JACC: HEART FAILURE

VOL. 2, NO. 6, 2014

ª 2014 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

ISSN 2213-1779/$36.00

PUBLISHED BY ELSEVIER INC.

http://dx.doi.org/10.1016/j.jchf.2014.08.001

EDITORIAL COMMENT

Cardiac Rehabilitation in Left Ventricular Assist Device Recipients Can it Bolster the Benefits of Restored Flow?* Gordon R. Reeves, MD, MPT, David J. Whellan, MD, MHS

I

n appropriately selected advanced heart failure

6 months post-implantation (11). Endurance training

(HF) patients, treatment with a left ventricular

was combined with various other modes of exercise,

assist device (LVAD) is associated with signifi-

such as strength training (10,13) or inspiratory

cant improvements in physical function and quality

muscle training (11), as well as with nonexercise

of life (QOL) (1). However, despite these improve-

interventions (12). Only the larger, nonrandomized

ments, impairments persist, with functional capacity

study (after 18 months) demonstrated a significant

frequently #50% of predicted (2–6) and gains in

improvement in exercise capacity in the interven-

both physical function and QOL lagging behind those

tion group compared with the control group (12).

of heart transplantation recipients (2,6,7). Cardiac

The other studies consistently showed improvement

rehabilitation (CR) has been shown to increase exer-

in functional capacity and health status in those

cise capacity, reduce HF symptoms, and improve

who received the study intervention, but did not

the health status in patients with chronic stable HF

demonstrate significant improvement compared with

who have a reduced ejection fraction (HFREF) (8,9),

the benefits achieved with LVAD therapy alone.

prompting the Centers for Medicare and Medicaid

SEE PAGE 653

Services to recently expand CR coverage to this patient population. However, it has not been estab-

The study by Kerrigan et al. (14) presented in this

lished if conventional CR provides additional benefit

issue of JACC: Heart Failure is, to our knowledge, the

to LVAD recipients.

largest prospective, randomized trial of exercise

The body of literature regarding the feasibility,

training in LVAD recipients to date, and it makes a

safety, and efficacy of exercise training in contem-

significant contribution to the existing small body of

porary, continuous flow LVADs is very limited and

literature. The investigators randomized 26 LVAD

includes 2 small (n ¼ #15) prospective, randomized

recipients in a 2:1 fashion to 6 weeks of endurance-

trials (10,11), a nonrandomized prospective study

based CR or usual care beginning approximately 3

(12) (n ¼ 70), and a retrospective cohort study

months post-LVAD implantation. Adherence to the

(13) (n ¼ 11 LVAD recipients). The exercise inter-

exercise intervention was excellent (84% completed

ventions in these studies all included endurance

by 6 weeks) as was retention, with 88% of the pa-

training conducted either at home (11,12) or super-

tients completing follow-up assessments. Exercise

vised in a facility (10,13). Exercise was initiated as

training was generally well-tolerated, with only 1

early as before hospital discharge (10) and as late as

adverse event (syncope and wide complex tachycardia) in >300 training sessions. There was a significant increase in peak oxygen consumption (VO2)

*Editorials published in JACC Heart Failure reflect the views of the

(10%) in those who received CR; however, similar to

authors and do not necessarily represent the views of JACC Heart Failure

previous studies, this was not significantly different

or the American College of Cardiology.

than the change in peak VO 2 in those randomized to

From the Sidney Kimmel Medical College, Thomas Jefferson University,

usual care.

Philadelphia, Pennsylvania. This work was supported by NIH Grants R01 AG045551. Dr. Reeves has received a research grant from the Thoratec

Despite ongoing LVAD support, peak VO 2 re-

Corporation. Dr. Whellan has reported that he has no relationships rele-

mained impaired in both study arms. The limited

vant to the contents of this paper to disclose.

improvement in peak VO2 seen here and in other

Reeves and Whellan

JACC: HEART FAILURE VOL. 2, NO. 6, 2014 DECEMBER 2014:660–2

Cardiac Rehabilitation in LVAD Recipients

studies (2–5) seems contrary to clinical trial data

than peak VO 2 (17). Peripheral factors, including

that showed significant improvement in physical

decreased muscle bulk and a shift in skeletal muscle

function, HF symptoms, and health status with

fiber type and capillary density, contribute to func-

LVAD therapy (1). This apparent discrepancy un-

tional impairments in chronic stable HFREF pa-

derscores our limited understanding of the de-

tients (18). Persistent functional impairments despite

terminants of exercise capacity and associated QOL,

hemodynamic support from an LVAD suggest peri-

as well as the relative importance of peak VO2 (15)

pheral factors might continue to limit physical

in LVAD recipients.

function and diminish QOL in LVAD recipients. Many

Fortunately, the paper by Kerrigan et al. (14) pro-

of the skeletal muscle abnormalities associated with

vides additional insights into the potential benefit

chronic HFREF are responsive to exercise training,

of exercise training in LVAD recipients. Of note,

and the findings by Kerrigan et al. suggest a potential

there was a statistically and clinically significant

beneficial role for this therapy in LVAD recipients

improvement in health status with exercise training.

as well.

Interventions to further improve patient-centered

In conclusion, although the evidence regarding the

outcomes are an important priority, especially for

role of exercise training in LVAD recipients is very

patients living with LVADs as destination therapy.

limited, the present study by Kerrigan et al. (14)

In addition, this was the first study of continuous-

supports the feasibility, safety, and potential for

flow LVAD recipients to report a change in strength

benefit. With better knowledge of the functional im-

in response to exercise training. Baseline leg strength

pairments that persist with LVAD support and their

was approximately half that observed in an age-

impact on health status and clinical outcomes, the

matched healthy cohort. Although not specifically

growing population of patients living with LVADs

targeted by the study’s endurance-based interven-

may be able to realize the benefits of exercise thera-

tion, leg strength improved significantly in the CR

pies tailored specifically to their needs. Given all that

group compared with the control group.

is asked of patients to undergo LVAD implantation

The importance of skeletal muscle function in

and the significant resources utilized for their care,

patients receiving LVADs is gaining increased atten-

the goal is to maximize the benefit, and exercise

tion. Skeletal muscle weakness is an important

training is likely one important step in making that a

marker of frailty and has been associated with an

reality.

increased risk of poor clinical outcomes following LVAD implantation (16). Kerrigan et al. previously

REPRINT REQUESTS AND CORRESPONDENCE : Dr.

showed that leg strength was associated with health

Gordon R. Reeves, 925 Chestnut Street, Mezzanine,

status in LVAD recipients, and that leg strength was

Philadelphia, Pennsylvania 19107. E-mail: gordon.

potentially more important to physical limitations

[email protected].

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Cardiac Rehabilitation in LVAD Recipients

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KEY WORDS cardiac rehabilitation, exercise, heart failure, left ventricular assist device