Supervised Exercise Training in Patients with Chronic Thromboembolic Pulmonary Hypertension as Early Follow-Up Treatment after Pulmonary Endarterectomy: A Prospective Cohort Study

Abstract

Background: Data on exercise training in chronic thromboembolic pulmonary hypertension (CTEPH) after pulmonary endarterectomy (PEA) as well as data on clinical and haemodynamic changes shortly after PEA are lacking. Objective: The objective of this prospective study was to analyse the safety, feasibility, and the effectiveness of combined supervised inpatient rehabilitation in patients with CTEPH directly after PEA. Methods: CTEPH patients started a 19-week rehabilitation program (3 weeks as inpatients and continued at home for another 16 weeks) with supervised exercise training as follow-up treatment shortly after PEA. Haemodynamics were assessed by right heart catheterisation before PEA and 22 weeks after PEA. Non-invasive assessments as trans-thoracic echocardiography and 6-min walking distance (6MWD) were performed before PEA and after 3 (that is, beginning of rehabilitation), 6, and 22 weeks following PEA. Adverse events were recorded throughout the study. Results: Forty-five CTEPH patients were included (49% female, 57.6 ± 12.4 years old, 60% WHO functional class III). Rehabilitation was started 3.3 ± 0.9 weeks after PEA. Exercise training was well tolerated in all patients without severe side effects. Haemodynamics measured by right heart catheterisation significantly improved from pre-PEA to 22 weeks post-PEA in cardiac output (+1.2 ± 1.5 L/min, 33.4%, p = 0.001) and mean pulmonary arterial pressure (-19 ± 13 mm Hg,-39.6%, p < 0.0001). Right heart size measured by echocardiography, 6MWD, quality of life, and oxygen saturation significantly improved not only within the first 3 weeks after PEA but also during the following 19 weeks of exercise training. Conclusions: Supervised exercise training was feasible as early follow-up treatment after PEA. Further controlled studies are needed to discriminate the effects of PEA and early followup rehabilitation. Trial Registration: The study was regis-Nagel et al.

Comparative Effectiveness of Exercise Training for Patients With Chronic Thromboembolic Pulmonary Hypertension After Pulmonary Endarterectomy: A Systematic Review and Meta-Analysis

“…We retrieved 73 articles for more detailed analysis after 68 initial articles were identified by the search and included 4 studies in our systematic review (Figure 1). There were four prepost interventional studies, encompassing 208 exercise-training participants between 2012 and 2020 (17,(21)(22)(23). All studies used a supervised exercise training programme combined with aerobic exercise (treadmill or bicycle Ergometer) and resistance training.…”

“…Exercise training has improved the exercise capacity for up to 3 months in patients with CTEPH after PEA, independent of the post-surgery hemodynamic response (17,(21)(22)(23). However, the evidence of the effect of exercise training on patients with CTEPH after PEA is limited.…”

Early Pulmonary Rehabilitation after Pulmonary Endarterectomy: Both Safe and Effective?

“…For a long time in the past, intense physical activity has been discouraged for patients with pulmonary hypertension (PH) due to the risk of worsening of the disease; nevertheless, during the last decade, exercise training has been shown to improve exercise capacity, quality of life, and possibly pulmonary hemodynamics among patients with PH [2], although confirmatory studies are still needed. Under this scope, the study of Nagel et al [1] adds further interesting data to this field.…”

“…We read with great interest the study of Nagel et al [1] regarding pulmonary rehabilitation (PR) as an early follow-up treatment after pulmonary endarterectomy (PEA). For a long time in the past, intense physical activity has been discouraged for patients with pulmonary hypertension (PH) due to the risk of worsening of the disease; nevertheless, during the last decade, exercise training has been shown to improve exercise capacity, quality of life, and possibly pulmonary hemodynamics among patients with PH [2], although confirmatory studies are still needed.…”

“…In the study of Nagel et al [1], patients with residual PH received the same PR program and were not analyzed as a separate group. However, changes in exercise capacity and hemodynamics with time are different in these patients [4], while long-term outcomes are worse [5].…”