Exercise in heart failure patients supported with a left ventricular assist device

doi:10.1016/j.healun.2014.11.001

The Journal of Heart and Lung Transplantation

Volume 34, Issue 4, April 2015, Pages 489-496

https://doi.org/10.1016/j.healun.2014.11.001 Get rights and content

After implantation of a continuous-flow left ventricular assist device (CF-LVAD), exercise capacity in heart failure patients remains reduced with peak oxygen uptake (peak VO₂) values averaging from 11 to 20 ml/kg/min. Total cardiac output in CF-LVAD patients during exercise is predominantly determined by pump speed, the pressure difference across the pump, and in some cases ejection through the aortic valve. Fixed pump speed utilized in CF-LVADs may provide insufficient support, resulting in a moderate cardiac output increase during increased physical strain. Ongoing studies are evaluating whether pump speed changes in response to varied loading conditions may enable LVADs to provide sufficient support even during strenuous exercise. In the currently used devices, evidence suggests that focus on optimizing non-cardiac peripheral parameters is vital. Extra-cardiac potentially reversible factors are anemia with low oxygen-carrying capacity, obesity and general deconditioning with low muscle mass. In addition, exercise training in CF-LVAD patients can improve peak VO₂. To design interventions to improve functional capacity in patients treated with modern durable LVADs, a detailed understanding of exercise physiology in a continuous-flow circulatory system is necessary. In this review we address the different components of exercise physiology in LVAD patients and point out potential solutions or areas of future research.

Section snippets

Review strategy

A systematic literature search in PubMed was conducted by identifying studies on exercise capacity in LVAD patients using the search terms “exercise capacity,” “oxygen uptake,” “peak oxygen consumption,” “LVAD,” “CF-LVAD,” “exercise training” and “submaximal exercise.” In the relevant studies, baseline characteristics in the form of age, gender, device type, pump settings, indication, support duration, etiology and echocardiographic measurements were systematically collected. Parameters of

Pulsatile- vs continuous-flow LVADs

The currently used second- and third-generation CF-LVADs operate with a pulseless flow, either axial or centrifugal.⁷ HeartMate II (HMII; Thoratec Corporation, Pleasanton, CA) and HeartWare (HVAD; HeartWare International, Inc., Framingham, MA) devices are the most commonly used second- and third-generation pumps, respectively. These non-pulsatile devices are set at a fixed pump speed regardless of patient activity. The HMII can be regulated from 6,000 to 15,000 revolutions per minute (rpm),

CF-LVAD pump speed

Pump flow is largely dependent on pump speed in CF-LVAD patients. Brassard et al showed that increased CF-LVAD pump speed enhances CO during light exercise compared with exercise at a fixed pump speed.¹⁹ Thus, according to Fick’s equation, one would expect exercise capacity to improve during exercise with increased pump speed. Accordingly, in a double-blind, randomized manner, it was recently demonstrated that incrementally increasing pump speed during maximal exercise testing improves peak VO₂

Disclosure statement

F.G. was a speaker for Thoratec, Inc. M.H.J. has no conflicts of interest to disclose. This study was supported by the Danish Heart Foundation (14-R97-A5013-22858).

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Cited by (96)

Preoperative and mid-term right ventricular systolic function assessment, at rest and during exercise, with speckle-tracking echocardiography after left ventricular assist device implantation
2024, Hellenic Journal of Cardiology
The study aimed to compare pre- and postoperative resting as well as postprocedural resting and exertional right ventricular speckle-tracking echocardiographic parameters at a mid-term follow-up after left ventricular assist device (LVAD) implantation.
Patients with implanted third-generation LVADs with hydrodynamic bearings were prospectively enrolled (NCT05063006). Myocardial deformation was evaluated before pump implantation and at least three months after the procedure, both at rest and during exercise.
We included 22 patients, 7.3 months (IQR, 4.7-10.2) after the surgery. The mean age was 58.4 ± 7 years, 95.5% were men, and 45.5% had dilated cardiomyopathy. The RV strain analysis was feasible in all subjects both at rest and during exercise. The RV free wall strain (RVFWS) worsened from −13% (IQR, −17.3 to −10.9) to −11.3% (IQR, −12.9 to −6; p = 0.033) after LVAD implantation with a particular decline in the apical RV segment [-11.3% (IQR, −16.4 to −6.2) vs −7.8% (IQR, −11.7 to −3.9; p = 0.012)]. The RV four-chamber longitudinal strain (RV4CSL) remained unchanged [-8.5% (IQR, −10.8 to −6.9) vs −7.3% (IQR, −9.8 to −4.7; p = 0.184)]. Neither RVFWS (−11.3% (IQR, −12.9 to −6) vs −9.9% (IQR, −13.5 to −7.5; p = 0.077) nor RV4CSL [−7.3% (IQR, −9.8 to −4.7) vs −7.9% (IQR, −9.8 to −6.3; p = 0.548)] changed during the exercise test.
In patients who are pump-supported, the right ventricular free wall strain tends to worsen after LVAD implantation and remains unchanged during a cycle ergometer stress test.
Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support
2022, Journal of Heart and Lung Transplantation
Citation Excerpt :
Cardiopulmonary exercise test (CPET), has been used as a component of the recovery assessment protocol.16,49,50 Most studies demonstrate an improvement in the NYHA functional class, but the peak O2 consumption (pVO2) after LVAD implantation remains impaired.51 Because exercise capacity is impacted by extracardiac factors, a low pVO2 on its own should not preclude consideration for LVAD weaning.49,52
Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.
Global best practices consensus: Long-term management of patients with hybrid centrifugal flow left ventricular assist device support
2022, Journal of Thoracic and Cardiovascular Surgery
Six months after withdrawal of the HeartWare HVAD System (HVAD; Medtronic) from sale, approximately 4000 patients continue ongoing support with this device. In light of the diminishing experience, this global consensus document summarizes key management recommendations.
International experts with experience in the management of patients with ongoing HVAD support were invited to summarize key aspects of patient and pump management and highlight differences in the current HeartMate 3 (Abbott Laboratories) ventricular assist device. Clinicians from high-implanting HVAD sites reviewed current literature and reported experience to generate a consensus statement.
Specific guidelines to assist in the management of ongoing HVAD patients are developed. Key management protocols and helpful techniques developed from experienced clinicians are combined into a short guideline document. As experience with HeartMate 3 increases, key differences in approach to management are highlighted, where appropriate.
With decreasing worldwide experience in the ongoing management of HVAD-supported patients, this consensus guideline provides a summary of best practice techniques from international centers. Differences in HeartMate 3 management are highlighted.
Oxygen Uptake During Activities of Daily Life in Patients Treated With a Left Ventricular Assist Device
2022, Journal of Heart and Lung Transplantation
Citation Excerpt :
It is clear that the fact that patients perform simple ADLs at oxygen uptakes closer to their peak values than matched controls impacts the life of these patients at least by adding time needed to complete necessary tasks. It is likely that “smart pumps” with the ability to regulate flow in response to increased metabolic demands10,23,24 would increase the cardiopulmonary reserve of LVAD recipients and hence decrease the time needed to complete such tasks. As shown for some ADLs in this study, this might improve QOL and should motivate future engineering of such adaptive pumps.
Oxygen consumption during activities of daily life (ADL) is not described in recipients of left ventricular assist device (LVAD). We aimed to investigate the relation between oxygen consumption during predefined ADLs and measures of functional capacity (FC) in stable-phase LVAD recipients.
LVADs and controls were matched on gender, age, BMI, smoking status, and ethnicity. VO₂ was measured using mobile equipment (K5, Cosmed, Rome, Italy) while putting on vest and LVAD equipment(1), folding towels(2), putting on socks and shoes(3), putting bottles in a cupboard(4), making a bed(5), walking on stairs without(6) and with extra weight(7), and sweeping the floor(8). Submaximal FC was tested by means of 6 minute walk test (6MWT) and peak oxygen uptake (pVO₂) to test maximal FC.
Fifteen LVAD patients and 16 controls were included; Patients were 61 ± 10years, all males with BMI 28 ± 5kg/m² and implanted with Heartmate 3 (DT: 60%). PVO₂ was 14.9 ± 2.2 ml/kg/min in patients and 39.6 ± 7.7 in controls (p < 0.001). Oxygen consumption expressed as percent of pVO₂ for each task in patients vs controls was (%): ADL1: 41 ± 5 vs 21 ± 4, ADL2: 41 ± 6 vs 22 ± 5 %, ADL3: 50 ± 16 vs 24 ± 5%, ADL4: 45 ± 12 vs 22 ± 4, ADL5: 50 ± 8 vs 23 ± 4, ADL6: 66 ± 10 vs 30 ± 4, ADL7: 65 ± 10 vs 31 ± 5, ADL8: 75 ± 10 vs 39 ± 12, (p < 0.001 for all). During 6MWT LVAD patients used 96% ± 8 % of their pVO₂.
Recipients of durable LVADs perform daily life activities at oxygen uptake levels much closer to their peak cardiopulmonary reserve than matched healthy controls.
Long-term preservation of functional capacity and quality of life in advanced heart failure patients with bridge to transplant therapy: A report from Japanese nationwide multicenter registry
2022, International Journal of Cardiology
Under the revised heart allocation system in the United States, bridge to transplant (BTT) patients with left ventricular assist device (LVAD) have a longer waitlist period, as they are now lowly prioritized. However, little is known regarding the long-term trajectory of functional capacity (FC) and health-related quality of life (HR-QOL) among BTT-LVAD patients.
We retrospectively analyzed 442 consecutive patients with BTT-LVAD between April 2013 and May 2019 from a Japanese nationwide registry. FC (New York Heart Association [NYHA] functional class, peak oxygen uptake [VO₂], and 6-min walk test [6MWT]) and HR-QOL (European Quality of Life [EQ-5D index] and Visual Analogue Scale [EQ-VAS]) were assessed at baseline and for up to 60 months after LVAD implantation.
During the follow-up period of 30 months (IQR 18–42 months), 100 (22.6%) patients underwent transplantation, 37 (8.3%) died, and 14 (3.1%) underwent explantation for recovery. Mean peak VO₂, 6MWT distance, EQ-5D index, and EQ-VAS significantly improved 3 months after LVAD implantation (p = 0.0012, p = 0.0037, p < 0.001, p < 0.001, respectively). Furthermore, these improvements were sustained for up to 60 months following LVAD implantation. Major adverse events including device failure, infection, stroke, and bleeding, which occurred within the first 3 months after LVAD implantation may have not affected FC or HR-QOL for up to 60 months (p = 0.15, p = 0.22, respectively).
BTT patients showed long-term preservation of FC and HR-QOL, suggesting that BTT remains an option despite the long waiting time to HTx.
Importance of blood pressure control and adequate neurohormonal treatment in LVAD patients: Comment to paper by Tran T. et al.
2021, Journal of Heart and Lung Transplantation

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State of ArtExercise in heart failure patients supported with a left ventricular assist device

Section snippets

Review strategy

Pulsatile- vs continuous-flow LVADs

CF-LVAD pump speed

Disclosure statement

J Heart Lung Transplant

JACC Cardiovasc Imaging

J Heart Lung Transplant

J Heart Lung Transplant

J Am Coll Cardiol

J Heart Lung Transplant

J Card Fail

J Thorac Cardiovasc Surg

J Heart Lung Transplant

J Am Coll Cardiol

J Heart Lung Transplant

J Heart Lung Transplant

Am J Cardiol

J Heart Lung Transplant

J Heart Lung Transplant

J Am Coll Cardiol

J Heart Lung Transplant

J Heart Lung Transplant

J Am Coll Cardiol

J Card Fail

Am J Cardiol

Transplant Proc

A multi-modal intervention in management of left ventricular assist device outpatients: dietary counselling, controlled exercise and psychosocial support

Eur J Cardiothorac Surg

Exercise performance of chronic heart failure patients in the early period of support by an axial-flow left ventricular assist device as destination therapy

Artif Organs

Long-term use of a left ventricular assist device for end-stage heart failure

N Engl J Med

The impact of acute reduction of continuous-flow left ventricular assist device support on cardiac and exercise performance

Heart

Design concepts and principle of operation of the HeartWare ventricular assist system

ASAIO J

Relationship between pump speed and exercise capacity during HeartMate II left ventricular assist device support: influence of residual left ventricular function

Eur J Heart Fail

State of Art
Exercise in heart failure patients supported with a left ventricular assist device