Preoperative Exercise Testing Research Articles

Prognostic significance of preoperative exercise tolerance in patients with early-stage lung cancer

ObjectiveTo investigate the influence of simple preoperative exercise tests as prognostic factors for early-stage lung cancer. MethodsThis single-institution retrospective study included consecutive patients who underwent pulmonary resection for stage 0 to I lung cancer between April 2017 and December 2019. Before surgery, 7 metabolic equivalents of task in the double Master 2-step test were loaded into the exercise echocardiogram. The relationship between prognosis and exercise stress test results in terms of availability, symptoms, and saturation of percutaneous oxygen was investigated. ResultsThis study included 862 patients with pathological stage 0 to I lung cancer. Among the 862 patients, 673 patients (78.1%) who were able to complete 7 metabolic equivalents of task exercise for 3 minutes without assistance were classified into the complete group. The 5-year survival of the complete group was significantly better than that of the incomplete group. Multivariable analysis revealed that age (hazard ratio, 1.06; P = .008), male sex (hazard ratio, 2.23; P = .011), carcinoembryonic antigen level >5 ng/mL (hazard ratio, 2.33; P = .011), and inability to complete 7 metabolic equivalents of task exercise (hazard ratio, 3.90; P < .001) were the prognostic factors. Patients in the older group who had the ability to complete exercise had a better prognosis than those in the younger group without the ability (P = .003). ConclusionsPreoperative exercise ability is a prognostic factor for early-stage lung cancer. Patients who can tolerate an exercise load of 7 metabolic equivalents of task, even if they are aged 70 years or older, have a better prognosis than patients younger than age 70 years without exercise tolerance.

Preoperative Stress Testing before Non-Cardiac Surgery.

The current guidelines from various medical societies provide a good summary of data regarding various preoperative exercise tests in patients prior to non-cardiac surgical interventions. However, there is no consensus among experts on the appropriateness of these methods for identifying risk groups for potential perioperative complications. A large volume of published studies describes the role of preoperative exercise stress testing impact in improving the prediction of potential cardiovascular (CV) risk in patients after non-cardiac surgery. Numerous stress tests are available in clinical practice, and the methods used and the best choice depends on the purpose of the study and the availability of equipment in the hospital. Traditionally, the value of exercise electrocardiography (ECG), or ECG stress test, has been based on the belief that it is beneficial for perioperative cardiac risk prediction. However, in the past two decades, the key role of this method has lost its importance due to the growing trend toward the use of imaging techniques. Moreover, in light of current trends, the six-minute walk test (6MWT) is a helpful tool in preoperative assessment and plays an important role in postoperative rehabilitation. Interestingly, the recent finding showed how 6MWT affects the risk of postoperative complications. Cardiopulmonary testing, as a dynamic clinical tool, determines the cardiorespiratory status of a patient. Various clinical indications for cardiopulmonary exercise testing include evaluation of therapy, stratification of risk factors, diagnosis of disease, and control of physical activity. Stress testing is one of the most practical ways of predicting perioperative risk and managing patients. This test is based on ischemia provoked by pharmacological agents or exercise. There is no established evidence of a significant advantage of pharmacological stress over exercise stress imaging in subjects who are capable enough to be physically active. All of these studies examined a stress test for induced myocardial ischemia. Currently, there are no data on the use of ischaemic stress tests, especially diastolic stress tests, in the assessment of perioperative risk before non-cardiac surgical interventions. We consider it promising and essential to continue research in this direction in patients with coronary heart disease and other categories of cardiac patients, in particular, comorbid and low-symptomatic individuals, before elective high-risk surgical interventions.

Haemodynamic determinants of improved aerobic capacity after tricuspid valve surgery in Ebstein anomaly

BackgroundAlthough tricuspid valve surgery improves functional capacity in patients with Ebstein anomaly, it is not always associated with improvement in aerobic capacity. The purpose of this study was to identify...

Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses.

BackgroundsThere is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery.MethodsA search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO2), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (VE/VCO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible.ResultsFifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO2 was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26–3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49–2.45). Preoperative AT and VE/VCO2 also demonstrated some positive trends. None of the included studies reported a negative trend.ConclusionsThis systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO2, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.Supplementary InformationThe online version contains supplementary material available at 10.1245/s10434-021-10251-3.

Better preoperative exercise function is associated with shorter hospital stay after paediatric pulmonary valve replacement or conduit revision.

Single centre retrospective cohort study of patients aged 8-18 years who underwent surgical pulmonary valve replacement. The primary predictor was preoperative percent predicted peak oxygen consumption, and primary outcome was total hospital length of stay. Clinical, imaging, and cardiopulmonary exercise test data were reviewed and compared to total hospital length of stay. Cox proportional hazards regression was used to examine the association between total hospital length of stay and percent predicted peak oxygen consumption. Three-hundred and seventy patients undergoing pulmonary valve replacement/conduit change between 2003 and 2017 at Boston Children's Hospital were identified. Ninety had preoperative cardiopulmonary exercise tests within 6 months of surgery. Exclusion for inadequate exercise data (n = 3) and imaging data (n = 1) left 86 patients for review. Patients with percent predicted peak oxygen consumption ≥ 70% (n = 46, 53%) had shorter total hospital length of stay (4.4 days) than the 40 with percent predicted peak oxygen consumption <70% (5.4 days, p = 0.007). Median percent predicted peak oxygen consumption increased over sequential surgical eras (p < 0.001), but total hospital length of stay did not correlate with surgical era, preoperative left ventricular function, or preoperative right ventricular dilation. Children undergoing surgical pulmonary valve replacement with better preoperative exercise capacity had shorter total hospital length of stay. Exercise capacity is a potentially modifiable factor prior to and after pulmonary valve replacement. Until more patients systematically undergo cardiopulmonary exercise tests, the full impact of optimisation of exercise capacity will not be known.

Using a Preoperative Exercise Test to Predict Postanesthesia Care Unit Admission in Patients Undergoing Bariatric Surgery

Background: Morbidly obese patients are prone to postoperative respiratory complications, which may result in their admission to the postanesthesia care unit (PACU). In this study, we evaluated how...

Adding objectivity to submaximal exercise testing by non-linear modelling of heart rate recovery profile (search-modelling)

Introduction Pre-operative exercise testing is widely used to assess perioperative risk. ‘Maximal’ tests, such as Cardiopulmonary Exercise Testing, are not always well tolerated. To overcome this sub-maximal exercise tests (SET) are increasingly being utilised. Though potentially better tolerated, results may be dependent on patient motivation and effort. Assessment of heart rate recovery (HRR), as a marker of underlying cardiac vagal activity, following SETs could potentially add objectivity. Several authors have unsuccessfully attempted to model HRR using a variety of non-linear functions(1). We hypothesised that a) an individual's HRR profile could be modelled using non-linear mixed effects modelling (NLME) and b) that the kinetics of an individual's HRR profile were the same, regardless of effort level. Methods Thirty-four healthy volunteers underwent three, six-minute SETs on a cycle ergometer. Individuals on beta-blockers or with contraindications to exercise testing were excluded. The first test was used to familiarise the volunteer with the test protocol and was undertaken at 20% of predicted maximum wattage (Wmax). The following two tests were delivered in a randomised order at 40% or 60% Wmax. Data on HRR was collected for 5-minutes on test cessation. HRR was modelled using the asymptotic regression function; Asymptote + (Maximum HR - Asymptote)*e-RateConstant*Time. Results The median age of the study population was 39 (range; 22-72) with 15% of the population possessing chronic co-morbidities. Figure 1 demonstrates the NLME model using a fit by maximum likelihood. Residual inspection revealed a homoscedastic distribution. The root mean square error (RMSE) for the model fitted values for both 40% and 60% Wmax was estimated at ±7bpm, demonstrating a good fit independent of work load. Modelling assumed that the asymptote and rate constant were fixed regardless of effort, however the maximum heart rate achieved on exercise cessation could vary between 40% and 60% Wmax. Discussion We suggest the rate constant (obtained from NLME modelling) could provide an index for an individual's fitness independent of patient work load. Further work is required to assess the minimum increase in HR required during SETs in order to establish a valid HRR profile and the influence of different types of exercise on HRR. SETs are easier to conduct, better tolerated and a cheaper more widely available alternative to maximal exercise testing. After further validation, we plan to begin clinical testing of this novel concept which has the potential to provide widespread access to objective exercise testing which can be applied easily in any pre-operative clinic scenario.

Adding objectivity to submaximal exercise testing by assessment of heart rate recovery – A healthy volunteer study (search)

Introduction Pre-operative exercise testing is widely used to assess perioperative risk. ‘Maximal’ tests, such as Cardiopulmonary Exercise Testing, are not always well tolerated. To overcome this sub-maximal exercise tests (SET) are increasingly being utilised. Though potentially better tolerated, results may be dependent on patient motivation and effort. Measuring heart rate recovery (HRR) after SETs could potentially add objectivity. Quantifying HRR by calculating the difference between HR on exercise cessation and at one/two minutes into the recovery period (HRR1/HRR2) has been widely described(1). This study sought to assess the influence of SET effort level on the reproducibility of HRR and evaluate the reproducibility of novel methods for quantifying HRR. Methods Thirty-four healthy volunteers underwent three, six-minute SETs on a cycle ergometer. Individuals on beta-blockers or with contraindications to exercise testing were excluded. The first test was used to familiarise the volunteer with the test protocol and was undertaken at 20% of predicted maximum wattage (Wmax). The following two tests were delivered in a randomised order at 40% or 60% Wmax. Data on HRR was collected for 5-minutes on test cessation. Area under the (HR vs time) curve (AUC) and an effort corrected version of AUC (EC-AUC) were derived as novel indices of HRR. To ascertain the reproducibility of HRR indices, the intra-class correlation coefficient (ICC) and paired t-tests were estimated. Eight volunteers returned for a second day of exercise testing to determine the test-retest reliability. Results The median age of the study population was 39 (range; 22-72) with 15% of the population possessing chronic co-morbidities. The ICC for HRR1 was 0.15 (95%CI; 0-0.43). For HRR2 the ICC was 0.35 (0-0.68). The novel AUC method achieved an ICC of 0.61 (0.27-0.8). EC-AUC achieved an ICC of 0.46 (0.14-0.69). The test-retest reliability of HRR1 at 40% and 60% Wmax was 0.16 (0-0.79) and 0 (0-0.74) respectively. For HRR2 the test-retest reliability at 40% and 60% Wmax was 0 (0-0.7) and 0.2 (0-0.83). For AUC the test-retest reliability at 40% and 60% was 0.79 (0.26-0.95) and 0.55 (0-0.9). The test-retest reliability of EC-AUC at 40% and 60% was 0.65 (0.02-0.92) and 0.44 (0-0.87). Discussion HRR1/HRR2 demonstrated poor reproducibility across differing effort levels, suggesting they are influenced by level of exertion. The AUC methods displayed moderate reproducibility across and between the differing effort levels and may therefore be a superior way to quantify HRR post SET.

Adding objectivity to Submaximal Exercise testing by Assessment of heart Rate ReCovery—a Healthy volunteer study (SEARCH)

Preoperative exercise testing is widely used to assess perioperative risk. ‘Maximal’ exercise tests, such as cardiopulmonary exercise testing, can place an unnecessary burden on patients and are not always well tolerated. To overcome this sub-maximal exercise tests (SET) are increasingly being utilised. Although potentially better tolerated, being ‘submaximal’, results may be dependent on patient motivation and effort. Measuring heart rate recovery (HRR) after SETs could potentially add objectivity and provide further insight into patient myocardial fitness. Quantifying HRR by calculating the difference between HR on exercise cessation and at 1/2 min into the recovery period (HRR1/HRR2)1 has been widely described. This study sought to assess the influence of SET effort level on the reproducibility of HRR and evaluate the reproducibility of novel methods for quantifying HRR. Thirty-four healthy volunteers underwent three 6-min SETs on a cycle ergometer. Individuals on beta-blockers or with contraindications to exercise testing were excluded. The first test was used to familiarise the volunteer with the exercise test protocol and was undertaken at 20% of the volunteers predicted maximum wattage (Wmax). The following two tests were delivered in a randomised order at 40% or 60% Wmax. Data on HRR were collected for 5 min on test cessation. Area under the (HR vs time) curve (AUC) and an effort corrected version of AUC (EC-AUC) were derived as novel indices of HRR. To ascertain the reproducibility of HRR indices, the intra-class correlation coefficient (ICC) and paired t-tests were estimated. The median age of the study population was 39 (range, 22–72) yr with 15% of the population possessing chronic co-morbidities. The ICC for HRR1 was 0.15 [95% confidence interval (CI), 0–0.43], mean difference 9.7 (P≤0.001; 95% CI, 4.3–15.1). For HRR2 the ICC was 0.35 (95% CI, 0–0.68), mean difference 15.4 (P≤0.001; 95% CI, 11.1–19.7). The novel AUC method achieved an ICC of 0.61 (95% CI, 0.27–0.8), mean difference 646 (P=0.05; 95% CI, 245.4–1038.2). EC-AUC achieved an ICC of 0.46 (95% CI, 0.14–0.69), mean difference 0.03 (P=0.01, 95% CI, 0.05–0.01). HRR1/HRR2 demonstrated poor reproducibility across differing effort levels, suggesting they are influenced by level of exertion. The AUC methods displayed moderate reproducibility and therefore may be a superior way to quantify HRR after SET. Further work is required to explore the effect of differing exercise regimes on the AUC methods of quantifying HRR and assess their utility as a perioperative risk predictor in patient cohorts. Medical Research Scotland Vacation Scholarship. 1.Adabag S, Pierpont GL. Heart 2013; 99: 1711–2

Fit for surgery? Perspectives on preoperative exercise testing and training

There is a consistent relationship between physical activity, physical fitness, and health across almost all clinical contexts, including the perioperative setting. Physiological measurements obtained during physical exercise may be used to infer the risk of adverse outcome after major surgery. In particular, data obtained from perioperative cardiopulmonary exercise testing have an expanding role in perioperative care. Such information may be used to inform a variety of changes in clinical practice, including interventions that may reduce the risk of perioperative adverse events. Specifically, for patients undergoing major cancer surgery there is a complex interplay between different cancer treatments, including neoadjuvant therapies (chemo- and chemo- plus radiotherapy), surgery, and physical fitness, and the modulation of these relationships by perioperative exercise interventions. Preoperative cardiopulmonary exercise testing provides an objective evaluation of physical fitness and has been used to provide an individualized risk profile in order to guide collaborative decision-making, inform the consent process, characterize and optimize co-morbidities, and to triage patients to perioperative care. Furthermore, studies evaluating exercise interventions aimed at increasing preoperative exercise capacity have established that training improves physical fitness. However, to date, this literature is largely composed of feasibility and pilot studies with small sample sizes, which are in general underpowered to assess clinical outcomes. Adequately powered prospective multicentre studies are needed to characterize the most effective means of improving patient fitness before surgery and to evaluate the impact of such improvements on surgical and disease-specific (e.g. cancer) outcomes.

Preoperative Exercise Testing Is a Better Predictor of Postoperative Complications than Pulmonary Function Testing for Patients with Lung Cancer

Objective: The aim of this preliminary study was to evaluate the feasibility of exercise testing (ET) for predicting postoperative complications in patients with impaired pulmonary function. Methods: Thirteen patients were prospectively enrolled. The enrollment criteria were FEV1.0% 8 by the Goddard classification or interstitial pneumonia on chest computed tomography. Patients underwent testing for pulmonary function, six-minute walking test (6MWT), and stair-climbing test (SCT). Postoperative cardiopulmonary complications (PCPCs) were recorded. Results: Four patients developed PCPCs. There were no significant differences between the patients with PCPCs (n = 4) and those without PCPCs (n = 9) for background data and PFT. The distances achieved in the 6MWT were 503 ± 72.7 m for patients without PCPCs and 369 ± 50.7 m for patients with PCPCs (p = 0.011). The SCT climbing heights were 20.4 ± 5.3 m for patients without PCPCs and 14.9 ± 4.0 m for patients with PCPCs (P = 0.187). Cut-off points, including a 6MFT distance of less than 400 m, SCT height lower than 15 m, and SCT climbing speed less than 8.5 m/min, were predictive of CPCP. Conclusions: Exercise testing is more feasible for predicting postoperative cardiopulmonary complications than stationary pulmonary function testing.

Predicted Versus Observed Peak Oxygen Consumption After Major Pulmonary Resection

The aim of this study was to verify the accuracy of predicted postoperative peak VO(2) in predicting the actual peak VO(2) after major pulmonary resection. This was a prospective longitudinal series of 110 consecutive patients who underwent lobectomy (101 patients) or pneumonectomy (9 patients), with complete preoperative and postoperative (3 months) cardiopulmonary exercise testing (CPET). Predicted postoperative peak VO(2) was calculated by subtracting from the preoperative peak VO(2) the contribution of unobstructed pulmonary segments removed during operation. Predicted postoperative peak VO(2) and actual postoperative peak VO(2) were compared by the paired sign test. The average value of preoperative peak VO(2) was 16.8 mL/kg/min or 64.1% of predicted. The actual value of postoperative peak VO(2) was 15.9 mL/kg/min or 64.4% of predicted. The actual postoperative peak VO(2) was higher than the predicted postoperative peak VO(2) (15.9 versus 13.1 mL/kg/min; p < 0.0001; 64.4% versus 50.1%; p < 0.0001). Of the 23 patients with a predicted postoperative peak VO(2) less than 10 mL/kg/min, 19 had an actual postoperative peak VO(2) greater than 10 mL/kg/min (average value 13.3 mL/kg/min). All 11 patients with a predicted postoperative peak VO(2) less than 35% of predicted had an actual postoperative peak VO(2) greater than 35% of predicted (average value, 55.8%). The prediction of postoperative peak V̇O(2) using the segmental technique was inaccurate. The use of predicted postoperative peak VO(2) for patient selection must be cautioned against; future studies are warranted to refine its estimation.

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.

Abstract 16773: Exercise Tolerance and Vo2 Are Improved in Patients Undergoing Fontan Conversion with Arrhythmia Surgery

Background: Exercise tolerance in Fontan patients is known to decline with advancing age. The impact of improving right atrial flow dynamics and eliminating anti-arrhythmic medications on exercise tolerance is not known. Hypothesis: Successful Fontan conversion with arrhythmia surgery results in improvement in exercise tolerance over time. Methods: We reviewed data on patients who underwent Fontan conversion at our center since 1994. Fontan conversion surgery included arrhythmia surgery with pacemaker implantation. Exercise duration, peak HR, respiratory quotient, VO2, age at most recent exercise test and postoperative interval were recorded. Continuous variables were compared using two-tailed t-test method. Results: Fontan conversion with arrhythmia surgery has been performed on 132 pts at our institution. Pre-operative exercise testing was performed in 88 pts, with paired follow-up exercise data available on 29 pts. The mean age at Fontan conversion was 22.7 years. The mean interval from surgery to the most recent exercise stress test was 4.8 years (0.5-14.1 yrs). The mean exercise duration at baseline was 69% predicted for age and improved to a mean of 78% predicted for age at follow-up (p=0.02, mean duration in minutes: 6.9 at baseline, 8 at follow-up). The mean VO2 predicted for age improved from 53% to 64% (p&lt;0.01, mean VO2 in ml/kg/min increased from 22.3 to 25.8) (see graph below for results). No significant change was seen in peak heart rate (148 vs 150 bpm, p=NS). Conclusions: In contrast to an expected decline in exercise tolerance with age in Fontan patients, successful Fontan conversion with arrhythmia surgery results in improvement in exercise endurance and oxygen consumption over a 5 yr follow-up period. Data was only available in a limited subset of patients undergoing Fontan conversion. These findings suggest that aggressive measures to improve hemodynamics in Fontan patients can result in improvement in functional status in adulthood.

Exercise blood pressure response and perioperative complications after major vascular surgery

Earlier studies have shown that hypertensive or hypotensive blood pressure (BP) response during a preoperative treadmill exercise test in patients with peripheral arterial disease is associated with a two-fold increased risk of cardiovascular events and mortality. However, it is unknown if these patients also experience an increased perioperative complication risk at major vascular surgery. In total 665 consecutive patients with peripheral arterial disease underwent elective major vascular surgery (carotid endarterectomy, abdominal aorta repair, or lower extremity revascularization). Perioperative complications (infection, myocardial infarction, angina pectoris, cardiac arrhythmia, heart failure, cerebrovascular accident or spinal cord ischemia, dialyses, amputation, thrombectomy, reoperation or death) were defined as occurring within 30 days after surgery and were collected using medical records. Hypertensive BP response was defined as a difference between exercise systolic BP and resting systolic BP of more than 55 mmHg. Hypotensive BP response was defined as a drop in exercise systolic BP below resting systolic BP. Patients with a hypertensive BP response during a preoperative exercise test (n = 66) showed a higher risk of early perioperative thrombectomy [hazard ratio (HR) 2.80 95% CI (1.24-6.33)] compared with patients with a normal BP response (n = 582). Patients with a hypotensive BP response (n = 18) showed an increased risk of perioperative myocardial infarction [HR 3.69 95% CI (1.08-12.64)] and cardiac complications [HR 2.90 95% CI (1.02-8.19)] compared with patients with a normal BP response. Patients with an abnormal BP response have more cardiovascular complications at elective major vascular surgery.

Anesthesia Literature Review

Anesthesia Literature Review

Exercise performance and quality of life following surgical repair of anomalous aortic origin of a coronary artery in the pediatric population

We sought to evaluate exercise performance and quality of life in children after surgical repair of anomalous aortic origin of a coronary artery with an interarterial course. Patients who had surgery from October 2001 to January 2007 were eligible for inclusion. Exercise performance and quality of life were prospectively assessed by maximal exercise tests and age-appropriate questionnaires, respectively. We used t tests to compare pre- and postoperative exercise data and quality-of-life scores to published normative data. We performed linear regression analyses to assess associations between demographic, anatomic, and exercise variables and quality-of-life score. Of 25/27 patients, 64% were boys, 68% had anomalous right coronary, 32% were asymptomatic. Average age at surgery was 10.8 (+/-4.1) years; median follow-up was 14.5 (2 to 48) months. Postoperative percent-predicted exercise values were: peak heart rate 97 (+/-6), working capacity 91 (+/-15), maximal oxygen consumption 82 (+/-16). In those who had preoperative exercise testing (n = 11), resting and maximal heart rates decreased significantly without significant change in exercise performance. Average child quality of life was 85/100 (+/-13) and parent-proxy 88 (+/-11) compared with normal scores of 83 (+/-15) and 88 (+/-12), respectively. There is mild chronotropic impairment in children and adolescents following anomalous coronary artery repair without a decline in exercise performance. This does not appear to impair their overall quality of life. Because long-term effects on heart rate, exercise performance, and quality of life are unknown, serial exercise tests should be included as routine care of these patients.

SIMPLIFIED RISK STRATIFICATION IN ELECTIVE COLORECTAL SURGERY

Audit is a compulsory part of practice and all outcomes are now scrutinized. Raw results may be used to compare performance but these may not accurately reflect case and patient mix. Risk stratification tools, such as American Society of Anaesthesiologists (ASA) and Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity (POSSUM), have been shown to predict morbidity and mortality at the expense of extra data collection. The Special Cooperative Audit of Rural Surgeons reported that two comorbidities increased mortality from 4% to 16, but this finding has not been confirmed. Our aim was to compare risk stratification tools and confirm or refute if comorbidities are accurate predictors of morbidity and mortality. We made use of an existing colorectal audit, which includes ASA, POSSUM, comorbidities and surgical outcomes. Our anaesthetic department provided data from preoperative cardiopulmonary exercise tests. A poor surgical outcome was defined as death, anastomotic leak and a complication requiring significant intervention. Data collection was complete for comorbidities, but only 79% cases had ASA scores, 72% completed POSSUM sets and 39% anaerobic threshold. POSSUM >30, ASA III and two comorbidities were all predictors of mortality and grade 3 complications. Anaerobic threshold <11 mL/min/kg did not predict poor surgical outcome. Anastomotic leak was not predicted by any of the scoring systems. ASA, POSSUM and the presence of two comorbidities were significant predictors of mortality and morbidity, excluding anastomotic leaks. Comorbidities are simple to collect and their correlation with outcome compares favourably with POSSUM. Comorbidities are a simple and quick method of risk stratification for colorectal surgery.

Cardiopulmonary Exercise Tests and Lung Cancer Surgical Outcome

Study objectives: Surgical resection remains the treatment of choice for anatomically resectable non-small cell lung cancer. However, the presence of associated comorbid conditions increases the risk of death and surgical complications. Several studies have evaluated the usefulness of preoperative exercise testing for predicting postoperative morbidity and mortality. The aim of this study was to establish whether exercise testing could predict poor surgical outcome in lung cancer surgery and whether the absolute value or percentage of predicted value is the better predictor of the surgical outcome. Design: The study was designed as a prospective study. Patients and setting: One hundred thirty patients with potentially operable lung cancer at Papworth Hospital over 2 years were recruited; of these, 101 underwent curative surgery. Interventions: Spirometry and cardiopulmonary exercise tests were performed for every patient (n 99), except for two patients with back problems. We also recorded the outcome of surgery, in particular, complications and mortality.

Cardiopulmonary Exercise Tests and Lung Cancer Surgical Outcome&lt;xref rid="AFF1"&gt;&lt;sup&gt;*&lt;/sup&gt;&lt;/xref&gt;

Surgical resection remains the treatment of choice for anatomically resectable non-small cell lung cancer. However, the presence of associated comorbid conditions increases the risk of death and surgical complications. Several studies have evaluated the usefulness of preoperative exercise testing for predicting postoperative morbidity and mortality. The aim of this study was to establish whether exercise testing could predict poor surgical outcome in lung cancer surgery and whether the absolute value or percentage of predicted value is the better predictor of the surgical outcome. The study was designed as a prospective study. One hundred thirty patients with potentially operable lung cancer at Papworth Hospital over 2 years were recruited; of these, 101 underwent curative surgery. Spirometry and cardiopulmonary exercise tests were performed for every patient (n = 99), except for two patients with back problems. We also recorded the outcome of surgery, in particular, complications and mortality. Mean maximum oxygen transport at peak exercise (Vo(2)peak) was 18.3 mL/kg/min (SD, 4.7 mL/kg/min), and mean percentage of predicted Vo(2)peak value was 84.4% (SD, 30%). Poor surgical outcome was significantly related to Vo(2)peak percentage of predicted (p < 0.01) but not to the actual oxygen uptake value. The use of the percentage of predicted Vo(2)peak value would be a better indicator of surgical outcome, since it predicts the surgical outcome better, and corrects for normal physiologic ranges. The threshold of Vo(2)peak for surgical intervention could be set between 50% and 60% of predicted without excess surgical mortality.