Exercise Guidelines for Inpatients Following Ventricular Assist Device Placement: A Systematic Review of the Literature

Abstract

Background: For patients with end-stage heart failure awaiting transplantation, lack of donor organs has created an increased need for alternatives such as left ventricular assist device (LVAD) implantation. The purpose of this study is to determine safe and effective exercise parameters for physical therapy in the acute care setting. Methods: A systematic literature review was conducted according to PRISMA guidelines using Sackett's Levels of Evidence to rate the evidence. Multiple databases were searched with inclusion criteria of: available in English, inpatient care up to 6 months postoperatively, description of intervention type and exercise parameters. Exclusion criteria: no defined exercise parameters, outpatient treatment, infection post VAD, or palliative or hospice care post VAD. Results: Six studies out of 1,291 articles met inclusion criteria. Common exercise parameters used were the Borg Rating of Perceived Exertion scale 11-13 (6-20 scale) or > 4 (0-10 scale), Dyspnea scale > 2 (0-4 scale) and > 5 (0-10 scale), mean arterial pressure (MAP) 70-95 mmHg, and LVAD flow > 3L/min. Levels of evidence ranged from case controlled to expert opinion. Conclusion: Current evidence on inpatient exercise parameters for patient's status post LVAD implantation is not sufficient to suggest definitive guidelines; however, these exercise parameters provide a reference for patient care.

Physical Capacity in LVAD Patients: Hemodynamic Principles, Diagnostic Tools and Training Control

“…These include the system alarm, a pump flow <3 liters and hemorrhaging (e.g., nosebleeds) (50, 51). If a pulmonary comorbidity exists, oxygen saturation should additionally be measured using a pulse oximeter and the test should be aborted if values are <90% (50). Relevant counter-indications of capacity diagnosis for this special patient collective have not yet been published.…”

Exercise Performance During the First Two Years After Left Ventricular Assist Device Implantation

“…More recently, the number of patients on long-term LVAD support has been substantially growing, leading to cardiac rehabilitation (CR) programs aimed at improving the limited functional capacity and the health status and at the optimisation of life quality in this particular patient population. Studies are available concerning the effectiveness and safety of exercise training during a CR program just after LVAD implantation (10–15), however the available evidence is still not strong enough to draw conclusive guidelines for LVAD patients (16). To the authors knowledge, data are lacking in addition to these reports about the long-term exercise performance related to a second CR stay and whether this is effectively improves patients' physical performance.…”

The Rehabilitation of Patients With Advanced Heart Failure After Left Ventricular Assist Device Placement: A Narrative Review

“…There are few existing exercise guidelines for inpatient cardiac rehabilitation programs. A review by Scheiderer et al described parameters for safe and effective exercise in the inpatient setting. These include keeping the Borg Rate of Perceived Exertion score at no higher than 13/20; keeping the Borg Dyspnea Scale at no higher than 5/10; and keeping pain related to claudication at no higher than 2/4 on the Fontaine Scale.…”

“…The investigators recommended stopping therapy if the patient experiences signs and symptoms of angina, electrocardiographic changes including ST shifts no greater than 1 mm, increasing ventricular arrhythmias, decreased oxygen saturation, symptoms of orthostasis or ataxia, or significant changes in systolic blood pressure. They recommended maintaining the mean arterial pressure (MAP) at 70 to 90 mmHg and the LVAD flow above 3 L/min .…”