Cardiopulmonary Exercise Testing Following Open Repair for a Proximal Thoracic Aortic Aneurysm or Dissection

Cardiac rehabilitation and acute aortic dissection: understanding and addressing the evidence GAP a systematic review

Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO2 max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.

Improved Maximal Workload and Systolic Blood Pressure After Cardiac Rehabilitation Following Thoracic Aortic Repair: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

It is of clinical importance to gain more knowledge about the risks and benefits of exercise in patients recovering from thoracic aortic repair. Therefore, the aim of this review was to perform a meta-analysis on changes in cardiorespiratory fitness, blood pressure, and the incidence of adverse events during cardiac rehabilitation (CR) in patients recovering from thoracic aortic repair.

REVIEW METHODS

We performed a systematic review and random-effects meta-analysis of outcomes before versus after outpatient CR in patients recovering from thoracic aortic repair. The study protocol was registered (PROSPERO CRD42022301204) and published. MEDLINE, EMBASE, and CINAHL were systematically searched for eligible studies. Overall certainty of evidence was scored with Grading of Recommendations Assessment, Development, and Evaluation (GRADE).

SUMMARY

We included five studies with data from in total 241 patients. Data from one study could not be used in our meta-analysis because they were provided in a different unit of measure. Four studies with data of 146 patients were included in the meta-analysis. The mean maximal workload increased with 28.7 W (95% CI: 21.8-35.6 W, n = 146, low certainty of evidence). The mean systolic blood pressure during exercise testing increased with 25.4 mm Hg (95% CI: 16.6-34.3, n = 133, low certainty of evidence). No exercise-induced adverse events were reported. These outcomes indicate that CR seems beneficial and safe to improve exercise tolerance in patients recovering from thoracic aortic repair, although outcomes were based on data from a small, heterogeneous group of patients.

2022 ACC/AHA guideline for the diagnosis and management of aortic disease: A report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Brazilian Society for Angiology and Vascular Surgery guidelines on abdominal aortic aneurysm

The Brazilian Society of Angiology and Vascular Surgery, through the Guidelines Project, presents new Abdominal Aortic Aneurysm Guidelines, on the subject of care for abdominal aortic aneurysm patients. Its development prioritized descriptive guidelines, using the EMBASE, LILACS, and PubMed databases. References include randomized controlled trials, systematic reviews, meta-analyses, and cohort studies. Quality of evidence was evaluated by a pair of coordinators, aided by the RoB 2 Cochrane tool and the Newcastle Ottawa Scale forms. The subjects include juxtarenal aneurysms, infected aneurysms, and new therapeutic techniques, especially endovascular procedures. The current version of the guidelines include important recommendations for the primary topics involving diagnosis, treatment, and follow-up for abdominal aortic aneurysm patients, providing an objective guide for medical practice, based on scientific evidence and widely available throughout Brazil.

Hemodynamic Response in Ascending Aorta Surgery Patients during Moderate Intensity Resistance Training

Background

In patients undergoing ascending aortic surgery (AAS), postsurgical physical exercise with a safe and effective exercise prescription is recommended. Resistance training is associated with blood pressure (BP) elevations that may increase the risk of new aortic dissection or rupture. However, the acute hemodynamic response to resistance training for this patient group is unknown.

Aim

The aim of this study was to investigate peak systolic BP (SBP) increases in AAS patients during moderate intensity resistance training.

Methods

SBP was measured continuously beat-to-beat with a noninvasive method during three sets of leg presses at moderate intensity. A 15-repetition maximum strength test was performed to estimate the maximal amount of resistance a participant could manage 15 times consecutively (equivalent to approximately 60-65% of their maximum strength).

Results

The study had 48 participants in total, i.e., 24 cases and 24 controls. Both groups consisted of 10 females (42%) and 14 males (58%). The case group had a mean age of 60.0 (SD ± 11.9) years and a mean of 16.3 months since surgery (minimum 4.4 and maximum 39.6 months). 22 of the 24 cases received antihypertensive medication. The median baseline BP was 119/74 mmHg among cases and 120/73 mmHg among controls. During the first set of leg presses, the median peak SBP was 152 mmHg, in the second set 154 mmHg, and in the third set 165 mmHg. Corresponding values in controls were 170 mmHg, 181 mmHg, and 179 mmHg. The highest peak SBP registered in an AAS patient was 190 mmHg and in any healthy control was 287 mmHg.

Conclusion

The findings indicate that AAS patients in control of their BP have the endurance to perform 3 sets of resistance training at moderate intensity as their SBP increases with a maximum of 39% from the baseline compared to the 51% increase in the control group.

Efficacy and Safety of Exercise Testing and Rehabilitation for Aortic Dissection Patients: A SCOPING REVIEW

OBJECTIVE

Although physical exercise has established benefits for long-term cardiovascular health, concern regarding further aortic events has limited the evidence for exercise among aortic dissection (AD) patients. The objective was to perform a scoping review of the current concepts and gaps in the literature regarding the benefit and safety of cardiovascular testing and rehabilitation among post-AD patients.

REVIEW METHODS

A scoping review of the literature search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Eligibility criteria included any studies with AD in relation to exercise rehabilitation or testing and physical or mental health. Electronic databases were queried for relevant studies (last queried, November 1, 2021).

RESULTS

Six observational studies were included with a total of 381 patients with AD, all of whom underwent surgical intervention. Study heterogeneity prevented data synthesis and a formal systematic review, although four dominant themes emerged: cardiovascular-related outcomes, aorta-related outcomes, quality of life (QoL), and serious adverse events. Patients with AD have reduced baseline physical capacity and QoL. Rehabilitation programs may increase both physical status and QoL. Rates of serious adverse rates are minimal yet poorly defined.

CONCLUSIONS

Within the context of apparent benefits from cardiovascular testing and rehabilitation for patients with AD who have undergone intervention, this scoping review highlights the need for increased comparative research specific to exercise among patients with AD and outcomes such as mortality and reinterventions.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate. Structure: Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease" provides recommendations to guide clinicians in the diagnosis, genetic evaluation and family screening, medical therapy, endovascular and surgical treatment, and long-term surveillance of patients with aortic disease across its multiple clinical presentation subsets (ie, asymptomatic, stable symptomatic, and acute aortic syndromes).

METHODS

A comprehensive literature search was conducted from January 2021 to April 2021, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, CINHL Complete, and other selected databases relevant to this guideline. Additional relevant studies, published through June 2022 during the guideline writing process, were also considered by the writing committee, where appropriate.

STRUCTURE

Recommendations from previously published AHA/ACC guidelines on thoracic aortic disease, peripheral artery disease, and bicuspid aortic valve disease have been updated with new evidence to guide clinicians. In addition, new recommendations addressing comprehensive care for patients with aortic disease have been developed. There is added emphasis on the role of shared decision making, especially in the management of patients with aortic disease both before and during pregnancy. The is also an increased emphasis on the importance of institutional interventional volume and multidisciplinary aortic team expertise in the care of patients with aortic disease.

Individualized exercise prescription and cardiac rehabilitation following a spontaneous coronary artery dissection or aortic dissection

Aims

Prescribed aerobic-based exercise training is a low-risk fundamental component of cardiac rehabilitation (CR). Secondary prevention therapeutic strategies following a spontaneous coronary artery dissection (SCAD) or aortic dissection (AD) should include CR. Current exercise guidance for post-dissection patients recommends fundamental training components including target heart rate zones are not warranted. Omitting fundamental elements from exercise prescriptions risks safety and makes it challenging for both clinicians and patients to understand and implement recommendations in real-world practice. We review the principles of exercise prescription for CR, focusing on translating guidelines and evidence from well-studied high-risk CR populations to support the recommendation that exercise testing and individualized exercise prescription are important for patients following a dissection.

Methods and results

When patients self-perceive exercise intensity there is a tendency to underestimate intensities within metabolic domains that should be strictly avoided during routine exercise training following a dissection. However, exercise testing associated with CR enrolment has gained support and has not been linked to adverse events in optimally medicated post-dissection patients. Graded heart rate and blood pressure responses recorded throughout exercise testing provide key information for developing an exercise prescription. An exercise prescription that is reflective of medical history, medications, and cardiorespiratory fitness optimizes patient safety and yields improvements in blood pressure control and cardiorespiratory fitness, among other benefits.

Conclusion

This clinical practice and education article demonstrates how to develop and manage a CR exercise prescription for post-acute dissection patients that can be safe and effective for maintaining blood pressure control and improving cardiorespiratory fitness pre-post CR.

Is Exercise Blood Pressure Putting the Brake on Exercise Rehabilitation after Acute Type A Aortic Dissection Surgery?

(1) Background: Exercise is recommended to improve physical fitness in patients recovering from acute type A aortic dissection (ATAAD). However, surgery corrects the diseased blood vessels and reduces the risk of ATAAD, but it does not redefine a safe exercise blood pressure (BP) threshold. This review aimed to discuss whether the safe threshold of exercise BP can be upregulated after ATAAD surgery to increase exercise intensity with additional benefits. (2) Data sources: The PubMed databases were searched with the keywords “type A acute aortic dissection surgery”, “exercise”, “BP”, “stress”, and variations of these terms. (3) Study selection: Data from clinical trials, guidelines, and recent reviews were selected for review. (4) Results: Regular exercise can be considered a cardioprotective intervention for aortic dissection patients by attenuating hemodynamic responses at rest and during exercise. Previous studies have mainly focused on moderate-intensity aerobic exercise. In practice, the exercise systolic BP of some patients was higher than 160 mm Hg without adverse events, which indicates that the training intensity may be underestimated for patients after ATAAD surgery. Limited studies suggest a light-to-moderate resistance training for selected patients because it may cause a greater increase in BP. (5) Conclusions: Moderate-intensity continuous aerobic exercise supplemented by low-intensity resistance training is appropriate for cardiac rehabilitation after ATAAD surgery. The BP increase based on the normal exercise BP response, corresponding to the moderate-intensity is relatively safe. For high-risk post-ATAAD patients, considering the overall volume of training, personalizing the exercise regimen to remain within “safe” BP limits, and avoiding excessive fluctuations in BP should be the primary considerations for exercise training.

Subjective assessment underestimates surgical risk: On the potential benefits of cardiopulmonary exercise testing for open thoracoabdominal repair

Background

Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the preoperative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies.

Methods

As part of routine preoperative patient contact, patients scheduled for major surgery were prospectively “eyeballed” (ICE) by two experienced clinicians before more detailed history taking that also included the American Society of Anesthesiologists score classification. Each patient was subjectively judged to be either “frail” or “not frail” by ICE and “fit” or “unfit” from a thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of postoperative outcomes using established CPET “cut‐off” metrics incorporating peak pulmonary oxygen uptake, V̇O_2PEAK at the anaerobic threshold (V̇O₂‐AT), and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single‐center prospective National Health Service database. Data were analyzed using the Chi‐square automatic interaction detection decision tree method.

Results

A total of 127 patients were examined that comprised 58% male and 42% female patients aged 69 ± 10 years with a body mass index of 29 ± 7 kg/m². Patients were poorly conditioned with a V̇O_2PEAK almost 20% lower than predicted for age, sex‐matched healthy controls with 35% exhibiting a V̇O₂‐AT < 11 ml/kg/min. Disagreement existed between the subjective assessments of risk with ∼34% of patients classified as not frail on ICE were considered unfit by notes review (p < .0001). Furthermore, ∼35% of patients considered not frail on ICE and ∼31% of patients considered fit by notes review exhibited a V̇O₂‐AT < 11 ml/kg/min, and of these, ∼28% and ∼19% were classified as intermediate to high risk.

Conclusions

These findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help us to improve perioperative risk assessment and better direct critical care provision in patients scheduled for “high‐stakes” surgery including open thoracoabdominal aortic aneurysm repair.

Evolution of Early Postoperative Cardiac Rehabilitation in Patients with Acute Type A Aortic Dissection

Introduction: Surgically treated acute type A aortic dissection (ATAAD) patients are often restricted from physical exercise due to a lack of knowledge about safe blood pressure (BP) ranges. The aim of this study was to describe the evolution of early postoperative cardiac rehabilitation (CR) for patients with ATAAD. Methods: This is a retrospective study of 73 patients with ATAAD who were referred to the CR department after surgery. An incremental symptom-limited exercise stress test (ExT) on a cyclo-ergometer was performed before and after CR, which included continuous training and segmental muscle strengthening (five sessions/week). Systolic and diastolic blood pressure (SBP and DBP) were monitored before and after all exercise sessions. Results: The patients (78.1% male; 62.2 ± 12.7 years old; 54.8% hypertensive) started CR 26.2 ± 17.3 days after surgery. During 30.4 ±11.6 days, they underwent 14.5 ± 4.7 sessions of endurance cycling training, and 11.8 ± 4.3 sessions of segmental muscle strengthening. At the end of CR, the gain of workload during endurance training and functional capacity during ExT were 19.6 ± 10.2 watts and 1.2 ± 0.6 METs, respectively. The maximal BP reached during endurance training was 143 ± 14/88 ± 14 mmHg. The heart rate (HR) reserve improved from 20.2 ± 13.9 bpm to 33.2 ± 16.8 bpm while the resting HR decreased from 86.1 ± 17.4 bpm to 76.4 ± 13.3 bpm. Conclusion: Early post-operative exercise-based CR is feasible and safe in patients with surgically treated ATAAD. The CR effect is remarkable, but it requires a close BP monitoring and supervision by a cardiologist and physical therapist during training.

Gait speed is a preoperative indicator of postoperative events after elective proximal aortic surgery

OBJECTIVE

The study objective was to evaluate whether 5-m gait speed, an established marker of frailty, is associated with postoperative events after elective proximal aortic surgery.

METHODS

We performed a retrospective review of 435 patients aged more than 60 years who underwent elective proximal aortic surgery, defined as surgery on the aortic root, ascending aorta, or aortic arch through median sternotomy. Patients completed a 5-m gait speed test within 30 days before surgery. We evaluated the association between categoric (slow, ≤0.83 m/s and normal, >0.83 m/s) and continuous gait speed and the likelihood of experiencing the composite outcome before and after adjustment for European System for Cardiac Operative Risk Evaluation II. The composite outcome included in-hospital mortality, renal failure, prolonged ventilation, and discharge location. Secondary outcomes were 1-year mortality and 5-year survival.

RESULTS

Of the study population, 30.3% (132/435) were categorized as slow. Slow walkers were significantly more likely to have in-hospital mortality, prolonged ventilation, and renal failure, and were less likely to be discharged home (all P < .05). The composite outcome was 2 times more likely to occur for slow walkers (gait speed categoric adjusted odds ratio, 2.08; 95% confidence interval, 1.27-3.40; P = .004). Moreover, a unit (1 m/s) increase in gait speed (continuous) was associated with 73% lower risk of experiencing the composite outcome (odds ratio, 0.27; 95% confidence interval, 0.11-0.68; P = .006).

CONCLUSIONS

Slow gait speed is a preoperative indicator of risk for postoperative events after elective proximal aortic surgery. Gait speed may be an important tool to complement existing operative risk models, and its application may identify patients who may benefit from presurgical and postsurgical rehabilitation.

Effectiveness of early rehabilitation following aortic surgery: a nationwide inpatient database study

OBJECTIVE

Exercise immediately after aortic surgery is controversial with limited evidence. The present study aimed to assess whether early rehabilitation commencing within 3 days of aortic surgery improves physical functions at discharge more than usual care in patients after aortic surgery.

METHODS

We used the Japanese Diagnosis Procedure Combination database, a nationwide inpatient database from more than 1600 acute care hospitals that covers approximately 75% of all intensive care unit (ICU) beds in Japan. We identified patients who underwent open or endovascular aortic surgery and were admitted to the ICU between July 2010 and March 2018. Patients beginning rehabilitation within 3 days of aortic surgery were defined as the early rehabilitation group and the remaining patients as the usual care group. We used inverse probability of treatment weighting analyses to compare outcomes between the two groups.

RESULTS

Among 121,024 eligible patients, there were 44,746 (37.0%) in the early rehabilitation group and 76,278 (63.0%) in the usual care group. In inverse probability of treatment weighting analyses, Barthel index scores at discharge were significantly higher in the early rehabilitation group than in the usual care group (difference, 4.0; 95% confidence interval, 2.8-5.2). The early rehabilitation group had significantly lower in-hospital mortality, lower total hospitalization costs, shorter ICU stay, and shorter hospital stay than the usual care group.

CONCLUSION

Early rehabilitation within 3 days of aortic surgery was associated with improved physical functions at discharge, shorter ICU and hospital stays, and lower hospitalization costs without increased mortality.

Cardiorespiratory Fitness After Open Repair for Acute Type A Aortic Dissection - A Prospective Study

Cardiorespiratory fitness (as measured by peak oxygen consumption [VO2peak]) is an independent predictor of cardiovascular disease and all-cause mortality. Limited data exist on VO2peak following repair for an acute type A aortic dissection (ATAAD) or proximal thoracic aortic aneurysm (pTAA). This study prospectively evaluated VO2peak, functional capacity, and health-related quality of life (HR-QOL) following open repair. Participants with a history of an ATAAD (n = 21) or pTAA (n = 43) performed cardiopulmonary exercise testing (CPX), 6-minute walk testing, and HR-QOL at 3 (early) and 15 (late) months following open repair. The median age at time of surgery was 55-years-old and 60-years-old in the ATAAD and pTAA groups, respectively. Body mass index significantly increased between early and late timepoints for both ATAAD (p = 0.0245, 56% obese) and pTAA groups (p = 0.0045, 54% obese). VO2peak modestly increased by 0.8 mLO2·kg-1·min-1 within the ATAAD group (p = 0.2312) while VO2peak significantly increased by 2.2 mLO2·kg-1·min-1 within the pTAA group (p = 0.0003). Anxiety significantly decreased in the ATAAD group whereas functional capacity and HR-QOL metrics (social roles and activities, physical function) significantly improved in the pTAA group (p values < 0.05). There were no serious adverse events during CPX. Cardiorespiratory fitness among the ATAAD group remained 36% below predicted normative values >1 year after repair. CPX should be considered post-operatively to evaluate exercise tolerance and blood pressure response to determine whether mild-to-moderate aerobic exercise should be recommended to reduce future risk of morbidity and mortality.

Quality of Life Worsens After Surgical Repair of Acute Type A Aortic Dissection

This study aimed to determine how acute type A aortic dissection (ATAAD) impacts patients' quality of life. The 36-Item Short Form Survey (SF-36) was used to measure quality of life. The eight SF-36 scales were aggregated into a two-factor summary: physical and mental component summary scales (PCS and MCS). One hundred fourteen patients were included in the ATAAD group and 81 patients in the aortic valve replacement (AVR) group. All patients underwent surgery between June 2007 and December 2018. Surveys were completed after the operation. The mean scaled score of the ATAAD group decreased significantly in all eight domains of the SF-36 survey after aortic dissection repair except mental health. Also, the postsurgery PCS score was significantly lower than the presurgery score (39 vs 49; P < 0.0001). Multivariable regression confirmed the negative impact of ATAAD on postsurgery PCS score and higher presurgery PCS score had a significant positive impact. The postsurgery MCS score did not change significantly (49 vs 50; P = 0.32), but higher preoperative MCS score had a significant positive impact on the postsurgery MCS score. Age, sex, connective tissue disorders, and stroke did not contribute significantly to the postsurgery PCS and MCS scores. The AVR group had significantly increased postsurgery PCS and MCS scores compared to the presurgery scores (47 vs 41; P < 0.0001) and (53 vs 51; P = 0.02) respectively. Patients reported significantly decreased physical health after recovery from acute type A aortic dissection repair. A multidisciplinary approach is needed to improve patients' quality of life.

Prognostic value of aerobic capacity and exercise oxygen pulse in postaortic dissection patients

BACKGROUND

Although recommendations encourage daily moderate activities in post aortic dissection, very little data exists regarding cardiopulmonary exercise testing (CPET) to personalize those patient's physical rehabilitation and assess their cardiovascular prognosis.

DESIGN

We aimed at testing the prognostic insight of CPET regarding aortic and cardiovascular events by exploring a prospective cohort of patients followed-up after acute aortic dissection.

METHODS

Patients referred to our department after an acute (type A or B) aortic dissection were prospectively included in a cohort between September 2012 and October 2017. CPET was performed once optimal blood pressure control was obtained. Clinical follow-up was done after CPET for new aortic event and major cardio-vascular events (MCE) not directly related to the aorta.

RESULTS

Among the 165 patients who underwent CPET, no adverse event was observed during exercise testing. Peak oxygen pulse was 1.46(1.22-1.84) mlO2/beat, that is, 97 (83-113) % of its predicted value, suggesting cardiac exercise limitation in a population under beta blockers (92% of the population). During a follow-up of 39(20-51) months from CPET, 42 aortic event recurrences and 22 MCE not related to aorta occurred. Low peak oxygen pulse (<85% of predicted value) was independently predictive of aortic event recurrence, while low peak oxygen uptake (<70% of predicted value) was an independent predictor of MCE occurrence.

CONCLUSION

CPET is safe in postaortic dissection patients should be used to not only to personalize exercise rehabilitation, but also to identify those patients with the highest risk for new aortic events and MCE not directly related to aorta.