Adequate physical and functional performance is an important prerequisite for renewed participation and integration in self‐determined private and (where appropriate) professional lives following ...left ventricular assist device (LVAD) implantation. During cardiac rehabilitation (CR), individually adapted exercise programs aim to increase exercise capacity and functional performance. A retrospective analysis of cardiopulmonary exercise capacity and functional performance in LVAD patients at discharge from a cardiac rehabilitation program was conducted. The results from 68 LVAD patients (59 males, 9 females; 55.9 ± 11.7 years; 47 HVAD, 2 MVAD, 15 HeartMate II, 4 HeartMate 3, and 4 different implanting centers) were included in the analysis. Exercise capacity was assessed using a cardiopulmonary exercise test on a bicycle ergometer (ramp protocol; 10 W/min). The 6‐min walk test was used to determine functional performance. At discharge from CR (53 ± 17 days after implantation), the mean peak work load achieved was 62.2 ± 19.3 W (38% of predicted values) or 0.79 ± 0.25 W/kg body weight. The mean cardiopulmonary exercise capacity (relative peak oxygen uptake) was 10.6 ± 5.3 mL/kg/min (37% of predicted values). The 6‐min walk distance improved significantly during CR (325 ± 106 to 405 ± 77 m; P < 0.01). No adverse events were documented during CR. The results show that, even following LVAD implantation, cardiopulmonary exercise capacity remains considerably restricted. In contrast, functional performance, measured by the 6‐min walk distance, reaches an acceptable level. Light everyday tasks seem to be realistically surmountable for patients, making discharge from inpatient rehabilitation possible. Long‐term monitoring is required in order to evaluate the situation and how it develops further.
Background To date, no studies on the feasibility or outcomes of cardiac rehabilitation (CR) after percutaneous mitral valve reconstruction using clipping procedures have been published. The aim of ...this study was to report on our first experiences with this special target group. Methods Monocentric retrospective analysis of 27 patients (72 + or - 12 years old, 52% female) who underwent multimodal inpatient CR in the first 2 month after MitraClipTM implantation. A six-minute-walking-test, a handgrip-strength-test and the Berg-Balance-Scale was conducted at the beginning and end of CR. Echocardiography was performed to rule out device-related complications. Results Adapted inpatient CR started 16 + or - 13 days after clipping intervention and lasted 22 + or - 4 days. In 4 patients (15%) CR had to be interrupted or aborted prematurely due to cardiac decompensations. All other patients (85%) completed CR period without complications. Six-minute-walking-distance improved from 272 + or - 97 to 304 + or - 111 m (p < .05) and dependence on rollator walker or walking aids was significantly reduced (p < .05). Results of handgrip-strength-test and Berg-Balance-Scale increased (p < .05). Overall, social-medical and psychological consultations were well received by the patients and no device-related complications occurred during rehabilitation treatments. Conclusions The results indicate that an adapted inpatient CR in selected patients after MitraClipTM implantation is feasible. Patients benefited from treatments both at functional and social-medical level and no device-related complications occurred. Larger controlled studies are needed. Keywords: Mitral regurgitation, Mitraclip, Cardiac rehabilitation, Exercise intervention
The prevalence of sarcopenia and its impact in older patients undergoing inpatient cardiac rehabilitation (iCR) after cardiac procedure has been insufficiently studied. The main aim of this study was ...to evaluate the prevalence of sarcopenia and quantify the functional capacity of older sarcopenic and non-sarcopenic patients participating in iCR.
Prospective, observational cohort study within the framework of the ongoing multicenter prehabilitation study "PRECOVERY". A sample of 122 patients ≥75 years undergoing iCR after cardiac procedure were recruited in four German iCR facilities and followed up 3 months later by telephone. At iCR (baseline), the Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F) questionnaire was used to identify sarcopenic patients. In addition, Katz-Index, Clinical Frailty Scale (CFS), handgrip strength (HGS), Short Physical Performance Battery (SPPB) and 6-minute walk distance (6MWD) measured functional capacity and frailty at baseline. Outcomes were prevalence of sarcopenia and the correlation of sarcopenia to functional capacity and frailty at baseline as well as the SARC-F score at follow-up. The Wilcoxon test was applied for pre-post-test analysis. Correlation between sarcopenia and 6MWD, SPPB score and HGS was tested with the eta coefficient with one-way ANOVA.
Complete assessments were collected from 101 patients (79.9 ± 4.0 years; 63% male). At baseline, the mean SARC-F score was 2.7 ± 2.1; 35% with sarcopenia. Other baseline results were Katz-Index 5.7 ± 0.9, CFS 3.2 ± 1.4, HGS 24.9 ± 9.9 kg, SPPB score 7.5 ± 3.3 and 6MWD 288.8 ± 136.5 m. Compared to baseline, fewer patients were sarcopenic (23% versus 35%) at follow-up. In the subgroup of sarcopenic patients at baseline (n = 35), pre-post comparison resulted in a significant SARC-F improvement (p = 0.017). There was a significant correlation between sarcopenia measured by SARC-F and poor results in the assessments of functional capacity (p < 0.001; r > 0.546).
The prevalence of sarcopenia in older patients at iCR after cardiac procedure is high (35%) and remains high at follow-up (23%). Sarcopenia screening is important since the diagnosis of sarcopenia in these patients correlates significantly with poor functional capacity. The results indicate that these patients may benefit from prehabilitation aimed at improving perioperative outcomes, increasing functional capacity and mitigating adverse effects.
German Clinical Trials Register (DRKS; http://www.drks.de ; DRKS00032256). Retrospectively registered on 13 July 2023.
Background Frailty is an indicator of a decline in quality of life and functional capacity in cardiac rehabilitation (CR) patients. Currently, there is no standardized assessment tool for frailty ...used in CR. The aim of this study was to determine if the Clinical Frailty Scale (CFS) is feasible for assessing frailty in CR. Methods Prospective, cross-sectional study within the framework of the ongoing multicenter prehabilitation study "PRECOVERY". Patients greater than or equal to75 years undergoing CR after cardiac procedure (n=122) were recruited in four German inpatient CR facilities. Assessments included: CFS, Katz-Index, hand grip strength (HGS), Short Physical Performance Battery (SPPB) and six-minute-walk test (6MWT). Outcomes were frailty (CFSgreater than or equal to4) and the correlation of frailty with assessments of functional capacity, activities of daily living and clinical parameters. Statistical analysis included descriptive statistics and correlations, using the spearman correlation coefficient and chi-square test to test for significance. Results Data from 101 patients (79.9+ or -4.0 years; 63% male) were analyzed. The mean CFS score was 3.2+ or -1.4; 41.6% were defined as frail (CFSgreater than or equal to4). The mean time required to assess the CFS was 0.20 minutes. The findings show that CFS correlates significantly (p<0.001) with the following factors: Katz-Index, HGS, SPPB-Score and 6MWT (rless than or equal to-0.575). In addition, CFS correlated with small to moderate effects with co-morbidities (r=0.250), as-needed medications and need for nursing assistance (rless than or equal to0.248). Conclusions The CFS assessment can be performed in under one minute and it correlates significantly with assessments of functional capacity, activities of daily living and clinical parameters in the CR setting. Trial registration German Clinical Trials Register (DRKS; Keywords: Cardiac surgery, Valve intervention, Frailty, Cardiac rehabilitation
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.
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.
LVAD in der kardiologischen Rehabilitation Schmidt, Thomas; Reiss, Nils
Herzschrittmachertherapie & Elektrophysiologie,
03/2023, Letnik:
34, Številka:
1
Journal Article
Recenzirano
Zusammenfassung
Nach der Implantation eines linksventrikulären Herzunterstützungssystems („left ventricular assist device“, LVAD) wird die Teilnahme an einem kardiologischen Rehabilitationsprogramm ...(KardReha) ausdrücklich empfohlen. Wesentliche Inhalte bilden neben vielen weiteren Bereichen insbesondere die Sport- und Bewegungstherapie sowie Aspekte der Rhythmuskontrolle. LVAD-Patienten erreichen im Verlauf in der Regel wieder eine gute Lebensqualität und zufriedenstellende funktionelle Kapazität. Die maximalen Leistungswerte blieben hingegen u. a. aufgrund der fest eingestellten Pumpenumdrehungszahl und des limitierten Herzzeitvolumens deutlich reduziert. Von besonderer Wichtigkeit ist daher ein strukturiertes und langfristiges körperliches Training – auch über den Zeitraum der KardReha Phase II hinaus – zur Optimierung der neuromuskulären Ansteuerung sowie der Stoffwechselprozesse innerhalb der Arbeitsmuskulatur. Einschränkungen in der körperlichen Leistungsfähigkeit können auch durch das Auftreten von supraventrikulären und ventrikulären Arrhythmien hervorgerufen werden. Ursächlich ist in beiden Fällen eine zunehmende hämodynamische Beeinträchtigung des rechten Herzens mit weiteren negativen hämodynamischen Konsequenzen für den vom LVAD generierten Fluss. Auch eine nicht adäquate Einstellung weiterer bereits implantierter kardialer elektronischer Geräte (z. B. implantierbarer Kardioverter-Defibrillator ICD oder kardiale Resynchronisationstherapie mit Defibrillator CRT-D) kann die Hämodynamik bei LVAD-Patienten entscheidend beeinflussen. In diesem Artikel soll im Folgenden auf leistungsphysiologische und rhythmologische Aspekte der LVAD-Therapie im Rahmen der KardReha eingegangen werden.
After implantation of a left ventricular assist device (LVAD), it is strongly recommended that patients participate in an inpatient cardiac rehabilitation program (CR). Relevant topics during CR ...include sports and exercise therapy as well as aspects of cardiac rhythm control. Over time, LVAD patients usually regain a good quality of life and an adequate functional capacity can be observed. However, maximum performance values remain markedly reduced, in part due to the fixed LVAD pump speed and the limited total cardiac output. Therefore, structured long-term exercise training programs (even beyond CR phase II) are of particular importance in order to optimize neuromuscular control and muscle metabolism. Limitations to physical performance values may also be caused by the occurrence of supraventricular and/or ventricular arrhythmias. In both cases, the cause is an increasing hemodynamic impairment of the right heart, which may also lead to a reduced LVAD pump flow. In addition, inadequate setting of other cardiac implantable electronic devices (e.g., implantable cardioverter-defibrillator ICD or cardiac resynchronization therapy with defibrillator CRT-D) may also have a crucial impact on hemodynamics after LVAD implantation. In this article, we will discuss specific aspects of LVAD therapy related to exercise and rhythm control, particularly in the context of CR programs.
The treatment of nonhealing and infected sternotomies after cardiac surgery is a challenging task with increased rates of mortality and morbidity, as well as high costs. A local vacuum therapy (ie, ...the vacuum-assisted closure system) permits the treatment of deep sternal infections due to continuous aspiration and a sealed dressing that stimulates granulation tissue formation. Aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the speed of potential rewiring. After some weeks of vacuum-assisted closure therapy, a complete preparation of the substernal structures is necessary. In this context, laceration of the right ventricle is a rare but life-threatening complication. We describe a new technique for sternal closure after vacuum-assisted wound treatment using Nitinol clips (Praesidia, Bologna, Italy), which can prevent these severe complications. Without any preparation of the substernal tissue the clips can be inserted in the parasternal space with consecutive proper stabilization of the sternum. This new method represents an easy, low-cost and complication-free procedure.
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