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

Bridge to Weight Loss: A Case Series

Durable left ventricular assist devices (LVADs) are a well-established therapeutic option for patients with advanced heart failure. These devices are often used to "bridge" patients to an orthotopic heart transplantation (HT). Unfortunately, many patients on LVAD support with a body mass index (BMI) above a certain value are not eligible for HT due a lack of suitable donors and the association between obesity and poor outcomes after HT. This case series describes three individuals on LVAD support who were able to successfully lose enough weight to qualify to be listed for an HT. We highlight a systematic, multidisciplinary approach to implementing guideline-driven weight loss strategies, including some aggressive methods ( ie , meal replacements, weight loss medications, and bariatric surgery). In addition to describing the weight loss outcomes, we also discuss barriers and medical challenges during weight loss that are unique to this population.

Obesity, Challenges, and Weight-Loss Strategies for Patients With Ventricular Assist Devices

For adults with advanced heart failure, class II/III obesity (body mass index ≥35 kg/m2) represents major challenges, and it is even considered a contraindication for heart transplantation (HT) at many centers. This has led to growing interest in preventing and treating obesity to help patients with advanced heart failure become HT candidates. Among all weight-loss strategies, bariatric surgery (BSx) has the greatest weight loss efficacy and has shown value in enabling select patients with left ventricular assist devices (LVADs) and obesity to lose sufficient weight to access HT. Nevertheless, both BSx and antiobesity medications warrant caution in the LVAD population. In this review, the authors describe and interpret the available published reports on the impact of obesity and weight-loss strategies for patients with LVADs from general and HT candidacy standpoints. The authors also provide an overview of the journey of LVAD recipients who undergo BSx and review major aspects of perioperative protocols.

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.

Current status and future directions in pediatric ventricular assist device

A ventricular assist device (VAD) is a form of mechanical circulatory support that uses a mechanical pump to partially or fully take over the function of a failed heart. In recent decades, the VAD has become a crucial option in the treatment of end-stage heart failure in adult patients. However, due to the lack of suitable devices and more complicated patient profiles, this therapeutic approach is still not widely used for pediatric populations. This article reviews the clinically available devices, adverse events, and future directions of design and implementation in pediatric VADs.

Hyoid Bone Syndrome in a Patient Undergoing Left Ventricular Assist Device Implantation

The clinical case describes the presence of hyoid bone syndrome (HBS) in a patient with a left ventricular assist device (LVAD) implantation, and the resolution of painful symptoms through an osteopathic manual technique (unwinding) applied to the tongue. To the knowledge of the authors, it is the first case report involving an LVAD patient with HBS treated with an osteopathic approach. The article briefly reviews the data relating to surgical therapy for patients with a clinical history of end-stage heart failure and symptoms related to HBS and posits some hypotheses on the presence of pain radiating from the hyoid bone to other areas of the body. The text reminds us to place greater clinical emphasis on the palpatory evaluation of the hyoid in the presence of non-specific painful symptoms.

Heart Failure in Cardiac Rehabilitation: A REVIEW AND PRACTICAL CONSIDERATIONS

PURPOSE

Exercise cardiac rehabilitation (CR) represents an evidence-based therapy for patients with heart failure with reduced ejection fraction (HFrEF) and this article provides a concise review of the relevant exercise testing and CR literature, including aspects unique to their care.

CLINICAL CONSIDERATIONS

A hallmark feature of HFrEF is exercise intolerance (eg, early-onset fatigue). Drug therapies for HFrEF target neurohormonal pathways to blunt negative remodeling of the cardiac architecture and restore favorable loading conditions. Guideline drug therapy includes β-adrenergic blocking agents; blockade of the renin-angiotensin system; aldosterone antagonism; sodium-glucose cotransport inhibition; and diuretics, as needed.

EXERCISE TESTING AND TRAINING

Various assessments are used to quantify exercise capacity in patients with HFrEF, including peak oxygen uptake measured during an exercise test and 6-min walk distance. The mechanisms responsible for the exercise intolerance include abnormalities in ( a ) central transport (chronotropic response, stroke volume) and ( b ) the diffusion/utilization of oxygen in skeletal muscles. Cardiac rehabilitation improves exercise capacity, intermediate physiologic measures (eg, endothelial function and sympathetic nervous system activity), health-related quality of life (HRQoL), and likely clinical outcomes. The prescription of exercise in patients with HFrEF is generally similar to that for other patients with cardiovascular disease; however, patients having undergone an advanced surgical therapy do present with features that require attention.

SUMMARY

Few patients with HFrEF enroll in CR and as such, many miss the derived benefits, including improved exercise capacity, a likely reduction in risk for subsequent clinical events (eg, rehospitalization), improved HRQoL, and adoption of disease management strategies.