what important changes occur in the patient with a continuous flow lvad

What Important Changes Occur In The

Patient With A Continuous Flow LVAD?

Skeletal Muscle Changes and Exercise

P. Christian Schulze

Division of Cardiology, Department of Medicine

Columbia University, New York, USA

The Chronic Fatigue Syndrome in HF

JHLT. 2014 Oct; 33(10): 996-1008

• Impaired Cardiac Output response

• Abnormal Endothelial Function

• Skeletal Muscle Dysfunction

• Malnutrition/Cachexia

• Cytokine Activation

• Anemia

• Sleep apnea

• Medication (ß-blockers)

• Psychological Factors (Depression)

The Impaired Cardiac Output Response

to Exercise in HF

Weber, Circ 1982;65:1215

Factors Contributing to

Exercise Intolerance in HF

EXERCISE PERFORMANCE

The Muscle Hypothesis

Exercise Muscle

Atrophic Deconditioned

Metabolically abnl

Afferents

Fatigue Breathlessness

Hypoxia

Ultrastructural Muscle Changes in HF

A Downward Spiral

Decreased CO

Sympathetic

Stimulation

Decreased SM Blood Flow

Vasoconstriction

Inactivity

Cytokine Activation Muscle wasting

Deconditioning

Anemia

Inactivity

Anorexia

Depression

More Muscle wasting

Deconditioning

Cachexia

LVAD

Functional Status HM II Destination Therapy Trial

Lack of Improved Peak VO2 post-VAD Peak VO2 in 60 HMII LVADs

0

5

10

15

Pre implant 3-6 mo 1 yr

11.2

Pe

ak V

O2

(m

l/kg

/min

)

Leibner JHLT 2012;S64

10.7

12.8

Increased Handgrip Strength post-VAD

Chung et al. JCF 2014

Increased Muscle Fiber CSA post-VAD

Khawaja et al. J Cachexia Sarcopenia Muscle. 2014

Increased Oxidative Type 1

Muscle Fibers post-VAD

Khawaja et al. J Cachexia Sarcopenia Muscle. 2014

Enhanced Oxidative Capacity post-VAD

Khawaja et al. JCSM. 2014

Khawaja JCSM 2014; Chokshi Circ 2012

Pre-VAD Post-VAD

0

1

2

3

4

p<0.01

Con

p<0.05

HO

MA

-IR

Improvement in Growth Hormone and

Insulin Resistance post-VAD

General Lack of Training Studies in

Patients Supported by LVAD

• Paucity of Data

• 3 single case studies

• 3 small series

• Training is safe + feasible

• Training appears to

improve submaximal and

maximal exercise

Kohli H, J Heart Lung Tx:2011; 30:1207

Training in pts with TAH

Mettauer B Medicine & Science in Sports 2001;33

Case Study

61 yo man on HM XVE

6 wks bicycle exercise

at @50% max HR

Laoutaris et al. Europ J Card Prev Rehab 2011; 18: 33

• 15 pts with LVAD or BiVAD 6 months post-implant

• Age 38±16 years

• Randomized 2:1 to training vs control

• 10 week training regimen

– Walking 30-45 minutes/day

– Bike or treadmill x 45 minutes for 3-5 days/week

– Respiratory training

Pre -Training Post-Training

Peak VO2 16.8±3.7 19.3±4.5*

VO2 AT 12±5.6 15.1±4.2*

VE/VCO2 40±6.5 35.9±5.6*

6MWD 462±88 527±76*

Quality of Life 49±13 38±12*

Training Effects post-LVAD

Exercise Training Post-LVAD Implantation

• Randomized 1:1 trial at 1 month post implant

• 14 consecutive VentraAssist BTT patients

• 7 patients with aerobic and strength training

• 7 patients with standard mobilization alone

Training and Mobilization Program

– 3 days/wk of 1 hour of gym based training

• 15 minutes stationary bicycling at 50% VO2

• 15 minutes on treadmill at 60% of speed during 6MWT

• Strength training

Mobilization Program alone

– ≥5 days/wk of walking

– Level 13 on Borg scale for 60 min

Hayes K et al. JHLT 2012;31:729

Exercise Date + Quality of Life

Pre vs Post-Training and Control

Training

Pre

Training

Post

Control

Pre

Control

Post

Peak VO2 10.5±2.3 14.8±4.9* 12.4±1.7 15.3±4.4*

Peak

Workload(W)

42±15 75±31* 50±22 79±45*

6MWD (m) 351±77 531±131* 367±129 489±95*

Qual of Life 30±11 60±24* 37±12 53±6*

Hayes K, JHLT 2012;31:729

Summary and Conclusion

LVAD placement improves quality-of-life and physical activity

in patients with advanced heart failure.

Improved systemic and local metabolism is associated with

ultrastructural changes in skeletal muscle and increased

oxidative capacity.

However, LVAD placement alone does not improve objective

markers of exercise tolerance such as peak VO2.

The role of exercise training and physical rehabilitation has to

be further clarified in systematic randomized studies.