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

1. 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

2. 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)

3. The Impaired Cardiac Output Response
to Exercise in HF
Weber, Circ 1982;65:1215

4. Factors Contributing to
Exercise Intolerance in HF
EXERCISE
PERFORMANCE

5. The Muscle Hypothesis
Exercise
Muscle
Atrophic
Deconditioned
Metabolically abnl
Afferents
Fatigue Breathlessness
Hypoxia

6. Ultrastructural Muscle Changes in HF

7. 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

8. Functional Status
HM II Destination Therapy Trial

9. 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
PeakVO2(ml/kg/min)
Leibner JHLT 2012;S64
10.7
12.8

10. Increased Handgrip Strength post-VAD
Chung et al. JCF 2014

11. Increased Muscle Fiber CSA post-VAD
Khawaja et al. J Cachexia Sarcopenia Muscle. 2014

12. Increased Oxidative Type 1
Muscle Fibers post-VAD
Khawaja et al. J Cachexia Sarcopenia Muscle. 2014

13. Enhanced Oxidative Capacity post-VAD
Khawaja et al. JCSM. 2014

14. Khawaja JCSM 2014; Chokshi Circ 2012
Pre-VAD Post-VAD
0
1
2
3
4
p<0.01
Con
p<0.05
HOMA-IR
Improvement in Growth Hormone and
Insulin Resistance post-VAD

15. 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

16. Mettauer B Medicine & Science in Sports 2001;33
Case Study
61 yo man on HM XVE
6 wks bicycle exercise
at @50% max HR

17. 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

18. 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

19. 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

20. 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.