How Cardiac Rehab Can Improve Functional Capacity in Patients with LVAD

Thank you to PCNA volunteer Nicole Interrante, RN-BSN- BC for this helpful article on cardiac rehab and LVAD.

Heart failure affects a staggering 26 million people worldwide.¹ Due to its increasing prevalence of those living with heart failure combined with an aging population, it is a major public health issue.³ In the United States, it is estimated that 6.2 million people are living with heart failure and that number is expected to increase to more than 8 million by the year 2030.¹ Heart failure has a significant financial impact on our healthcare system due to recurrent hospitalizations.³  A chronic heart failure diagnosis results in a mortality rate of 50 % in the first 5 years and 90 % in 10 years.¹

Patients affected by heart failure have an impaired quality of life due to disabling symptoms such as shortness of breath and fatigue that progresses in those with advanced disease3.  With improvements in medical management and mechanical circulatory support such as left ventricular assist devices,¹ or LVADS, cardiac rehab staff can now examine ways to enhance the quality of life and increase the functional capacity of those they serve. Cardiac rehab has proven to be effective in increasing quality of life in heart failure patients but little data is available on the improvements it has on those with LVADS or other circulatory devices.³

 LVADS are implanted heart pumps responsible for pumping oxygen-rich blood into the ascending aorta and throughout the body. The inflow cannula is connected to the base of the left ventricular apex and a percutaneous driveline is connected to a pump that is powered by two batteries. The controller regulates the functions and settings of the pump and provides messages and alarms³ as needed. Although the pump cannot be fully immersed in water, patients are able to enjoy activities and hobbies again, such as exercise and travel.4 These devices have made tremendous progress over the last few years3 and have led us to the introduction of the HeartMate 3. The HeartMate 3 shows the lowest device-related complications. They are smaller, virtually silent, more reliable, and more durable than their previous generations.³  Nearly 18,000 patients around the world are being supported by the HeartMate 3. ⁴

LVAD implantation serves as an effective treatment for advanced heart disease patients awaiting heart donation (bridge to transplant therapy) and those ineligible or unable to receive a heart transplant (destination therapy).¹ The third therapy strategy of LVAD implantation is known as bridge to recovery.^2. Due to a scarcity of available hearts for donation and advances in medical technology such as mechanical circulatory devices, it is likely that the use of LVADs will continue to increase and so will chances to improve the patient’s activity, longevity, and quality of life. ¹

The aim of this article is to discuss how cardiac rehab nurses and care providers can support, supervise and encourage symptom-limited exercise in patients with LVADs, with a goal of increasing myocardial function and quality of life. Cardiac rehab consists of exercise training, optimization of medical therapy within an interdisciplinary team, psycho-social support and guidance, and education/counseling.3 With that in mind,  LVAD patients consist of a specialized population with specific needs and care throughout their recovery process. The LVAD patient will be very deconditioned and will need a lot of education on their new device.3  Early mobilization and exercise therapy should be initiated to reduce the risk of adverse events as well as promote better outcomes.3 Exercise should be individualized and gradual, starting from low intensity at a maximum of 15-minute sessions. Exercise prescriptions should be more “thresh-hold based” aerobic intensity. It is best to promote a symptom-guided approach using a rate of perceived exertion (RPE) scale, and signs of exercise intolerance should be closely monitored.³  LVAD patients that attend supervised exercise have been shown to increase their exercise capacity and quality of life, as compared to the usual cardiac rehab participant, which shows that it is safe and beneficial. ³      

The goal for cardiac rehab is to “return recipients to a normal and independent life”(Passantino, et al, 2021), while improving mortality and morbidity.³ This occurred in a case discussed by Brown, et al.(2021) at Baylor University Medical Center in Dallas, Texas.² In this case, a 29-year-old woman with a congenital heart defect suffered a myocardial infarction, requiring venoarterial extracorporeal membrane oxygenation support (ECMO), a left ventricular and left atrial thrombectomy, and an aortic valve replacement. She was emergently implanted with an LVAD and discharged home to receive cardiac rehab.² Upon admission, she was intolerant to even light resistance and aerobic exercise and required frequent breaks throughout her therapy session.² Her electrocardiogram (EKG) was significant for tachycardia and frequent premature ventricular complexes at rest, as well as during exercise.² She reported symptoms of fatigue, shortness of breath, dizziness, and lightheadedness, with a rate of perceived exertion of 6 out of 10.² Brown et al. added that she frequently exhibited exercise intolerance, manifested by hypotension, nausea, and vomiting which resolved when laid supine and following the administration of fluids and certain medications.²

Nevertheless, the patient and her team persisted with an individualized treatment plan that was progressive and light to moderate in intensity.²  However, by the end of the 36 sessions of cardiac rehab, she was able to tolerate activities performed at moderate to high intensities such as jogging, boxing, weight lifting as well as more complex workouts such as battle ropes and kettlebell exercises without any rest breaks during the duration of her exercise session.²

The program was designed in hopes of returning her to previous recreational activities and so was it was based purely on symptoms and personal tolerance.³  Prior to the implementation of this regimen, her ejection fraction of 13 %  recovered to 55%, with normal filling pressures and a normal cardiac index at low LVAD resolutions/minute.² She was successfully explanted in September 2019, nine months after implantation.² In addition to her ability to return to a normal level of functioning, her functional exercise capacity (METS) improved from 3.559 at the end of the first 34 sessions to 6.315 by the beginning of her second round of cardiac rehab post LVAD explant surgery.²  

This optimistic case study calls for an aggressive, symptom-guided approach to assist our ever-growing LVAD population with their return to a proper level of functioning capacity. While the bridge to recovery is rare, the case from Baylor University demonstrates it is feasible for others who participate in cardiac rehab with LVADS to have a similar experience despite the treatment strategy (bridge to transplant, bridge to recovery, or destination therapy).²  More studies are warranted to explore the benefits of cardiac rehab in those with LVADS.² However, persistence and resilience from both the patient and care provider team, are necessary to make success stories like this one a reality in local cardiac rehab centers.

Additional Resources on Cardiac Rehab and LVAD

• Cardiac Rehab During COVID
• Cardiac Rehab Connections to Peripheral Artery Disease

References

1. Bowen, R., Graetz, T., Avidan, M. (July 2020). Statistics of heart failure and mechanical circulatory support in 2020. Annals of Translational Medicine. 8 (13).
2. Brown, K., Shirkey, H., Shock, T., Thornton, K., Rafael- Yarihuaman, A., Bindra, A. (September 2021). Impact of symptom-guided, progressive cardiac rehabilitation after left ventricular assist device implantation. Baylor University Medical Center. 35 (5).
3. Passantino, A., Vecchia, L., Corra, U., Scalvini, S., Pistono, M., Bussotti, M., Gambarin, F., Scrutinio, D., Rovere, M. (Aug 4 2021). The Future of exercise- based cardiac rehabilitation for patients with heart failure. Frontiers in Cardiac Medicine (8): 709898.
4. Abbott. Heartmate3 Left Ventricular Device: Website. Retrieved Sept 21, 2021.