Preoperative submaximal cardiopulmonary exercise testing and its association with early postoperative complications

BJA open Pub Date : 2025-04-24 DOI:10.1016/j.bjao.2025.100407

Zyad J. Carr , Jean Charchaflieh , Andres Brenes-Bastos , Hugo He , Hung-Mo Lin , Amanda Jankelovits , Emily Gu , Jill Zafar , Fed Ghali , Wei S. Tan , Paul Heerdt

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Abstract

Background

Early postoperative complication risk prediction would enhance perioperative surveillance and resource allocation. Reports have described brief submaximal cardiopulmonary exercise testing (CPET) for the routine assessment of cardiopulmonary disease. Compared with conventional CPET, it can be performed in 6 min and is used to predict peak CPET measurements. We aimed to determine whether submaximal CPET-derived measures outperform structured surveys in early postoperative complication detection.

Methods

An institutional review board-approved, single-centre, open-label, clinical device trial was conducted. A total of 101 participants undergoing noncardiac surgery, aged >60 yr, with revised cardiac risk index ≤2, self-reported metabolic equivalents >4 (METs in ml O₂ kg⁻¹ min⁻¹; self-endorsed reliably climbing two flights of stairs), were enrolled. Participants completed a subjective METs assessment, Duke Activity Status Index, and submaximal CPET that derived peak oxygen uptake (VO₂, ml O₂kg⁻¹ min⁻¹), METs, and gas exchange-derived pulmonary capacitance (GXCAP, in ml O₂ beat^-1 kPa^-1). Elastic net regularisation machine learning identified feature importance among study measures for the primary endpoint (Postoperative Morbidity Survey [POMS] ≥1), secondary endpoints (cardiac, pulmonary and renal domains of the POMS [POMS-CPR ≥1]), and length of stay. Adjusted multivariable regression models were used to identify significance.

Results

Of 101 participants, 53 (52.4%) had POMS ≥1. GXCAP to peak VO₂ slope (GXCAP-VO₂) was associated with POMS ≥1 (OR_adj 0.94; 95% CI 0.89–0.99; P=0.011) and increasing length of stay (OR_adj 0.98; 95% CI 0.96–0.99; P=0.01). GXCAP-VO₂ slope (OR_adj 0.93; 95% CI 0.88–0.99; P=0.015) was associated with POMS-CPR ≥1.

Conclusions

Compared with structured surveys (subjective METs or Duke Activity Status Index) or conventional peak CPET values (VO₂ or METs), a novel measure, GXCAP-VO₂ slope, offered superior early postoperative complication discrimination in low-morbidity subjects. These preliminary findings support GXCAP-VO₂ slope as a compelling investigational target for early postoperative complication risk, supporting the use of CPET to enhance early postoperative complication prediction.

Clinical trial registration

NCT05743673.

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术前次最大心肺运动试验及其与术后早期并发症的关系

背景术后并发症风险预测有助于围手术期监测和资源配置。有报告描述了简短的亚最大心肺运动试验（CPET）用于常规评估心肺疾病。与传统的CPET相比，它可以在6分钟内完成，并用于预测CPET测量的峰值。我们的目的是确定在早期术后并发症检测中，亚最大cpet衍生测量是否优于结构化调查。方法进行了一项机构审查委员会批准的、单中心、开放标签的临床器械试验。101名接受非心脏手术的参与者，年龄60岁，修正心脏风险指数≤2，自我报告代谢当量4 (METs in ml O2 kg - 1 min - 1；自我认可可靠地爬了两段楼梯)的人被纳入了研究。参与者完成了主观代谢当量评估、杜克活动状态指数（Duke Activity Status Index）和亚最大值CPET， CPET得出了峰值摄氧量（VO2, ml O2kg -1 min -1）、代谢当量和气体交换得出的肺电容（GXCAP，单位ml O2 -1 kPa-1）。弹性网正则化机器学习确定了主要终点（术后发病率调查[POMS]≥1）、次要终点（POMS的心脏、肺和肾领域[POMS- cpr≥1]）和住院时间的研究措施中的特征重要性。采用调整后的多变量回归模型来确定显著性。结果101例患者中，53例（52.4%）POMS≥1。GXCAP-VO2峰斜率（GXCAP-VO2）与POMS≥1相关(ORadj 0.94；95% ci 0.89-0.99；P=0.011)，住院时间增加(ORadj = 0.98；95% ci 0.96-0.99；P = 0.01)。GXCAP-VO2斜率(ORadj 0.93；95% ci 0.88-0.99；P=0.015)与POMS-CPR≥1相关。结论与结构化调查（主观METs或Duke Activity Status Index）或传统的峰值CPET值（VO2或METs）相比，一种新的测量方法GXCAP-VO2斜率在低发病率患者中提供了更好的早期术后并发症识别能力。这些初步发现支持GXCAP-VO2斜率作为早期术后并发症风险的一个有说服力的研究目标，支持使用CPET来增强早期术后并发症的预测。临床试验注册编号nct05743673。

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