20 Exercise Training in Valvular Heart Disease

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Introduction

Exercise training is the core component of cardiac rehabilitation in patients with coronary artery disease (CAD) and the positive effects have been studied extensively (see Chapter 17).^1–5 Markedly less information is available concerning the results of exercise training in patients with valvular heart disease (VHD). This is mainly due to the fact that patients with native VHD have rarely been considered candidates for exercise training. In the guidelines on the management of patients with VHD no comments are made on this topic in patients with native VHD or after valve surgery.⁶In the new recommendation by the working group on valvular heart disease of the European Society of Cardiology suggestions for exercise training after valve surgery are outlined.⁷

As long as patients are asymptomatic or mildly symptomatic with VHD they are usually not included in medically supervised exercise training programs as part of the conservative management. Therefore experience in patients with VHD and exercise training is limited.

Recommendations for exercise training in athletes with asymptomatic VHD have been dealt with by Pelliccia et al.⁸and Bonow et al.⁹

Until recently patients came to the attention of cardiologists after development of symptoms.

At this point training was usually not an option, because symptomatic patients need valve surgery or valve interventions. Thus also in these patients little experience with exercise training is available.

In patients with asymptomatic signiﬁcant mitral stenosis, exercise training may acutely increase heart rate, particularly in patients with atrial ﬁbrillation, and thus cause symptoms acutely. Studies on chronic exercise training in these patients are not available.

In women with documented mitral valve prolapse, a 12-week aerobic exercise program improved symptoms and functional capacity.

Compared with the control group, the exercise group showed a signiﬁcant decrease in anxiety, as well as increases in general well-being, functional capacity, and a decline in symptoms such as chest pain, fatigue, dizziness, and mood swings.¹⁰Thus a supervised program may be recommended for these patients. Contraindications for exercise training are present in patients with a history of syncope, documented to be arrhythmogenic in origin, family history of sudden death associated with mitral valve prolapse, repetitive forms of sustained and non-sustained supraventricular arrhythmias, particularly if exaggerated by exercise, and severe mitral regurgitation.

In asymptomatic patients with severe aortic stenosis, careful evaluation with exercise testing is required before embarking on a training program.

Exercise training is not an option, if during exercise testing a pathological response occurs (see Chapter 16). These patients require surgery, unless contraindications exist. Whether exercise training may be helpful or harmful in aggravating left ventricular hypertrophy in these patients has not been studied.

In patients with aortic regurgitation, dynamic exercise acutely increases heart rate, which short-

20

Exercise Training in Valvular Heart Disease

Christa Gohlke-Bärwolf

156

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ens diastole and the time available for aortic regurgitation. Yet bradycardia, induced in the chronic state of exercise training, prolongs diastole and may increase aortic regurgitation, and may theoretically aggravate left ventricular dysfunction. There are no studies examining the long-term effects of endurance training in aortic regurgitation.

In patients with severe symptoms, exercise training is usually not possible or feasible prior to surgery, although one could argue that a specially designed exercise training program, similar to programs used in patients with heart failure, might be of value prior to surgery to counteract the deconditioning that is usually present at the time of operation. But studies concerning this topic are not available.

Thus medically supervised exercise training was mainly started in the postoperative or post-interventional period as part of the management after valve surgery or valve interventions.

Exercise Training in Patients after Valve Surgery

Many studies in patients after bypass surgery have demonstrated the positive effects of exercise training.^2,3,11–16There is also convincing evidence from a randomized study by Belardinelli et al.¹⁷on the positive effects of exercise training in patients after interventional revascularization (PCI) (see Chapter 17).

The known positive effects of exercise training on cardiovascular fitness, such as an improvement in general circulatory response to exercise with reduced heart rate and blood pressure, greater exercise tolerance, and attenuated progression of coronary artery disease,¹⁸make a physical training program for patients after valve replacement particularly advisable since there are still patients who present for valve surgery after years of severe restriction of physical activity. This applies espe- cially to elderly patients. Cardiorespiratory fitness is further impaired by surgical trauma, the effects of cardiopulmonary bypass, postoperative anemia, and inactivity, with the result that patients recovering from successful cardiac surgery can be in a markedly reduced state of cardiorespiratory fitness. Improving this is one of the major goals of exercise training.

The most recent developments in valve surgery with excellent results in reconstructive surgical techniques have led to recommendations to operate at an earlier stage of the disease, even in the asymptomatic state.¹⁹This applies particularly to younger patients in generally good condition, who wish to exercise and return to work early after surgery.

The effect of exercise training in patients after valve replacement has been examined in only a few studies^20–23(Table 20-1, Figure 20-1). A consis- tent increase in exercise capacity of between 25%

and 38% was demonstrated without serious risks.

In a small study in patients after mitral valve replacement, slight hemolysis occurred, without serious valve dysfunction.²²

TABLE20-1. Studies of cardiac rehabilitation following heart valve surgery Study No. of patients Outcomes in comparison to controls

Sire 1987²⁰ 44 Work capacity increased by 38% at 6 months after surgery

Habel-Verge et al. 1987²² 10 Work capacity increased by 25% after 8 weeks of exercise training

Jairath et al. 1995²³ 29 Peak VO2increased by 25%, after 3 months. There was no difference to controls, but more than 50% in the control group exercised Newell et al. 1980²¹ 24 Controlled, but non-randomized study of exercise

training revealed improvements in cardiorespiratory fitness 12 and 24 weeks after surgery in the trained group

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In a recent study by Vanhees et al.,²⁴ it was shown that patients who had valve surgery had a similar improvement after physical training as other cardiac patients (relative increase in peak VO2of 25.9% as compared to patients after bypass surgery) (Figure 20-2).

21 trained pts

o23 untrained pts + 38 %

+ 37 %

2 3 6

Months after operation 12 40

60 80 100 120 140

CW (KJ)

NS 50

40 30 20 10 0

CABG (n=347) AMI (n=767) Valve (n=69) AP (n=79) HTX (n=9) Other (n=337) PTCA (n=194)

AMI + CABG (n=307)

Change in peak oxygen uptake (%)

NS

*

Comparison of training effects for peak VO₂ (F=7.76; P<0.001) in patients with various cardiac pathologies, expressed as relative change. The Tukey test was used for post-hoc comparisons, P<0.05. Data are presented as mean ±SEM. CABG, coronary artery bypass grafting; AMI, myocardial infarction; Valve, artificial valve implantation; AP, angina pectoris; HTX, heart transplantation; PTCA, percutaneous transluminal coronary angioplasty. *Significantly different; NS, not significantly different.

Time course of TOTAL Score Total Score

before surgery

1 month 3 months 6 months 48

50 52 54 56 58 60 62 64 66

FIGURE20-3. Changes in quality of life. (From Ueshima et al.²⁵)

With exercise training improvements in quality of life were also documented in patients after valve surgery²⁵(Figure 20-3).

Complications of Exercise Training

Studies evaluating the speciﬁc determinants of complications in patients after valve surgery are not available. Yet Vanhees et al.²⁴ studied the

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predictors of complications requiring resuscitation during exercise training in 1909 patients with various cardiac diseases, including 69 patients with valvular heart disease. One resuscitation per 29,214 patient hours of exercise occurred during exercise in hospital versus 1 resuscitation per 16,533 patient hours of exercise at the local sports club during the phase III rehabilitation. The intake of anti-arrhythmics (odds ratio 5.5; CI = 1.95–15.51; P < 0.001) and the presence of sig- niﬁcant (≥1mm) ST-segment depression during baseline exercise testing (odds ratio 1.6; CI = 1.21–2.06; P < 0.001) were positively associated with severe complications requiring resuscitation.

Exercise Haemodynamics after Valve Surgery

The hemodynamic improvement after valve surgery depends on preoperative degree of impairment and the valve lesion. In patients with aortic stenosis and impaired left ventricular function preoperatively, hemodynamics improve signiﬁcantly at rest and during exercise after valve surgery. In contrast, patients after mitral valve replacement have a markedly lower exercise tolerance; only 40–60% of patients have normal hemodynamics at rest and only 25% during exercise. In patients with mitral stenosis, pulmonary capillary wedge pressure falls signiﬁcantly after surgery as well as pulmonary hypertension. The degree of pulmonary hypertension preoperatively and the speed of postoperative regression of pulmonary hypertension is of importance for further management, including exercise training.^26–28

Besides symptomatic and hemodynamic improvement, several other factors need to be taken into account to determine the type and intensity of exercise training, including the degree of regression of left ventricular hypertrophy and improvement in left ventricular function following correction of the various valve lesions.

Evaluation for Exercise Training

Prior to inclusion in an exercise program all patients should undergo an exercise test (see Chapter 16). A submaximal exercise test can be

performed after completion of early mobilization and climbing two ﬂights of stairs without symptoms, usually 2 weeks after surgery. A symptom- limited (maximal exercise) test can be performed after 3 to 4 weeks.

Aortic Valve Surgery

Patients with pure aortic stenosis and normal ventricular function, those with aortic insufﬁciency and preserved left ventricular function pre- and postoperatively and an uncomplicated postoperative course can be expected to be candidates for exercise training postoperatively. This can usually be demonstrated by submaximal exercise testing at 2 weeks and a symptom-limited maximal exercise test 4 weeks after surgery.

Mitral Valve Surgery

Patients with isolated mitral valve insufﬁciency preoperatively due to mitral valve prolapse, espe- cially if they have undergone mitral valve recon- struction, with an uncomplicated postoperative course, can be included in an exercise program early.

Patients with mitral stenosis or a combined mitral valve lesion usually have a low exercise tolerance pre- and postoperatively. In addition, the residual gradient across the valve and the marked increase in gradient with rising heart rate make an exercise program for these patients particularly challenging. Before conditioning begins, the heart rate needs to be controlled by medication, preferably beta-blockers, both at rest and during exercise. This is particularly important for patients with atrial ﬁbrillation. If possible, atrial ﬁbrillation should be converted to sinus rhythm.

A program speciﬁcally designed for these patients, including walking, callisthenics, gymnas- tics and low level bicycle ergometry with special consideration of the heart rate achieved, appears to be of particular beneﬁt. These patients could follow the training groups for heart failure patients.

Additional factors to be taken into account when making recommendations concerning exercise and recreational activity in patients following valve replacement include previous

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level of training, age, weight, and postoperative functional status assessed by exercise testing, echocardiography, and Holter monitoring for arrhythmias.

As a simple guide to determine the optimal training level, the results of the exercise test and, in some cases, the exercise hemodynamics are very useful. The level of activity or exercise that is still associated with normal hemodynamics can be taken as a guide for leisure-time activities. If hemodynamics are not available, a rating of perceived exertion such as the Borg scale²⁹ or the so-called “talk test” are valuable measurements of the intensity of exertion.

The “talk test” refers to that level of exertion at which the patient can still hold a “small talk”

conversation.

Type of Exercise

Dynamic, aerobic type of exercise like walking, jogging, and cycling is preferable to isometric exercise. However, in elderly patients who present with problems of muscle weakness, high-intensity strength training to improve muscle strength and coordination has been shown to be of beneﬁt.^30,31 Swimming is associated with an energy require- ment equivalent to 100–150 watts, as far as the response of heart rate, norepinephrine (noradren- aline), and lactate levels are concerned.³²Patients should be informed about the amount of energy expenditure associated with different types of exercise and advised about the activities suitable for them.

Recommendations

Exercise prescription should include advice on aerobic and resistance training and should specify intensity, duration, frequency, and modality.

For aerobic exercise:

• Intensity (50–80% of exercise capacity)

• Heart rate guided:<130 beats/min

• Duration 20 to 60 minutes

• Frequency 3 to 5 times/week

• Modality: walking, cycling, treadmill, stair, climbing, arm ergometry.

For resistance exercise:

• Intensity: 5 repetitions for strength training, 8–15 repetitions for endurance training

• Duration: 1–3 sets of 6–10 different upper and lower body exercise (20–30 minutes)

• Frequency 2–3 times/week

• Modality: elastic bands, cuff weights, free weights, weight machines.

Start of Training

Training can be started at low intensity (heart rate approximately <100 beats/min) after 2 weeks in patients with aortic valve replacement or mitral valve repair and normal left ventricular function. In patients with mitral valve replacement and those with impaired left ventricular function, the start of training may need to be delayed until the third week, increasing slowly thereafter. In an over-anxious or over-competitive patient, a commercially available heart rate monitor during exercise training at home can be helpful to direct the exercise intensity.

Swimming can be started when the sternal wound is completely healed and the sternum is stable (usually after 2–3 months), providing that it does not cause pain or rhythm disturbances.

Several factors inﬂuence the time interval from the operation after which an exercise training program can be started and the type of training that is possible. These factors are outlined in Table 20-2.

TABLE20-2. Factors influencing exercise recommendations after valve replacement

Age of patient Weight

Previous level of training

Type of cardiac disease and valve replaced Postoperative functional status, determined by:

clinical assessment results of exercise testing hemodynamic status

Echocardiographically determined left ventricular function and size Arrhythmias identified by Holter monitoring

Source: Modified from Gohlke-Bärwolf et al. 1992.²⁶

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Conclusion

Exercise training as part of a multidisciplinary rehabilitation program is beneficial and advisable for all patients after valve surgery. Exercise leads to improvement of functional capacity, enhanced muscular endurance, strength, and flexibility, and contributes to overall lowering of cardiovascular risk. Physical conditioning and individually tai- lored exercise training are advisable for most patients after valve replacement, taking into account left ventricular function, previous level of training, the type of valve replaced, pulmonary hypertension, and heart rate. The general circulatory responses to exercise, like decreased heart rate and blood pressure at a given exercise load, and increased exercise tolerance, are of benefit to most of these patients, and could enable them to participate more fully in social activities and live a more active and productive life. This leads to an overall improvement in the quality of life for these patients.

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