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. 2025 Apr 24:14:100407.
doi: 10.1016/j.bjao.2025.100407. eCollection 2025 Jun.

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

Zyad J Carr  1   2 , Jean Charchaflieh  1   2 , Andres Brenes-Bastos  1   2 , Hugo He  3 , Hung-Mo Lin  2   3 , Amanda Jankelovits  1 , Emily Gu  1 , Jill Zafar  1   4 , Fed Ghali  1   5 , Wei S Tan  1   5 , Paul Heerdt  1   2
Affiliations

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

Zyad J Carr et al. BJA Open. .

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 (ORadj 0.94; 95% CI 0.89-0.99; P=0.011) and increasing length of stay (ORadj 0.98; 95% CI 0.96-0.99; P=0.01). GXCAP-VO2 slope (ORadj 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.

Keywords: early postoperative complications; preoperative evaluation; preoperative functional capacity; preoperative risk stratification; submaximal cardiopulmonary exercise testing.

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Conflict of interest statement

ZJC declares partial research funding from Shape Medical Systems, Inc (MN, USA). PMH declares consulting for Cardiage LLC and Baudax Bio, consulting and sponsored research for Edwards Lifesciences, and equity interest in emka Medical.

Figures

Figure 1
Figure 1
Postoperative Morbidity Survey (POMS) events as measured on postoperative day (POD) 1, 3, and 5.
Figure 2
Figure 2
CONSORT participant study flow diagram.
Figure 3
Figure 3
Age- and sex-adjusted submaximal cardiopulmonary exercise (smCPET)-derived peak VO2 in the studied cohort.
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See this image and copyright information in PMC

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