vulvular heart disease rehabilitation

1. Cardiac Rehabilitation in
Valvular Heart Disease Patients
Hiba Anis
MPT 3rd Sem (Cardiopulmonary)
Jamia Millia Islamia

3. Heart valves
• Atrioventricular valves
• Tricuspid
• Mitral
• Semilunar valves
• Aortic
• Pulmonary

4. Valvular Heart Disease
• Disease that involve any of the four heart valve
• VHD leads to haemodynamic instability either due to
• Stenosis
• Regurgitation/ insufficiency

5. Valvular Stenosis
• Valvular stenosis is a narrowing or obstruction of the valve orifice, resulting in a valve that does not open
adequately
• The causes of stenosis include degenerative calcification, rheumatic disease, and congenitally malformed
valves (e.g., bicuspid aortic valve).
• EFFECTS:
• The chamber behind the stenotic valve is subject to greater stress…. must generate more pressure
(work hard) to force blood through the narrowed opening
• initially, the heart compensates for the additional workload by gradual hypertrophy and dilation of the
myocardium, finally ending in heart failure

6. Valvular Regurgitation
• Regurgitation is the result of an incompetent valve that allows retrograde flow. Due to:
• scarring and retraction of valve leaflets
• Weakening of supporting structures
• It may be caused by rheumatic heart disease, infections, or congenital diseases (e.g.,
Marfan syndrome).
Effects:
Causes the heart to pump the same blood twice (as the blood comes back into the chamber)
• The heart dilates to accommodate more blood
• Ventricular dilation and hypertrophy eventually leads to heart failure

7. Valvular Heart Disease
1. Mitral Stenosis
2. Mitral regurgitation (most common regurgitation)
3. Aortic Stenosis (most common stenosis)
4. Aortic regurgitation
5. Tricuspid Stenosis
6. Tricuspid regurgitation
7. Pulmonary Stenosis
8. Pulmonary regurgitation

8. • Symptomatic heart valve disease heavily influences the performance of
daily living and quality of life.
• Surgical treatment, either valve replacement or repair, remains the
treatment of choice.
(Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC), European Association for Cardio-Thoracic Surgery (EACTS), Vahanian, A.,
Alfieri, O., Andreotti, F., Antunes, M. J., Barón-Esquivias, G., Baumgartner, H., Borger, M. A., Carrel, T. P., De Bonis, M., Evangelista, A., Falk, V., Iung, B., Lancellotti, P., Pierard, L.,
Price, S., Schäfers, H. J., Schuler, G., Stepinska, J., … Zembala, M. (2012). Guidelines on the management of valvular heart disease (version 2012). European heart journal, 33(19), 2451–
2496. https://doi.org/10.1093/eurheartj/ehs109)
• Following surgery, the transition to daily living may become a physical,
mental and social challenge

9. Surgical interventions for valvular
dysfunction
Include
• annuloplasty or
• valve replacement using a prosthetic valve.

10. • Annuloplasty tightens the annulus in an effort to restore the competence
of the valve.
• Prosthetic heart valves are divided into two main categories:
1. bioprostheses and
2. mechanical prostheses.
• Bioprosthetic valves are further classified as heterografts, homografts, and
stentless heterografts.
• Types of mechanical prosthetic heart valves include the caged-ball, tilting-disk,
and bileaflet valves.

11. • Before surgery, the surgeon typically discusses the choice of valve
with the patient, reviewing the fact that mechanical valves are more
durable but require lifelong anticoagulation due to much higher risk
for clotting and therefore embolism.

12. • Catheter-based procedures have emerged as alternatives to surgery for selected high-risk
patients.
• Transcatheter aortic valve replacement (TAVR) compared to surgical replacement was
studied extensively in the PARTNER study, and outcomes up to 2 years indicated that these
two procedures resulted in similar mortality, reduction of symptoms, and valve
hemodynamics
• Another type of catheter-based procedure involves repairing mitral regurgitation by
percutaneously implanting a clip that realigns the mitral valve leaflets.
• **Patients who undergo either of these procedures would not have a sternotomy and may be
able to progress more rapidly during CR

13. Referral to CR after Valve surgery
• Referral of patients to CR following valve replacement or repair is an AACVPR/AHA/ACC- endorsed
performance measure and is a covered indication for Medicare patients.
• A decision memorandum in 2006 from the Centers for Medicare and Medicaid Services concludes that the
evidence is adequate that CR is reasonable and necessary after HV repair or replacement .
• This memo focuses on phase 2, outpatient CR, which recommends up to 36 sessions and 2-3 sessions per
week. The sessions should include prescribed exercise, education, and counseling.
(Decision Memo for Cardiac Rehabilitation Programs (CAG-00089R). Washington, DC: Centers for Medicare and Medicaid Services. U.S. Department of Health and Human Services;
2006. Available at http:// www.cmms.hhs.gov/medicare-coverage-database/details/nca-decisionmemo.aspx?NCAId164&ver12&NCDId36&ncdver3&
NcaNameCardiacRehabilitationPrograms&IsPopupy&bc AAAAAAAAIAAA& ? Accessed July 6, 2011)

14. Cardiac rehabilitation for VHD
• Cardiac rehabilitation (CR) is a long-term program that involves prescribed
exercise, education, and counseling to limit physiological and psychological
effects of cardiac disease and to enhance the psychosocial and vocational status of
selected patients. (Thomas R et al. 2007)
• CR starts in the hospital, before discharge; continues after discharge, in a
supervised setting, usually with telemetry monitoring initially; and transitions to a
home-based program to be continued indefinitely

15. Inpatient rehabilitation
• Cardiac surgery patients (CABGs or valvular) are hospitalized for 4 to 6
days.
• To counteract the deleterious effects of bed rest and complications
associated with the cardiac surgery, range-of-motion activities, as well as
mobilization are initiated while in the hospital or in the early outpatient
setting.
• Stretching or flexibility activities can begin as early as 24 and 48 hours after
bypass surgery or uncomplicated MI, respectively. Patients may be seen
once daily and perform 10 to 15 repetitions of each exercise.
• post surgery patients should avoid traditional resistance training exercises
(with moderate to heavy weights), until the sternum has healed sufficiently,
generally by 3 months

16. • Surgery patients who experience sternal movement or wound complications
should perform lower extremity exercises only.
• Nevertheless, significant soft-tissue and bone damage of the chest wall can
occur during surgery. If this area does not receive range-of-motion exercise,
adhesions may develop and the musculature can become weaker and shorten,
accentuating postural problems and hindering strength gains.
• Aerobic exercise training for the postsurgical inpatient can be guided initially
using resting HR + 30 beats’min until more objective data from a symptom-
limited exercise test is generated.
• Valve surgery patients may have greater activity restrictions and/or longer
periods of symptoms prior to surgery. The resulting low functional capacity,
as well as advanced age, may require valve surgery patients to start and
progress at a slower rate.

17. Special considerations for VHD
• The exercise prescription and training of VHD patients following valve
replacement are similar to those for CABG patients.
• Patients undergoing heart valve surgery commonly present with impairment of
physical activity and physical capacity up to several years before surgery.
Combined with a period of bed rest after surgery, this patient group is therefore
not in an optimum state of physical fitness at hospital discharge and physical
rehabilitation is required
• The resulting low functional capacity requires these patients to start and to
progress slowly during the early stages of an exercise training program

18. • CR professionals should use standard exercise prescription methodology with these
patients but should take care to avoid upper extremity exercise (including resistance
training involving the upper extremities) until the sternum is stable and there are no
sternal wound healing issues.
• valve replacement surgery patients are not cured of VHD but instead have
exchanged native valve disease for prosthetic valve disease.
• Prevention of infections at prosthetic valve sites and management of
anticoagulation medications are important issues for the postsurgical patient

19. Special Considerations for Valve Repair Patients During CR
• Importance of anticoagulation therapy and precautions for exercise-related injuries and bleeding
• Precautions for upper extremity exercise and sternal healing
• Avoidance of resistance-type exercise with severe aortic stenosis or insufficiency

20. • Patients with VHD, but without valve repair or replacement, may also be referred for CR
for other coexisting conditions, such as MI, PCI, angina, or CABG.
• In these patients, critical aortic stenosis is a contraindication for both inpatient and
outpatient CR
• Patients with less severe aortic stenosis can exercise but may develop symptoms (e.g.,
dyspnea, angina, or syncope) during exercise
• Exercise training intensity should be kept under the threshold that precipitates the onset
of symptoms because these symptoms indicate that the cardiac output is not meeting the
demands of the exercise.
• Dyspnea during exercise is the primary symptom of exercise intolerance with mitral
stenosis, and is commonly seen in patients with severe aortic stenosis.
• A worsening of any of these symptoms over time may indicate worsening valve disease
and should be closely monitored.
• Absolute contraindications for resistance training include Marfan syndrome and severe,
symptomatic aortic stenosis

21. Intervention strategies for valve patients
• The goal for each patient is the prevention of reocclusion and advancing atherosclerosis, as well as
optimal exercise tolerance.
• The common problem for rehabilitation staff is to help patients understand that the disease has not
been cured by the procedure and that secondary prevention is important for preventing subsequent
clinical issues.
Safety Exercise Education
• Incision care, infection
prevention
• Long-term anticoagulant
therapy for mechanical valves
• Increased deconditioning and
older— gradual start at outset;
may result in conservative
exercise prescription
• Medications, motivation, and
encouragement to become
more active
• Anticoagulation and antibiotic
prophylaxis issues

22. Recommendation for CR after surgery
• Patients referred to CR require a thorough medical evaluation and symptom limited
exercise test before starting the program.
• Secondary prevention aspects of CR are particularly important for those patients with
concomitant CAD. Secondary prevention includes:
• nutritional counseling,
• tobacco cessation,
• blood pressure management,
• diabetes management, and
• lipid management.
• The patients attend group sessions to receive instruction in these areas, including
information about their medications.

23. • At program entry, the following assessments should be performed:
• Medical and surgical history including the most recent cardiovascular event,
comorbidities, and other pertinent medical history.
• Physical examination with an emphasis on the cardiopulmonary and
musculoskeletal systems.
• Review of recent cardiovascular tests and procedures including 12-lead
electrocardiogram (ECG), coronary angiogram, echocardiogram, stress test
• Current medications including dose, route of administration, and frequency
• CVD risk factors

24. • Routine preexercise assessment of risk for exercise should be performed
before, during, and after each rehabilitation session, and include the
following:
• HR.
• Blood pressure (BP).
• Body weight (weekly).
• Symptoms or evidence of change in clinical status not necessarily related to
activity (e.g., dyspnea at rest, light-headedness or dizziness, palpitations or
irregular pulse, chest discomfort).
• Symptoms and evidence of exercise intolerance.
• Change in medications and adherence to the prescribed medication regimen.
• Consideration of ECG surveillance that may consist of telemetry or hardwire
monitoring

25. Exercise prescription
• The symptom limited or submaximal exercise test helps to determine the
target HR range and is recommended before beginning CR
• Include both resistance and aerobic training
• Aerobic exercise:
• Frequency: 3-5 sessions per week;
• Intensity of 50%-80% of the HR achieved in exercise testing;
• Time: session duration of 30-60 minutes .(After a cardiac-related event, patients may
begin with as little as 5–10 min of aerobic conditioning with a gradual increase in
aerobic exercise time of 1–5 min per session or an increase in time per session of
10%–20% per week.)
• Type: Walking on a treadmill or riding a stationary bicycle is commonly used
(Balady, Gary J et al. “Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart
Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology
and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.” Circulation vol.
115,20 (2007): 2675-82. doi:10.1161/CIRCULATIONAHA.106.180945)

26. • Resistance training : General recommendations for dynamic resistance
exercise are
• Frequency of 2-3 times per week;
• Intensity: Initial load should allow 10–15 repetitions that can be lifted without straining
(30%–40% one repetition maximum [1-RM] for the upper body; 50%–60% for the
lower body)
• Volume: : 1-3 sets
• Type: Elastic bands with increasing strengths can be used by starting with the lightest
and then progressing. Hand weights (starting at 1 lb [0.45 kg]) can be used
• Progression: Increase slowly as the patient adapts to the program (2–5 lb wk1 [0.91–2.27
kg] for upper body and 5–10 lb wk1 for lower body [0.91–4.5 kg]).
• Isometric exercise is generally not recommended, because it might increase the blood
pressure.
• Warm-up and cool-down activities also are recommended, as well as relaxation
techniques at the end of the session
(Balady, Gary J et al. “Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart
Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology
and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation.” Circulation vol.
115,20 (2007): 2675-82. doi:10.1161/CIRCULATIONAHA.106.180945)

27. Issues specific to patients with valve surgery
• further considerations, depending on each patient’s unique history.
1. For patients who had open heart surgery with a median sternotomy,
precautions are important.
• The strongest force that challenges the sternotomy is the pectoralis muscles.
These muscles pull in opposite direction to the holding power of the wire
sutures. This may lead to sternal disruption.
• Predisposing factors include conditions that hinder bone healing, such as
smoking, osteoporosis, obesity, and steroids.

28. • Patients receive instruction in sternal precautions within the first few days after
surgery, which includes
• the proper method for going from supine to sitting position, which is rolling to one side and
propping oneself up on an elbow, rather than attempting a partial sit-up, which uses the rectus
abdominis muscles, and which can exert unequal pull on the sternum .
• Patients are taught the proper way to rise from a chair, which is by using one’s legs rather than
pushing down with the arms, which can stress the incision.
• Self hugging or hugging a pillow when coughing or sneezing can help to brace the incision.
Coughing can produce a greater disruptive force to the incision than lifting 40 lb (18 kg). These
techniques are begun on an inpatient basis but should be continued after discharge to minimize
sternal stress and pain

29. • Resistance exercises for the shoulders, especially internal rotation and adduction with
elastic bands should be minimal initially and progressed according to the patient’s pain
level. Pushing doors and opening car doors can produce 11-13 lb force (5-6 kg) on the
sternum(Brocki, Thorup & Andreasen et al 2010).
• Sternal protection precautions should be rigorously followed for at least the first 3
months after surgery, and lifting should be limited to less than 10 lb (4.5 kg)
(Westerdahl& Möller et al 2010)
• Patients with a mechanical prosthesis require lifelong warfarin medication. Patients who
receive a bioprosthesis or MV repair should receive warfarin for 3 months after surgery
(Butchart et al 2005)
• Even though phase 2 CR exercise modalities are not high impact, patients should still be
counseled to use caution with home activities that could cause a high-impact injury, such
as falls.

30. Thank you !