A left ventricular assist device, or LVAD, is a mechanical pump that is implanted inside a person's chest to help a weakened heart pump blood. Unlike a total artificial heart, the LVAD doesn't replace the heart. It just helps it do its job

1. CENTER FOR PHYSIOTHERAPY AND REHABILITATION SCIENCE
JAMIA MILLIA ISLAMIA
Topic; Exercise Training Recommendation For Individual With Left Ventricular Assistive Device.
Javid Ahmad Dar
MPT- 3rd Semester
Roll no.- 19MPC0003

2. LVAD
• A left ventricular assist device, or LVAD, is a mechanical
pump that is implanted inside a person's chest to help a
weakened heart pump blood. Unlike a total artificial heart,
the LVAD doesn't replace the heart. It just helps it do its job

4. • Regular exercise training improves exercise tolerance and quality of life in patents with
LVAD Around 5–25% of heart failure (HF) patients reach an end-stage condition, despite
the use of optimal medical therapy. At this stage two option are currently indicated:
• Ventricular assistive device (VAD) implantation,
• Heart transplantation (HT),
• And because of the scarcity of heart donors, the VAD option is In the modern setting of an
increasing HF population emerging as a strategy for bridge to HT or as a destination
therapy (DT) for those ineligible for heart transplantation
Introduction

5. FITT RECOMMENDATIONS FOR INDIVIDUALS W HEART
TRANSPLANTATION AND LEFT VENTRICULAR ASSIST
DEVICE

6. • Due to the continuous flow of the LVAD (i.e., lacking pulsatile flow), BP (i.e., mean
arterial pressure [MAP]) is measured by Doppler instead of auscultation via stethoscope.
• Resting mean pressure should be controlled to between 70 and 80 mm Hg (115). In
general, MAP should mildly increase with increasing work rates.
• Studies have shown safe performance of exercise in inpatient settings with MAP
maintained between 70 and 90 mm Hg (110). HR during exercise increases in a manner
that is generally linear with an increase in work rate. LVAD typically have modest
increases in flow rate (possibly as high as 10 L · min−1) during progressive intensity
exercise.
• Early-onset fatigue is common with exercise. When starting an exercise training program,
fatigue later in the day may be reported. If fatigue occurs, intermittent exercise may
reduce the level of fatigue experienced from subsequent exercise training sessions.

7. Contraindications
• Unstable angina
Uncontrolled hypertension — that is, resting systolic blood pressure >180 mm Hg and/or resting
diastolic blood pressure >110 mm Hg
• Orthostatic blood pressure drop of >20 mm Hg with symptoms
• Significant aortic stenosis (aortic valve area <1.0 cm2)
• Uncontrolled atrial or ventricular arrhythmias
• Uncontrolled sinus tachycardia (>120 beats · min−1)
• Uncompensated heart failure
• Active pericarditis or myocarditis
• Recent embolism (pulmonary or systemic)
• Acute thrombophlebitis
• Acute systemic illness or fever Uncontrolled diabetes mellitus
• Severe orthopedic conditions that would prohibit exercise
• Other metabolic conditions, such as acute thyroiditis, hypokalemia, hyperkalemia, or hypovolemia
(until adequately treated)
• Severe psychological disorder

8. Adverse Responses to Inpatient Exercise Leading to Exercise
Discontinuation
• Diastolic blood pressure (DBP) ≥110 mm Hg
Decrease in systolic blood pressure (SBP) >10 mm Hg during exercise with
• increasing workload
Significant ventricular or atrial arrhythmias with or without associated
• signs/symptoms
Second- or third-degree heart block
Signs/symptoms of exercise intolerance including angina, marked dyspnoea,
• Inappropriate bradycardia (drop >10bpm)
• and electrocardiogram (ECG) changes suggestive of ischemia
• Fatigue, onset of angina with exercise,
• Failure of monitoring equipment
• Light headedness ,confusion, ataxia, cynosis,nausea

9. Evidence In Favour Of Exercise Testing In Ventricular Assist Device Patients
• Limited but promising data are available concerning the safety and efficacy of early mobilization
(7–10days post-implant) and Exercise training in VAD
• In 2011, Laoutaris et al. provided the first evidence of the feasibility and efficacy of ET in patients
with either left ventricular (LVAD) or biventricular (BiVAD)
• assist devices participating in a 10-week exercise program, 6.3 ± 4 months post-implantation.
• Exercise training improved functional capacity (peak VO2, 6MWT), exertional ventilatory
response (VE/VCO2 slope), and quality of life (QoL). Subsequently

10. • Adamopoulos et al. extended these findings, showing that long-term ET also decreased N-terminal
pro B-type natriuretic peptide (NT-proBNP) and triggered myocardial growth factors involved in
evolution signalling pathways, in both LVAD and BiVAD patients.
• A multi-model long-term (18 months) ET intervention increased the percentage of predicted peak
VO2 in LVAD recipients.
• Kerrigan et al. in a 2:1 randomisation trial comparing usual care vs. ET (which included 18 aerobic
exercise sessions at 60 – 80% of HR reserve), showed that ET improved exercise capacity (peak
VO2 by 10%, treadmill time by 3.1min, 6MWT distance by 52.3m), QoL (Kansas City
Cardiomyopathy Questionnaire score by 14.4 points), and leg strength (17%). recently, Marko et
al. confirmed the improvement in peak VO2 a and muscle strength in patients with LVAD

11. How to implement exercise ?
• Based on the available data, the HFA Committees hereby presents practical advice on the modality
of exercise implementation in VAD patients.
• However we should keep in mind that the following are only general recommendations:
• the implementation in clinical practice is conditioned by local expertise, individual recipient factor
(e.g. timing of referral, type of intervention delivered, multidisciplinary approach), characteristics
of the VAD recipients (e.g. combined vs. single surgical interventions, indications for implantation,
underlying clinical condition, co-morbidities), and available national recommendations and
facilities.

12. S.NO. 1 title Methodology Result Conclusion
Author ; Jung et al.,
2016
Journal ; The
journal of heart and
lung transplantation
Impact factor; 7.9
Pump speed
modulations and
sub-maximal
exercise
tolerance in left
ventricular assist
device
recipients: A
double-blind,
randomized trial
In this studyPatients has each
completed 3 exercise sessions on
an ergometer cycle. On Day 1
workload at anaerobic threshold
AT was defined. On Day 2 of the
study, 2 sub-maximal tests at a
workload below anaerobic
threshold AT were undertaken:
one at fixed baseline pump speed
(Speedbase) and the other with
baseline pump speed þ 800 rpm
(Speedinc). The sequence of the
2 sub-maximal tests was
determined by randomization.
Both patient and
physician were blinded to the
sequence. Exercise duration,
oxygen consumption (VO2) and
rate of
perceived exertion (RPE), using
the Borg scale (score 6 to 20),
were recorded.
Nineteen patients (all with a
HeartMate II ventricular assist
device) completed 57 exercise
tests. Baseline pump speed was
9,326 +_ 378 rpm. At AT,
workload was 63 +_ 26 W (25 to
115 W)
and VO2 was 79 +_ 14% of
maximum. Exercise duration
improved by 106 +_ 217 seconds
(13%)
in Speedinc compared with
Speedbase (837 +_ 358 vs 942
+_ 359 seconds; p ¼ 0.048). The
RPE was
13.2 +_ 2.5 in Speedbase vs 12.7
+_ 2.4 in Speedinc (p ¼ 0.2).
increasing pump speed by
800 rpm during sustained,
low-intensity physical
activity is
safe and prolongs exercise
duration in patients
supported with a HeartMate
II device. Automated pump
speed increase during light
exercise may contribute to
improved quality of life by
facilitating ADLs.

13. S.NO. 1 title Methodology Result Conclusion
Author ; Hayes et
al., 2012
Journal ; The
journal of heart and
lung transplantation
Impact factor; 7.9
Effects of exercise
training on exercise
capacity and
quality of life in
patients with a left
ventricular assist
device: A preliminary
randomized controlled
trial
This prospective, randomized
controlled trial with concealed
allocation, assessor blinding,
and intention-to-treat analysis
investigated the effect of
exercise training on exercise
capacity and QOL
in 14 patients who underwent
LVAD insertion as a bridge to
heart transplantation. Exercise
training
consisted of 8 weeks of gym-
based aerobic and strengthening
exercises 3 times a week, with a
progressive mobilization
program, compared with the
control group that completed
mobilization alone.
Exercise capacity was measured
before and after the intervention
using maximal cardiopulmonary
exercise testing and 6-minute
walk distance (6MWD). QOL
was measured using the Short
Form
36-item assessment.
No adverse events were
reported. There was a trend
toward greater improvement
in peak
oxygen consumption (VO2),
6MWD, and QOL in the
exercise group (n 7)
compared with the control
group (n 7); however, no
significant between-group
difference was detected for
improvements in
peak VO2 [mean difference
(exercise – control)] of 2.96
ml/kg/min (95% confidence
interval, 1.04 to
6.97), 6MWD at 54 meters
(51 to 159 meters), and
QOL scores over time (p
0.05).
Exercise training is feasible
and safe in patients with a
LVAD. Trends toward
greater
improvement in exercise
capacity and QOL after
exercise training warrant
further investigation in a
larger trial.

14. References
Jung, M. H., Houston, B., Russell, S. D., & Gustafsson, F. (2017). Pump speed modulations and sub-maximal exercise tolerance in left ventricular assist device recipients: A double-
blind, randomized trial. The Journal of Heart and Lung Transplantation, 36(1), 36-41.
Hayes, K., Leet, A. S., Bradley, S. J., & Holland, A. E. (2012). Effects of exercise training on exercise capacity and quality of life in patients with a left ventricular assist device: a
preliminary randomized controlled trial. The Journal of heart and lung transplantation, 31(7), 729-734.
anga HV, Leung A, Jantz J, Choudhary G, Stabile L Levine DJ, Sharma SC, Wu WC. Supervised exercise training versus usual care in ambulatory patients with left ventricular assist
devices: a systematic review. PLoS One 2017;12:e0174323.
Mahfood Haddad T, Saurav A, Smer A, Azzouz MS, Akinapelli A, Williams MA, Alla VM. Cardiac rehabilitation in patients with left ventricular assist device: a systematic review and
meta-analysis. J Cardiopulm Rehabil Prev 2017;37:390 – 396.
Alsara O, Reeves RK, Pyfferoen MD, Trenary TL, Engen DJ, Vitse ML, Kessler SM, Kushwaha SS, Cavel AL, Thomas RJ, Lopez-Jimenez F, Park SJ, Perez-Terzic CM. Inpatient
rehabilitation outcomes for patients receiving left ventricular assist device. Am J Phys Med Rehabil 2014;93:860 – 868.
Laoutaris ID, Dritsas A, Adamopoulos S, Manginas A, Gouziouta A, Kallistratos MS, Koulopoulou M, Voudris V, Cokkinos DV, Sfirakis P. Benefits of physical training on exercise
capacity, inspiratory muscle function, and quality of life in patients with ventricular assist devices long-term post implantation. Eur J Cardiovasc Prev Rehabil 2011;18:33 – 40.
Kerrigan DJ, Williams CT, Ehrman JK, Saval MA, Bronsteen K, Schairer JR, Swaffer M, Brawner CA, Lanfear DE, Selektor Y, Velez M, Tita C, Keteyian SJ. Cardiac rehabilitation
improves functional capacity and patient-reported health status in patients with continuous-flow left ventricular assist devices: the Rehab-VAD randomized controlled trial. JACC Heart
Fail 2014;2:653–659.
Marko C, Danzinger G, Käferbäck M, Lackner T, Müller R, Zimpfer D, Schima H, Moscato F. Safety and efficacy of cardiac rehabilitation for patients with continu-
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