Exercise and weight loss with a left ventricular assist device: A case report and review of the literature

With changes in the heart transplant allocation system in the United States, the use of left ventricular device therapy (LVAD) as a bridge to transplant has decreased. Currently, one of the primary reasons to implant a device is for patient support until they can lose weight to qualify for transplant. This paper reviews the outcomes of various weight loss strategies for patients with LVADs including weight reduction surgery and cardiac rehab. Additionally, results of the use of GLP1 agonists on weight loss in general and in heart failure patients is reviewed. Finally, because of the unique issues involving exercise for patients with LVADs, we review safe exercise techniques with instructions for patients.

Depressive symptoms, right ventricular function, and muscular strength are associated with peak oxygen uptake in patients with implantable left ventricular assist devices

BACKGROUND

Left ventricular assist device (LVAD) implantation is among the most effective treatment options for patients with severe heart failure. Although previous studies have examined the factors related to peak oxygen uptake (peak VO2 ), they were limited by the few patients involved and their focus on medical and physical functions. Therefore, this study comprehensively examined the factors associated with peak VO2 , which is an important prognostic factor in patients with implantable LVADs.

METHODS

Eighty-nine patients who underwent initial LVAD implantation and were eligible for cardiopulmonary exercise testing (CPX) between May 2014 and September 2021 were included. The patients' mean age was 48 ± 12 years, and 70% were males. Based on previous studies, the cut-off was set at 12 and 14 mL/kg/min for patients taking β-blocker and those not taking β-blockers, respectively. Furthermore, factors associated with peak VO2 were examined using multivariate logistic regression analysis.

RESULTS

The mean time from surgery to CPX administration was 73 ± 40 days. The high group had a higher cardiac index, right ventricular stroke work index (RVSWI), and isometric knee extensor muscular strength and lower Patient Health Questionnaire-9 (PHQ-9) and B-type natriuretic peptide values than the low group. Multivariate logistic regression analysis showed that RVSWI and KEMS were positively correlated, whereas PHQ-9 was negatively associated with peak VO2 .

CONCLUSION

Right ventricular function, depressive symptoms, and lower limb muscular strength were associated with exercise capacity in patients with implantable LVADs.

Supervised exercise training in patients with advanced heart failure and left ventricular assist device: A multicentre randomized controlled trial (Ex-VAD trial)

AIMS

Small studies and observations suggested that exercise training may improve peak oxygen consumption (peakVO2 ) in patients with advanced heart failure and left ventricular assist device (LVAD). We investigated whether in this patient group a supervised exercise training can improve exercise capacity.

METHODS AND RESULTS

In this multicentre, prospective, randomized, controlled trial, patients with stable heart failure and LVAD were randomly assigned (2:1) to 12 weeks of supervised exercise training or usual care, with 12 weeks of follow-up. The primary endpoint was the change in peakVO2 after 12 weeks (51 patients provided a power of 90% with an expected group difference in peakVO2 of 3 ml/kg/min). Secondary endpoints included changes in submaximal exercise capacity and quality of life. Among 64 patients enrolled (97% male, mean age 56 years), 54 were included in the analysis. Mean difference in the change of peakVO2 after 12 weeks was 0.826 ml/min/kg (95% confidence interval [CI] -0.37, 2.03; p = 0.183). There was a positive effect of exercise training on 6-min walk distance with a mean increase in the intervention group by 43.4 m (95% CI 16.9, 69.9; p = 0.0024), and on the Kansas City Cardiomyopathy Questionnaire physical domain score (mean 14.3, 95% CI 3.7, 24.9; p = 0.0124), both after 12 weeks. The overall adherence was high (71%), and there were no differences in adverse events between groups.

CONCLUSION

In patients with advanced heart failure and LVAD, 12 weeks of exercise training did not improve peakVO2 but demonstrated positive effects on submaximal exercise capacity and physical quality of life.

Standardised Exercise Prescription for Patients with Chronic Coronary Syndrome and/or Heart Failure: A Consensus Statement from the EXPERT Working Group

Whereas exercise training, as part of multidisciplinary rehabilitation, is a key component in the management of patients with chronic coronary syndrome (CCS) and/or congestive heart failure (CHF), physicians and exercise professionals disagree among themselves on the type and characteristics of the exercise to be prescribed to these patients, and the exercise prescriptions are not consistent with the international guidelines. This impacts the efficacy and quality of the intervention of rehabilitation. To overcome these barriers, a digital training and decision support system [i.e. EXercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool], i.e. a stepwise aid to exercise prescription in patients with CCS and/or CHF, affected by concomitant risk factors and comorbidities, in the setting of multidisciplinary rehabilitation, was developed. The EXPERT working group members reviewed the literature and formulated exercise recommendations (exercise training intensity, frequency, volume, type, session and programme duration) and safety precautions for CCS and/or CHF (including heart transplantation). Also, highly prevalent comorbidities (e.g. peripheral arterial disease) or cardiac devices (e.g. pacemaker, implanted cardioverter defibrillator, left-ventricular assist device) were considered, as well as indications for the in-hospital phase (e.g. after coronary revascularisation or hospitalisation for CHF). The contributions of physical fitness, medications and adverse events during exercise testing were also considered. The EXPERT tool was developed on the basis of this evidence. In this paper, the exercise prescriptions for patients with CCS and/or CHF formulated for the EXPERT tool are presented. Finally, to demonstrate how the EXPERT tool proposes exercise prescriptions in patients with CCS and/or CHF with different combinations of CVD risk factors, three patient cases with solutions are presented.

Exercise Performance and Quality of Life of Left Ventricular Assist Device Patients After Long-Term Outpatient Cardiac Rehabilitation

PURPOSE

Exercise performance and quality of life (QoL) of left ventricular assist device (LVAD) patients improve after early cardiac rehabilitation (CR). The purpose of this study was to examine the efficacy of multiprofessional long term phase 3 outpatient CR, and whether cardiopulmonary exercise testing (CPX) and 6-min walk testing (6MWT) post-LVAD implantation predict hospital readmission.

METHODS

This retrospective observational cohort study included 29 LVAD patients (58.6 ± 7.7 yr, female: 13.8%, body mass index: 29.4 ± 3.3 kg/m 2 ). Functional performance tests (CPX, 6MWT, sit-to-stand test), QoL, and psychological surveys (Kansas City Cardiomyopathy Questionnaire, hospital anxiety and depression scale, and Control Convictions about Disease and Health [KKG]) were performed at baseline and at the end of CR.

RESULTS

The CR was initiated at a median (IQR) of 159 (130-260) d after LVAD implantation for a duration of 340 (180-363) d with 46.8 ± 23.2 trainings. The 6MWT (408.4 ± 113.3 vs 455.4 ± 115.5 m, P = .003) and sit-to-stand test (16.7 ± 6.9 vs 19.0 ± 5.3 repetitions, P = .033) improved, but relative peak oxygen uptake (V˙ o2peak : 9.4 [8.2-14.4] vs 9.3 [7.8-13.4] mL/min/kg, P = .57) did not change. Using receiver operating characteristic curve analysis, baseline V˙ o2peak values were associated with readmission 1-yr after CR onset (C-statistic = 0.88) with a cutoff value of V˙ o2peak < 9.15 mL/min/kg (100% sensitivity, 78% specificity, P < .001). The Kansas City Cardiomyopathy Questionnaire self-efficacy and knowledge (+6.3 points), QoL (+5.0 points), and social limitation (+7.1 points) demonstrated clinically important changes. In addition, the hospital anxiety and depression scale showed a significant reduction in anxiety (4.6 ± 3.2 vs 2.6 ± 2.4, P = .03).

CONCLUSIONS

Long-term CR is safe and LVAD outpatients showed improvement of QoL, anxiety, and submaximal exercise performance. In addition, V˙ o2peak and 6MWT have prognostic value for readmission.

Outcomes of Patients Referred for Cardiac Rehabilitation After Left Ventricular Assist Device Implantation

A single-center continuous-flow left ventricular assist device (LVAD) cohort (n = 503) was reviewed for patients with information on cardiac rehabilitation (CR) participation (n = 273) over a 13-year period. The analysis was then limited LVAD recipients who fit into three main CR categories: those who graduated CR (n = 138), those who were able to but declined participation (n = 61), and those who were too sick to complete or start CR (n = 28). To assess the association between CR categories and mortality and hospitalizations on LVAD support, multivariate cox regression and negative binomial regression analyses were performed, respectively. Among those who started CR and had the opportunity to finish (enough follow-up time, insurance coverage), 79% graduated. Those who graduated CR had a 96% survival at 1 year (95% confidence interval [CI], 91-98). Compared with the graduated group, those in the too sick group had an increased hazards rate of mortality (hazard ratio, 2.85; 95% CI, 1.49-5.44; p < 0.01) and an increase in the incidence rate of hospitalizations (incidence rate ratio, 1.74; 95% CI, 1.14-2.66, p = 0.01). This study is the largest to date to report outcomes of LVAD recipients referred for CR. The lower readmission rates and high survival in the group that graduated CR provides further evidence for the safety of CR in LVAD recipients.

FORCE Risk Stratification Tool for Pediatric Cardiac Rehabilitation and Fitness Programs

Risk stratification is required to set an exercise prescription for cardiac rehabilitation, but an optimal scheme for congenital heart disease (CHD) is unknown. We piloted a system based on hemodynamic rather than anatomic factors: function, oxygen level, rhythm, complex/coronary anatomy, and elevated load (FORCE). Feasibility, efficacy, and safety of the FORCE tool were evaluated. Patients < 22 years old participating in the Cardiac Fitness Program at Boston Children's Hospital between 02/2017 and 12/2021 were retrospectively analyzed. Assigned FORCE levels, anatomy, adverse events, fitness and exercise test data were collected. Of 63 attempts at FORCE classification, 62 (98%) were successfully classified while one with restrictive cardiomyopathy was not. Thirty-nine (62%) were FORCE 1, 16 (25%) were FORCE 2, and seven (11%) were FORCE 3. Almost half of FORCE 1 patients had simple or complex CHD and the majority of FORCE 2 patients had single ventricle CHD. FORCE 3 patients were more likely to have serious arrhythmias or cardiomyopathy than those in FORCE 1 or 2 (p < 0.001). Postural orthostatic tachycardia syndrome patients appeared in FORCE 1 only. No adverse events occurred over 958 total sessions. The total number of fitness sessions/participant was similar across FORCE levels. It was feasible to risk stratify patients with CHD using a clinical FORCE tool. The tool was effective in categorizing patients and simple to use. No adverse events occurred with fitness training over nearly 1000 exercise training sessions. Adding diastolic dysfunction to the original model may add utility.

Safety and Feasibility of Exercise Rehabilitation in Children with Ventricular Assist Devices

Children with advanced heart failure may require ventricular assist devices (VAD) while awaiting heart transplantation. Currently, no data exist regarding the safety of exercise rehabilitation (ER) in children on VAD support. The purpose of this study was to determine the safety and feasibility of ER in children on VAD support awaiting heart transplantation. Eligible patients underwent VAD placement between 1998 and 2019; both inpatient and outpatient participants were included. After VAD implantation and when ambulatory, patients were enrolled in ER. Exercise sessions were scheduled three times a week and consisted of aerobic and musculoskeletal conditioning. A total of 29 patients (59% male, mean age 14 ± 3.2 years) were included with a median VAD duration of 120 ± 109 days. Cardiac diagnoses included cardiomyopathy (81%) and congenital heart disease (19%). VAD type included pulsatile (59%) and continuous-flow devices (41%). Eight hundred and sixty-four (85%) ER sessions were successfully completed and began at a mean of 49 days (range 19-108) after VAD implant. No adverse events, including episodes of hypotension, significant complex arrhythmia, or VAD malfunction occurred during exercise testing or ER, and no sessions were discontinued prematurely. Pediatric patients on VAD support can safely participate in ER with relatively high compliance, and sessions can be implemented early after VAD implantation. Given the safety profile, ER in pediatric VAD recipients, which is a modifiable pre-transplant risk factor that may improve functional capacity, warrants further study as a potential modality to improve post-transplant outcomes.

Cardiac Rehabilitation in Patients With Ventricular Assist Device

PURPOSE

The aim of this study was to investigate changes in exercise capacity (EC) and quality of life (QoL) of patients with ventricular assist devices (VADs) during cardiac rehabilitation (CR).

METHODS

Data from patients with VAD implantation and subsequent CR between 2007 and 2017 were analyzed retrospectively. Measures of the 6-min walk test [6MWT] distance, Functional Independence Measure [FIM], ergometry, MacNew Heart Disease Questionnaire [MNH], and Hospital Anxiety and Depression Scale [HADS] at entry and discharge were examined.

RESULTS

Data from 110 patients (age 53 ± 12 yr; male 82%) were analyzed. Patients improved during CR significantly in the 6MWT (114 ± 85 m, P < .001), ergometry (20 ± 17 W, P = .002), FIM (8 ± 7 points, P < .001), and MNH (0.8 ± 0.7 points, P < .001). Initial HADS levels were high with a mean value of 9 and did not improve during CR (-0.4 ± 5 points, P = .637). Significant differences of improvements in the 6MWT were observed between left and biventricular VAD (129 ± 90 m vs 85 ± 67 m, P = .043) as well as destination therapy and bridge-to-transplant (184 ± 88 m vs 102 ± 82 m, P = .005).

CONCLUSIONS

Patients with VAD implantation had statistically and clinically significant improvements in EC and QoL as assessed with the MNH during CR. Patients on destination therapy showed a larger benefit from CR than bridge-to-transplant patients and patients with left VAD improved more than biventricular VAD patients.

Relationship between muscle strength and rehospitalization in ventricular assist device patients

We examined the relationship between leg extensor muscle strength (LEMS) at discharge and rehospitalization within 1 year in patients with a newly implanted ventricular assist device (VAD). This study included 28 patients who had received a VAD at our institution between October 2013 and February 2019, all of whom had been discharged for 1 year. The patients were divided into two groups according to their LEMS at discharge (higher strength [group H] and lower strength [group L]), based on the median value of the 55.2 kg-force (kgf)/body weight (BW) equation. Exercise performance parameters (e.g., grip strength, 6-min walk distance, and peak VO₂) and laboratory data concerning nutritional status were also collected. Nine patients (64.3%) in group L were rehospitalized within 1 year after discharge. The rehospitalization rate was significantly higher in group L than group H (p = 0.020). Compared with discharge, patients exhibited higher grip strength (56.3 vs. 48.6 kg/BW, respectively; p = 0.011), 6-min walk distances (588 vs. 470 m, respectively; p = 0.002), and peak VO₂ (15.4 vs. 11.9 mL/min/kg, respectively; p < 0.001) at 1 year after discharge. However, the LEMS (57.4 vs. 58.0 kgf/BW, respectively; p = 0.798) did not increase after discharge in VAD patients who avoided rehospitalization. LEMS at discharge was associated with rehospitalization after VAD surgery; a high LEMS improves the likelihood of avoiding rehospitalization.

Exercise in patients with left ventricular devices: The interaction between the device and the patient

Advances in the engineering of surgically implanted, durable left ventricular assist devices (LVAD) has led to improvements in the two-year survival of patients on LVAD support, which is now comparable to that of heart transplant (HT) recipients. And with the advent of magnetic levitation technology, both the survival rate and average time on LVAD support are expected to improve even further. However, despite these advances, the functional capacity of patients on LVAD support remains reduced compared to those who received a HT. A few small clinical trials have shown improvement in functional capacity with exercise training. Peak oxygen uptake improves modestly (10%-20%) with exercise training, suggesting a possible celling-effect linked to the ability of the LVAD to increase flow during exercise. This paper reviews both (a) the effect of the LVAD on the cardiorespiratory responses during a single, acute bout of exercise up to maximum and (b) the central and peripheral adaptations that occur among patients with an LVAD who undergo an exercise training regimen. We also address the tenets of the exercise prescription that are unique to patients with a durable LVAD.

Rethinking Rehabilitation: A REVIEW OF PATIENT POPULATIONS WHO CAN BENEFIT FROM CARDIAC REHABILITATION

Although cardiac rehabilitation (CR) is safe and highly effective for individuals with various cardiovascular health conditions, to date there are only seven diagnoses or procedures identified by the Centers for Medicare & Medicaid Services that qualify for referral. When considering the growing number of individuals with cardiovascular disease (CVD), or other health conditions that increase the risk for CVD, it is important to determine the extent for which CR could benefit these populations. Furthermore, there are some patients who may currently be eligible for CR (spontaneous coronary artery dissection, left ventricular assistant device) but make up a relatively small proportion of the populations that are regularly attending and participating. Thus, these patient populations and special considerations for exercise might be less familiar to professionals who are supervising their programs. The purpose of this review is to summarize the current literature surrounding exercise testing and programming among four specific patient populations that either do not currently qualify for (chronic and end-stage renal disease, breast cancer survivor) or who are eligible but less commonly seen in CR (sudden coronary artery dissection, left ventricular assist device). While current evidence suggests that individuals with these health conditions can safely participate in and may benefit from supervised exercise programming, there is an immediate need for high-quality, multisite clinical trials to develop more specific exercise recommendations and support the inclusion of these populations in future CR programs.

Depressive symptoms interfere with the improvement in exercise capacity by cardiac rehabilitation after left ventricular assist device implantation

BACKGROUND

Although depressive symptoms are associated with an increased risk of readmission after left ventricular assist device (LVAD) implantation, it is unclear whether they affect the efficacy of exercise-based cardiac rehabilitation (EBCR). This study aimed to investigate the effect of depressive symptoms on EBCR efficacy.

METHODS

We analyzed 48 patients who participated in EBCR after LVAD implantation (mean age 45 ± 12 years; 60% male). Patients were classified into two groups using the Zung Self-Rating Depression Scale (SDS): depressive group (SDS ≥40, n = 27) and non-depressive group (SDS <40, n = 21). We examined changes in peak oxygen uptake (VO₂ ), knee extensor muscular strength (KEMS), and quality of life (QOL) during EBCR using analysis of covariance.

RESULTS

Although baseline characteristics were similar between the two groups, the non-depressive group was less likely to receive diuretics (22% vs. 52%, p = 0.030). Peak VO₂ , KEMS, and QOL significantly increased over time in both groups (all p < 0.05). The depressive group had a significantly lower change in peak VO₂ than the non-depressive group (2.7 vs. 1.6 ml/kg/min; mean difference: -1.1 ml/kg/min, 95% confidence interval [CI]: -0.045 to -2.17; p = 0.041, d = 0.59). There was no between-group difference regarding the change in KEMS or QOL. Adjusting for the baseline value, a significant difference between groups was observed only in peak VO₂ (p = 0.045).

CONCLUSIONS

Although EBCR significantly improved exercise capacity after LVAD implantation, depressive symptoms interfered with this improvement. Further studies are needed to determine whether psychological interventions for depression, in addition to EBCR, would improve the response to EBCR after LVAD implantation.

Variation in Cardiac Rehabilitation for Pediatric Ventricular Assist Device Recipients Across North America

Despite increasing utilization of continuous-flow pediatric ventricular assist devices (VAD) in children, data on exercise testing and cardiac rehabilitation (CR) are unknown. We described variation in CR practices and identified barriers to exercise testing and CR. A survey was performed through the Advanced Cardiac Therapies Improving Outcomes Network (ACTION) representing pediatric VAD centers across North America. Descriptive statistics were performed. A multidisciplinary cohort of 52 respondents from 28 pediatric VAD centers responded. Although 38% reported performing exercise testing, most (65%) used 6 minute walk tests rather than formal cycle or treadmill exercise testing. While all respondents refer to physical therapy during the initial inpatient stay for VAD placement, only 52% refer to a CR program. When performed, CR was performed at an ACTION center (84%), a local specialized center (21%), or a home-based CR program (26%). Commonly cited barriers to either CR or exercise testing were inadequate resources, inadequate implementation logistics knowledge, concerns about safety, inability of patients to travel to a CR facility, and concern about utility of exercise testing or CR. Over 90% of centers were interested in implementing a standardized pediatric VAD CR program. Utilization of exercise testing and CR after VAD placement is variable. Despite perceived barriers, most pediatric VAD centers are interested in implementing a standardized CR program for recipients. In response to this interest, we plan to implement a standardized CR protocol to all ACTION pediatric VAD centers in an effort to improve pretransplant waitlist rehabilitation and post-transplant outcomes.

The Future of Exercise-Based Cardiac Rehabilitation for Patients With Heart Failure

Cardiac rehabilitation (CR) is a comprehensive program that includes exercise training, titration of medical therapy, lifestyle modification, educational support, and psychosocial assessment. All these components are safe and beneficial resulting in significant improvements in quality of life, functional capacity, mortality, and hospital readmission. Current guidelines support its use in a broad spectrum of cardiac disease. This review focuses on exercise-based CR for heart failure (HF) patients in whom CR is a recommended treatment. Exercise should be prescribed according to a personalized approach, optimizing, and tailoring the rehabilitative program to the patient's characteristics. Specific CR programs are dedicated to older patients, those with HF and preserved ejection fraction, and recipients of cardiac implantable electronic devices or left ventricular assistance device. Telemedicine may increase CR participation and overcome some of the barriers that limit its utilization.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 1

BACKGROUND

Although cardiovascular rehabilitation (CR) is well accepted in general, CR-attendance and delivery still considerably vary between the European countries. Moreover, clinical and prognostic effects of CR are not well established for a variety of cardiovascular diseases.

METHODS

The guidelines address all aspects of CR including indications, contents and delivery. By processing the guidelines, every step was externally supervised and moderated by independent members of the "Association of the Scientific Medical Societies in Germany" (AWMF). Four meta-analyses were performed to evaluate the prognostic effect of CR after acute coronary syndrome (ACS), after coronary bypass grafting (CABG), in patients with severe chronic systolic heart failure (HFrEF), and to define the effect of psychological interventions during CR. All other indications for CR-delivery were based on a predefined semi-structured literature search and recommendations were established by a formal consenting process including all medical societies involved in guideline generation.

RESULTS

Multidisciplinary CR is associated with a significant reduction in all-cause mortality in patients after ACS and after CABG, whereas HFrEF-patients (left ventricular ejection fraction <40%) especially benefit in terms of exercise capacity and health-related quality of life. Patients with other cardiovascular diseases also benefit from CR-participation, but the scientific evidence is less clear. There is increasing evidence that the beneficial effect of CR strongly depends on "treatment intensity" including medical supervision, treatment of cardiovascular risk factors, information and education, and a minimum of individually adapted exercise volume. Additional psychologic interventions should be performed on the basis of individual needs.

CONCLUSIONS

These guidelines reinforce the substantial benefit of CR in specific clinical indications, but also describe remaining deficits in CR-delivery in clinical practice as well as in CR-science with respect to methodology and presentation.

One year improvement of exercise capacity in patients with mechanical circulatory support as bridge to transplantation

AIMS

Mechanical circulatory support (MCS) results in substantial improvement of prognosis and functional capacity. Currently, duration of MCS as a bridge to transplantation (BTT) is often prolonged due to shortage of donor hearts. Because long-term results of exercise capacity after MCS are largely unknown, we studied serial cardiopulmonary exercise tests (CPETs) during the first year after MCS implantation.

METHODS AND RESULTS

Cardiopulmonary exercise tests at 6 and 12 months after MCS implantation in BTT patients were retrospectively analysed, including clinical factors related to exercise capacity. A total of 105 MCS patients (67% male, 50 ± 12 years) underwent serial CPET at 6 and 12 months after implantation. Power (105 ± 35 to 114 ± 40 W; P ≤ 0.001) and peak VO2 per kilogram (pVO2/kg) improved significantly (16.5 ± 5.0 to 17.2 ± 5.5 mL/kg/min (P = 0.008)). Improvement in pVO2 between 6 and 12 months after LVAD implantation was not related to heart failure aetiology or haemodynamic severity prior to MCS. We identified maximal heart rate at exercise as an important factor for pVO2. Younger age and lower BMI were related to further improvement. At 12 months, 25 (24%) patients had a normal exercise capacity (Weber classification A, pVO2 > 20 mL/kg/min).

CONCLUSIONS

Exercise capacity (power and pVO2) increased significantly between 6 and 12 months after MCS independent of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile or heart failure aetiology. Heart rate at exercise importantly relates to exercise capacity. This long-term improvement in exercise capacity is important information for the growing group of long-term MCS patients as this is critical for the quality of life of patients.

Clinical Outcomes, Trends in Weight, and Weight Loss Strategies in Patients With Obesity After Durable Ventricular Assist Device Implantation

PURPOSE OF REVIEW

To discuss clinical outcomes, changes in weight, and weight loss strategies of patients with obesity post left ventricular assist device (LVAD) implantation.

RECENT FINDINGS

Despite increased complications in patients with obesity after LVAD implantation, survival is comparable to patients without obesity. A minority of patients with obesity lose significant weight and become eligible for heart transplantation after LVAD implantation. In fact, a great majority of such patients gain weight post-implantation. Obesity by itself should not be considered prohibitive for LVAD therapy but, rather, should be incorporated into the overall risk assessment for LVAD implantation. Concerted strategies should be developed to promote sustainable weight loss in patients with obesity and LVAD to improve quality of life, eligibility, and outcomes after heart transplantation. Investigation of the long-term impact of weight loss on patients with obesity with LVAD is warranted.

Feasibility of high-intensity interval training in patients with left ventricular assist devices: a pilot study

Aims

Patients with left ventricular assist device (LVAD) suffer from persistent exercise limitation despite improvement of their heart failure syndrome. Exercise training (ET) programmes to improve aerobic capacity have shown modest efficacy. High‐intensity interval training (HIIT), as an alternative to moderate continuous training, has not been systematically tested in this population. We examine the feasibility of a short, personalized HIIT programme in patients with LVAD and describe its effects on aerobic capacity and left ventricular remodelling.

Methods and results

Patients on durable LVAD support were prospectively enrolled in a 15‐session, 5 week HIIT programme. Turndown echocardiogram, Kansas City Cardiomyopathy Questionnaire, and cardiopulmonary exercise test were performed before and after HIIT. Training workloads for each subject were based on pretraining peak cardiopulmonary exercise test work rate (W). Percentage of prescribed training workload completed and adverse events were recorded for each subject. Fifteen subjects were enrolled [10 men, age = 51 (29–71) years, HeartMate II = 12, HeartMate 3 = 3, and time on LVAD = 18 (3–64) months]. Twelve completed post‐training testing. HIIT was well tolerated, and 90% (inter‐quartile range: 78, 99%) of the prescribed workload (W) was completed with no major adverse events. Improvements were seen in aV̇O₂ at ventilatory threshold [7.1 (6.5, 9.1) to 8.5 (7.7, 9.3) mL/kg/min, P = 0.04], work rate at ventilatory threshold [44 (14, 54) to 55 (21, 66) W, P = 0.05], and left ventricular end‐diastolic volume [168 (144, 216) to 159 (124, 212) mL, n = 7, P = 0.02]. HIIT had no effect on maximal oxygen consumption (V̇O_2peak) or Kansas City Cardiomyopathy Questionnaire score.

Conclusions

Cardiopulmonary exercise test‐guided HIIT is feasible and can improve submaximal aerobic capacity in stable patients with chronic LVAD support. Further studies are needed on its effects on the myocardium and its potential role in cardiac rehabilitation programmes.

Cardiopulmonary Rehabilitation in Pediatric Patients With Congenital and Acquired Heart Disease

BACKGROUND

Heart disease in children and adolescents is common, approaching 1.0% of the population. In those patients with complex physiology and severe cardiac dysfunction, the inability to participate in physical activity results in significant obstacles to normal acts of daily living and significantly diminished quality of life. Attempts to study the practicality and benefits of cardiopulmonary rehabilitation (CR) programs in this population have been hampered by the heterogeneity of lesions, lack of facilities, and trained personnel to supervise these types of programs. Although there are numerous articles on CR in children with cardiac disease, all suffer from the same basic problems of small sample size, short duration of study, and heterogeneous study populations.

PURPOSE

The purpose of this review was to first evaluate the current rehabilitation literature on both congenital cardiac defects and acquired abnormalities-in this latter group placing a significant emphasis on cardiomyopathies, as well as the special populations in the peri-transplant period and/or mechanical circulatory support. Second, we discussed what is known about practical approaches to CR for the various types of pediatric-specific cardiac conditions. This limited data will be supplemented by the current approach of our institution to CR in these populations with the understanding that this is by no means a consensus approach to these patients. Finally, we summarized research goals for this growing group of patients.

CONCLUSION

Cardiopulmonary rehabilitation in pediatric congenital and acquired heart disease is currently a field in its infancy. Significant strides have been made for complex heart disease and impaired myocardial function. Current research holds the promise for the development of programs that are practical, scalable, and can be implemented in most clinical sites within the foreseeable future.

Determinants of Functional Capacity and Quality of Life After Implantation of a Durable Left Ventricular Assist Device

Continuous-flow left ventricular assist devices (LVAD) are increasingly used as destination therapy in patients with end-stage heart failure and, with recent improvements in pump design, adverse event rates are decreasing. Implanted patients experience improved survival, quality of life (QoL) and functional capacity (FC). However, improvement in FC and QoL after implantation is not unequivocal, and this has implications for patient selection and preimplantation discussions with patients and relatives. This article identifies preimplantation predictors of lack of improvement in FC and QoL after continuous-flow LVAD implantation and discusses potential mechanisms, allowing for the identification of potential factors that can be modified. In particular, the pathophysiology behind insufficient improvement in peak oxygen uptake is discussed. Data are included from 40 studies, resulting in analysis of >700 exercise tests. Mean peak oxygen uptake was 13.4 ml/kg/min (equivalent to 48% of predicted value; 259 days after implantation, range 31–1,017 days) and mean 6-minute walk test distance was 370 m (182 days after implantation, range 43–543 days). Finally, the interplay between improvement in FC and QoL is discussed.

Characteristics, Therapeutic Needs, and Scope of Patients With a Continuous-Flow Left Ventricular Device Entering Cardiac Rehabilitation: A RETROSPECTIVE ANALYSIS

BACKGROUND

With an increasing number of left ventricular assist devices (LVADs) being implanted, the need for adequate cardiac rehabilitation (CR) regimens meeting the special needs of these patients arises. Only a few studies have reported experience gained on this topic. Structured CR strategies are poorly implemented. The aim was to evaluate the characteristics, therapeutic needs, and scope of LVAD patients at admission to CR within a greater cohort in order to identify their special CR needs.

METHODS

Retrospective single-center study; 69 LVAD patients (50.7 ± 13.6 y; 59 male; 48 HVAD; 21 HeartMate II) who completed first inpatient CR were included. Patient records were used to document relevant medical information (including the results of a 6-min walk test and a maximal isometric strength test for quadriceps femoral muscles in both legs) and the International Classification of Functioning, Disability and Health for classification of health and health-related domains.

RESULTS

Patient characteristics demonstrated a heterogeneous group: CR was started 44 ± 38.6 d after implantation; CR duration was 28 ± 9.7 d. Despite similar etiology, physical and psychological condition was diverse, although, overall a high degree of impairment was present, especially in the body function (79.7%) and activity and participation (95.7%) domains. The results demonstrated the need for a highly individualized approach in the somatic and also in the education, psychosocial, and social therapeutic regimes.

CONCLUSION

The results demonstrate a heterogeneous group with a high level of impairment and special needs in many CR domains. The development and evaluation of a special highly individualized approach of CR, which meets the special needs of these patients, is needed.

Continuous LVAD monitoring reveals high suction rates in clinically stable outpatients

Suction of the left ventricle can lead to potentially life‐threatening events in left ventricular assist device (LVAD) patients. With the resolution of currently available clinical LVAD monitoring healthcare professionals are unable to evaluate patients’ suction occurrences in detail. This study investigates occurrences and durations of suction events and their associations with tachycardia in stable outpatients. Continuous high‐resolution LVAD data from HVAD patients were analyzed in the early outpatient period for 15 days. A validated suction detection from LVAD signals was used. Suction events were evaluated as suction rates, bursts of consecutive suction beats, and clusters of suction beats. The occurrence of tachycardia was analyzed before, during, and after suction clusters. Furthermore, blood work, implant strategy, LVAD speed setting, inflow cannula position, left ventricular diameters, and adverse events were evaluated in these patients. LVAD data of 10 patients was analyzed starting at 78 ± 22 postoperative days. Individuals’ highest suction rates per hour resulted in a median of 11% (range 3%‐61%). Bursts categorized as consecutive suction beats with n = 2, n = 3‐5, n = 6‐15, and n > 15 beats were homogenously distributed with 10.3 ± 0.8% among all suction beats. Larger suction bursts were followed by shorter suction‐free periods. Tachycardia during suction occurred in 12% of all suction clusters. Significant differences in clinical parameters between individuals with high and low suction rates were only observed in left ventricular end‐diastolic and end‐systolic diameters (P < .02). Continuous high‐resolution LVAD monitoring sheds light on outpatient suction occurrences. Interindividual and intraindividual characteristics of longitudinal suction rates were observed. Longer suction clusters have higher probabilities of tachycardia within the cluster and more severe types of suction waveforms. This work shows the necessity of improved LVAD monitoring and the implementation of an LVAD speed control to reduce suction rates and their concomitant burden on the cardiovascular system.

Approaches to improving exercise capacity in patients with left ventricular assist devices: an area requiring further investigation

Introduction: Left ventricular assist device (LVAD) implantation has become a well-established treatment option for patients with end stage heart failure (HF) who are refractory to medical therapy. While LVADs implantation does effectively improve hemodynamic performance many patients still possess peripheral pathological adaptations often present in end-stage HF. Therefore, increased attention has been placed on investigating the effects of exercise training for patients with LVADs to improve clinical outcomes. However, the available evidence on exercise training for patients with LVADs is limited. Areas covered: The purpose of this narrative review is to summarize: 1) The evolution of LVAD technology and usage; 2) The physiological responses to exercise in patients with LVADs; 3) The available evidence regarding exercise training; 4) Potential strategies to implement exercise training programs for this patient population. Expert opinion: The available evidence for exercise training to improve physical function and clinical outcomes for patients with LVADs is promising but limited. Future research is needed to further elucidate the ideal exercise training parameters, method of delivery for exercise training, and unique barriers and facilitators to exercise training for patients receiving LVAD implantation.

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

Restoring pulsatility and peakVO2 in the era of continuous flow, fixed pump speed, left ventricular assist devices: 'A hypothesis of pump's or patient's speed?'

Despite significant improvement in survival and functional capacity after continuous flow left ventricular assist device implantation, the patient's quality of life may remain limited by complications such as aortic valve insufficiency, thromboembolic episodes and gastrointestinal bleeding attributed to high shear stress continuous flow with attenuated or absence of pulsatile flow and by a reduced peak oxygen consumption (peakVO₂) primarily associated with a fixed pump speed operation. Revision of current evidence suggests that high technology pump speed algorithms, a 'hypothesis of decreasing pump's speed' to promote pulsatile flow and a 'hypothesis of increasing pump's speed' to increase peakVO₂, may only partially reverse these barriers. A 'hypothesis of increasing patient's speed' is introduced, suggesting that exercise training may further contribute to the patient's recovery, enhancing peakVO₂ and pulsatile flow by improving skeletal muscle oxidative capacity and strength, peripheral vasodilatory and ventilatory responses, favour changes in preload/afterload and facilitate native flow, formulating the rationale for further studies in the field.

Inpatient Cardiac Rehabilitation of LVAD Patients-Updated Recommendations from the Working Group of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases

Cardiac rehabilitation physicians are faced to an increasing number of heart failure patients supported by left ventricular assist devices (LVAD). Many of these patients have complex medical issues and prolonged hospitalizations and therefore need special cardiac rehabilitation strategies including psychological, social, and educational support which are actually poorly implemented.Cardiac rehabilitation with clear guidance and more evidence should be considered as an essential component of the patient care plan especially regarding the increasing number of destination patients and their long-term follow-up.In this article the working group for postimplant treatment and rehabilitation of LVAD patients of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases has summarized and updated the recommendations for the cardiac rehabilitation of LVAD patients considering the latest literature.

The Rehabilitation of Patients With Advanced Heart Failure After Left Ventricular Assist Device Placement: A Narrative Review

Because more patients with advanced heart failure are receiving a left ventricular assist device (LVAD) as destination therapy or a bridge to transplantation, there is increasing attention on functional outcomes and quality of life after LVAD implantation. Rehabilitation providers in the acute inpatient rehabilitation setting increasingly will treat patients with an LVAD and should understand the exercise physiology, medical management, rehabilitation considerations, and outcomes after rehabilitation for patients with an LVAD. The purpose of this article is to provide the physiatrist with a comprehensive understanding of the rehabilitation of patients with advanced heart failure and LVAD implantation. Changes in relevant organ system physiology and exercise physiology after LVAD are summarized. Safety of rehabilitation and program considerations for acute inpatient rehabilitation are reviewed. Recommendations for medical management and prevention of secondary complications seen in patients with an LVAD are outlined. A discussion of outcomes after acute inpatient rehabilitation, the dual diagnosis of stroke and LVAD placement, and long-term cognitive, functional, and quality-of-life outcomes after LVAD placement is presented.

LVAD Pump Flow Does Not Adequately Increase With Exercise

Left ventricular assist devices (LVADs) restore cardiovascular circulatory demand at rest with a spontaneous increase in pump flow to exercise. The relevant contribution of cardiac output provided by the LVAD and ejected through the aortic valve for exercises of different intensities has been barely investigated in patients. The hypothesis of this study was that different responses in continuous recorded pump parameters occur for maximal and submaximal intensity exercises and that the pump flow change has an impact on the oxygen uptake at peak exercise (pVO₂ ). Cardiac and pump parameters such as LVAD flow rate (Q_LVAD ), heart rate (HR), and aortic valve (AV) opening were analyzed from continuously recorded LVAD data during physical exercises of maximal (bicycle ergometer test) and submaximal intensities (6-min walk test and regular trainings). During all exercise sessions, the LVAD speed was kept constant. Cardiac and pump parameter responses of 16 patients for maximal and submaximal intensity exercises were similar for Q_LVAD : +0.89 ± 0.52 versus +0.59 ± 0.38 L/min (P = 0.07) and different for HR: +20.4 ± 15.4 versus +7.7 ± 5.8 bpm (P < 0.0001) and AV-opening with 71% versus 23% of patients (P < 0.0001). Multi-regression analysis with pVO₂ (R²  = 0.77) showed relation to workload normalized by bodyweight (P = 0.0002), HR response (P = 0.001), AV-opening (P = 0.02), and age (P = 0.06) whereas the change in Q_LVAD was irrelevant. Constant speed LVADs provide inadequate support for maximum intensity exercises. AV-opening and improvements in HR show an important role for higher exercise capacities and reflect exercise intensities. Changes in pump flow do not impact pVO₂ and are independent of AV-opening and response in HR. An LVAD speed control may lead to adequate left ventricular support during strenuous physical activities.

Exercise-based cardiac rehabilitation for people with implantable ventricular assist devices

BACKGROUND

Heart failure is the end stage of heart disease, and the prevalence and incidence of the condition is rapidly increasing. Although heart transplantation is one type of surgical treatment for people with end-stage heart failure, donor availability is limited. Implantable ventricular assist devices (VADs) therefore offer an alternative treatment to heart transplantation. Although two studies reported the beneficial effects of exercise-based cardiac rehabilitation (CR) on functional capacity and quality of life (QOL) by performing systematic reviews and meta-analyses, both systematic reviews included studies with limited design (e.g. non-randomised, retrospective studies) or participants with implantable or extracorporeal VADs.

OBJECTIVES

To determine the benefits and harms of exercise-based CR for people with implantable VADs.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, Embase, PsycINFO, Conference Proceedings Citation Index-Science (CPCI-S) on Web of Science, CINAHL, and LILACS on 3 October 2017 with no limitations on date, language, or publication status. We also searched two clinical trials registers on 10 August 2017 and checked the reference lists of primary studies and review articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) regardless of cluster or individual randomisation, and full-text studies, those published as abstract only, and unpublished data were eligible. However, only individually RCTs and full-text publications were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted outcome data from the included studies. We double-checked that data were entered correctly by comparing the data presented in the systematic review with the study reports. We had no dichotomous data to analyse and used mean difference or standardised mean difference with 95% confidence intervals (CIs) for continuous data. Furthermore, we assessed the quality of evidence as it relates to those studies that contribute data to the meta-analyses for the prespecified outcomes, using GRADEpro software.

MAIN RESULTS

We included two studies with a total of 40 participants in the review. Exercise-based CR consisted of aerobic or resistance training or both three times per week for six to eight weeks. Exercise intensity was 50% of oxygen consumption (VO2) reserve, or ranged from 60% to 80% of heart rate reserve. Two serious adverse events were observed in one trial, in which participants did not complete the study due to infections. Furthermore, a total of four participants in each group required visits to the emergency department, although these participants did complete the study. Summary scores from the 36-item Short Form Health Survey (SF-36) and the Kansas City Cardiomyopathy Questionnaire (KCCQ) were measured as quality of life. One trial reported that the KCCQ summary score improved by 14.4 points in the exercise group compared with 0.5 points in the usual care group. The other trial reported that the SF-36 total score improved by 29.2 points in the exercise group compared with 16.3 points in the usual care group. A large difference in quality of life was observed between groups at the end of follow-up (standardised mean difference 0.88, 95% CI -0.12 to 1.88; 37 participants; 2 studies; very low-quality of evidence). However, there was no evidence for the effectiveness of exercise-based CR due to the young age of the participants, high risk of performance bias, very small sample size, and wide confidence intervals, which resulted in very low-quality evidence. Furthermore, we were not able to determine the effect of exercise-based CR on mortality, rehospitalisation, heart transplantation, and cost, as these outcomes were not reported.

AUTHORS' CONCLUSIONS

The evidence is currently inadequate to assess the safety and efficacy of exercise-based CR for people with implantable VADs compared with usual care. The amount of RCT evidence was very limited and of very low quality. In addition, the training duration was very short term, that is from six to eight weeks. Further high-quality and well-reported RCTs of exercise-based CR for people with implantable VADs are needed. Such trials need to collect data on events (mortality and rehospitalisation), patient-related outcomes (including quality of life), and cost-effectiveness.

Does a Comprehensive Inpatient Rehabilitation Program Improve Patients' and Caregivers' Emotional State in LVAD Patients?

Few studies evaluated the effect of cardiac rehabilitation programs on perceived emotional and health status of left ventricular assist device (LVAD) patients, and none explored their effect on caregivers' strain. We enrolled 119 adult LVAD patients, together with their caregivers (n = 91), in two Rehabilitation Institutes that provided inpatient multidisciplinary activities. At admittance and prior to discharge they completed questionnaires evaluating patient emotional state and subjective perception of health status, caregiver strain, and patient and caregiver perception of the VAD. Six months after discharge, patients and caregivers were contacted again and asked specific questions about their quality of life. Patients' state anxiety and depression symptoms significantly diminished at discharge (0.000), whereas their perception of general health status rose (0.000). Caregivers' perceived strain also significantly decreased (0.001) and the perceived device management skill grew both for patients and caregivers (0.000). A substantial amount (36%) of psychologically frail patients and caregivers, although improving their emotional condition, never reached that of the less frail subjects. At the 6-month follow-up, both patients and caregivers appeared stable in evaluating respectively their general health and their caregiving-related strain, compared to discharge. Our data show that a comprehensive inpatient rehabilitation program improves the emotional state of LVAD patients and of their caregivers, even in psychologically frailer subjects. Team approach makes patients and caregivers self-confident about device management, increasing their knowledge, clarifying their doubts, and encouraging them to handle the difficulties met during the rehabilitation period, suggesting strategies to cope with daily life at home.

Left ventricular assist device: exercise capacity evolution and rehabilitation added value

BACKGROUND

With more than 15,000 implanted patients worldwide and a survival rate of 80% at 1-year and 59% at 5-years, left ventricular assist device (LVAD) implantation has become an interesting strategy in the management of heart failure patients who are resistant to other kinds of treatment. There are limited data in the literature on the change over time of exercise capacity in LVAD patients, as well as limited knowledge about the beneficial effects that rehabilitation might have on these patients. Therefore, the aim of our study was to evaluate the evolution of exercise capacity on a cohort of patients implanted with the same device (HeartWare^©) and to analyse the potential impact of rehabilitation.

METHODS

Sixty-two patients implanted with a LVAD between June 2011 and June 2015 were screened. Exercise capacity was evaluated by cardiopulmonary exercise testing at 6 weeks, 6 and 12 months after implantation.

RESULTS

We have observed significant differences in the exercise capacity and evolution between the trained and non-trained patients. Some of the trained patients nearly normalised their exercise capacity at the end of the rehabilitation programme.

CONCLUSIONS

Exercise capacity of patient implanted with a HeartWare^© LVAD increased in the early period after implantation. Rehabilitation allowed implanted patients to have a significantly better evolution compared to non-rehabilitated patients.

Exercise Performance During the First Two Years After Left Ventricular Assist Device Implantation

Exercise performance of patients with left ventricular assist devices (LVADs) improves after postimplant cardiac rehabilitation (CR). Few studies assess the effectiveness of a CR and its long-term effect of exercise performance. For this purpose, we retrospectively analyzed data from LVAD patients, who underwent a stationary CR twice after pump implantation. Data from exercise training and cardiopulmonary exercise tests (CPETs) were analyzed. Fifteen patients (age: 57 ± 10 years, male 87%) were admitted to the rehabilitation clinic twice 39 ± 18 and 547 ± 197 days after LVAD implantation. An improvement from the beginning to the end of the second CR was observed in bicycle ergometer training (14.0 ± 8.8 vs. 35.7 ± 14.7 W; p < 0.001), in muscular strength (e.g., leg press: 41 ± 10 vs. 53 ± 14 kg; p < 0.001), and in 6 minute walk distance (421 ± 126 m vs. 480 ± 133 m; p = 0.040). Between the first and the second CR, improvement in all the training modules was observed as well as an increase in CPETs peak workload (56 ± 24 vs. 83 ± 26 W; p < 0.001) but not in peak oxygen consumption (12.3 ± 3.2 vs. 12.2 ± 4.0 ml/min/kg; p = 0.906). Thus, over long implant periods, patients showed improvement of their exercise performance in the submaximal load range, but no change in the aerobic capacity was observed.

[Cardiac rehabilitation in heart failure]

Heart failure is a malignant disorder with increasing prevalence and a high socioeconomic impact. Sceletal muscle myopathy seems to play a key role in the development of exercise intolerance. Cardiac rehabilitation for heart failure mainly adresses training, namely moderate continuous endurance training or interval training in combination with resistance training, and is highly recommended in the current ESC-guidelines. Following a multimodal concept cardiac rehabilitation also implements optimisation of neurohumoral therapy, education and counselling to empower self-care as well as psychosocial support.

Supervised exercise training versus usual care in ambulatory patients with left ventricular assist devices: A systematic review

Implantation of left ventricular assist devices (LVAD) has increased because of improved safety profile and limited availability of heart transplantation. Although supervised exercise training (ET) programs are known to improve exercise capacity and quality of life (QoL) in heart failure (HF) patients, similar data is inconclusive in LVAD patients. Thus, we performed a systematic review on studies that incorporated supervised ET and measured peak oxygen uptake in LVAD patients. A total of 150 patients in exercise and 55 patients in control groups were included from 8 studies selected from our predefined criteria. Our systematic review suggests supervised ET has an inconsistent effect on exercise capacity and QoL when compared to control groups undergoing usual care. A quantitative sub-analysis was performed with 4 studies that provided enough data to compare peak oxygen uptake and QoL at baseline and at follow-up. After at least 6 weeks of training, LVAD patients undergoing supervised ET demonstrated significant improvement in exercise capacity (standardized mean difference [SMD] = 0.735, 95% Confidence Interval-[CI], 0.31-1.15 units of the standard deviation, P = 0.001) and QoL scores (SMD = 1.58, 95% CI 0.97-2.20 units of the standard deviation, P <0.001) when compared to the usual care group, with no serious adverse events with exercise. These results suggest that supervised ET is safe and can improve patient outcomes in LVAD patients when compared to the usual care.

Physical Capacity in LVAD Patients: Hemodynamic Principles, Diagnostic Tools and Training Control

Over time left ventricular assist devices (LVAD) have become an alternative to heart transplantation because of enormous technical development and miniaturization. Most patients present a significant improvement in clinical conditions and exercise capacity. Nevertheless, exercise tolerance remains markedly limited even after LVAD implantation compared to a control group. The complex physiological and hemodynamic changes in LVAD patients, both at rest and during exercise, are not yet understood, or at least not completely.

It is the aim of the present paper to describe the current state of scientific knowledge. Furthermore, the spectrum of diagnostic tools, including the noninvasive inert gas rebreathing method for measurement of cardiac output and associate parameters, are discussed. Options for training control in this special patient group are presented.