Left Ventricular Assist Device and Exercise

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1 Left Ventricular Assist Device and Exercise Marie Christine Iliou Réadaptation cardiaque et prévention secondaire Hôpital Corentin Celton- HUPO Issy les Moulineaux

Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux

rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two

with a commercial company : Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock

2 Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship Grant/Research Support Consulting Fees/Honoraria Major Stock Shareholder/Equity Royalty Income Ownership/Founder Intellectual Property Rights Other Financial Benefit Company ResMed Servier, Astra Zenezca None None None None None

3 Indications Trochu JN. Arch Cardiovasc Dis 2012;105:114-21

4 Left Ventricular Assist Devices Bridge or Destination therapy

5 Cardio-vascular adaptations to exercise Healthy HF LVAD HR Chronotropic insufficiency Chronotropic insufficiency Preload preload and filling pressure preload and filling pressure Afterload Contractility Impaired depending on LV function Systemic vasc resist Cardiac Output Inability to But not normal

6 Other adaptations to exercise Respiratory rate VE Healthy HF LVAD Improvements in ventilatory efficiency and respiratory strengh Muscular fibers Use type I fibers > II Atrophy, wasting Switch type I-> II mitochondrial density unknown Endothelium and muscle flow Endothelial dysfunction oxygen diffusion to muscle Improvement of endoth function and muscle flow. But peripheral vascular function is compromised by the no-pulsatility Sympathetic function with para withdrawal Overstimulation Improvement of baroreflex activity (at rest)

7 Physiology exercise with LVAD Loyaga-Rendon R. J Heart Lung Transplant 2015;34:

8 Physiology exercise with LVAD Opening Ao valve % VO2 without increase in CO Loyaga-Rendon R. J Heart Lung Transplant 2015;34:

9 Factors of exercise intolerance in LVAD pts Type of LVAD (PF vs CF): Speed in CF LVAD: Native contractility: Time after implantation: RV dysfunction: Pulmonary function: Peripheral factors: Minimal or no effect on peak VO2 Low increase peak VO2 due to increased O 2 extraction Important contribution to excercise capacity Maximal improvements on peak VO2 at 3 months Studies suggest that RV function may be not limiting ex capacity, but require further evaluation Continued impairements in respiratory muscles and ventilationperfusion coupling are more important limitation than pulmonary vasc resistance Limited investigations have focused on musculo-skeletal function, anemia, and endothelial dysfunction Loyaga-Rendon R. J Heart Lung Transplant 2015;34:

10 Exercise capacity HF vs LVAD Mancini D, Circulation 1998;98:1178

11 Exercise capacity with LVAD Author n Findings Burrell (2015) 48 Invasive exercise hemodynamic testing : - Exercise is associated with a modest increase device output and rapid Pcwp - Progressive aortic regurgitation is associated with limited ex capacity Kerrigan (2015) 24 % HR reserve is a good predictor of % VO2 reserve in non paced patients (in these RPE is a suitable surrogate measure) Benton (2015) 37 Peak VO2 at 6 months reached 14,7 ml/kg/min (51 % of predicted)

12 Long term effects 67 patients LVEF LV EDD Maybaum S. Circulation 2007;115:

13 Symptoms LV Dysfunction Peripheral modifications

Heart Failure Class Level LVEF < 40 % - Global management - Long term programmes I A - Patient Education - Treatment adjustements Preserved LVEF - Improvement of QOL - Reduction of hospitalisations

14 Heart Failure Class Level LVEF < 40 % - Global management - Long term programmes I A - Patient Education - Treatment adjustements Preserved LVEF - Improvement of QOL - Reduction of hospitalisations II b C CRT - mamimize effects of CRT - Evaluation of resynchronization I B LVAD - Physical reconditionning - Patient Education : device and anticoagulants IIa C Transplantation - Pre-transplantation - Specific after surgery, physiology and immunology I B - Psycho-social support

15 Exercise training in LVAD 15 patients (10 ExT et 5 Control), 37 ± 17 years Training : home-based bike or treadmill 45 min (Borg 12-14), 3 à 5/week + inspiratory muscle trainin 2-3/week 10 weeks + 15 % Laoutaris I. Eur J Cardiovasc Prev Rehab 2011;18:33-40

16 Ex Training Control Ex Training group Peak VO % * VT % * VE/VCO2-10 % * 6 WT + 14 % * Pi max (insp P 1 ) + 38 %* Spi max (insp P max) + 42 % *

Exercise training Study year n age type duration Peak VO 2 Training Laoutaris 2011 10/5 40 LVAD, BiVAD 10 weeks + 15 % 45, 3-5/week endurance + Insp muscle Hayes

nutrition Compostella 2013 26 63 Jarvik, Berlin 2 weeks Id IC 6 /week Endurance, gym, respiratory T Kaparolat 2013 11 45 Berlin, HM II 8 weeks + 3 % 90 3/sem

17 Exercise training Study year n age type duration Peak VO 2 Training Laoutaris /5 40 LVAD, BiVAD 10 weeks + 15 % 45, 3-5/week endurance + Insp muscle Hayes /7 46 VentrAssist 8 weeks + 29 % 60 3/week Continuous T + resistance Kugler /36 52 HeartMate II, Heartware 18 months + 13 % Home + psychosocial + nutrition Compostella Jarvik, Berlin 2 weeks Id IC 6 /week Endurance, gym, respiratory T Kaparolat Berlin, HM II 8 weeks + 3 % 90 3/sem Endurance, gym, respiratory T Alsara HM II, VA, DuraHeart 1 week Autonomy scores improvement Marko LVAD 4,5 weeks + 28 % Endurance, walking, strenght

18 Predictors of weaning from LVAD?? CPET, a tool for myocardial recovery prediction?? Peak VO2 indepent of the pump speed can be used as an indicator for myocardial recovery (30 patients : 20 explanted vs 10 transplanted, Noor) sbp response to exercise (reach > 120 mmhg) provides sufficient CV reserve to tolerate weaning (106 pts, 38 explanted, Fukumitsu) Recently a novel scoring (33 pts pulsatile, 45 continuous flow) RV function? Imamura T. Circ J 2015;79: 560-6

73 % Nurses, psychologists 22 % Cardiologist specilaized in CR 22 % Training programs Endurance

19 Exercise training for LVAD in Europe 77 LVAD implanting centers : 45 have Ex T program 71 % early post-discharge, 24 % offer a long-term maintenance program Professionals Physiotherapists 73 % Nurses, psychologists 22 % Cardiologist specilaized in CR 22 % Training programs Endurance : 84 % Resistance : 47 % Respiratory muscle training : 55 % Ben Gal T, Int J Cardiol 2015;201:215-19

20 French registry (preliminary results) 7 centers 66 patients (54 males), 56 ± 11 years CR referral : 100 days (21-553) post VAD implant Indications : 65.5 % ischemic CM, 22.3 % DCM 72 % had CPx Exercise training : 24 sessions as mean No adverse event Kubas S on behalf to GERS

21 TAH vs LVAD Kholi H. J Heart Lung Transplant 2011;30:

2 ml/kg/min, ml/kg/min, 80 80 watts watts VT1 SV1 = 9.2 9.

22 Total Artificial Heart Mr P S, 50 years ans 71 kg 1m70 Peak Pic VO2 VO2 = = ml/kg/min, ml/kg/min, watts watts VT1 SV1 = ml/kg/min, watts Peak VO2 = 16.3 ml/kg/min, 90 watts VT1 = 12.9 ml/kg/min, 50 watts

05 Peak VO2 max (ml/kg/mn) 12.6 ± 3.2 16.7 ± 4.9 <0.05 VT1 (ml/kg/mn) 10 ± 3.4 13.4 ± 4 <0.

23 Preliminary results in the «true life» 23 patients 17 men, mean age 52 years CR 71 ± 32 days after implantation 35 Ex T sessions : endurance and resistance CPET workload (watts) 52.7 ± ± 20 <0.05 Peak VO2 max (ml/kg/mn) 12.6 ± ± 4.9 <0.05 VT1 (ml/kg/mn) 10 ± ± 4 < % VE/VCO2 slope 45.5 ± 9 43 ± 8 NS 6 walking test distance(m) ± ± 90 <0.05 Iliou MC, unpublished

24 Conclusions LVAD implantation improves the exercise capacity of HF patients This improvement is limited and related with device functioning, native left and right ventricular contractility, pulmonary, muscular, vessels and nerve systems abnormalities Exercise training is these patients means a great deal for all the LVAD patients and much more for the bridge indications.

Cardiac Rehabilitation and Electromyostimulation

CREMS-HF Cardiac Rehabilitation and Electromyostimulation Dr Marie Christine Iliou Dr Bénédicte Vergès CREMS-HF study GERS SFC Déclaration de Relations Professionnelles Disclosure Statement of Financial