Vigorous physical training after aortic valve replacement: analysis of 10 patients

Exercise-based cardiac rehabilitation for adults after heart valve surgery

BACKGROUND

The impact of exercise-based cardiac rehabilitation (CR) following heart valve surgery is uncertain. We conducted an update of this systematic review and a meta-analysis to assess randomised controlled trial evidence for the use of exercise-based CR following heart valve surgery.

OBJECTIVES

To assess the benefits and harms of exercise-based CR compared with no exercise training in adults following heart valve surgery or repair, including both percutaneous and surgical procedures. We considered CR programmes consisting of exercise training with or without another intervention (such as an intervention with a psycho-educational component).

SEARCH METHODS

We searched the Cochrane Central Register of Clinical Trials (CENTRAL), in the Cochrane Library; MEDLINE (Ovid); Embase (Ovid); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO); PsycINFO (Ovid); Latin American Caribbean Health Sciences Literature (LILACS; Bireme); and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science (Clarivate Analytics) on 10 January 2020. We searched for ongoing trials from ClinicalTrials.gov, Clinical-trials.com, and the World Health Organization International Clinical Trials Registry Platform on 15 May 2020.

SELECTION CRITERIA

We included randomised controlled trials that compared exercise-based CR interventions with no exercise training. Trial participants comprised adults aged 18 years or older who had undergone heart valve surgery for heart valve disease (from any cause) and had received heart valve replacement or heart valve repair. Both percutaneous and surgical procedures were included.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data. We assessed the risk of systematic errors ('bias') by evaluating risk domains using the 'Risk of bias' (RoB2) tool. We assessed clinical and statistical heterogeneity. We performed meta-analyses using both fixed-effect and random-effects models. We used the GRADE approach to assess the quality of evidence for primary outcomes (all-cause mortality, all-cause hospitalisation, and health-related quality of life).

MAIN RESULTS

We included six trials with a total of 364 participants who have had open or percutaneous heart valve surgery. For this updated review, we identified four additional trials (216 participants). One trial had an overall low risk of bias, and we classified the remaining five trials as having some concerns. Follow-up ranged across included trials from 3 to 24 months. Based on data at longest follow-up, a total of nine participants died: 4 CR versus 5 control (relative risk (RR) 0.83, 95% confidence interval (CI) 0.26 to 2.68; 2 trials, 131 participants; GRADE quality of evidence very low). No trials reported on cardiovascular mortality. One trial reported one cardiac-related hospitalisation in the CR group and none in the control group (RR 2.72, 95% CI 0.11 to 65.56; 1 trial, 122 participants; GRADE quality of evidence very low). We are uncertain about health-related quality of life at completion of the intervention in CR compared to control (Short Form (SF)-12/36 mental component: mean difference (MD) 1.28, 95% CI -1.60 to 4.16; 2 trials, 150 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD 2.99, 95% CI -5.24 to 11.21; 2 trials, 150 participants; GRADE quality of evidence very low), or at longest follow-up (SF-12/36 mental component: MD -1.45, 95% CI -4.70 to 1.80; 2 trials, 139 participants; GRADE quality of evidence very low; and SF-12/36 physical component: MD -0.87, 95% CI -3.57 to 1.83; 2 trials, 139 participants; GRADE quality of evidence very low).  AUTHORS' CONCLUSIONS: Due to lack of evidence and the very low quality of available evidence, this updated review is uncertain about the impact of exercise-CR in this population in terms of mortality, hospitalisation, and health-related quality of life. High-quality (low risk of bias) evidence on the impact of CR is needed to inform clinical guidelines and routine practice.

[Rehabilitation of valvular patient]

Valvular disease is the second indication of cardiac rehabilitation (CR) after coronary artery disease. Patients suffering valvular disease are addressed to CR after valvular repair, and are usually old. Valvular replacement are the most frequent, and more and more patients being treated by TAVI are addressed to CR. CR takes place on two phases: From the seventh (day 7) to the fifteenth (day 15) day: management of complications, respiratory physio, and help to autonomy if necessary. From the fifteenth day (day 15): rehabilitation to exercise after an exercise stress test with or without MVO₂ measurement. Because the patients are taking anticoagulants and are at risk of endocarditis, therapeutic education takes an important place during the stage. CR of patients suffering valvular disease has demonstrated its usefulness with: An increase of exercise capacity in all kind of valvular disease; A reduction of left ventricular hypertrophy in patients with aortic valve stenosis. No serious complication was observed in all studies regarding CR in patients with valvular disease.

Exercise-based cardiac rehabilitation for patients following open surgical aortic valve replacement and transcatheter aortic valve implant: a systematic review and meta-analysis

Objectives

Exercise-based cardiac rehabilitation (CR) may be beneficial to patients following transcatheter aortic valve implantation (TAVI) and open surgical aortic valve replacement (SAVR). We aimed to undertake a systematic review and meta-analysis to evaluate the efficacy, safety and costs of exercise-based CR post-TAVI and post-SAVR.

Methods

We searched numerous databases, including Embase, CENTRAL and MEDLINE, up to October 2017. We included randomised controlled trials (RCTs) and non-randomised controlled trials (non-RCTs) of exercise-based CR compared with no exercise control in TAVI or SAVR patients ≥18 years. Data extraction and risk of bias assessments were performed independently by two reviewers. Narrative synthesis and meta-analysis (where appropriate) were carried out for all relevant outcomes, and a Grading of Recommendations Assessment, Development and Evaluation (GRADE) analysis was also performed.

Results

Six studies, all at low risk of bias, were included: three RCTs and three non-RCTs (total of 27 TAVI, 99 SAVR and 129 mixed patients), with follow-up of 2-12 months. There was an increase in pooled exercise capacity (standardised mean difference: 0.41, 95% CI 0.11 to 0.70; moderate certainty evidence as assessed by GRADE), with exercise-based rehabilitation compared with control. Data on other outcomes including quality of life and clinical events were limited.

Conclusions

Exercise-based CR probably improves exercise capacity of post-TAVI and post-SAVR patients in the short term. Well conducted multicentre fully powered RCTs of ≥12 months follow-up are needed to fully assess the clinical and cost-effectiveness of exercise-based CR in this patient population.

PROSPERO Protocol Registration Number

CRD42017084716.

Cardiac rehabilitation increases physical capacity but not mental health after heart valve surgery: a randomised clinical trial

OBJECTIVE

The evidence for cardiac rehabilitation after valve surgery remains sparse. Current recommendations are therefore based on patients with ischaemic heart disease. The aim of this randomised clinical trial was to assess the effects of cardiac rehabilitation versus usual care after heart valve surgery.

METHODS

The trial was an investigator-initiated, randomised superiority trial (The CopenHeart_VR trial, VR; valve replacement or repair). We randomised 147 patients after heart valve surgery 1:1 to 12 weeks of cardiac rehabilitation consisting of physical exercise and monthly psycho-educational consultations (intervention) versus usual care without structured physical exercise or psycho-educational consultations (control). Primary outcome was physical capacity measured by VO₂ peak and secondary outcome was self-reported mental health measured by Short Form-36.

RESULTS

76% were men, mean age 62 years, with aortic (62%), mitral (36%) or tricuspid/pulmonary valve surgery (2%). Cardiac rehabilitation compared with control had a beneficial effect on VO₂ peak at 4 months (24.8 mL/kg/min vs 22.5 mL/kg/min, p=0.045) but did not affect Short Form-36 Mental Component Scale at 6 months (53.7 vs 55.2 points, p=0.40) or the exploratory physical and mental outcomes. Cardiac rehabilitation increased the occurrence of self-reported non-serious adverse events (11/72 vs 3/75, p=0.02).

CONCLUSIONS

Cardiac rehabilitation after heart valve surgery significantly improves VO₂ peak at 4 months but has no effect on mental health and other measures of exercise capacity and self-reported outcomes. Further research is needed to justify cardiac rehabilitation in this patient group.

TRIAL REGISTRATION NUMBER

NCT01558765, Results.

Exercise-based cardiac rehabilitation for adults after heart valve surgery

BACKGROUND

Exercise-based cardiac rehabilitation may benefit heart valve surgery patients. We conducted a systematic review to assess the evidence for the use of exercise-based intervention programmes following heart valve surgery.

OBJECTIVES

To assess the benefits and harms of exercise-based cardiac rehabilitation compared with no exercise training intervention, or treatment as usual, in adults following heart valve surgery. We considered programmes including exercise training with or without another intervention (such as a psycho-educational component).

SEARCH METHODS

We searched: the Cochrane Central Register of Controlled Trials (CENTRAL); the Database of Abstracts of Reviews of Effects (DARE); MEDLINE (Ovid); EMBASE (Ovid); CINAHL (EBSCO); PsycINFO (Ovid); LILACS (Bireme); and Conference Proceedings Citation Index-S (CPCI-S) on Web of Science (Thomson Reuters) on 23 March 2015. We handsearched Web of Science, bibliographies of systematic reviews and trial registers (ClinicalTrials.gov, Controlled-trials.com, and The World Health Organization International Clinical Trials Registry Platform).

SELECTION CRITERIA

We included randomised clinical trials that investigated exercise-based interventions compared with no exercise intervention control. The trial participants comprised adults aged 18 years or older who had undergone heart valve surgery for heart valve disease (from any cause) and received either heart valve replacement, or heart valve repair.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data. We assessed the risk of systematic errors ('bias') by evaluation of bias risk domains. Clinical and statistical heterogeneity were assessed. Meta-analyses were undertaken using both fixed-effect and random-effects models. We used the GRADE approach to assess the quality of evidence. We sought to assess the risk of random errors with trial sequential analysis.

MAIN RESULTS

We included two trials from 1987 and 2004 with a total 148 participants who have had heart valve surgery. Both trials had a high risk of bias.There was insufficient evidence at 3 to 6 months follow-up to judge the effect of exercise-based cardiac rehabilitation compared to no exercise on mortality (RR 4.46 (95% confidence interval (CI) 0.22 to 90.78); participants = 104; studies = 1; quality of evidence: very low) and on serious adverse events (RR 1.15 (95% CI 0.37 to 3.62); participants = 148; studies = 2; quality of evidence: very low). Included trials did not report on health-related quality of life (HRQoL), and the secondary outcomes of New York Heart Association class, left ventricular ejection fraction and cost. We did find that, compared with control (no exercise), exercise-based rehabilitation may increase exercise capacity (SMD -0.47, 95% CI -0.81 to -0.13; participants = 140; studies = 2, quality of evidence: moderate). There was insufficient evidence at 12 months follow-up for the return to work outcome (RR 0.55 (95% CI 0.19 to 1.56); participants = 44; studies = 1; quality of evidence: low). Due to limited information, trial sequential analysis could not be performed as planned.

AUTHORS' CONCLUSIONS

Our findings suggest that exercise-based rehabilitation for adults after heart valve surgery, compared with no exercise, may improve exercise capacity. Due to a lack of evidence, we cannot evaluate the impact on other outcomes. Further high-quality randomised clinical trials are needed in order to assess the impact of exercise-based rehabilitation on patient-relevant outcomes, including mortality and quality of life.

Effect of comprehensive cardiac rehabilitation after heart valve surgery (CopenHeartVR): study protocol for a randomised clinical trial

Background

Heart valve diseases are common with an estimated prevalence of 2.5% in the Western world. The number is rising due to an ageing population. Once symptomatic, heart valve diseases are potentially lethal, and heavily influence daily living and quality of life. Surgical treatment, either valve replacement or repair, remains the treatment of choice. However, post surgery, the transition to daily living may become a physical, mental and social challenge. We hypothesise that a comprehensive cardiac rehabilitation programme can improve physical capacity and self-assessed mental health and reduce hospitalisation and healthcare costs after heart valve surgery.

Methods

A randomised clinical trial, CopenHeart_VR, aims to investigate whether cardiac rehabilitation in addition to usual care is superior to treatment as usual after heart valve surgery. The trial will randomly allocate 210 patients, 1:1 intervention to control group, using central randomisation, and blinded outcome assessment and statistical analyses. The intervention consists of 12 weeks of physical exercise, and a psycho-educational intervention comprising five consultations. Primary outcome is peak oxygen uptake (VO₂ peak) measured by cardiopulmonary exercise testing with ventilatory gas analysis. Secondary outcome is self-assessed mental health measured by the standardised questionnaire Short Form 36. Also, long-term healthcare utilisation and mortality as well as biochemistry, echocardiography and cost-benefit will be assessed. A mixed-method design is used to evaluate qualitative and quantitative findings encompassing a survey-based study before the trial and a qualitative pre- and post-intervention study.

Discussion

The study is approved by the local regional Research Ethics Committee (H-1-2011-157), and the Danish Data Protection Agency (j.nr. 2007-58-0015).

Trial registration

ClinicalTrials.gov (http://NCT01558765).

A randomised clinical trial of comprehensive cardiac rehabilitation versus usual care for patients treated for infective endocarditis--the CopenHeartIE trial protocol

INTRODUCTION

Infective endocarditis (IE) is among the most serious infectious diseases in the western world. Treatment requires lengthy hospitalisation, high-dosage antibiotic therapy and possible valve replacement surgery. Despite advances in treatment, the 1-year mortality remains at 20-40%. Studies indicate that patients experience persisting physical symptoms, diminished quality of life and difficulties returning to work up to a year postdischarge. No studies investigating the effects of rehabilitation have been published. We present the rationale and design of the CopenHeart(IE) trial, which investigates the effect of comprehensive cardiac rehabilitation versus usual care for patients treated for IE.

METHODS AND ANALYSIS

We will conduct a randomised clinical trial to investigate the effects of comprehensive cardiac rehabilitation versus usual care on the physical and psychosocial functioning of patients treated for IE. The trial is a multicentre, parallel design trial with 1 : 1 individual randomisation to either the intervention or control group. The intervention consists of five psychoeducational consultations provided by specialised nurses and a 12-week exercise training programme. The primary outcome is mental health (MH) measured by the standardised Short Form 36 (SF-36). The secondary outcome is peak oxygen uptake measured by the bicycle ergospirometry test. Furthermore, a number of exploratory analyses will be performed. Based on sample size calculation, 150 patients treated for left-sided (native or prosthetic valve) or cardiac device endocarditis will be included in the trial. A qualitative and a survey-based complementary study will be undertaken, to investigate postdischarge experiences of the patients. A qualitative postintervention study will explore rehabilitation participation experiences.

ETHICS AND DISSEMINATION

The study complies with the Declaration of Helsinki and was approved by the regional research ethics committee (no H-1-2011-129) and the Danish Data Protection Agency (no 2007-58-0015). Study findings will be disseminated widely through peer-reviewed publications and conference presentations.

REGISTRATION

Clinicaltrials.gov identifier: NCT01512615.

Decreased aerobic capacity 4 years after aortic valve replacement in male patients operated upon for chronic aortic regurgitation

Exercise testing is underutilized in patients with valve disease. We have previously found a low physical work capacity in patients with aortic regurgitation 6 months after aortic valve replacement (AVR). The aim of this study was to evaluate aerobic capacity in patients 4 years after AVR, to study how their peak oxygen uptake (peakVO₂) had changed postoperatively over a longer period of time. Twenty-one patients (all men, 52 ± 13 years) who had previously undergone cardiopulmonary exercise testing (CPET) pre- and 6 months postoperatively underwent maximal exercise testing 49 ± 15 months postoperatively using an electrically braked bicycle ergometer. Breathing gases were analysed and the patients' physical fitness levels categorized according to Åstrand's and Wasserman's classifications. Mean peakVO₂ was 22·8 ± 5·1 ml × kg⁻¹ × min⁻¹ at the 49-month follow-up, which was lower than at the 6-month follow-up (25·6 ± 5·8 ml × kg⁻¹ × min⁻¹, P = 0·001). All but one patient presented with a physical fitness level below average using Åstrand's classification, while 13 patients had a low physical capacity according to Wasserman's classification. A significant decrease in peakVO₂ was observed from six to 49 months postoperatively, and the decrease was larger than expected from the increased age of the patients. CPET could be helpful in timing aortic valve surgery and for the evaluation of need of physical activity as part of a rehabilitation programme.

Home-based exercise rehabilitation with telemedicine following cardiac surgery

We evaluated the feasibility of a home-based rehabilitation programme, which was designed to resemble an in-hospital rehabilitation programme. Patients who underwent cardiac surgery (EuroSCORE 0–10) followed a one-month home rehabilitation programme supervised by a nurse-tutor and a physiotherapist. Physiotherapy was performed at home with calisthenic exercises and bicycle-ergometer tests. Patients transmitted the recorded ECGs by telephone to a service centre. They also performed a 6-minute walking test and filled in a satisfaction questionnaire at the end of the programme. A total of 47 patients were enrolled in the study. There were 3050 telephone calls, of which 3012 (99%) were scheduled and 38 were unscheduled. No further action was required in 95% of calls. There were 809 sessions for calisthenic exercises and 1039 for exercise training. There was a significant increase in the 6-minute walking test distance at the end of the programme compared to the baseline (404 m vs. 307 m, P < 0.001). Patient satisfaction, as measured in a questionnaire, was about 95% overall. This type of home rehabilitation using telemedicine appears to be worth implementing in selected categories of patients.

Changes in serum biochemical responses during cardiac rehabilitation

PURPOSE

The objective of the study was to establish the difference in the exercise response profile of the enzymes lactate dehydrogenase (LDH), lactate dehydrogenase isoenzyme 1 (LDH-1), creatine kinase (CK), and creatine kinase polypeptide subunit MB (CK-MB) after a 12-wk cardiac rehabilitation exercise program.

METHODS

Nineteen male nonblockade recent postmyocardial infarction patients (PMIP), aged 60.7 +/- 6.5 yr, performed a graded exercise test on a motorized treadmill until volitional cessation or reaching any of the American College of Sports Medicine criteria. After this, a 12-wk exercise-based cardiac rehabilitation program was adopted at a frequency of 3x wk-1. Each subject was then retested using the same protocol and intensity. Blood samples were collected by venipuncture from the antecubital vein into Vacutainer tubes preexercise, immediately, postexercise, and 24 h later. The blood samples were then centrifuged to obtain serum before being transported to the laboratory for enzymatic analysis by conventional methods.

RESULTS

a) a 12-wk cardiac rehabilitation exercise program had no influence on the serum activities of enzymes at rest; b) the same exercise reduced the enzyme activity level after training; and c) LDH and CK values returned to normal faster after the program.

CONCLUSIONS

These findings provide further evidence for the benefits of exercise-based cardiac rehabilitation and demonstrate that an exercise test provokes a temporary serum enzyme response, which does not reflect myocardial damage.

Asymptomatic Aortic Insufficiency in a Runner

In brief The case of an asymptomatic 21-year-old male college sprinter demonstrates that aortic insufficiency may go undiagnosed despite severe underlying cardiac pathology: A murmur detected during the preparticipation exam was the first sign. Activity modification was an important initial intervention. Echocardiography documented severe aortic regurgitation. An exercise multiple gated acquisition (MUGA) scan identified abnormal ejection fractions. After valve replacement, the patient's return to competition was guided by echocardiography, exercise testing, and input of the medical team and family.