest was 2.6+/-0.8 (group A) vs 2.9+/-0.6 cm(2) (group B, p=0.025), valvular resistance 13.4+/-4.8 (group A) vs 13.6+/-2.9 dyn x s x cm(-5) (group B, p>0.05). All individuals were stressed up to 100 W (dPmax/mean 21+/-6.8/11+/-3.6, group A vs 11+/-2.9/6+/-1.3 mmHg, group B). 56% of group A and 85% of group B could be stressed up to 175 W with dPmax/mean 24.5+/-8.3/12+/-4.2 and 16+/-3.6/8+/-1.4 mmHg, respectively (p<0. 01). Heart rate and blood pressure behavior were comparable. Left ventricular mass regression (preoperatively 369.3+/-76.4 vs 277.3+/-80.7 g at last examination, p<0.01) was significant in group A but did not reach normal values (group B, 227.8+/-71.1; p<0.01). Bicuspid aortic valve reconstruction reduces left ventricular volume load significantly. Although residual mild subclinical obstruction and incompetence were observed, the behavior of hemodynamics at exercise was comparable to controls. The clinical relevance of these findings in long term follow-up has to be evaluated.

Adolescent↗
PubMed2006

Comparison of pre- and postoperative pulmonary function in obese and non-obese female patients undergoing coronary artery bypass graft surgery.

OBJECTIVE AND BACKGROUND: Various studies have suggested that body size and in-hospital mortality are related. However, only a few analysed the effects of obesity on pulmonary complications following coronary artery bypass graft surgery (CABG). The purpose of the present study was to assess early changes in lung volumes, respiratory complications and arterial blood gas tension following CABG in obese women. METHODS: Pulmonary function tests (PFTs), treadmill exercise capacity tests (TM), arterial blood gases and pulmonary complications were studied in 124 obese (mean age 57.2+/-5.8 years) and 108 non-obese (mean age 58.6+/-5.9 years) female patients undergoing elective CABG. PFT, TM tests, arterial blood gas analyses and CXR were performed in the preoperative and postoperative periods and pulmonary complications were recorded. Breathing and coughing exercises, early ambulation and pulmonary clearing techniques were used by physical therapists to prevent pulmonary complications after CABG surgery. RESULTS: Postoperative PFT and TM tests deteriorated significantly in both groups (P<0.0001). The deterioration in the obese group was highly significant. The postoperative deterioration of blood gas measurements in obese patients was also statistically significant compared to non-obese patients. Early pulmonary complications developed in 21 (16.94%) of the obese patients and in 10 (9.25%) of non-obese patients. Duration of mechanical ventilation, intensive care unit and hospital stays were longer compared to the non-obese patients (P=0.008, P<0.0001, P=0.0386, respectively). CONCLUSION: Obesity has a detrimental effect on pulmonary function, exercise capacity, blood gas measurements and complications rates in postoperative period following CABG surgery.

Blood Gas Analysis↗
PubMed2002

Effect of lung volume reduction surgery for severe emphysema on right ventricular function.

Lung volume reduction surgery (LVRS) can improve the functional capacity of selected patients with severe emphysema. Hypothesized physiologic effects of LVRS include an improvement in right ventricular function, although this has not been investigated in detail. To help clarify this issue, we used fast-thermistor thermodilution at rest and during submaximal upright exercise in 12 patients, before and 6 mo after bilateral LVRS. Preoperatively, all patients had severe airflow obstruction, with a mean FEV(1) of 0.69 L and an RV-to-TLC ratio of 0.67. Six months after LVRS, significant improvements occurred in respiratory function measures (+0.39 L in FEV(1), p < 0.002; and +/- 0.15 in RV/TLC ratio, p < 0.002) and in right ventricular function indexes measured at rest (+0.21 L in cardiac index [CI], p < 0.01; and +3.0 ml in stroke volume, p < 0.01) and during exercise (+0.9 L in CI, p < 0.002; +10.0 ml in stroke volume index, p < 0.002; and +20% in ejection fraction [EF], p < 0.002). A significant correlation was found between pre- to postoperative changes in the EF response to exercise and changes in the RV/TLC ratio (R = -0.68; p = 0.01). We conclude that a significant improvement in right ventricular performance, particularly during exercise, can occur 6 mo after bilateral LVRS.

Exercise↗
PubMed1994

The superiority of exercise testing over spirometry in the evaluation of postoperative lung function for patients with pulmonary disease.

Thoracic surgeons have often been embarrassed by the discrepancy between an improvement in symptoms and the unchanged or even worse results of spirometry in postoperative patients with either bullae or inflammatory lung disease. Forty-four patients with lung diseases, who underwent a total of 47 operations, were categorized as follows: 12 cases of empyema, 16 cases of giant bulla (undergoing surgery a total of 19 times), 4 cases of bronchiectasis, and 12 cases of other miscellaneous diseases. All patients were tested preoperatively and again 4-6 months after surgery on both the spirometer and treadmill exercise tests. The forced vital capacity (FVC) and forced expiratory volume (FEV1.0) results were as follows: the empyema group 1.82 +/- 0.52 liters preoperatively to 1.93 +/- 0.69 liters postoperatively and 1.47 +/- 0.44 liters to 1.56 +/- 0.53 liters, respectively; and the giant bulla group, 3.49 +/- 0.96 liters to 3.35 +/- 0.77 liters and 2.35 +/- 0.96 liters to 2.48 +/- 0.69 liters, respectively. However, the exercise time was prolonged in the empyema group from 6.00 +/- 3.77 min to 8.33 +/- 3.80 min (P < 0.01) and in the giant bulla group from 11.83 +/- 3.71 min to 12.92 +/- 2.84 min (P < 0.05). It was thus concluded that exercise testing should be chosen for the postoperative evaluation of patients with inflammatory pulmonary disease and giant bullae, especially if any discrepancies are seen between spirometry and performance status, because on the basis of our results, it appears that the benefits obtained by surgery are best measured by the dynamic values of exercise testing and not by the static values of spirometry at rest.

Adult↗
PubMed1987

[Clinical and paraclinical findings on status following prosthetic heart valve replacement with special reference to the behavior of pulmonary pressure].

Retrospectively were evaluated clinical findings of 151 patients with condition after replacement of artificial cardiac valves (Björk-Shiley), who were treated in our department of cardiology in 1986. The patients with mitral valve replacement (MVR) and mitral valve and aortic valve replacement showed the highest rate of individualisation in comparison to aortic valve replacement. 18 patients showed complications and acute deteriorations, respectively, two of which had a fatal course. In 53 patients the bicycle-ergometric exercises were performed with measurement of the pulmonary pressure. Of these patients the majority indeed subjectively improved in their behaviour, however, the objective exercise tolerance was altogether low and the rate of invalidisation increased in comparison to the preoperative rate. The pulmonary pressure at rest in the majority of the patients was reduced mostly in dependence on the initial values. Increases appeared only sporadically. Under exercise, however, particularly the patients with mitral valve replacement showed pathological increases of pressure. Altogether the best results showed patients with aortic valve replacement also with regard to the shrinking of the radiologically established size of the heart.

Adolescent↗
PubMed2005

Patients with positive preoperative stress tests undergoing vascular surgery.

OBJECTIVE: To examine the perioperative cardiac morbidity and mortality in patients undergoing major vascular surgery with beta-blockade after a positive stress test or cardiac catheterization. DESIGN: Retrospective review of a quality assurance database. SETTING: A university teaching hospital. PARTICIPANTS: A consecutive series of 31 patients undergoing peripheral vascular or aortic surgery after a positive stress test or catheterization between November 2001 and September 2003. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: All 31 patients had a preoperative positive stress test and/or cardiac catheterization, with 12 having multiple areas at risk for myocardial ischemia. None had an intervening coronary revascularization. Twenty-seven had at least one of the intermediate clinical predictors as defined by the American College of Cardiology and 7 had a left ventricular ejection fraction < 40%. Twenty-three patients had been on a beta-blocker and continued on it, while the remainder started on it de novo perioperatively. None of the patients suffered from myocardial infarction, congestive heart failure, or cardiac death perioperatively. CONCLUSIONS: This case series reports on the authors' experience with patients undergoing high-risk vascular surgery after a positive stress test or catheterization, but without an intervening coronary intervention. All patients received perioperative beta-blockade and had a very low adverse cardiac event rate. With reduction of adverse events by beta-blockade, the likelihood of a positive event may be reduced and the utility of the test in risk stratification may be questioned.

Aged↗
PubMed1994

Optimization of sphincter function after the ileoanal reservoir procedure. A prospective, randomized trial.

PURPOSE: Impairment of sphincter function in patients who undergo ileoanal reservoir is usually most severe immediately after ileostomy closure. Therefore, a prospective, randomized trial was undertaken to assess the potential value of preileostomy closure sphincter-strengthening exercises to improve early functional outcome. METHODS: Patients were randomized either to a control group (Group 1) or to undergo a five-week pelvic floor exercise program (Group 2). An incontinence score from 0 to 20 was used to clinically assess the functional results. Anorectal manometric assessment included: high-pressure zone length, mean resting pressure, highest resting pressure, mean squeezing pressure, and highest squeezing pressure. The paired t-test was used to compare the functional results preoperatively and at the time of ileostomy closure. This time corresponded to the conclusion of the exercise program or the equivalent time period for the control group. RESULTS: Twenty-six patients who underwent double-stapled ileoanal reservoir between July 1991 and June 1992 were studied. They included 16 males and 10 females with a mean age of 38 (range, 17-69) years. When both evaluations were compared, the mean incontinence score decreased from 0.2 to 2.8 (delta = 2.6) in Group 1 and from 0.2 to 2.0 (delta = 1.8) in Group 2 (P = 0.07). None of the changes between the preoperative and postoperative clinical and physiologic evaluations were statistically significant (P > 0.05). CONCLUSION: Sphincter-strengthening exercises before ileostomy closure did not minimize the transient impairment of functional results.

Adolescent↗
PubMed1999

Longterm effects of pulmonary resection on cardiopulmonary function.

BACKGROUND: Major lung resection decreases ventilatory capacity and reduces exercise tolerance, impairing postoperative quality of life. But we have often seen respiratory symptoms improve during several years of postoperative followup. In the current study, we evaluated postoperative changes in cardiopulmonary function on exertion of patients with lung cancer surviving for more than three years, and the corresponding changes of their respiratory symptoms. METHODS: The effects of pulmonary resection on cardiopulmonary function were evaluated in eight patients with lung cancer. Pulmonary function tests and hemodynamic study at rest and during exercise were performed before, in the early (4 to 6 months) and late (42 to 48 months) postoperative phases after major lung resection. RESULTS: None of the eight patients had any remarkable symptoms before lung resection. In the early postoperative study, the general condition of five patients deteriorated compared with their preoperative status. In the late postoperative study, four patients showed an improvement of their daily activities from the early postoperative phase. Pulmonary function in the late postoperative phase did not show major changes except for airway resistance and percentage of carbon monoxide diffusing capacity as compared with the early phase, which showed deterioration as compared with the preoperative period. Cardiac index and stroke volume index were significantly decreased during exercise on maximal effort in the late postoperative phase compared with other phases. These results suggest that the peak blood flow per unit of remaining lung during exercise becomes lower with time after lung resection, indicating deterioration of the condition of the pulmonary vascular bed. The deterioration was also revealed from the pressure-flow curve. CONCLUSIONS: The condition of the pulmonary vascular bed after major lung resection does not improve, even in the late postoperative phase, although clinical symptoms were sometimes improved compared with the early postoperative period.

Aged↗
PubMed1985

Exercise-induced ST-segment elevation possibly caused by coronary artery spasm. A case presentation and review.

A 36-year-old man with classic angina pectoris had marked ST-segment elevation (STE) in the inferior leads on stress-testing in the absence of chest pain. There was no evidence of previous myocardial infarction (MI). Selective coronary arteriography delineated severe obstructions in the right coronary artery (RCA) with additional left circumflex coronary artery (LCx) obstruction. Left ventricular cine-angiography established that there was normal contractility and confirmed the absence of past MI. Coronary artery bypass graft surgery to the RCA and LCx was unfortunately complicated by an acute transmural inferoposterolateral MI. Treadmill stress testing 6 weeks after surgery failed to demonstrate the preoperative ST-segment change. The patient may have developed exercise-induced coronary artery spasm superimposed on the severe proximal RCA stenosis; this in turn may have caused the inferior STE. Exercise-induced STE is reviewed.

Adult↗
PubMed1998

Preparation of high-risk patients for major thoracic surgery.

For a least a decade, many patients have benefitted from new indications of major thoracic surgery owing to improvements in the surgical and anesthetic procedures of thoracic surgery. Identification of risk factors of perioperative morbidity and mortality becomes of paramount importance when trying to lesson the postoperative mortality rate to 1% or less. The careful assessment of the candidates for thoracic surgery with a multidisciplinary approach is the cornerstone of such an objective. The lower mortality rate should be achievable with a preoperative preparation of the patients of a rehabilitation and nutritional program and a pharmacologic treatment optimization.

Exercise Therapy↗
PubMed2000

Demand dynamic cardiomyoplasty: mechanograms prove incomplete transformation of the rested latissimus dorsi.

BACKGROUND: In dynamic cardiomyoplasty, standard stimulation produces high fatigue resistance but also undesirable dynamic characteristics of the latissimus dorsi (LD). Based on results of intermittent stimulation in animals we introduced demand stimulation, a lighter regimen of LD activity-rest stimulation, and the mechanogram, a noninvasive method to determine the contractile characteristics of LD wrap. METHODS: Surgery and standard stimulation was according to the technique of Carpentier and Chachques, demand stimulation and LD wrap mechanogram were as we previously described. The LD contraction is synchronized to heart systole by mechanogram and echocardiography, and extent of transformation by tetanic fusion frequency analysis. A total of 22 patients were studied to date. Data for the 8 subjects who attained 6-month follow-up are reported. Four of them were lightly stimulated from the conditioning period, whereas 4 others were converted to light and then demand stimulation after years of standard stimulation. Patients were followed up with respect to survival, functional class, hospital admission rate, medication used, cardiopulmonary exercise testing, and LD wrap mechanography. RESULTS: Latissimus dorsi wrap slowness reverses by the activity-rest regimen, even after years of standard stimulation (Tetanic fusion frequency of 11 +/- 2 Hz after standard stimulation vs 30 +/- 3 Hz after demand regimen, p < 0.0001). After demand dynamic cardiomyoplasty there are no deaths. Quality of life is substantially improved with significant reduction of heart failure symptoms (New York Heart Association class: preoperative 3.0 +/- 0.0, post-demand dynamic cardiomyoplasty 1.5 +/- 0.2, p < 0.0001). In the subgroup of patients lightly stimulated from LD conditioning, exercise capacity tends to increase over preoperative values more than 2 years after operation (VO2 max: preoperative 12.3 +/- 0.7 vs 16.6 +/- 1.7 post-demand dynamic cardiomyoplasty, p = 0.05). CONCLUSIONS: Demand stimulation and mechanography of the LD wrap are safe procedures that could offer long-term benefits of dynamic cardiomyoplasty to patients with pharmacologically intractable heart failure.

Adult↗
PubMed1991

[Is ventilatory anaerobic threshold useful for preoperative assessment?].

The anaerobic threshold (VAT), obtained by measurement of ventilatory volume and by expiratory gas analysis, and the anaerobic threshold (LAT), obtained directly from the lactic acid value in the blood, were compared and evaluated during exercise load in 25 patients with mitral valve disease. Exercise loading was performed with an ergometer using a multistep method of increases of 5 W (Group A, 11 cases) or 10 W (Group B, 14 cases) per minute. The oxygen uptake value at the points of 0.5 mmol.l-1 and 1.0 mmol.l-1 increase in the lactic acid values when compared with the starting values were designated as 0.5 LAT and 1.0 LAT. VAT was found in 4 of 11 (36%) patients in Group A and in 12 of 14 (86%) patients in Group B and the ratio obtained was significantly higher in Group B than in A. The 0.5 LAT values for Group A and B were 2.4 +/- 0.5 and 2.2 +/- 0.3, respectively. The 1.0 LAT values were 2.9 +/- 0.7 and 2.7 +/- 0.4, and among the two groups no significant difference was found concerning 0.5 LAT or 1.0 LAT. VAT was seen in 16 or 25 patients and the average VAT value of the 16 was roughly at the midpoint between the average values for 0.5 LAT and 1.0 LAT. Therefore in patients in which VAT was seen with the expiratory gas method, VAT and LAT values were basically equivalent. However, in Group A, VAT was seen in only 4 of 11 patients and it is a fact that it is difficult to find VAT without a suitable exercise load.

Anaerobic Threshold↗