Cardiopulmonary Exercise Testing in Repaired Tetralogy of Fallot: Multiparametric Overview and Correlation with Cardiac Magnetic Resonance and Physical Activity Level

Patients with repaired Tetralogy of Fallot (rToF) typically report having preserved subjective exercise tolerance. Chronic pulmonary regurgitation (PR) with varying degrees of right ventricular (RV) dilation as assessed by cardiac magnetic resonance imaging (MRI) is prevalent in rToF and may contribute to clinical compromise. Cardiopulmonary exercise testing (CPET) provides an objective assessment of functional capacity, and the International Physical Activity Questionnaire (IPAQ) can provide additional data on physical activity (PA) achieved. Our aim was to assess the association between CPET values, IPAQ measures, and MRI parameters. All rToF patients who had both an MRI and CPET performed within one year between March 2019 and June 2021 were selected. Clinical data were extracted from electronic records (including demographic, surgical history, New York Heart Association (NYHA) functional class, QRS duration, arrhythmia, MRI parameters, and CPET data). PA level, based on the IPAQ, was assessed at the time of CPET. Eighty-four patients (22.8 ± 8.4 years) showed a reduction in exercise capacity (median peak VO2 30 mL/kg/min (range 25–33); median percent predicted peak VO2 68% (range 61–78)). Peak VO2, correlated with biventricular stroke volumes (RVSV: β = 6.11 (95%CI, 2.38 to 9.85), p = 0.002; LVSV: β = 15.69 (95% CI 10.16 to 21.21), p < 0.0001) and LVEDVi (β = 8.74 (95%CI, 0.66 to 16.83), p = 0.04) on multivariate analysis adjusted for age, gender, and PA level. Other parameters which correlated with stroke volumes included oxygen uptake efficiency slope (OUES) (RVSV: β = 6.88 (95%CI, 1.93 to 11.84), p = 0.008; LVSV: β = 17.86 (95% CI 10.31 to 25.42), p < 0.0001) and peak O2 pulse (RVSV: β = 0.03 (95%CI, 0.01 to 0.05), p = 0.007; LVSV: β = 0.08 (95% CI 0.05 to 0.11), p < 0.0001). On multivariate analysis adjusted for age and gender, PA level correlated significantly with peak VO2/kg (β = 0.02, 95% CI 0.003 to 0.04; p = 0.019). We observed a reduction in objective exercise tolerance in rToF patients. Biventricular stroke volumes and LVEDVi were associated with peak VO2 irrespective of RV size. OUES and peak O2 pulse were also associated with biventricular stroke volumes. While PA level was associated with peak VO2, the incremental value of this parameter should be the focus of future studies.

Depression and Anxiety Are Associated with Physical Performance in Patients Undergoing Cardiac Rehabilitation: A Retrospective Observational Study

Background: Cardiac rehabilitation (CR) combined with stress management training has been shown to be associated with fewer clinical events than CR alone. However, there have been no reports on the associations of CR with the psychological condition and detailed physical activities evaluated on the same day. Method: One hundred outpatients who participated in a CR program were graded on the hospital anxiety and depression scale (HADS). We divided them into a high HADS group (n = 32) and a normal HADS group (n = 68) and investigated by whole patients, ischemic heart disease (IHD) patients, and heart failure patients. Results: Overall, the patient age was 70.5 ± 9.6 years, the percentage of males was 73.0%, and the body mass index was 23.4 (21.7–26.0) kg/m2. In the high HADS group, overall functional mobility was poor and the distance in a two-minute walking test was short. Especially in IHD patients, the high HADS group showed high fat mass in body composition and low exercise tolerance and ventilator equivalents in cardiopulmonary exercise test. Conclusions: Depression and anxiety involved poor physical performance in CR outpatients and particularly involved low exercise tolerance in IHD patients. To evaluate accurate physical performance, it is necessary to investigate psychological condition.

Use of exogenic phosphocreatine in ICU rehabilitation of patients with COVID-19 (pilot study)

The objective: to establish the possible effectiveness of exogenous phosphocreatine as a component of pharmacological support during the resuscitation stage of rehabilitation measures in critically ill patients with COVID-19.Subjects and Methods. Within a randomized study, 21 patients diagnosed with COVID-19 were divided into two groups: Group 1 (patients received the infusion of exogenous phosphocreatine as part of intensive care) and Group 2 (patients received standard intensive care) against the background of rehabilitation measures. Patients were assessed for muscle strength using the MRC scale, exercise tolerance by Borg rating, oxygenation parameters, routine clinical laboratory blood tests, dependence on respiratory support, outcome on day 10 of therapy, and hospital outcome.Results. The effectiveness of the use of the exogenous phosphocreatine as a component of pharmacological support during the resuscitation stage of rehabilitation measures in critical patients has been confirmed by positive dynamics: an increase in muscle strength (the MRC score in the group receiving exogenous phosphocreatine on day 10 was 0.5 points higher) and an increase in exercise tolerance (Borg rating in the group receiving exogenous phosphocreatine on day 10 was 1.5 points higher), significant increase in oxygenation based on arterial blood saturation data, and significant increase in lymphocyte count by 25% in the group receiving exogenous phosphocreatine.Conclusion. Exogenous phosphocreatine is a candidate drug for pharmacological support during resuscitation stage of rehabilitation of critical patients with COVID-19.

Late Exercise Tolerance Testing Using a Dynamic High Intensity Interval Multidirectional Movement Protocol

ObjectiveAnalyze the utility of a 5-step exertional rehab protocol (ERP) that included High Intensity Interval Multi-Directional Movement (HIIT-MD) or step 5. We assessed the incidence and etiologies of exercise intolerance (EI) during Step 5 in concussed patients who tolerated maximal linear exertion.BackgroundExertional testing can be used to determine appropriate levels of exercise tolerance (ET) in concussed patients. Traditionally linear modalities have been used to determine max ET prior to clearance. HIIT-MD protocols can be the next appropriate step to bridge clearance for more dynamic activities.Design/MethodsRetrospective chart review included 130 step 5 trials for EI; of those, 72 had pre/postexercise King Devick (KD) and force plate (FP) testing. Patients were 10–59 years old and clinic visits occurred 2019–2020. EI rate was recorded and failure reason was documented by our clinic's concussion specialist. The difference between pre/post exercise KD and FP was investigated.ResultsOf 130 step 5 trials, 21.54% failed due to EI. Reason for EI included the onset of symptoms (82.1%), followed by signs of dysautonomia (39.3%). Symptoms and dysautonomia combined were noted in 35.7% of those with EI. Symptoms appeared in combination with another marker 69.6% of the time. The average change in KD times pre/post exercise testing was +2.52 seconds longer in the EI group compared to −2.45 seconds shorter in the ET group (p = 0.62). The EI group demonstrated an average change of 0.36 deg/sec sway velocity increase after exercise compared to 0.13 deg/sec in the ET group (p = 0.93).ConclusionsThere is evidence for the utility of a HITT-MD protocol for dynamic exercise/sports clearance. Exercise testing progression and concussion clearance should include a dynamic HITT-MD protocol to ascertain no late phase dynamic EI. Dysautonomia and/or vestibulocular aggravation may be contributors to late phase EI. If EI exists, identifying and targeting underlying causes can aid optimal recovery.

Subclinical Vestibular Deficits Illustrated in Patients With Exercise Intolerance After mTBI Using Force Plate Protocols

ObjectiveInvestigate the changes in sway velocity vestibular markers in mTBI patients with exercise intolerance (EI) during exertional testing as part of a 5-Step Exertional Rehab Protocol (ERP).BackgroundExertional testing can be used to determine one's therapeutic exercise threshold. A number of systems have been shown to be related to Exercise Intolerance (EI) including autonomic, cervical, and vestibular, and visual. Vestibular function can be measured before and after exercise and may shed light into its impact on EI.Design/MethodsRetrospective review of 342 trials of exertional testing in mTBI patients, ages 10–60, in 2020. Exertional testing was completed with pre/post force plate sway velocity calculated. Protocol A involved single leg stances, while protocol B involved 2 feet stances. A concussion specialist determined exercise tolerance (ET) by evaluating for the onset of signs/symptoms or cardiovagal dysautonomia.ResultsOf 342 exertional test trials, 34.8% exhibited EI due to symptom exacerbation and/or signs of autonomic dysfunction. Vestibular Force Plate sway velocities in both protocol A and B were significantly worsened in the EI group by an average change of 0.32 deg/sec, compared to those in the ET group who exhibited only an average change of 0.03 deg/sec sway velocity (p = 0.0004). The EI group using protocol A, showed an average change of 0.86 deg/sec compared to those in the ET group using protocol A, who exhibited only an average change of 0.03 deg/sec sway velocity (p = 0.0041). EI group using protocol B, showed an average change of 0.12 deg/sec sway velocity compared to those in the ET group using protocol B, who also exhibited an average change of 0.03 deg/sec (p = 0.0013).ConclusionsSubclinical vestibular markers such as sway velocity measures may be used to identify etiologies for EI in mTBI. Furthermore, these vestibular testing may be a subclinical measure that can aid exercise and sport clearance decisions.

Impact of Outpatient-Based Exercise Prescription on Stable Rheumatic Heart Disease and Post Coronavirus Infection Individual- A Case Report

The outcome of covid-19 patients with co-morbidities has reported to be poor. Post covid exercise-based rehabilitation may have a major role in improving exercise tolerance and quality of life in post-covid-19 patients with co-morbidities. This case report discusses the clinical scenario of a 35-year-old person who is a known case of stable rheumatic heart disease since 29 years and recently diagnosed with covid-19 moderate pneumonia. He was referred to post covid outpatient department for post-covid physiotherapy rehabilitation. After one month of structured exercise-based rehabilitation, improvement recorded in his SF-12 and 6-minute walk distance. COVID-19 patients with co-morbidities seemed to have a poor prognosis, according to various studies. Post covid exercise-based rehabilitation may have a major role in improving exercise tolerance and quality of life in post-covid-19 patients with co-morbidities. There is no structured rehabilitative protocol designed for such unusual combination as of now hence our study focuses on this lacunae. This case report discusses the clinical scenario of a 35-year-old person who is a known case of stable Rheumatic heart disease in the last 29 years and recently diagnosed with COVID-19 moderate pneumonia. He was referred to post covid outpatient department for post-covid physiotherapy rehabilitation. The individual followed a structured exercise-based rehabilitation protocol for one month 6 times/week and improvement recorded in his SF-12 and 6-minute walk distance. There was improvement in six-minute walk distance by 150 meters and rate of perceived exertion was also improved from 9 score to 7 in 6-20 borg scale post one month. In comparison to pre-Rehabilitation, SF-12 improved the quality of life in both physical and mental sore. This case report concluded that there was a definite improvement in the walking distance and quality of life of the patient after post COVID physiotherapy rehabilitation.