The document discusses cardiac rehabilitation after mitral valve repair, highlighting the importance of exercise training which improves exercise tolerance while addressing concerns about potential damage to the repair. It reviews the necessity of antithrombotic therapy post-surgery and provides evidence that such therapy is essential for at least the first six weeks. The findings support early rehabilitation as safe and beneficial in improving patient outcomes without increasing complications.

1. Cardiac Rehabilitation after
Mitral Valve Repair
Ph Meurin, MC Iliou, A Bendriss,
B Pierre, S Corone ,P Cristofini et JY
Tabet
On behalf of the Working group of
Cardiac Rehabilitation
of the French Society of Cardiology

2. Background (1) :
Exercise tolerance after mitral
valve repair
Exercise duration
700
650
600
550
Before Surgery 7 months after
Exercise duration 678 605
(1) Le Tourneau . Circulation 2000; 36 : 2263-9.
peak VO2
22
21,5
21
20,5
20
19,5
19
Before Surgery 7 months after
216 + 80 days after MVR; n = 16
*

3. Therefore
• After MVR , Exercise training is necessary
BUT
• Shall we Damage the repair results ?
•Surgeons are reluctant to allow training
because the mitral scar could be fragil

4. Background (2) :
Antithrombotic Therapy after
MVRepair :
• No Guideline1.2.3
• No Study
(1)Borrow et al. ACC/AHA guidelines for the management
of patients with valvular heart disease.
J Am Coll Cardiol 1998; 31 :1486-1580
(2) Gohlke-Barwolf C et al.Guidelines for prevention of
thromboembolic events in valvular heart disease.
Eur Heart J 1995; 16 : 1320-30
(3) Salem DN et al. Antithrombotic therapy in valvular heart disease.
Seventh ACCP Conference on Antithrombotic and Thrombolytic therapy.
Chest 2004; 126 : 457S

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((1133 CCeennttrreess,, SSeepptteemmbbeerr 22000022--JJuullyy 22000033))
Patients :
-Selection :
-every patients
transferred to a Cardiac
Rehabilitation Centre less
than 60 days after MVR
-Endpoints :
-Echo, VO2, clinical
evaluation

6. Results

7. Population
• N = 251 (261 selected); 59 + 14 years old
• Men 70 %
MI Aetiology
Euro Heart
Survey1
FSC
Degenerative 69 % 61.3 %
Rheumatic 10 % 14.2 %
Ischaemic 11 % 7.3 %
Endocarditis 5 % 3.5 %
Others 5 % 13.7 %
(1)Iung et al. The Euro Heart Survey on valvular heart Disease Eur Heart J 2003;24 : 1231-43

8. 60%
50%
40%
30%
20%
10%
0%
Pre Operative NYHA Class
I II III IV
NYHA
REPLA
Registre Européen
Braunberger
Pre Op LVEF :
Iung et al. The Euro Heart Survey on valvular heart Disease Eur Heart J 2003;24 : 1231-43.
Braunberger et al. very long term results (more than 20 years) of valve repair with carpentier's
techniques in non rheumatic mitral valve insufficiency. Circulation 2001 ; 104 (suppl I) : I-8-I-11
55 + 10 %
Pre Op NYHA :
2.3 + 0.9
FSC

9. Mitral valve repair Associated Surgery
120%
100%
80%
60%
40%
20%
0%
1
Kind of operation
Anneau
Resec
Transpo
Anneau seul
Commissurotomie
Patch
Annuloplasty
Resection
Transposition
Isolated Ann
Commissuro
Patch
14,00%
12,00%
10,00%
8,00%
6,00%
4,00%
2,00%
0,00%
1
AoVR
CABG
Tric Plasty
Cox
P Maker
Others

10. Thromboembolic Events

11. Antithrombotic Therapy (AT)
• Vitamin K Antagonist (VKA) Group :
• Heparin (high dose) started on Day 1
• VKA started between Day 3 and Day 6
• Heparin stopped when INR > 2
• Aspirin (ASA) Group
• ASA started between day 2 and day 6
• Heparin (low dose) stopped between day 5 and day 10
• No AT Group :
• Heparin (low dose) stopped between day 5 and day 10

12. 10 Transient Ischaemic neurologic Attacks
(TIA) 24.2 J (4-52) after MVR
• Predisposing causes ?
– Age
– Sex
– Size LA or LV
– AF
– Associated surgery
– Mitral leaflet involved
– Carpentier's classification
Not related to the
occurrence of a TIA

13. TIA and Antithrombotic Therapy
-
169 pts : VKA alone
15 : VKA + Aspirin
39 : Aspirin alone
28 : No AT
25,00%
20,00%
15,00%
10,00%
5,00%
5 of the 28 patients receiving no
antithrombotic had a TIA : 18 %
5 of the 223 pts receiving VKA and/or aspirin
had a TIA : 2%
OR = 9.0
P<0.0001
0,00%
VKA / ASP No AT

14. The real question : is an
Antithrombotic therapy
necessary after MV repair,
even in patients in whom choice
of AT is not influenced
by a concomitant pathology ?

15. Population where the choice of
AT is actually open
• After excluding patients in whom AT
indication was modified by a concomitant
pathology
– Concomitant surgery
• AoVR, CABG …
– Pre or post operative AF
•Population available for the study n= 143

16. 7 TIA among 143 patients :
30,00%
25,00%
20,00%
VKA group : 3/91
ASA group :0/36
No AT group : 4/16 *
*
*
15,00%
10,00%
5,00%
0,00%
VKA ASA No AT
1
,8
,6
,4
. 0 10 20 30 40 50 60 70
,2
0
Time (days)
VKA + ASA Group
No AT group
Log rank =15.8, p<0.0001
TIA free
ns

17. Conclusion
• An Antithrombotic Therapy is necessary at
least during the first 6 post operative weeks
after MV repair even in patients in sinus
rythm and without concomitant pathology
•There seems to be no advantages
in performing early anticoagulation therapy
compared with antiplatelet regimen ?

18. Rehabilitation : Modalities
• Delays :
• Surgery-CPT1 : 20.7 + 10.2 J
• CPT1- CPT2 : 20.6 + 15.7 J
• Sessions :
• Gymnastic sessions : 13.7 + 5.4
• Ergometric bicycle :11 +4
– Mean training workload 58.3 + 27.5 Watts
• Mean THR : 103.2 + 17.7 bpm

19. Echographic Mitral Repair
Evolution
MI1 = 0.59 + 0.05
MI2 = 0.57 + 0.05
60%
50%
40%
30%
20%
10%
0%
Day 19
Day 39
0 I II III-IV
Day 19 48% 43% 9% 0%
Day 39 52% 39% 9% 0%
LVEF1 = 53 + 10
LVEF2 = 55 + 9
(p<0.05)
LVEDV1 = 113
LVEDV2 = 109
(p<0.05)

20. Cardiopulmonary Exercise tests Evolution
22
20
18
16
14
12
10
Day 20 Day 41
Peak VO2 16,3 20
AT 12,2 14,2
O2 pulse 10,5 12,3
% increase p
Peak VO2 + 22 % 10-4
AT + 16 % 10-4
O2 pulse + 18 % 10-4
Ex duration + 34 % 10-4
Chron reserve + 18 % 10-4

21. Conclusion
Early Exercise Training after MVR
• Is efficient :
• Peak VO2 : +22%; AT : + 16%…
• Is Safe :
• Neither new onset nor MI aggravation
• Management of usual post operative complications
• An antithrombotic therapy is necessary during the
first weeks following MVR