Impaired cardiopulmonary reserve in an elderly population is related to postoperative morbidity and length of hospital stay after radical cystectomy.

OBJECTIVE: To determine the relationship of preoperatively measured cardiorespiratory function, to the development of postoperative complications and length of hospital stay (LOS) in a cohort of patients undergoing radical cystectomy (RC), as RC and conduit formation is curative but is associated with significant postoperative morbidity and mortality. PATIENTS AND METHODS: Consecutive patients planned to have RC underwent cardiopulmonary exercise testing (CPET) to a standardised protocol. The results of the CPET were 'blinded' from the clinicians involved in the care of the patients. Patients were prospectively monitored for the primary outcome of postoperative complications, as defined by a validated classification (Clavien-Dindo). Secondary outcome included LOS and mortality. RESULTS: In all, 82 patients underwent CPET before RC. Eight patients did not subsequently undergo RC and a further five did not exercise sufficiently to allow for appropriate determination of the cardiopulmonary variables of interest. There was a significant difference in LOS between those patients who had a major perioperative complication (Clavien score > 3) and those that did not (16 vs 30 days; P < 0.001; hazard ratio [HR] 3.6, 95% confidence interval [CI] 2.1-6.3). The anaerobic threshold (AT) remained as the only significant independent predictor variable for the presence or absence of major postoperative complications (odds ratio 0.74, 95% CI 0.57-0.97; P = 0.03). When the optimal predictive value of AT of 12 mL/min/kg was used as a fitness marker, there was a significant relationship between fitness and LOS (median LOS: 'unfit' 22 days vs 'fit' 16 days; HR 0.47, 95% CI 0.28-0.80; P = 0.006) CONCLUSION: Impaired preoperative cardiopulmonary reserve was related to major morbidity, prolonged LOS and increased use of critical care resource after RC. This has important health and economic implications for risk assessment, rationalisation of postoperative resource and the potential for therapeutic preoperative intervention with exercise therapy.

Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation.

Liver transplantation has a significant early postoperative mortality rate. An accurate preoperative assessment is essential for minimizing mortality and optimizing limited donor organ resources. This study assessed the feasibility of preoperative submaximal cardiopulmonary exercise testing (CPET) for determining the cardiopulmonary reserve in patients being assessed for liver transplantation and its potential for predicting 90-day posttransplant survival. One hundred eighty-two patients underwent CPET as part of their preoperative assessment for elective liver transplantation. The 90-day mortality rate, critical care length of stay, and hospital length of stay were determined during the prospective posttransplant follow-up. One hundred sixty-five of the 182 patients (91%) successfully completed CPET; this was defined as the ability to determine a submaximal exercise parameter: the anaerobic threshold (AT). Sixty of the 182 patients (33%) underwent liver transplantation, and the mortality rate was 10.0% (6/60). The mean AT value was significantly higher for survivors versus nonsurvivors (12.0 ± 2.4 versus 8.4 ± 1.3 mL/minute/kg, P < 0.001). Logistic regression revealed that AT, donor age, blood transfusions, and fresh frozen plasma transfusions were significant univariate predictors of outcomes. In a multivariate analysis, only AT was retained as a significant predictor of mortality. A receiver operating characteristic curve analysis demonstrated sensitivity and specificity of 90.7% and 83.3%, respectively, with good model accuracy (area under the receiver operating characteristic curve = 0.92, 95% confidence interval = 0.82-0.97, P = 0.001). The optimal AT level for survival was defined to be >9.0 mL/minute/kg. The predictive value was improved when the ideal weight was substituted for the actual body weight of a patient with refractory ascites, even after a correction for the donor's age. In conclusion, the preoperative cardiorespiratory reserve (as defined by CPET) is a sensitive and specific predictor of early survival after liver transplantation. The predictive value of CPET requires further evaluation.

Submaximal exercise testing predicts perioperative hospitalization after aortic aneurysm repair.

BACKGROUND: Aortic aneurysm repair is a high-risk surgical procedure. Patients are often elderly, with multiple comorbidities that predispose them to perioperative morbidity. Use of endovascular aneurysm repair (EVAR) has increased due to reduced early perioperative risk. This study assessed whether preoperative cardiopulmonary exercise testing (CPET) could be used to predict morbidity and hospital length of stay (LOS) after aortic aneurysm repair. METHODS: A total of 185 patients underwent surgical repair (84 open repairs, 101 EVAR) and had adequate determination of a submaximal CPET parameter (anaerobic threshold). RESULTS: Patient comorbidities and cardiorespiratory fitness, derived from CPET, were similar between surgical procedures. Patients undergoing EVAR had fewer complications (10% vs 32%; P<.0001) and shorter mean (standard deviation [SD]) hospital LOS of 5.7 (9.3) days vs 14.4 (10.9) days compared with open repair (P<.0001). The hospital LOS was significantly increased in patients with one or more complications in both groups compared with those with no complications. In the open repair group, the level of fitness, as defined by anaerobic threshold, was an independent predictor of postoperative morbidity and hospital LOS. When the optimal anaerobic threshold (10 mL/min/kg) derived from receiver operator curve analysis was used as a cutoff value, unfit patients stayed significantly longer than fit patients in critical care (mean, 6.4 [SD, 6.9] days vs 2.4 [SD, 2.9] days; P=.002) and in the hospital (mean, 23.1 [SD, 14.8] days vs 11.0 [SD, 6.1] days; P<.0001). In contrast, fitness in the EVAR group was not predictive of postoperative morbidity but did have predictive value for hospital LOS. CONCLUSIONS: Cardiorespiratory fitness holds significant clinical value before aortic aneurysm repair in predicting postsurgical complications and duration of critical care and hospital LOS. Preoperative measurement of fitness could then direct clinical management with regard to operative choice, postoperative resource allocation, and informed patient decision making.

Submaximal cardiopulmonary exercise testing predicts complications and hospital length of stay in patients undergoing major elective surgery.

OBJECTIVE: To investigate the null hypothesis that an objective, noninvasive technique of measuring cardiorespiratory reserve, does not improve the preoperative assessment of patient risk of postoperative complications, when compared with a standard questionnaire-based assessment of functional capacity. SUMMARY BACKGROUND DATA: Postoperative complications may be increased in patients with reduced cardiorespiratory function. Activity questionnaires are subjective, whereas cardiopulmonary exercise testing (CPET) provides an objective definition of cardiorespiratory reserve. The use of preoperative CPET to predict postoperative complications is not fully defined. METHOD: CPET and an algorithm-based activity assessment (Veterans Activity Questionnaire Index [VASI]) were performed on consecutive patients (n = 171) with low subjective functional capacity (metabolic equivalent score [METS] < 7), being assessed for major surgery. A morbidity survey determined postoperative day 7 complications. Logistic regression defined independent predictors of complication group. Receiver-operating curve (ROC) analysis defined the predictive value of CPET to outcome. P < 0.05 value demonstrated significance. RESULTS: Objective cardiorespiratory reserve did not differ between operated (n = 116) and nonoperated patients (n = 55). Median complication rate on postoperative day 7 was 1. Patients with >1 complication had an increase in hospital LOS compared to the group with < or =1 complication (26 vs. 10 days; P < 0.001). Anaerobic threshold (AT) was higher in the group with < or =1 complication (11.9 vs. 9.1 mL/kg/min; P = 0.001) and demonstrated high accuracy (AUC = 0.85), sensitivity (88%), and specificity (79%), at an optimum AT of 10.1 mL/kg/min (defined by the furthest left point on the ROC curve). AT, VASI, and surgical reintervention were independent predictors of complication group. Preoperative AT significantly improved outcome prediction when compared with the use of VASI alone. CONCLUSION: An objective measure of cardiorespiratory reserve was an independent predictor of a major surgical group with increased postoperative complications and hospital LOS. AT measurement significantly improved outcome prediction compared with an algorithm-based activity assessment.

High-intensity interval training (HIT) for effective and time-efficient pre-surgical exercise interventions.

The advancement of perioperative medicine is leading to greater diversity in development of pre-surgical interventions, implemented to reduce patient surgical risk and enhance post-surgical recovery. Of these interventions, the prescription of pre-operative exercise training is gathering momentum as a realistic means for enhancing patient surgical outcome. Indeed, the general benefits of exercise training have the potential to pre-operatively optimise several pre-surgical risks factors, including cardiorespiratory function, frailty and cognitive function. Any exercise programme incorporated into the pre-operative pathway of care needs to be effective and time efficient in that any fitness gains are achievable in the limited period between the decision for surgery and operation (e.g. 4 weeks). Fortunately, there is a large volume of research describing effective and time-efficient exercise training programmes within the discipline of sports science. Accordingly, the objective of our commentary is to synthesise contemporary exercise training research, both from non-clinical and clinical populations, with the overarching aim of informing the development of effective and time-efficient pre-surgical exercise training programmes. The development of such exercise training programmes requires the careful consideration of several key principles, namely frequency, intensity, time, type and progression of exercise. Therefore, in light of more recent evidence demonstrating the effectiveness and time efficiency of high-intensity interval training-which involves brief bouts of intense exercise interspersed with longer recovery periods-the principles of exercise training programme design will be discussed mainly in the context of such high-intensity interval training programmes. Other issues pertinent to the development, implementation and evaluation of pre-operative exercise training programmes, such as individual exercise prescription, training session monitoring and potential barriers and risks to high-intensity exercise are also discussed. The evidence presented suggests that individually prescribed and supervised high-intensity interval training programmes, encompassing a variety of exercise modes represent an effective and safe means of exercise therapy prior to surgery.