Effects of different exercise testing methods on left ventricular deformation and its correlation with cardiopulmonary exercise capacity in competitive athletes – semi-recumbent ergometer vs. treadmill testing

Effects of different exercise testing methods on left ventricular deformation and its correlation with cardiopulmonary exercise capacity in competitive athletes – semi-recumbent ergometer vs. treadmill testing | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effects of different exercise testing methods on left ventricular deformation and its correlation with cardiopulmonary exercise capacity in competitive athletes – semi-recumbent ergometer vs. treadmill testing Joscha Kandels, Stephan Stöbe, Alexander Kogel, Pierre Hepp, Helge Riepenhof, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2725090/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract Background Global longitudinal strain (GLS) and global myocardial work index (GWI) allow early detection of subclinical changes in left ventricular (LV) systolic function. The aim of the study was to investigate the immediate effects of maximum physical exercise by different exercise testing methods on LV deformation parameters in competitive athletes and to analyze their correlation with cardiopulmonary exercise capacity. Methods To reach maximum physical exercise, cardiopulmonary exercise testing (CPET) was performed by semi-recumbent ergometer in competitive handball players (n = 13) and by treadmill testing in competitive football players (n = 19). Maximum oxygen uptake (VO 2max ) indexed to body weight (relative VO 2max ) was measured in all athletes. Transthoracic echocardiography and blood pressure measurements were performed at rest and five minutes after CPET in all athletes. GLS, GWI and their changes before and after CPET (ΔGLS, ΔGWI) were correlated with (relative) VO 2max . Results In handball and football players, GLS and GWI did not differ significantly before and after CPET. There were no significant correlations between GLS and relative VO 2max , but moderate correlations were found between Δ GWI and relative VO 2max in handball (r = 0.631; P = 0.021) and football players (r = 0.592; P = 0.008). Furthermore, handball (46.7 ml/min*kg ± 4.7 ml/min*kg vs. 37.4 ml/min*kg ± 4.2; P = 0.004) and football players (58.3 ml/min*kg ± 3.7 ml/min*kg vs. 49.7 ml/min*kg ± 6.8; P = 0.002) with an increased ΔGWI after CPET showed a significant higher relative VO 2max . Conclusion Maximum physical exercise has an immediate effect on LV deformation, irrespective of the used testing method. The correlation of relative VO 2max with ΔGWI, identifies GWI as an echocardiographic parameter for characterizing the current individual training status of athletes. echocardiography athletes cardiopulmonary exercise test deformation longitudinal strain work index Figures Figure 1 Introduction In competitive athletes, transthoracic echocardiography (TTE) is a widely used noninvasive imaging modality that allows the assessment of left ventricular (LV) systolic function by LV ejection fraction (EF) and by LV deformation analysis by speckle tracking 1 , 2 . Global longitudinal strain (GLS) is defined as the percentage longitudinal shortening (change in length compared to baseline length) during systole. GLS allows early detection of subclinical myocardial damage, e.g., due to myocardial fibrosis 3 – 8 . Normal GLS values range from − 16.0 to -22.0% 9 . Whereas GLS is load-dependent, global myocardial work index (GWI) is a modern echocardiographic deformation parameter that has been shown to be afterload-independent and related to myocardial deformation and contractile function 10 , 11 . For this reason, GWI might offer advantages over GLS in athletes exposed to different afterload conditions during exercise. Normal values of GWI range from 1900 to 2100 mmHg% 9 . In contrast to LVEF, GLS and GWI have been shown to be reliable in distinguishing between physiological adaption (e.g., LV hypertrophy due to exercise) and pathological changes (e.g., hypertrophic cardiomyopathy) in the athletes’ heart 12 , 13 . Cardiopulmonary exercise testing (CPET) is an established method to characterize the pulmonary, vascular, musculoskeletal, and cardiac system in competitive athletes. Maximum oxygen uptake (VO 2max ) is considered the international standard for determining physical capacity. CPET can be helpful to assess and optimize the athlete’s current training condition 14 , 15 , 16 . Since VO 2max is highly dependent on the athlete’s body type, it is often indexed to body weight (relative VO 2max ). In addition to the athlete’s body type, age, gender, and sport type also appear to have a significant impact on VO 2max . In healthy males aged 18 and 30 years, a mean relative VO 2max of 48 ml/min*kg has been reported 17 . In general CPET is performed using a cycle ergometer or treadmill 18 , 19 . The cycle ergometer is well applicable in patients with unfavorable conditions (e.g. obesity, joint issues, deconditioning) and allows convenient intra-test procedures (ECG, blood pressure, blood sampling) due to less movement artefacts. Treadmill ergometry is more susceptible to movement artefacts, yet it allows running at predefined speed and incline, activates more muscle groups and can lead to higher levels of peak oxygen uptake 19 , 20 . The objective of the present study was to investigate the effect of maximum physical exercise by different testing methods on LV deformation in competitive athletes and to analyze the relationship between cardiopulmonary exercise capacity and LV deformation parameters. We hypothesized that the effect of maximum physical exercise on LV deformation does not differ between the two testing methods and GWI can be used as a surrogate parameter for VO 2max . Methods Study population and study design The study population (n = 32) was composed of competitive handball (n = 13) and football (n = 19) players from the first handball and football division in Germany. Handball and football players were considered separately due to their different physical constitution and the cardiovascular demands resulting from different types of exercise. All athletes provided informed consent after full explanation of the purpose and order of all procedures. The study was conducted in accordance with the Declaration of Helsinki and was approved by the ethical committee of the University of Leipzig ( 073/18-ek ). All athletes were enrolled in the outpatient clinic of cardiology from May until July 2020 (handball players) and in July 2021 (football players). They were tested for SARS-CoV-2 and had a negative PCR test taken at most 48 hours before the examination. All athletes were asymptomatic and completely free of cardiovascular diseases or risk factors. A physical examination including vital parameters was performed in all subjects. Further, an electrocardiogram at rest, incremental CPET, and TTE (before and 5 minutes after CPET) were performed. Blood pressure measurements were performed brachial in suspine position at rest and 5 minutes after CPET at the time when TTE examination was started. Incremental cardiopulmonary exercise test for handball players CPET was performed on a semi-recumbent ergometer (GE eBike, GE Healthcare GmbH, Solingen, Germany) at a constant speed of 60–70 revolutions per minute (rpm). The test started at a workload of 50W with an increase of 50W every 3 minutes until volitional exhaustion occurred. Each subject continued for an additional 5-minute recovery period at a workload of 25W. In the CPET, ergospirometry data were collected using a digital spirometer (Vyntus™ CPX, Vyaire Germany, Hoechberg, Germany). Absolut and relative oxygen consumption (VO 2max ) were assessed to characterize the respiratory function of athletes. VO 2max , minute ventilation (VE), and heart rate (HR) (GE Cardiosoft, GE Healthcare GmbH, Solingen, Germany) were monitored continuously at rest, during CPET, and during recovery. In addition to VO 2max the individual fitness index for weight-independent comparisons of athletes’ cardiopulmonary exercise capacity was calculated by the following: absolute VO 2max /(weight 0,73 ) 21 . Incremental cardiopulmonary exercise test for football players Run performance diagnostics were done on a treadmill (HP Cosmos, Traunstein, Germany) to determine VO 2max (Comsed, Rome, Italy), peak performance (P peak ), maximum heart rate (HR max ), and lactate threshold (LT), as well as running economy and fractional utilization of VO 2max at LT. The testing protocol contained a 2-phase test consisting of an incremental, sub-maximal exercise test (phase 1) followed by a ramp test (phase 2) interspersed with an 8 min break (4 min active walking at 4 km/h followed by 4 min passive rest) 22 . Athletes started the incremental test at 8.0 km/h at a treadmill incline of 0%. The test was completed when i) blood lactate has increased by ≥ 1 mmol/L compared to the previous stage, ii) Borg value was > 17 (on the 6–20 scale), iii) the respiratory exchange ratio was > 1.0 in two consecutive stages. Criteria ii) and iii) were introduced to prevent athletes who do not achieve a blood lactate increase of ≥ 1 mmol/L from becoming prematurely exhausted before the upcoming ramp protocol. The last stage was terminated when the result of the blood lactate level of the previous stage was displayed and was ≥ 1 mmol/L compared with the penultimate stage (generally 1 to 1.5 minutes). The start speed of the ramp test and the speed of LT determined in the incremental test (equal to the speed of the stage before the lactate increase of ≥ 1 mmol/L) were increased by 1 km/h every minute until voluntary exhaustion. Transthoracic echocardiography TTE was performed using a Vivid E9 or E95 ultrasound system with a 4Vc phased array probe (GE Healthcare Vingmed Ultrasound AS, Horten, Norway). Post-processing analyses were performed with the EchoPac software (Version 203, GE Healthcare Vingmed Ultrasound AS, Horten, Norway). LV morphology was characterized by LV dimensions (M-Mode) including LV length, relative wall thickness (RWT), LV mass (LVM) (by the Devereux formula), and LV mass index (LVMi) according to current recommendations 23 . LV systolic function was characterized by LVEF based on LV end-diastolic (LVEDV) and end-systolic volume (LVESV) assessed by LV biplane planimetry by the modified Simpson’s rule in the apical 2- and 4-chamber view as well as by Cardiac Index (CI) (by Doppler echocardiography) 24 . Myocardial deformation was characterized by GLS using 2D speckle tracking analysis of the apical long axis-, 2-, and 4-chamber-view according to current recommendations 3 , 25 , 26 . The endocardial contour was manually adjusted, whereas only segments with accurate tracking were accepted. Tracking areas were manually adjusted to enable full myocardial tracking. Additionally, GWI was calculated by using the longitudinal strain analysis of the apical LV long axis-, 2-, and 4-chamber-view coupled with the noninvasive blood pressure measurements to attain a pressure-strain loop of the LV 27 . In all athletes, the change in GLS (ΔGLS) and GWI (ΔGWI) was calculated before compared with after CPET. Diastolic function was characterized by maximum blood flow velocities (V max ) of E- and A-wave, E/A-ratio, myocardial V max of e’ and a’ of the basal septal and lateral mitral annulus, septal and lateral E/e´-ratio (including average E’/e’-ratio (septal and lateral)) and systolic pulmonary artery pressure (sPAP) according to current recommendations 28 . Statistical analysis All statistical analyses were performed using SPSS Statistics (version 24.0, IBM, Armonk, NY) and Microsoft Office Excel (version 16.53, Microsoft). Continuous variables were expressed as mean value ± standard deviation (SD). Further, percentage changes after CPET compared to resting conditions were stated. In consideration of the small sample size, we decided to forgo distribution analyses. Statistical significance was accepted for P value < 0.05. The student’s t-test was used to compare the echocardiographic results before and after CPET. Comparisons between more than two groups (subgroup analyses) were performed by one-way Analysis of Variance (ANOVA). Pearson correlation coefficient r was used to test the correlation between different echocardiographic parameters at rest, after CPET and for the percentage change of each parameter after CPET compared to resting conditions: r ≤ 0.5 (poor correlation), r = 0.5–0.7 (moderate correlation) and r ≥ 0.7 (good correlation). Intra- and interobserver variabilities of main echocardiographic parameters (LV volumes, LVEF, GLS, CI, sPAP) were assessed in randomly selected athletes (n = 10). The second investigator used the same datasets, and both were blinded to each other’s results. Results Baseline characteristics of handball and football players are shown in Table 1 . Table 1 Baseline characteristics Semi-recumbent ergometer Treadmill Mean values ± SD at rest after CPET P value at rest after CPET P value Age (year) 25.2 ± 3.5 - 22.1 ± 4.7 - Sex (% of male) 13 (100) - 19 (100%) - Weight (kg) 98.4 ± 8.2 - - 79.1 ± 10.6 - - Height (cm) 193.3 ± 7.5 - - 181.5 ± 7.8 - - BSA (m 2 ) 2.3 ± 0.1 - - 1.99 ± 0.17 - - BMI (kg/m 2 ) 26.3 ± 1.7 - - 23.9 ± 2.0 - - BPs (mmHg) 126.0 ± 10.5 152.6 ± 14.0 < 0.001* 133.8 ± 11.1 149.0 ± 14.7 < 0.001* BPd (mmHg) 80.8 ± 7.3 65.5 ± 9.7 < 0.001* 82.2 ± 7.7 78.0 ± 10.2 0.090 HR (bpm) 68 ± 9 91 ± 13 < 0.001* 64 ± 12 91 ± 14 < 0.001* * statistically significant (p < 0.05). SD = standard deviation. BSA = body surface area; BMI = body mass index; BPs = systolic blood pressure; BPd = diastolic blood pressure; HR = heart rate; CPET = cardiopulmonary exercise testing Semi-recumbent ergometer Left ventricular volumes were significantly lower after physical exertion compared to resting conditions (Table 2 ). Left ventricular ejection fraction was similar before and after CPET (Table 2 ). E/A-ratio was significantly decreased after physical exertion, mainly due to a reduction of the A-wave (Table 3 ). Myocardial early (e’) diastolic tissue velocities were significantly lower, although this did not lead to a reduction of E/e’, mainly due to consistent passive diastolic filling velocities (E-wave) (Table 3 ). After CPET sPAP was still in normal ranges. Table 2 Conventional echocardiographic parameters of left ventricular morphology and function Semi-recumbent ergometer Treadmill Mean values ± SD at rest after CPET P value at rest after CPET P value IVSD (mm) 9.9 ± 0.9 10.5 ± 1.1 0.073 9.8 ± 1.8 10.8 ± 1.5 0.009* PWD (mm) 9.7 ± 1.9 10.0 ± 1.0 0.301 9.4 ± 1.9 9.8 ± 2.5 0.494 LVEDD (mm) 57.5 ± 3.8 54.5 ± 3.5 0.001* 57.5 ± 4.2 53.4 ± 4.1 < 0.001* LVESD (mm) 35.0 ± 3.3 34.1 ± 3.4 0.359 36.4 ± 4.8 34.5 ± 3.9 0.048* LVL (mm) 92.9 ± 5.7 91.1 ± 7.5 0.404 91.3 ± 5.6 88.0 ± 5.6 0.0194* LVM (g) 215.1 ± 39.7 215.0 ± 39.5 0.993 219.4 ± 55.9 221.0 ± 43.0 0.873 LVMI (g/m 2 ) 62.1 ± 3.6 63.1 ± 7.4 0.349 101.4 ± 22.6 110.8 ± 20.3 0.059 RWT 0.32 ± 0.06 0.37 ± 0.04 < 0.001* 0.32 ± 0.07 0.39 ± 0.07 < 0.001* LVEDV (ml) 162.9 ± 23.5 145.2 ± 20.9 0.010* 164.8 ± 26.8 138.6 ± 24.1 < 0.001* LVESV (ml) 51.2 ± 11.5 48.5 ± 11.2 0.402 57.5 ± 17.7 50.0 ± 12.7 0.019* LVSV (ml) 111.7 ± 16.3 96.7 ± 16.4 0.006* 107.3 ± 15.3 88.6 ± 15.0 < 0.001* EF (%) 68.6 ± 4.4 66.6 ± 6.0 0.089 65.8 ± 6.9 64.3 ± 5.6 0.258 CI (l/m 2 ) 3.1 ± 0.7 3.9 ± 0.8 < 0.001* 3.1 ± 0.6 4.1 ± 0.8 < 0.001* GLS (%) -18.8 ± 1.6 -18.1 ± 1.7 0.079 -18.3 ± 1.7 -17.7 ± 1.6 0.119 GWI (mmHg%) 1837.7 ± 316.0 1974.7 ± 222.6 0.197 1899.3 ± 280.7 1963.5 ± 370.0 0.461 * statistically significant (p < 0.05). SD = standard deviation. IVSD = Interventricular septum diameter; PWD = Posterior wall diameter; LVEDD = left ventricular end-diastolic diameter; LVESD = left ventricular end-systolic diameter; LVL = left ventricular length; LVM = left ventricular mass; LVMi = LVM index; RWT = relative wall thickness; LVEDV = left ventricular end-diastolic volume; LVESV = left ventricular end-systolic volume; LVSV = left ventricular stroke volume; EF = ejection fraction; CI = cardiac index; GLS = global longitudinal strain; GWI = Global myocardial work index Table 3 Parameters of left ventricular diastolic and right ventricular function Semi-recumbent ergometer Treadmill Mean values ± SD at rest after CPET P value at rest after CPET P value E-wave (m/s) 0.76 ± 0.15 0.72 ± 0.16 0.385 0.73 ± 0.16 0.71 ± 0.20 0.668 A-wave (m/s) 0.43 ± 0.08 0.64 ± 0.19 0.002* 0.41 ± 0.08 0.60 ± 0.19 < 0.001* E/A-ratio 1.82 ± 0.50 1.19 ± 0.40 < 0.001* 1.87 ± 0.67 1.24 ± 0.35 < 0.001* Average e‘ 0.16 ± 0.04 0.14 ± 0.02 0.004* 0.15 ± 0.02 0.13 ± 0.02 < 0.001* Average a‘ 0.08 ± 0.01 0.09 ± 0.02 0.097 0.07 ± 0.01 0.09 ± 0.02 < 0.001* Average e‘/a‘-ratio 1.90 ± 0.29 1.59 ± 0.37 0.011* 1.78 ± 0.49 1.49 ± 0.50 0.021* Average E/e‘-ratio 4.94 ± 1.11 5.09 ± 1.01 0.602 4.94 ± 1.17 5.39 ± 1.28 0.007* TAPSE (cm) 2.1 ± 1.3 2.0 ± 0.9 0.652 1.9 ± 0.7 2.0 ± 1.2 0.757 sPAP (mmHg) 25.0 ± 4.3 23.8 ± 3.5 0.879 23.7 ± 2.9 22.5 ± 1.8 0.309 * statistically significant (p < 0.05). SD = standard deviation. Global longitudinal strain (-18.8 ± 1.6% vs. -18.1 ± 1.7%; P = 0.079) and GWI did not differ before and after CPET (1838 ± 316mmHg% vs. 1975 ± 223mmHg%; P = 0.197). Specifically, GWI increased in eight and decreased in five handball players after CPET (Fig. 1 ). Athletes with an increase in GWI after CPET showed higher relative VO 2max values (46.7 ml/min*kg ± 4.7 ml/min*kg vs. 37.4 ml/min*kg ± 4.2; P = 0.004) (Fig. 1 ). Athletes with a decrease in GWI after CPET had the lowest relative VO 2max values (Fig. 1 ). At maximum physical exercise VO 2max was 4214 ± 489 ml/min and relative VO 2max was 43.1 ± 6.4 ml/min*kg. Calculated fitness index was 149 ± 20 ml/min*kg. No correlation with VO 2max or relative VO 2max was shown for GLS at rest, after CPET, and ΔGLS. In contrast, there was a correlation between GWI after CPET and VO 2max (r = 0.631; P = 0.021), Δ GWI and VO 2max (r = 0.762; P = 0.002), as well as Δ GWI and relative VO 2max (r = 0.671; P = 0.012; Table 4 ). Table 4 Correlations between left ventricular deformation and cardiopulmonary exercise capacity Semi-recumbent ergometer Treadmill Mean values ± SD Pearson’s R P value Pearson’s R P value VO 2max vs. GLS at rest 0.047 0.880 0.219 0.367 VO 2max vs. GLS after CPET -0.067 0.828 -0.041 0.869 VO 2max vs. ΔGLS -0.136 0.657 -0.325 0.175 Relative VO 2max vs. GLS at rest -0.019 0.952 0.008 0.974 Relative VO 2max vs. GLS after CPET 0.112 0.716 0.094 0.701 Relative VO 2max vs. ΔGLS 0.159 0.605 0.093 0.706 VO 2max vs. GWI at rest -0.428 0.144 0.031 0.901 VO 2max vs. GWI after CPET 0.631 0.021* 0.336 0.160 VO 2max vs. ΔGWI 0.762 0.002* 0.346 0.147 Relative VO 2max vs. GWI at rest -0.415 0.159 -0.099 0.688 Relative VO 2max vs. GWI after CPET 0.502 0.080 0.459 0.048* Relative VO 2max vs. ΔGWI 0.671 0.012* 0.592 0.008* * statistically significant (p < 0.05). SD = standard deviation. VO 2max = maximum oxygen uptake; GLS = global longitudinal strain; GWI = global myocardial work index; CPET = cardiopulmonary exercise testing; Δ = change before and after CPET Treadmill testing Left ventricular volumes were significantly lower after physical exertion compared to resting conditions (Table 2 ). Left ventricular ejection fraction was similar before and after CPET (Table 2 ). E/A-ratio and E/e’ were significantly lower after CPET (Table 2 ). sPAP was in normal ranges before and after CPET. Global longitudinal strain (-18.3 ± 1.7% vs. -17.7 ± 1.6%; P = 0.119) and GWI did not differ before and after CPET (1899 ± 281mmHg% vs. 1963 ± 370mmHg%; P = 0.461). GWI increased in 11 and decreased in eight football players after CPET (Fig. 1 ). Athletes with an increase in GWI after CPET showed higher relative VO 2max values (58.3 ml/min*kg ± 3.7 ml/min*kg vs. 49.7 ml/min*kg ± 6.8; P = 0.002) (Fig. 1 ). At maximum physical exercise VO 2max was 4306 ± 594 ml/min and relative VO 2max was 54.7 ± 6.5 ml/min*kg. Calculated fitness index was 178 ± 20 ml/min*kg. No correlation with VO 2max or relative VO 2max was shown for GLS at rest, after CPET, and ΔGLS. However, GWI after CPET and relative VO 2max (r = 0.459; P = 0.048) as well as Δ GWI and relative VO 2max (r = 0.592; P = 0.008) showed moderate correlations (Table 4 ). Intra- and interobserver variabilities Intraobserver variabilities of GLS measurements were 2.16% at rest ( P = 0.638) and 2.61% after CPET ( P = 0.491). Interobserver variabilities of GLS measurements were 3.91% at rest ( P = 0.337) and 4.23% after CPET ( P = 0.312). Intra- and interobserver variabilities for LV volumes, LVEF, CI, and sPAP measurements were < 5% without reaching statistical significance. Discussion The main findings of the present study are: (1) GLS and GWI did not differ significantly before and after semi-recumbent ergometer and treadmill testing. (2) There was no significant correlation between GLS and (relative) VO 2max , but (3) there were significant correlations between Δ GWI and relative VO 2max in semi-recumbent ergometer and treadmill testing. Baseline echocardiographic parameters Changes of conventional echocardiographic parameters after CPET (e.g. LV volumes), were in line with the results of previous studies and have already been described 29 . Both, low intra- and interobserver variabilities highlight the quality of data acquisition as well as the robustness of conventional but also deformation parameters, e.g. GLS 7 . Impact of maximum exercise on global longitudinal strain The impact of pre- and afterload conditions on LV systolic function has already been described 30 . In general data analyzing the impact of physical stress on LV deformation are scarce and the results of previous studies are highly heterogeneous. Some previous clinical studies have proven a significant impact of pre- and afterload conditions on GLS 31 , 32 , 33 , 34 . Nevertheless, GLS was not able to predict load-independent contractility in a porcine model 35 . The impact of different CPET methods on global longitudinal strain in competitive athletes has not been described before. Liang et al. assessed GLS in 15 swimming athletes before and after high-intensity exercise, where GLS was significantly lower after high-intensity exercise 36 . The decrease of GLS was explained by negative effects on myocardial cells based on anaerobic glycolysis due to ischemia, hypoxia, and the formation of lactic acid with a reduction of myocardial contraction force and consequently, a decrease of LV myocardial contractile function 37 . These results were in contrast to Gruca et al., where GLS was significantly increased in 69% of 111 male elite basketball players in the first minute after maximum physical exertion due to treadmill testing 38 . The increase of GLS at peak exercise was explained by a lower baseline and peak HR, which could not be observed in our study. Neither athletes on semi-recumbent ergometer and treadmill showed significant correlations with HR or differences of mean GLS before and after CPET. Mean GLS was slightly lower after both, semi-recumbent ergometer and treadmill testing, but did not reach statistical significance. This finding can be explained by higher blood pressure after CPET and consequently higher afterload conditions which was already described in an experimental pig model of aortic banding 34 . It needs to be considered that athletes of different sports are exposed to different forms of physical exercise, and these in turn also have different effects on the cardiovascular system especially on LV remodeling. However, the results of our study are consistent with those of Santoro et al. where GLS was assessed in 27 male water polo players and did not differ significantly before and after 6 repetitions of 100-m freestyle swimming sets 39 . Whereas Gianturco et al. demonstrated a very strong correlation between VO 2max and GLS in a cohort of 20 soccer referees and proposed GLS as a specific parameter to assess football referees performance 40 , there was no significant correlation between VO 2max and GLS in our study. The lack of correlation between GLS and VO2 max does not allow us to draw conclusions about cardiopulmonary exercise capacity based on GLS values in male handball and football players. The discrepancy between the results of Gianturco et al. and our study could be most likely explained by different training conditions. Impact of maximum exercise on global myocardial work index Global myocardial work index has proven to be a reliable method for assessing LV function and is capable of detecting subtle myocardial changes. In noninvasive estimation of LV pressure, GWI based on the pressure strain loop incorporates the current afterload condition and is able to assess LV mechanical function and the myocardial oxygen consumption 41 . Sengupta et al. assessed GWI in 24 recreational athletes before as well as up to a maximum of 2 and 72 hours after completing a marathon and found either a decrease in GWI or no change in GWI 42 . A decrease of GWI was attributed to differences in HR and lower LV filling volumes. According to the results of the present study, both aspects could also be observed in professional athletes immediately after CPET, because TTE was performed 5 minutes after CPET in the present study. GWI has proved to be afterload-independent permitting a more comprehensive assessment of LV systolic function 11 , which is beneficial in athletes exposed to different physical exercise. Although systolic blood pressure as a surrogate parameter for afterload conditions was increased in all athletes after CPET. In this study, irrespective of the CPET method, mean GWI did not differ before and after CPET and an individual increase or decrease in GWI was observed in each athlete. This finding lead to the assumption that LV deformation is significantly affected by maximum exercise, whereas the method of exercise testing, semi-recumbent ergometer or treadmill, does not make a difference. Correlation between VO 2max and GWI Tokodi et al. described a moderate correlation between CPET-derived relative VO 2max and GWI at rest in a cohort of 20 elite swimmers 43 , which was not observed in our study. However, there was a significant correlation between relative VO 2max and Δ GWI in both cohorts. This observation can be explained by the fact that well-trained athletes with higher fitness levels show a pronounced increase in GWI after CPET according to their relative VO 2max , whereas a decrease in GWI after CPET seems to be associated with a lower cardiopulmonary exercise capacity. It can be assumed that Δ GWI can be considered as a surrogate parameter to assess the current training condition of athletes. Limitations The number of subjects was limited by the size of the teams in the German handball and football Bundesliga studied at Leipzig University Hospital. However, these highly selected young and healthy competitive athletes highlight the exceptionality of the present cohort. Therefore, the results are not directly applicable to patients with cardiovascular disease. Both semi-recumbent ergometer and treadmill testing could not be performed in all athletes due to their limited time schedule for testing. The modality of incremental cardiopulmonary exercise test was predetermined by the respective medical team leader. Conclusion VO2 max is considered an important indicator of athlete's training condition and maximum performance capacity. In the present study we confirmed that maximum exercise has a significant effect on LV deformation, irrespective of the exercise method. The impact of maximum physical exercise on LV deformation did not differ between semi-recumbent ergometer and treadmill testing. Further, we were able to demonstrate a significant correlation between ΔGWI and VO2 max directly after CPET, so that the current training condition or maximum performance capacity of an athlete might also be estimated by a single modern imaging parameter instead of only VO2 max . Further studies are needed to clarify whether athletes who demonstrate a decrease in GWI and a lower VO2 max after CPET actually have a higher performance potential and thus their maximal performance capacity can be further improved. If so, GWI could be used as a modern imaging parameter to characterize the athletes’ maximum performance capacity, which would considerably enrich and simplify individual performance diagnostics. Declarations Ethical Approval All athletes provided informed consent to participate and publish after full explanation of the purpose and order of all procedures. The study was conducted in accordance with the Declaration of Helsinki and was approved by the ethical committee of the University of Leipzig ( 073/18-ek ). Competing interests The authors have nothing to declare. Authors' contributions A.H., J.K. and S.F. designed the study. A.H. and S.S. performed all the echocardiographic examinations. J.K. and S.S. analysed the data. A.K. performed the statistics. J.K. and S.S. wrote the manuscript. The rest of the authors provided critical feedback and helped shape the research, analysis and manuscript. Funding No funding Availability of data and materials The authors confirm that the data supporting the findings of this study are available within the article. References Mitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, Horton K, Ogunyankin KO, Palma RA, Velazquez EJ. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. Journal of the American Society of Echocardiography 2019;32:1–64. Grazioli G, Sanz M, Montserrat S, Vidal B, Sitges M. Echocardiography in the evaluation of athletes. F1000Res 2015;4:151. Voigt JU, Pedrizetti G, Lysyansky P, Marwick TH, Houle HC, Baumann R et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging 2015:16: 1–11. Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, Galderisi M, Marwick T, Nagueh SF, Sengupta PP, Sicari R, Smiseth OA, Smulevitz B, Takeuchi M, Thomas JD, Vannan M, Voigt J-U, Zamorano JL. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr 2011;24:277–313. Tops LF, Delgado V, Marsan NA, Bax JJ. Myocardial strain to detect subtle left ventricular systolic dysfunction: LV systolic dysfunction and GLS. Eur J Heart Fail 2017;19:307–313. Biering-Sørensen T, Biering-Sørensen SR, Olsen FJ, Sengeløv M, Jørgensen PG, Mogelvang R, Shah AM, Jensen JS. Global Longitudinal Strain by Echocardiography Predicts Long-Term Risk of Cardiovascular Morbidity and Mortality in a Low-Risk General Population: The Copenhagen City Heart Study. Circ: Cardiovascular Imaging 2017;10. Cheng S, Larson MG, McCabe EL, Osypiuk E, Lehman BT, Stanchev P, Aragam J, Benjamin EJ, Solomon SD, Vasan RS. Reproducibility of Speckle-Tracking-Based Strain Measures of Left Ventricular Function in a Community-Based Study. Journal of the American Society of Echocardiography 2013;26:1258–1266.e2. Kouris NT, Kostopoulos VS, Psarrou GA, Kostakou PM, Tzavara C, Olympios CD. Left ventricular ejection fraction and Global Longitudinal Strain variability between methodology and experience. Echocardiography 2021;38:582–589. Truong VT, Vo HQ, Ngo TNM, Mazur J, Nguyen TTH, Pham TTM, Le TK, Phan H, Palmer C, Nagueh SF, Chung ES. Normal Ranges of Global Left Ventricular Myocardial Work Indices in Adults: A Meta-Analysis. J Am Soc Echocardiogr 2021:S0894-7317(21)00826-9. Hubert A, Le Rolle V, Leclercq C, Galli E, Samset E, Casset C, Mabo P, Hernandez A, Donal E. Estimation of myocardial work from pressure–strain loops analysis: an experimental evaluation. European Heart Journal - Cardiovascular Imaging 2018;19:1372–1379. Chan J, Edwards NFA, Khandheria BK, Shiino K, Sabapathy S, Anderson B, Chamberlain R, Scalia GM. A new approach to assess myocardial work by non-invasive left ventricular pressure–strain relations in hypertension and dilated cardiomyopathy. European Heart Journal - Cardiovascular Imaging 2019;20:31–39. Bewarder Y, Lauder L, Kulenthiran S, Schäfer O, Ukena C, Percy Marshall R, Hepp P, Laufs U, Stöbe S, Hagendorff A, Böhm M, Mahfoud F, Ewen S. Global longitudinal strain differentiates physiological hypertrophy from maladaptive remodeling. IJC Heart & Vasculature 2022;40:101044. BorziÌ D, Saladino S, Losi V, Faro D, Monte I. Strain and myocardial work index during echo exercise to evaluate myocardial function in athletes. J Cardiovasc Echography 2022;32:82. Petek BJ, Gustus SK, Wasfy MM. Cardiopulmonary Exercise Testing in Athletes: Expect the Unexpected. Curr Treat Options Cardio Med 2021;23:49. Fleg JL, Piña IL, Balady GJ, Chaitman BR, Fletcher B, Lavie C, Limacher MC, Stein RA, Williams M, Bazzarre T. Assessment of Functional Capacity in Clinical and Research Applications: An Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation 2000;102:1591–1597. Fletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock ML. Exercise Standards: A Statement for Healthcare Professionals From the American Heart Association. Circulation 1995;91:580–615. Shvartz E, Reibold RC. Aerobic fitness norms for males and females aged 6 to 75 years: a review. Aviat Space Environ Med 1990;61:3–11. Albouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise testing and its applicationThis is a reprint of a paper that appeared in Heart , October 2007, Volume 93, pages 1285–92. Reprinted with kind permission of the authors and publisher. Postgraduate Medical Journal 2007;83:675–682. Datta D, Normandin E, ZuWallack R. Cardiopulmonary exercise testing in the assessment of exertional dyspnea. Ann Thorac Med 2015;10:77. O’Donnell DE, Elbehairy AF, Faisal A, Webb KA, Neder JA, Mahler DA. Exertional dyspnoea in COPD: the clinical utility of cardiopulmonary exercise testing. Eur Respir Rev 2016;25:333–347. Jensen K, Johansen L, Secher NH. Influence of body mass on maximal oxygen uptake: effect of sample size. European Journal of Applied Physiology 2001;84:201–205. Stöggl TL, Blumkaitis JC, Strepp T, Sareban M, Simon P, Neuberger EWI, Finkenzeller T, Nunes N, Aglas L, Haller N. The Salzburg 10/7 HIIT shock cycle study: the effects of a 7-day high-intensity interval training shock microcycle with or without additional low-intensity training on endurance performance, well-being, stress and recovery in endurance trained athletes—study protocol of a randomized controlled trial. BMC Sports Sci Med Rehabil 2022;14:84. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt J-U. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1–39.e14. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al. Recommendation for cardiac chamber quantification by echocardiography in adults: an up-date from the American Society of Echocardiography and the European Association of Cardi-ovascular Imaging. Eur Heart J: Cardiovasc Imaging 2015:16: 233–270. Mor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr 2011:24: 277–313. Thomas JD, Badano LP. EACVI-ASE-industry initiative to standardize deformation imaging: a brief update from the co-chairs. Eur Heart J Cardiovasc Imaging 2013:14: 1039–1040. Russell K, Eriksen M, Aaberge L, Wilhelmsen N, Skulstad H, Remme EW, Haugaa KH, Opdahl A, Fjeld JG, Gjesdal O, Edvardsen T, Smiseth OA. A novel clinical method for quantification of regional left ventricular pressure–strain loop area: a non-invasive index of myocardial work. European Heart Journal 2012;33:724–733. Nagueh SF, Smiseth OA, Appleton CP, Byrd BF, Dokainish H, Edvardsen T et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiog-raphy: An Update from the American Society of Echocardiography and the European Associa-tion of Cardiovascular Imaging. J Am Soc Echocardiogr 2016:29: 277–314. Nixon PGF. Human circulation regulation during physical stress. L. B. Rowell. Oxford University Press, London, 1986. No. of pages: 416. Price: £35.00. Stress Med 1988;4:124–125. Zimmer H-G. Who Discovered the Frank-Starling Mechanism? Physiology 2002;17:181–184. Nafati C, Gardette M, Leone M, Reydellet L, Blasco V, Lannelongue A, Sayagh F, Wiramus S, Antonini F, Albanèse J, Zieleskiewicz L. Use of speckle-tracking strain in preload-dependent patients, need for cautious interpretation! Ann Intensive Care 2018;8:29. Roy C, Duclos G, Nafati C, Gardette M, Lopez A, Pastene B, Gaudray E, Boussuges A, Antonini F, Leone M, Zieleskiewicz L. Left ventricular longitudinal strain variations assessed by speckle-tracking echocardiography after a passive leg raising maneuver in patients with acute circulatory failure to predict fluid responsiveness: A prospective, observational study. Ehrman R, ed. PLoS ONE 2021;16:e0257737. Carasso S, Cohen O, Mutlak D, Adler Z, Lessick J, Reisner SA, Rakowski H, Bolotin G, Agmon Y. Differential effects of afterload on left ventricular long- and short-axis function: Insights from a clinical model of patients with aortic valve stenosis undergoing aortic valve replacement. American Heart Journal 2009;158:540–545. Donal E, Bergerot C, Thibault H, Ernande L, Loufoua J, Augeul L, Ovize M, Derumeaux G. Influence of afterload on left ventricular radial and longitudinal systolic functions: a two-dimensional strain imaging study. European Journal of Echocardiography 2009;10:914–921. Dahle GO, Stangeland L, Moen CA, Salminen P-R, Haaverstad R, Matre K, Grong K. The influence of acute unloading on left ventricular strain and strain rate by speckle tracking echocardiography in a porcine model. American Journal of Physiology-Heart and Circulatory Physiology 2016;310:H1330–H1339. Liang C, Ma Y, Gao C, Zhang J, Yang M, Chen G, Fu S, Zhu T. Two-dimensional strain echocardiography technology for evaluation of myocardial strain in swimming athletes after high-intensity exercise. Echocardiography 2017;34:169–175. Scharhag J, Herrmann M, Urhausen A, Haschke M, Herrmann W, Kindermann W. Independent elevations of N-terminal pro–brain natriuretic peptide and cardiac troponins in endurance athletes after prolonged strenuous exercise. American Heart Journal 2005;150:1128–1134. Gruca MM, Cheema B, Garg G, Ryan J, Thomas JD, Rigolin VH, Zielinski AR, Puthumana JJ. Strain echocardiography to describe left ventricular function pre- and postexercise in elite basketball athletes: A feasibility study. Echocardiography 2021;38:1165–1172. Santoro A, Alvino F, Antonelli G, Cameli M, Bertini M, Molle R, Mondillo S. Left Ventricular Strain Modifications after Maximal Exercise in Athletes: A Speckle Tracking Study. Echocardiography 2015;32:920–927. Gianturco L, Bodini B, Gianturco V, Lippo G, Solbiati A, Turiel M. Left ventricular longitudinal strain in soccer referees. Oncotarget 2017;8:39766–39773. Takaoka H, Takeuchi M, Odake M, Yokoyama M. Assessment of myocardial oxygen consumption (Vo2) and systolic pressure-volume area (PVA) in human hearts. European Heart Journal 1992;13:85–90. Sengupta S, Jain R, Burkule N, Olet S, Khandheria BK. Myocardial Work Index: A Novel Method for Assessment of Myocardial Function in South Asian Recreational Athletes. Journal of Patient-Centered Research and Reviews 2020;7:147–156. Tokodi M, Oláh A, Fábián A, Lakatos BK, Hizoh I, Ruppert M, Sayour AA, Barta BA, Kiss O, Sydó N, Csulak E, Ladányi Z, Merkely B, Kovács A, Radovits T. Novel insights into the athlete’s heart: is myocardial work the new champion of systolic function? Eur Heart J Cardiovasc Imaging 2022;23:188–197. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2725090","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":186260163,"identity":"65c28a6d-8425-40f7-85b7-ea678863a4fd","order_by":0,"name":"Joscha 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01:29:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2725090/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2725090/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":34868320,"identity":"8b02c320-946b-481b-9211-c1bee6deccfd","added_by":"auto","created_at":"2023-03-27 14:39:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":97596,"visible":true,"origin":"","legend":"\u003cp\u003eRelative VO\u003csub\u003e2max \u003c/sub\u003ein competitive handball (\u003cstrong\u003eA1\u003c/strong\u003e) and football players (\u003cstrong\u003eB1\u003c/strong\u003e) with increased (­↑) global myocardial work index (GWI) after cardiopulmonary exercise test (CPET) compared to the athletes with decreased GWI (↓). The correlation between the change of GWI (DGWI) after CPET with relative VO\u003csub\u003e2max\u003c/sub\u003e as a surrogate parameter for cardiopulmonary exercise capacity in competitive handball (\u003cstrong\u003eA2\u003c/strong\u003e) and football players (\u003cstrong\u003eB2\u003c/strong\u003e).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-2725090/v1/c24d451d23bfa58bfaa6b3f8.png"},{"id":34868322,"identity":"fbd07c93-21e1-45fe-90a7-78104324c621","added_by":"auto","created_at":"2023-03-27 14:39:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1005629,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2725090/v1/16ffa5d6-43aa-4116-ba5f-6d9b56cb28f9.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of different exercise testing methods on left ventricular deformation and its correlation with cardiopulmonary exercise capacity in competitive athletes – semi-recumbent ergometer vs. treadmill testing","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn competitive athletes, transthoracic echocardiography (TTE) is a widely used noninvasive imaging modality that allows the assessment of left ventricular (LV) systolic function by LV ejection fraction (EF) and by LV deformation analysis by speckle tracking\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eGlobal longitudinal strain (GLS) is defined as the percentage longitudinal shortening (change in length compared to baseline length) during systole. GLS allows early detection of subclinical myocardial damage, e.g., due to myocardial fibrosis\u003csup\u003e\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. Normal GLS values range from \u0026minus;\u0026thinsp;16.0 to -22.0%\u003csup\u003e9\u003c/sup\u003e. Whereas GLS is load-dependent, global myocardial work index (GWI) is a modern echocardiographic deformation parameter that has been shown to be afterload-independent and related to myocardial deformation and contractile function\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. For this reason, GWI might offer advantages over GLS in athletes exposed to different afterload conditions during exercise. Normal values of GWI range from 1900 to 2100 mmHg%\u003csup\u003e9\u003c/sup\u003e. In contrast to LVEF, GLS and GWI have been shown to be reliable in distinguishing between physiological adaption (e.g., LV hypertrophy due to exercise) and pathological changes (e.g., hypertrophic cardiomyopathy) in the athletes\u0026rsquo; heart\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eCardiopulmonary exercise testing (CPET) is an established method to characterize the pulmonary, vascular, musculoskeletal, and cardiac system in competitive athletes. Maximum oxygen uptake (VO\u003csub\u003e2max\u003c/sub\u003e) is considered the international standard for determining physical capacity. CPET can be helpful to assess and optimize the athlete\u0026rsquo;s current training condition\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Since VO\u003csub\u003e2max\u003c/sub\u003e is highly dependent on the athlete\u0026rsquo;s body type, it is often indexed to body weight (relative VO\u003csub\u003e2max\u003c/sub\u003e). In addition to the athlete\u0026rsquo;s body type, age, gender, and sport type also appear to have a significant impact on VO\u003csub\u003e2max\u003c/sub\u003e. In healthy males aged 18 and 30 years, a mean relative VO\u003csub\u003e2max\u003c/sub\u003e of 48 ml/min*kg has been reported\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn general CPET is performed using a cycle ergometer or treadmill\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. The cycle ergometer is well applicable in patients with unfavorable conditions (e.g. obesity, joint issues, deconditioning) and allows convenient intra-test procedures (ECG, blood pressure, blood sampling) due to less movement artefacts. Treadmill ergometry is more susceptible to movement artefacts, yet it allows running at predefined speed and incline, activates more muscle groups and can lead to higher levels of peak oxygen uptake\u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe objective of the present study was to investigate the effect of maximum physical exercise by different testing methods on LV deformation in competitive athletes and to analyze the relationship between cardiopulmonary exercise capacity and LV deformation parameters. We hypothesized that the effect of maximum physical exercise on LV deformation does not differ between the two testing methods and GWI can be used as a surrogate parameter for VO\u003csub\u003e2max\u003c/sub\u003e.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and study design\u003c/h2\u003e \u003cp\u003eThe study population (n\u0026thinsp;=\u0026thinsp;32) was composed of competitive handball (n\u0026thinsp;=\u0026thinsp;13) and football (n\u0026thinsp;=\u0026thinsp;19) players from the first handball and football division in Germany. Handball and football players were considered separately due to their different physical constitution and the cardiovascular demands resulting from different types of exercise. All athletes provided informed consent after full explanation of the purpose and order of all procedures. The study was conducted in accordance with the Declaration of Helsinki and was approved by the ethical committee of the University of Leipzig (\u003cb\u003e073/18-ek\u003c/b\u003e).\u003c/p\u003e \u003cp\u003eAll athletes were enrolled in the outpatient clinic of cardiology from May until July 2020 (handball players) and in July 2021 (football players). They were tested for SARS-CoV-2 and had a negative PCR test taken at most 48 hours before the examination. All athletes were asymptomatic and completely free of cardiovascular diseases or risk factors. A physical examination including vital parameters was performed in all subjects. Further, an electrocardiogram at rest, incremental CPET, and TTE (before and 5 minutes after CPET) were performed. Blood pressure measurements were performed brachial in suspine position at rest and 5 minutes after CPET at the time when TTE examination was started.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eIncremental cardiopulmonary exercise test for handball players\u003c/h2\u003e \u003cp\u003eCPET was performed on a semi-recumbent ergometer (GE eBike, GE Healthcare GmbH, Solingen, Germany) at a constant speed of 60\u0026ndash;70 revolutions per minute (rpm). The test started at a workload of 50W with an increase of 50W every 3 minutes until volitional exhaustion occurred. Each subject continued for an additional 5-minute recovery period at a workload of 25W. In the CPET, ergospirometry data were collected using a digital spirometer (Vyntus\u0026trade; CPX, Vyaire Germany, Hoechberg, Germany). Absolut and relative oxygen consumption (VO\u003csub\u003e2max\u003c/sub\u003e) were assessed to characterize the respiratory function of athletes. VO\u003csub\u003e2max\u003c/sub\u003e, minute ventilation (VE), and heart rate (HR) (GE Cardiosoft, GE Healthcare GmbH, Solingen, Germany) were monitored continuously at rest, during CPET, and during recovery. In addition to VO\u003csub\u003e2max\u003c/sub\u003e the individual fitness index for weight-independent comparisons of athletes\u0026rsquo; cardiopulmonary exercise capacity was calculated by the following: absolute VO\u003csub\u003e2max\u003c/sub\u003e/(weight\u003csup\u003e0,73\u003c/sup\u003e)\u003csup\u003e21\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eIncremental cardiopulmonary exercise test for football players\u003c/h2\u003e \u003cp\u003eRun performance diagnostics were done on a treadmill (HP Cosmos, Traunstein, Germany) to determine VO\u003csub\u003e2max\u003c/sub\u003e (Comsed, Rome, Italy), peak performance (P\u003csub\u003epeak\u003c/sub\u003e), maximum heart rate (HR\u003csub\u003emax\u003c/sub\u003e), and lactate threshold (LT), as well as running economy and fractional utilization of VO\u003csub\u003e2max\u003c/sub\u003e at LT. The testing protocol contained a 2-phase test consisting of an incremental, sub-maximal exercise test (phase 1) followed by a ramp test (phase 2) interspersed with an 8 min break (4 min active walking at 4 km/h followed by 4 min passive rest)\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAthletes started the incremental test at 8.0 km/h at a treadmill incline of 0%. The test was completed when i) blood lactate has increased by \u0026ge;\u0026thinsp;1 mmol/L compared to the previous stage, ii) Borg value was \u0026gt;\u0026thinsp;17 (on the 6\u0026ndash;20 scale), iii) the respiratory exchange ratio was \u0026gt;\u0026thinsp;1.0 in two consecutive stages. Criteria ii) and iii) were introduced to prevent athletes who do not achieve a blood lactate increase of \u0026ge;\u0026thinsp;1 mmol/L from becoming prematurely exhausted before the upcoming ramp protocol. The last stage was terminated when the result of the blood lactate level of the previous stage was displayed and was \u0026ge;\u0026thinsp;1 mmol/L compared with the penultimate stage (generally 1 to 1.5 minutes). The start speed of the ramp test and the speed of LT determined in the incremental test (equal to the speed of the stage before the lactate increase of \u0026ge;\u0026thinsp;1 mmol/L) were increased by 1 km/h every minute until voluntary exhaustion.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eTransthoracic echocardiography\u003c/h2\u003e \u003cp\u003eTTE was performed using a Vivid E9 or E95 ultrasound system with a 4Vc phased array probe (GE Healthcare Vingmed Ultrasound AS, Horten, Norway). Post-processing analyses were performed with the EchoPac software (Version 203, GE Healthcare Vingmed Ultrasound AS, Horten, Norway). LV morphology was characterized by LV dimensions (M-Mode) including LV length, relative wall thickness (RWT), LV mass (LVM) (by the Devereux formula), and LV mass index (LVMi) according to current recommendations\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. LV systolic function was characterized by LVEF based on LV end-diastolic (LVEDV) and end-systolic volume (LVESV) assessed by LV biplane planimetry by the modified Simpson\u0026rsquo;s rule in the apical 2- and 4-chamber view as well as by Cardiac Index (CI) (by Doppler echocardiography)\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Myocardial deformation was characterized by GLS using 2D speckle tracking analysis of the apical long axis-, 2-, and 4-chamber-view according to current recommendations\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e. The endocardial contour was manually adjusted, whereas only segments with accurate tracking were accepted. Tracking areas were manually adjusted to enable full myocardial tracking.\u003c/p\u003e \u003cp\u003eAdditionally, GWI was calculated by using the longitudinal strain analysis of the apical LV long axis-, 2-, and 4-chamber-view coupled with the noninvasive blood pressure measurements to attain a pressure-strain loop of the LV\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e. In all athletes, the change in GLS (ΔGLS) and GWI (ΔGWI) was calculated before compared with after CPET.\u003c/p\u003e \u003cp\u003eDiastolic function was characterized by maximum blood flow velocities (V\u003csub\u003emax\u003c/sub\u003e) of E- and A-wave, E/A-ratio, myocardial V\u003csub\u003emax\u003c/sub\u003e of e\u0026rsquo; and a\u0026rsquo; of the basal septal and lateral mitral annulus, septal and lateral E/e\u0026acute;-ratio (including average E\u0026rsquo;/e\u0026rsquo;-ratio (septal and lateral)) and systolic pulmonary artery pressure (sPAP) according to current recommendations\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed using SPSS Statistics (version 24.0, IBM, Armonk, NY) and Microsoft Office Excel (version 16.53, Microsoft). Continuous variables were expressed as mean value\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Further, percentage changes after CPET compared to resting conditions were stated. In consideration of the small sample size, we decided to forgo distribution analyses. Statistical significance was accepted for \u003cem\u003eP\u003c/em\u003e value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The student\u0026rsquo;s t-test was used to compare the echocardiographic results before and after CPET. Comparisons between more than two groups (subgroup analyses) were performed by one-way Analysis of Variance (ANOVA). Pearson correlation coefficient \u003cem\u003er\u003c/em\u003e was used to test the correlation between different echocardiographic parameters at rest, after CPET and for the percentage change of each parameter after CPET compared to resting conditions: \u003cem\u003er\u003c/em\u003e\u0026thinsp;\u0026le;\u0026thinsp;0.5 (poor correlation), \u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.5\u0026ndash;0.7 (moderate correlation) and \u003cem\u003er\u003c/em\u003e\u0026thinsp;\u0026ge;\u0026thinsp;0.7 (good correlation).\u003c/p\u003e \u003cp\u003eIntra- and interobserver variabilities of main echocardiographic parameters (LV volumes, LVEF, GLS, CI, sPAP) were assessed in randomly selected athletes (n\u0026thinsp;=\u0026thinsp;10). The second investigator used the same datasets, and both were blinded to each other\u0026rsquo;s results.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eBaseline characteristics of handball and football players are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eBaseline characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSemi-recumbent ergometer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eTreadmill\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMean values\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eat rest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eafter CPET\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eat rest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eafter CPET\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (year)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.2\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.1\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex (% of male)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19 (100%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eWeight (kg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e79.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHeight (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e193.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e181.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBSA (m\u003c/b\u003e\u003csup\u003e\u003cb\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.99\u0026thinsp;\u0026plusmn;\u0026thinsp;0.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI (kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBPs (mmHg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e152.6\u0026thinsp;\u0026plusmn;\u0026thinsp;14.0\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e133.8\u0026thinsp;\u0026plusmn;\u0026thinsp;11.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e149.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBPd (mmHg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.8\u0026thinsp;\u0026plusmn;\u0026thinsp;7.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003e65.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.7\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e82.2\u0026thinsp;\u0026plusmn;\u0026thinsp;7.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e78.0\u0026thinsp;\u0026plusmn;\u0026thinsp;10.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.090\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHR (bpm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68\u0026thinsp;\u0026plusmn;\u0026thinsp;9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91\u0026thinsp;\u0026plusmn;\u0026thinsp;13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e64\u0026thinsp;\u0026plusmn;\u0026thinsp;12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e91\u0026thinsp;\u0026plusmn;\u0026thinsp;14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). SD\u0026thinsp;=\u0026thinsp;standard deviation. BSA\u0026thinsp;=\u0026thinsp;body surface area; BMI\u0026thinsp;=\u0026thinsp;body mass index; BPs\u0026thinsp;=\u0026thinsp;systolic blood pressure; BPd\u0026thinsp;=\u0026thinsp;diastolic blood pressure; HR\u0026thinsp;=\u0026thinsp;heart rate; CPET\u0026thinsp;=\u0026thinsp;cardiopulmonary exercise testing\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSemi-recumbent ergometer\u003c/h2\u003e \u003cp\u003eLeft ventricular volumes were significantly lower after physical exertion compared to resting conditions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Left ventricular ejection fraction was similar before and after CPET (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). E/A-ratio was significantly decreased after physical exertion, mainly due to a reduction of the A-wave (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Myocardial early (e\u0026rsquo;) diastolic tissue velocities were significantly lower, although this did not lead to a reduction of E/e\u0026rsquo;, mainly due to consistent passive diastolic filling velocities (E-wave) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). After CPET sPAP was still in normal ranges.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eConventional echocardiographic parameters of left ventricular morphology and function\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSemi-recumbent ergometer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eTreadmill\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean values\u003c/b\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eat rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eafter CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eP\u003c/span\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eat rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eafter CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eP\u003c/span\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIVSD (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.073\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.009*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePWD (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.494\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVEDD (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e57.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e54.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.5\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVESD (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e35.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e36.4\u0026thinsp;\u0026plusmn;\u0026thinsp;4.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e34.5\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.048*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVL (mm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e92.9\u0026thinsp;\u0026plusmn;\u0026thinsp;5.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e91.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.0\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.0194*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVM (g)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e215.1\u0026thinsp;\u0026plusmn;\u0026thinsp;39.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e215.0\u0026thinsp;\u0026plusmn;\u0026thinsp;39.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.993\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e219.4\u0026thinsp;\u0026plusmn;\u0026thinsp;55.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e221.0\u0026thinsp;\u0026plusmn;\u0026thinsp;43.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.873\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVMI (g/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e62.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e101.4\u0026thinsp;\u0026plusmn;\u0026thinsp;22.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e110.8\u0026thinsp;\u0026plusmn;\u0026thinsp;20.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.059\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRWT\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.37\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.32\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.39\u0026thinsp;\u0026plusmn;\u0026thinsp;0.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVEDV (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162.9\u0026thinsp;\u0026plusmn;\u0026thinsp;23.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e145.2\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.010*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e164.8\u0026thinsp;\u0026plusmn;\u0026thinsp;26.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e138.6\u0026thinsp;\u0026plusmn;\u0026thinsp;24.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVESV (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51.2\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e57.5\u0026thinsp;\u0026plusmn;\u0026thinsp;17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e50.0\u0026thinsp;\u0026plusmn;\u0026thinsp;12.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.019*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLVSV (ml)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e111.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e96.7\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.006*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e107.3\u0026thinsp;\u0026plusmn;\u0026thinsp;15.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e88.6\u0026thinsp;\u0026plusmn;\u0026thinsp;15.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEF (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68.6\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e66.6\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.089\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e64.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.258\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCI (l/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003cb\u003e)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e4.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGLS (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-18.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-18.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.079\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-17.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.119\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGWI (mmHg%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1837.7\u0026thinsp;\u0026plusmn;\u0026thinsp;316.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1974.7\u0026thinsp;\u0026plusmn;\u0026thinsp;222.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.197\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1899.3\u0026thinsp;\u0026plusmn;\u0026thinsp;280.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1963.5\u0026thinsp;\u0026plusmn;\u0026thinsp;370.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.461\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). SD\u0026thinsp;=\u0026thinsp;standard deviation. IVSD\u0026thinsp;=\u0026thinsp;Interventricular septum diameter; PWD\u0026thinsp;=\u0026thinsp;Posterior wall diameter; LVEDD\u0026thinsp;=\u0026thinsp;left ventricular end-diastolic diameter; LVESD\u0026thinsp;=\u0026thinsp;left ventricular end-systolic diameter; LVL\u0026thinsp;=\u0026thinsp;left ventricular length; LVM\u0026thinsp;=\u0026thinsp;left ventricular mass; LVMi\u0026thinsp;=\u0026thinsp;LVM index; RWT\u0026thinsp;=\u0026thinsp;relative wall thickness; LVEDV\u0026thinsp;=\u0026thinsp;left ventricular end-diastolic volume; LVESV\u0026thinsp;=\u0026thinsp;left ventricular end-systolic volume; LVSV\u0026thinsp;=\u0026thinsp;left ventricular stroke volume; EF\u0026thinsp;=\u0026thinsp;ejection fraction; CI\u0026thinsp;=\u0026thinsp;cardiac index; GLS\u0026thinsp;=\u0026thinsp;global longitudinal strain; GWI\u0026thinsp;=\u0026thinsp;Global myocardial work index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParameters of left ventricular diastolic and right ventricular function\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eSemi-recumbent ergometer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eTreadmill\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean values\u003c/b\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eat rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eafter CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eP\u003c/span\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eat rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eafter CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eP\u003c/span\u003e \u003cb\u003evalue\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eE-wave (m/s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.76\u0026thinsp;\u0026plusmn;\u0026thinsp;0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.385\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.668\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eA-wave (m/s)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.43\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.41\u0026thinsp;\u0026plusmn;\u0026thinsp;0.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.60\u0026thinsp;\u0026plusmn;\u0026thinsp;0.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eE/A-ratio\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.82\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.19\u0026thinsp;\u0026plusmn;\u0026thinsp;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.87\u0026thinsp;\u0026plusmn;\u0026thinsp;0.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.24\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage e\u0026lsquo;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.14\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.004*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.13\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage a\u0026lsquo;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.097\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.07\u0026thinsp;\u0026plusmn;\u0026thinsp;0.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.09\u0026thinsp;\u0026plusmn;\u0026thinsp;0.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage e\u0026lsquo;/a\u0026lsquo;-ratio\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.90\u0026thinsp;\u0026plusmn;\u0026thinsp;0.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.59\u0026thinsp;\u0026plusmn;\u0026thinsp;0.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.011*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.78\u0026thinsp;\u0026plusmn;\u0026thinsp;0.49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.49\u0026thinsp;\u0026plusmn;\u0026thinsp;0.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.021*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAverage E/e\u0026lsquo;-ratio\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.09\u0026thinsp;\u0026plusmn;\u0026thinsp;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.602\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.94\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.007*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTAPSE (cm)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.652\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.757\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003esPAP (mmHg)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.0\u0026thinsp;\u0026plusmn;\u0026thinsp;4.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.879\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.309\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003e* statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). SD\u0026thinsp;=\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eGlobal longitudinal strain (-18.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6% vs. -18.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.079) and GWI did not differ before and after CPET (1838\u0026thinsp;\u0026plusmn;\u0026thinsp;316mmHg% vs. 1975\u0026thinsp;\u0026plusmn;\u0026thinsp;223mmHg%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.197). Specifically, GWI increased in eight and decreased in five handball players after CPET (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Athletes with an increase in GWI after CPET showed higher relative VO\u003csub\u003e2max\u003c/sub\u003e values (46.7 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 ml/min*kg vs. 37.4 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Athletes with a decrease in GWI after CPET had the lowest relative VO\u003csub\u003e2max\u003c/sub\u003e values (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At maximum physical exercise VO\u003csub\u003e2max\u003c/sub\u003e was 4214 \u0026plusmn; 489 ml/min and relative VO\u003csub\u003e2max\u003c/sub\u003e was 43.1 \u0026plusmn; 6.4 ml/min*kg. Calculated fitness index was 149 \u0026plusmn; 20 ml/min*kg.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eNo correlation with VO\u003csub\u003e2max\u003c/sub\u003e or relative VO\u003csub\u003e2max\u003c/sub\u003e was shown for GLS at rest, after CPET, and ΔGLS. In contrast, there was a correlation between GWI after CPET and VO\u003csub\u003e2max\u003c/sub\u003e (r\u0026thinsp;=\u0026thinsp;0.631; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021), \u003cb\u003eΔ\u003c/b\u003eGWI and VO\u003csub\u003e2max\u003c/sub\u003e (r\u0026thinsp;=\u0026thinsp;0.762; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), as well as \u003cb\u003eΔ\u003c/b\u003eGWI and relative VO\u003csub\u003e2max\u003c/sub\u003e (r\u0026thinsp;=\u0026thinsp;0.671; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.012; Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCorrelations between left ventricular deformation and cardiopulmonary exercise capacity\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eSemi-recumbent ergometer\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eTreadmill\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMean values\u003c/b\u003e\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cb\u003eSD\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePearson\u0026rsquo;s R\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003ePearson\u0026rsquo;s R\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eP value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GLS at rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.047\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.880\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.219\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.367\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GLS after CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.067\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.828\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.041\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.869\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. ΔGLS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.657\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.325\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.175\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelative VO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GLS at rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.952\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.008\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.974\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelative VO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GLS after CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.716\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.701\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelative VO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. ΔGLS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.605\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.706\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GWI at rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.428\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.144\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.031\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.901\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GWI after CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.631\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.021*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.336\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. ΔGWI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.762\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.346\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.147\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelative VO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GWI at rest\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-0.415\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.099\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.688\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelative VO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. GWI after CPET\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.502\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.459\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.048*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRelative VO\u003c/b\u003e\u003csub\u003e\u003cb\u003e2max\u003c/b\u003e\u003c/sub\u003e \u003cb\u003evs. ΔGWI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.671\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.012*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.592\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.008*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e* statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). SD\u0026thinsp;=\u0026thinsp;standard deviation. VO\u003csub\u003e2max\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;maximum oxygen uptake; GLS\u0026thinsp;=\u0026thinsp;global longitudinal strain; GWI\u0026thinsp;=\u0026thinsp;global myocardial work index; CPET\u0026thinsp;=\u0026thinsp;cardiopulmonary exercise testing; Δ\u0026thinsp;=\u0026thinsp;change before and after CPET\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eTreadmill testing\u003c/h2\u003e \u003cp\u003eLeft ventricular volumes were significantly lower after physical exertion compared to resting conditions (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Left ventricular ejection fraction was similar before and after CPET (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). E/A-ratio and E/e\u0026rsquo; were significantly lower after CPET (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). sPAP was in normal ranges before and after CPET.\u003c/p\u003e \u003cp\u003eGlobal longitudinal strain (-18.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7% vs. -17.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.119) and GWI did not differ before and after CPET (1899\u0026thinsp;\u0026plusmn;\u0026thinsp;281mmHg% vs. 1963\u0026thinsp;\u0026plusmn;\u0026thinsp;370mmHg%; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.461). GWI increased in 11 and decreased in eight football players after CPET (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Athletes with an increase in GWI after CPET showed higher relative VO\u003csub\u003e2max\u003c/sub\u003e values (58.3 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 ml/min*kg vs. 49.7 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). At maximum physical exercise VO\u003csub\u003e2max\u003c/sub\u003e was 4306 \u0026plusmn; 594 ml/min and relative VO\u003csub\u003e2max\u003c/sub\u003e was 54.7 \u0026plusmn; 6.5 ml/min*kg. Calculated fitness index was 178 \u0026plusmn; 20 ml/min*kg.\u003c/p\u003e \u003cp\u003eNo correlation with VO\u003csub\u003e2max\u003c/sub\u003e or relative VO\u003csub\u003e2max\u003c/sub\u003e was shown for GLS at rest, after CPET, and ΔGLS. However, GWI after CPET and relative VO\u003csub\u003e2max\u003c/sub\u003e (r\u0026thinsp;=\u0026thinsp;0.459; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.048) as well as \u003cb\u003eΔ\u003c/b\u003eGWI and relative VO\u003csub\u003e2max\u003c/sub\u003e (r\u0026thinsp;=\u0026thinsp;0.592; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008) showed moderate correlations (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eIntra- and interobserver variabilities\u003c/h2\u003e \u003cp\u003eIntraobserver variabilities of GLS measurements were 2.16% at rest (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.638) and 2.61% after CPET (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.491). Interobserver variabilities of GLS measurements were 3.91% at rest (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.337) and 4.23% after CPET (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.312). Intra- and interobserver variabilities for LV volumes, LVEF, CI, and sPAP measurements were \u0026lt;\u0026thinsp;5% without reaching statistical significance.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThe main findings of the present study are:\u003c/h2\u003e \u003cp\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003e(1)\u003c/span\u003e \u003cem\u003eGLS and GWI did not differ significantly before and after semi-recumbent ergometer and treadmill testing.\u003c/em\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003e(2)\u003c/span\u003e \u003cem\u003eThere was no significant correlation between GLS and (relative) VO\u003c/em\u003e\u003csub\u003e\u003cem\u003e2max\u003c/em\u003e\u003c/sub\u003e, \u003cem\u003ebut\u003c/em\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003e(3)\u003c/span\u003e \u003cem\u003ethere were significant correlations between\u003c/em\u003e \u003cspan type=\"BoldItalic\" class=\"BoldItalic\" name=\"Emphasis\"\u003eΔ\u003c/span\u003e\u003cem\u003eGWI and relative VO\u003c/em\u003e\u003csub\u003e\u003cem\u003e2max\u003c/em\u003e\u003c/sub\u003e \u003cem\u003ein semi-recumbent ergometer and treadmill testing.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eBaseline echocardiographic parameters\u003c/h2\u003e \u003cp\u003eChanges of conventional echocardiographic parameters after CPET (e.g. LV volumes), were in line with the results of previous studies and have already been described\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. Both, low intra- and interobserver variabilities highlight the quality of data acquisition as well as the robustness of conventional but also deformation parameters, e.g. GLS\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eImpact of maximum exercise on global longitudinal strain\u003c/h2\u003e \u003cp\u003eThe impact of pre- and afterload conditions on LV systolic function has already been described\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. In general data analyzing the impact of physical stress on LV deformation are scarce and the results of previous studies are highly heterogeneous. Some previous clinical studies have proven a significant impact of pre- and afterload conditions on GLS\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e,\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. Nevertheless, GLS was not able to predict load-independent contractility in a porcine model\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e. The impact of different CPET methods on global longitudinal strain in competitive athletes has not been described before.\u003c/p\u003e \u003cp\u003eLiang et al. assessed GLS in 15 swimming athletes before and after high-intensity exercise, where GLS was significantly lower after high-intensity exercise\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e. The decrease of GLS was explained by negative effects on myocardial cells based on anaerobic glycolysis due to ischemia, hypoxia, and the formation of lactic acid with a reduction of myocardial contraction force and consequently, a decrease of LV myocardial contractile function\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e. These results were in contrast to Gruca et al., where GLS was significantly increased in 69% of 111 male elite basketball players in the first minute after maximum physical exertion due to treadmill testing\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e. The increase of GLS at peak exercise was explained by a lower baseline and peak HR, which could not be observed in our study. Neither athletes on semi-recumbent ergometer and treadmill showed significant correlations with HR or differences of mean GLS before and after CPET. Mean GLS was slightly lower after both, semi-recumbent ergometer and treadmill testing, but did not reach statistical significance. This finding can be explained by higher blood pressure after CPET and consequently higher afterload conditions which was already described in an experimental pig model of aortic banding\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. It needs to be considered that athletes of different sports are exposed to different forms of physical exercise, and these in turn also have different effects on the cardiovascular system especially on LV remodeling. However, the results of our study are consistent with those of Santoro et al. where GLS was assessed in 27 male water polo players and did not differ significantly before and after 6 repetitions of 100-m freestyle swimming sets\u003csup\u003e\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eWhereas Gianturco et al. demonstrated a very strong correlation between VO\u003csub\u003e2max\u003c/sub\u003e and GLS in a cohort of 20 soccer referees and proposed GLS as a specific parameter to assess football referees performance\u003csup\u003e\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e\u003c/sup\u003e, there was no significant correlation between VO\u003csub\u003e2max\u003c/sub\u003e and GLS in our study. The lack of correlation between GLS and VO2\u003csub\u003emax\u003c/sub\u003e does not allow us to draw conclusions about cardiopulmonary exercise capacity based on GLS values in male handball and football players. The discrepancy between the results of Gianturco et al. and our study could be most likely explained by different training conditions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eImpact of maximum exercise on global myocardial work index\u003c/h2\u003e \u003cp\u003eGlobal myocardial work index has proven to be a reliable method for assessing LV function and is capable of detecting subtle myocardial changes. In noninvasive estimation of LV pressure, GWI based on the pressure strain loop incorporates the current afterload condition and is able to assess LV mechanical function and the myocardial oxygen consumption\u003csup\u003e\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSengupta et al. assessed GWI in 24 recreational athletes before as well as up to a maximum of 2 and 72 hours after completing a marathon and found either a decrease in GWI or no change in GWI\u003csup\u003e\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u003c/sup\u003e. A decrease of GWI was attributed to differences in HR and lower LV filling volumes. According to the results of the present study, both aspects could also be observed in professional athletes immediately after CPET, because TTE was performed 5 minutes after CPET in the present study. GWI has proved to be afterload-independent permitting a more comprehensive assessment of LV systolic function\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e, which is beneficial in athletes exposed to different physical exercise. Although systolic blood pressure as a surrogate parameter for afterload conditions was increased in all athletes after CPET. In this study, irrespective of the CPET method, mean GWI did not differ before and after CPET and an individual increase or decrease in GWI was observed in each athlete. This finding lead to the assumption that LV deformation is significantly affected by maximum exercise, whereas the method of exercise testing, semi-recumbent ergometer or treadmill, does not make a difference.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation between VO\u003csub\u003e2max\u003c/sub\u003e and GWI\u003c/h2\u003e \u003cp\u003eTokodi et al. described a moderate correlation between CPET-derived relative VO\u003csub\u003e2max\u003c/sub\u003e and GWI at rest in a cohort of 20 elite swimmers\u003csup\u003e\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u003c/sup\u003e, which was not observed in our study. However, there was a significant correlation between relative VO\u003csub\u003e2max\u003c/sub\u003e and \u003cb\u003eΔ\u003c/b\u003eGWI in both cohorts. This observation can be explained by the fact that well-trained athletes with higher fitness levels show a pronounced increase in GWI after CPET according to their relative VO\u003csub\u003e2max\u003c/sub\u003e, whereas a decrease in GWI after CPET seems to be associated with a lower cardiopulmonary exercise capacity. It can be assumed that \u003cb\u003eΔ\u003c/b\u003eGWI can be considered as a surrogate parameter to assess the current training condition of athletes.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThe number of subjects was limited by the size of the teams in the German handball and football Bundesliga studied at Leipzig University Hospital. However, these highly selected young and healthy competitive athletes highlight the exceptionality of the present cohort. Therefore, the results are not directly applicable to patients with cardiovascular disease. Both semi-recumbent ergometer and treadmill testing could not be performed in all athletes due to their limited time schedule for testing. The modality of incremental cardiopulmonary exercise test was predetermined by the respective medical team leader.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eVO2\u003csub\u003emax\u003c/sub\u003e is considered an important indicator of athlete's training condition and maximum performance capacity. In the present study we confirmed that maximum exercise has a significant effect on LV deformation, irrespective of the exercise method. The impact of maximum physical exercise on LV deformation did not differ between semi-recumbent ergometer and treadmill testing. Further, we were able to demonstrate a significant correlation between ΔGWI and VO2\u003csub\u003emax\u003c/sub\u003e directly after CPET, so that the current training condition or maximum performance capacity of an athlete might also be estimated by a single modern imaging parameter instead of only VO2\u003csub\u003emax\u003c/sub\u003e. Further studies are needed to clarify whether athletes who demonstrate a decrease in GWI and a lower VO2\u003csub\u003emax\u003c/sub\u003e after CPET actually have a higher performance potential and thus their maximal performance capacity can be further improved. If so, GWI could be used as a modern imaging parameter to characterize the athletes\u0026rsquo; maximum performance capacity, which would considerably enrich and simplify individual performance diagnostics.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll athletes\u0026nbsp;provided informed consent to participate and publish after full explanation of the purpose and order of all procedures. The study was conducted in accordance with the Declaration of Helsinki and\u0026nbsp;was approved by the ethical committee of the University of Leipzig (\u003cstrong\u003e073/18-ek\u003c/strong\u003e).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests \u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have nothing to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA.H., J.K. and S.F. designed the study. A.H. and S.S. performed all the echocardiographic examinations. J.K. and S.S. analysed the data. A.K. performed the statistics. J.K. and S.S. wrote the manuscript. The rest of the authors provided critical feedback and helped shape the research, analysis and manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funding\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors confirm that the data supporting the findings of this study are available within the article.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMitchell C, Rahko PS, Blauwet LA, Canaday B, Finstuen JA, Foster MC, Horton K, Ogunyankin KO, Palma RA, Velazquez EJ. Guidelines for Performing a Comprehensive Transthoracic Echocardiographic Examination in Adults: Recommendations from the American Society of Echocardiography. Journal of the American Society of Echocardiography 2019;32:1\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrazioli G, Sanz M, Montserrat S, Vidal B, Sitges M. Echocardiography in the evaluation of athletes. F1000Res 2015;4:151.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVoigt JU, Pedrizetti G, Lysyansky P, Marwick TH, Houle HC, Baumann R et al. Definitions for a common standard for 2D speckle tracking echocardiography: consensus document of the EACVI/ASE/Industry Task Force to standardize deformation imaging. Eur Heart J Cardiovasc Imaging 2015:16: 1\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G, Galderisi M, Marwick T, Nagueh SF, Sengupta PP, Sicari R, Smiseth OA, Smulevitz B, Takeuchi M, Thomas JD, Vannan M, Voigt J-U, Zamorano JL. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr 2011;24:277\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTops LF, Delgado V, Marsan NA, Bax JJ. Myocardial strain to detect subtle left ventricular systolic dysfunction: LV systolic dysfunction and GLS. Eur J Heart Fail 2017;19:307\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBiering-S\u0026oslash;rensen T, Biering-S\u0026oslash;rensen SR, Olsen FJ, Sengel\u0026oslash;v M, J\u0026oslash;rgensen PG, Mogelvang R, Shah AM, Jensen JS. Global Longitudinal Strain by Echocardiography Predicts Long-Term Risk of Cardiovascular Morbidity and Mortality in a Low-Risk General Population: The Copenhagen City Heart Study. Circ: Cardiovascular Imaging 2017;10.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng S, Larson MG, McCabe EL, Osypiuk E, Lehman BT, Stanchev P, Aragam J, Benjamin EJ, Solomon SD, Vasan RS. Reproducibility of Speckle-Tracking-Based Strain Measures of Left Ventricular Function in a Community-Based Study. Journal of the American Society of Echocardiography 2013;26:1258\u0026ndash;1266.e2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKouris NT, Kostopoulos VS, Psarrou GA, Kostakou PM, Tzavara C, Olympios CD. Left ventricular ejection fraction and Global Longitudinal Strain variability between methodology and experience. Echocardiography 2021;38:582\u0026ndash;589.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTruong VT, Vo HQ, Ngo TNM, Mazur J, Nguyen TTH, Pham TTM, Le TK, Phan H, Palmer C, Nagueh SF, Chung ES. Normal Ranges of Global Left Ventricular Myocardial Work Indices in Adults: A Meta-Analysis. \u003cem\u003eJ Am Soc Echocardiogr\u003c/em\u003e 2021:S0894-7317(21)00826-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHubert A, Le Rolle V, Leclercq C, Galli E, Samset E, Casset C, Mabo P, Hernandez A, Donal E. Estimation of myocardial work from pressure\u0026ndash;strain loops analysis: an experimental evaluation. European Heart Journal - Cardiovascular Imaging 2018;19:1372\u0026ndash;1379.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChan J, Edwards NFA, Khandheria BK, Shiino K, Sabapathy S, Anderson B, Chamberlain R, Scalia GM. A new approach to assess myocardial work by non-invasive left ventricular pressure\u0026ndash;strain relations in hypertension and dilated cardiomyopathy. European Heart Journal - Cardiovascular Imaging 2019;20:31\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBewarder Y, Lauder L, Kulenthiran S, Sch\u0026auml;fer O, Ukena C, Percy Marshall R, Hepp P, Laufs U, St\u0026ouml;be S, Hagendorff A, B\u0026ouml;hm M, Mahfoud F, Ewen S. Global longitudinal strain differentiates physiological hypertrophy from maladaptive remodeling. IJC Heart \u0026amp; Vasculature 2022;40:101044.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBorzi\u0026Igrave; D, Saladino S, Losi V, Faro D, Monte I. Strain and myocardial work index during echo exercise to evaluate myocardial function in athletes. J Cardiovasc Echography 2022;32:82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePetek BJ, Gustus SK, Wasfy MM. Cardiopulmonary Exercise Testing in Athletes: Expect the Unexpected. Curr Treat Options Cardio Med 2021;23:49.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFleg JL, Pi\u0026ntilde;a IL, Balady GJ, Chaitman BR, Fletcher B, Lavie C, Limacher MC, Stein RA, Williams M, Bazzarre T. Assessment of Functional Capacity in Clinical and Research Applications: An Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation 2000;102:1591\u0026ndash;1597.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFletcher GF, Balady G, Froelicher VF, Hartley LH, Haskell WL, Pollock ML. Exercise Standards: A Statement for Healthcare Professionals From the American Heart Association. Circulation 1995;91:580\u0026ndash;615.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShvartz E, Reibold RC. Aerobic fitness norms for males and females aged 6 to 75 years: a review. Aviat Space Environ Med 1990;61:3\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlbouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise testing and its applicationThis is a reprint of a paper that appeared in \u003cem\u003eHeart\u003c/em\u003e, October 2007, Volume\u0026nbsp;93, pages 1285\u0026ndash;92. Reprinted with kind permission of the authors and publisher. \u003cem\u003ePostgraduate Medical Journal\u003c/em\u003e 2007;83:675\u0026ndash;682.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDatta D, Normandin E, ZuWallack R. Cardiopulmonary exercise testing in the assessment of exertional dyspnea. Ann Thorac Med 2015;10:77.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Donnell DE, Elbehairy AF, Faisal A, Webb KA, Neder JA, Mahler DA. Exertional dyspnoea in COPD: the clinical utility of cardiopulmonary exercise testing. Eur Respir Rev 2016;25:333\u0026ndash;347.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJensen K, Johansen L, Secher NH. Influence of body mass on maximal oxygen uptake: effect of sample size. European Journal of Applied Physiology 2001;84:201\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSt\u0026ouml;ggl TL, Blumkaitis JC, Strepp T, Sareban M, Simon P, Neuberger EWI, Finkenzeller T, Nunes N, Aglas L, Haller N. The Salzburg 10/7 HIIT shock cycle study: the effects of a 7-day high-intensity interval training shock microcycle with or without additional low-intensity training on endurance performance, well-being, stress and recovery in endurance trained athletes\u0026mdash;study protocol of a randomized controlled trial. BMC Sports Sci Med Rehabil 2022;14:84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt J-U. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 2015;28:1\u0026ndash;39.e14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L et al. Recommendation for cardiac chamber quantification by echocardiography in adults: an up-date from the American Society of Echocardiography and the European Association of Cardi-ovascular Imaging. Eur Heart J: Cardiovasc Imaging 2015:16: 233\u0026ndash;270.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMor-Avi V, Lang RM, Badano LP, Belohlavek M, Cardim NM, Derumeaux G et al. Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography. J Am Soc Echocardiogr 2011:24: 277\u0026ndash;313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThomas JD, Badano LP. EACVI-ASE-industry initiative to standardize deformation imaging: a brief update from the co-chairs. Eur Heart J Cardiovasc Imaging 2013:14: 1039\u0026ndash;1040.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRussell K, Eriksen M, Aaberge L, Wilhelmsen N, Skulstad H, Remme EW, Haugaa KH, Opdahl A, Fjeld JG, Gjesdal O, Edvardsen T, Smiseth OA. A novel clinical method for quantification of regional left ventricular pressure\u0026ndash;strain loop area: a non-invasive index of myocardial work. European Heart Journal 2012;33:724\u0026ndash;733.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNagueh SF, Smiseth OA, Appleton CP, Byrd BF, Dokainish H, Edvardsen T et al. Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiog-raphy: An Update from the American Society of Echocardiography and the European Associa-tion of Cardiovascular Imaging. J Am Soc Echocardiogr 2016:29: 277\u0026ndash;314.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNixon PGF. Human circulation regulation during physical stress. L. B. Rowell. Oxford University Press, London, 1986. No. of pages: 416. Price: \u0026pound;35.00. \u003cem\u003eStress Med\u003c/em\u003e 1988;4:124\u0026ndash;125.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZimmer H-G. Who Discovered the Frank-Starling Mechanism? Physiology 2002;17:181\u0026ndash;184.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNafati C, Gardette M, Leone M, Reydellet L, Blasco V, Lannelongue A, Sayagh F, Wiramus S, Antonini F, Alban\u0026egrave;se J, Zieleskiewicz L. Use of speckle-tracking strain in preload-dependent patients, need for cautious interpretation! Ann Intensive Care 2018;8:29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRoy C, Duclos G, Nafati C, Gardette M, Lopez A, Pastene B, Gaudray E, Boussuges A, Antonini F, Leone M, Zieleskiewicz L. Left ventricular longitudinal strain variations assessed by speckle-tracking echocardiography after a passive leg raising maneuver in patients with acute circulatory failure to predict fluid responsiveness: A prospective, observational study. Ehrman R, ed. \u003cem\u003ePLoS ONE\u003c/em\u003e 2021;16:e0257737.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCarasso S, Cohen O, Mutlak D, Adler Z, Lessick J, Reisner SA, Rakowski H, Bolotin G, Agmon Y. Differential effects of afterload on left ventricular long- and short-axis function: Insights from a clinical model of patients with aortic valve stenosis undergoing aortic valve replacement. American Heart Journal 2009;158:540\u0026ndash;545.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDonal E, Bergerot C, Thibault H, Ernande L, Loufoua J, Augeul L, Ovize M, Derumeaux G. Influence of afterload on left ventricular radial and longitudinal systolic functions: a two-dimensional strain imaging study. European Journal of Echocardiography 2009;10:914\u0026ndash;921.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDahle GO, Stangeland L, Moen CA, Salminen P-R, Haaverstad R, Matre K, Grong K. The influence of acute unloading on left ventricular strain and strain rate by speckle tracking echocardiography in a porcine model. American Journal of Physiology-Heart and Circulatory Physiology 2016;310:H1330\u0026ndash;H1339.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiang C, Ma Y, Gao C, Zhang J, Yang M, Chen G, Fu S, Zhu T. Two-dimensional strain echocardiography technology for evaluation of myocardial strain in swimming athletes after high-intensity exercise. Echocardiography 2017;34:169\u0026ndash;175.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eScharhag J, Herrmann M, Urhausen A, Haschke M, Herrmann W, Kindermann W. Independent elevations of N-terminal pro\u0026ndash;brain natriuretic peptide and cardiac troponins in endurance athletes after prolonged strenuous exercise. American Heart Journal 2005;150:1128\u0026ndash;1134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGruca MM, Cheema B, Garg G, Ryan J, Thomas JD, Rigolin VH, Zielinski AR, Puthumana JJ. Strain echocardiography to describe left ventricular function pre- and postexercise in elite basketball athletes: A feasibility study. Echocardiography 2021;38:1165\u0026ndash;1172.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSantoro A, Alvino F, Antonelli G, Cameli M, Bertini M, Molle R, Mondillo S. Left Ventricular Strain Modifications after Maximal Exercise in Athletes: A Speckle Tracking Study. Echocardiography 2015;32:920\u0026ndash;927.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGianturco L, Bodini B, Gianturco V, Lippo G, Solbiati A, Turiel M. Left ventricular longitudinal strain in soccer referees. Oncotarget 2017;8:39766\u0026ndash;39773.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTakaoka H, Takeuchi M, Odake M, Yokoyama M. Assessment of myocardial oxygen consumption (Vo2) and systolic pressure-volume area (PVA) in human hearts. European Heart Journal 1992;13:85\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSengupta S, Jain R, Burkule N, Olet S, Khandheria BK. Myocardial Work Index: A Novel Method for Assessment of Myocardial Function in South Asian Recreational Athletes. Journal of Patient-Centered Research and Reviews 2020;7:147\u0026ndash;156.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTokodi M, Ol\u0026aacute;h A, F\u0026aacute;bi\u0026aacute;n A, Lakatos BK, Hizoh I, Ruppert M, Sayour AA, Barta BA, Kiss O, Syd\u0026oacute; N, Csulak E, Lad\u0026aacute;nyi Z, Merkely B, Kov\u0026aacute;cs A, Radovits T. Novel insights into the athlete\u0026rsquo;s heart: is myocardial work the new champion of systolic function? Eur Heart J Cardiovasc Imaging 2022;23:188\u0026ndash;197.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"echo-research-and-practice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Echo Research \u0026 Practice](https://echo.biomedcentral.com/)","snPcode":"44156","submissionUrl":"https://submission.nature.com/new-submission/44156/3","title":"Echo Research \u0026 Practice","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"echocardiography, athletes, cardiopulmonary exercise test, deformation, longitudinal strain, work index","lastPublishedDoi":"10.21203/rs.3.rs-2725090/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2725090/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eGlobal longitudinal strain (GLS) and global myocardial work index (GWI) allow early detection of subclinical changes in left ventricular (LV) systolic function. The aim of the study was to investigate the immediate effects of maximum physical exercise by different exercise testing methods on LV deformation parameters in competitive athletes and to analyze their correlation with cardiopulmonary exercise capacity.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eTo reach maximum physical exercise, cardiopulmonary exercise testing (CPET) was performed by semi-recumbent ergometer in competitive handball players (n\u0026thinsp;=\u0026thinsp;13) and by treadmill testing in competitive football players (n\u0026thinsp;=\u0026thinsp;19). Maximum oxygen uptake (VO\u003csub\u003e2max\u003c/sub\u003e) indexed to body weight (relative VO\u003csub\u003e2max\u003c/sub\u003e) was measured in all athletes. Transthoracic echocardiography and blood pressure measurements were performed at rest and five minutes after CPET in all athletes. GLS, GWI and their changes before and after CPET (ΔGLS, ΔGWI) were correlated with (relative) VO\u003csub\u003e2max\u003c/sub\u003e.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn handball and football players, GLS and GWI did not differ significantly before and after CPET. There were no significant correlations between GLS and relative VO\u003csub\u003e2max\u003c/sub\u003e, but moderate correlations were found between \u003cb\u003eΔ\u003c/b\u003eGWI and relative VO\u003csub\u003e2max\u003c/sub\u003e in handball (r\u0026thinsp;=\u0026thinsp;0.631; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.021) and football players (r\u0026thinsp;=\u0026thinsp;0.592; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.008). Furthermore, handball (46.7 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;4.7 ml/min*kg vs. 37.4 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.004) and football players (58.3 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;3.7 ml/min*kg vs. 49.7 ml/min*kg\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8; \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002) with an increased ΔGWI after CPET showed a significant higher relative VO\u003csub\u003e2max\u003c/sub\u003e.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eMaximum physical exercise has an immediate effect on LV deformation, irrespective of the used testing method. The correlation of relative VO\u003csub\u003e2max\u003c/sub\u003e with ΔGWI, identifies GWI as an echocardiographic parameter for characterizing the current individual training status of athletes.\u003c/p\u003e","manuscriptTitle":"Effects of different exercise testing methods on left ventricular deformation and its correlation with cardiopulmonary exercise capacity in competitive athletes – semi-recumbent ergometer vs. treadmill testing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-27 14:39:16","doi":"10.21203/rs.3.rs-2725090/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Major revision","date":"2023-06-09T20:29:49+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2023-06-06T13:15:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53778e71-0985-4558-a871-f83c2bdbf18c","date":"2023-05-24T03:17:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"a3b51f28-9f56-4210-b8fe-0b5f8d8f594b","date":"2023-04-16T15:22:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"12348a8f-89db-44d9-818c-2a2c5008d15f","date":"2023-03-28T14:01:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-03-25T12:28:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-03-24T18:55:19+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-03-24T15:13:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"Echo Research \u0026 Practice","date":"2023-03-23T01:17:23+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"echo-research-and-practice","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [Echo Research \u0026 Practice](https://echo.biomedcentral.com/)","snPcode":"44156","submissionUrl":"https://submission.nature.com/new-submission/44156/3","title":"Echo Research \u0026 Practice","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5967f13f-9e67-45b9-8f65-90933bf1159d","owner":[],"postedDate":"March 27th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2023-08-09T21:29:15+00:00","versionOfRecord":[],"versionCreatedAt":"2023-03-27 14:39:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-2725090","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2725090","identity":"rs-2725090","version":["v1"]},"buildId":"-HB7Z8yhvgn0wM9Nzuekk","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}