Outcomes And Data Collection
Primary outcome
Physical capacity is measured after 1 and 4 months by peak VO2 using cardiopulmonary exercise testing , and is performed in accordance with current guidelines . An ergometer bicycle is used, monitoring heart rate, blood pressure, ECG and gas exchange during workload and in the recovery period. Optimal test duration is 810 min with a pre- and post-test phase of 24 min. Gas, volume and ambient calibration are performed before each session to address changes in room temperature, humidity and air O2 content. A ramp protocol is used with initial workload of 25 or 50 watts, increasing by 12.5 watts/min gradually until exhaustion. Exhaustion is evaluated by a respiratory exchange ratio 1.10, reach of anaerobic threshold , or the patients subjective exhaustion. The peak V02 is determined after standard definitions as the highest V02 measured during the test.
The person who performs the test is either a medical doctor or a nurse with cardiology patient experience. To equally encourage patients independent of the person present, a guide has been developed by the research group, and regular supervision of each tester by a primary investigator is maintained. For safety reasons, criteria for an early test termination have been defined.
Secondary outcome
Self-assessed mental health is measured by the mental health component scale of the SF-36 at 1, 4 and 6 months.
Exploratory outcome measures
What Happens After I Leave The Hospital
It can take several weeks after valve replacement for you to feel normal again. Hopefully, youll feel much better than normal, especially if you were previously experiencing fatigue, shortness of breath, and other symptoms associated with a faulty heart valve.
Before you leave the hospital, well take plenty of time to explain what to expect during this portion of your healing process. Youll also receive specific instructions regarding your medications, physical activity, diet, and other crucial details pertaining to valve replacement.
My best medical advice for a successful outcome after heart valve replacement includes:
- Taking all medications exactly as prescribed, some of which may be new for you, such as blood thinners
- Following care instructions for surgical incisions
- Getting plenty of rest
- Participating in activities as directed, such as walking, but not overdoing
- Keeping your appointments for labs and doctor visits as scheduled, which may include diagnostic studies to access your new valves function and bloodwork to check medication levels
Even after youve recovered and are, perhaps, feeling like a new person, expect to return for periodic checks of your valve and heart health. Its important to keep these appointments so I can identify any problems early, when theyre usually easiest to treat.
What Should I Expect Immediately After Heart Valve Replacement
Most patients can expect to spend time in the intensive care unit after the procedure so that we can carefully monitor how your new valve is functioning and how your body is responding. Youll likely sleep through your ICU visit though.
You can expect to stay in the hospital for two to five days overall. During that time, well get you up and moving so you can begin to rebuild your strength. This may start with short trips to the bathroom and proceed to leisurely strolls in the hallway with a nurse or physical therapist at your side.
Ill also stop by to see how youre feeling, leave orders for your care with the hospital staff, and evaluate your progress.
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Determinants Of Valvular Heart Disease And Comorbidities
Patients with valvular disease suffer from limitation of exercise capacity and are frequently deconditioned. Especially in elder patients, daily life activities and independence are jeopardized. Following heart surgery patients are often troubled with impaired quality of life, depression, anxiety, or posttraumatic stress reactions .
Accompanying illness has a negative impact on early and late survival after surgery such as impairment of renal function as well as coronary, cerebrovascular and peripheral artery disease . The type of valve lesion that leads to surgery is also of prognostic importance: whether there is an acute destruction of the valve like in endocarditis or a chronic lesion progressing over many years like degenerative or rheumatic disease, the presence of a combined valve lesion or mere insufficiency.
Hemodynamic improvement after valve replacement depends on the extent of preoperative impairment, LV function and the specific valve lesion. Exercise capacity is dependent on ejection fraction, severity of the valve disease, pulmonary resistance, presence of cardiac arrhythmias such as atrial fibrillation and the type of valve replacement. The time to reach the maximum load capacity can range from a few weeks after uncomplicated aortic valve replacement with preserved ejection fraction up to several months, especially if the mitral valve is involved, with higher grade aortic insufficiency and depressed cardiac function .
What About Exercising After Heart Valve Surgery Asks Brent
By Adam Pick on July 9, 2014
I received a great question from Brent about exercise after heart valve surgery. In his email, Brent writes to me, Adam Im an active guy who likes to play racquetball, swim, hike, bike, golf and bowl. I was diagnosed with severe aortic stenosis and recently told I need surgery. I feel pretty darn good at 66 even though I do get winded a little easier these days. How long after surgery can I do all the things Im doing now? Is there anything I should do after surgery to help me exercise sooner than later? Thanks, Brent
To provide Brent a great answer, I contacted Dr. Rawn Salenger, a heart valve surgeon from the University of Maryland, who has a clinical interest in how patient recovery from heart surgery. So you know, Dr. Salenger is an incredibly nice guy, who has successfully operated on many patients from our community including Kathleen Ryan, Gene Bove and Jeffrey Moore.
In Dr. Salengers response to Brents question, he starts by discussing the advantages of heart valve surgery and the time needed for the sternum to heal:
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Studies On The Impact Of Rehabilitation On Mortality Exercise Capacity Quality Of Life Return To Work And Cost Effectiveness
Studies regarding cardiac rehabilitation in valve disease are scarce. Most data are derived from retrospective cohort studies or prospective but uncontrolled studies.
In a retrospective cohort study, De Vries evaluated the health insurance data of about 22% of the population in the Netherlands . The mean follow-up was 4 years with a minimum of 180 days. Cardiac rehabilitation was associated with a significant benefit on mortality for patients with bypass and/or valve surgery, with no difference seen between the single bypass surgery or a combination bypass + valve intervention . Furthermore this survival benefit was independent of age as well as type of valve surgery .
Goel published similar results in a monocentric, retrospective study with a mean follow-up of 6.8 years after rehabilitation in combined heart valve and bypass surgery. Rehabilitation was associated with a significant reduction in mortality , the effect being more pronounced in mitral valve defects . By contrast Pack in a retrospective study of the Mayo Clinic did not find any effect on survival .
In mitral valve repair patients Meurin showed that exercise testing performed 21±10 days after surgery allowed to prescribe an exercise aerobic training driven by the measured heart rate at the anaerobic threshold that improved peakVO2, peak power, peak oxygen puls and chronotropic reserve significantly .
Exercise For Seniors After Heart Surgery
This week Sheldon asks, hi, what kind of exercises can the elderly perform to improve their heart conditions after heart surgery or with PAD?
Heart disease is the leading cause of death in America and there are over 500,000 coronary bypass procedures every year. I see many seniors after open heart surgery, including bypass surgery and valve repair or replacement surgery. That is why exercise for seniors after heart surgery is so important.
It is vital, that even though you feel very weak and uninspired to do anything, you need to begin increasing your activity level right away. Slowly at first, then gradually getting back to your former self as the weeks progress. This is the best way to get started with exercise for seniors after heart surgery.
In the hospital I encourage seniors to take a walk at least 4 times per day. This is a small walk of 100 to 300 feet only. Make sure you are not pushing or pulling with any more than 5-10 pounds of force during the first 8-12 weeks after surgery. This is most important when getting in and out of bed. If it feels like you are lifting or pushing a gallon of milk, which is over 8 pounds, then you are using too much force. This is good to keep in mind with exercise for seniors after heart surgery.
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Differences In Rehabilitation Of Patients After Valve Replacement Versus Coronary Patients
The actual exercise prescription for patients with recent valve replacement or repair is the same used for CABG surgery patients . However, the physical activity of these patients may have been more restricted for an extended period of time prior to the surgical intervention. Early after valvular surgery, the spontaneous exercise capacity improvement is weak and consequently, the resulting low functional capacity may require these patients to initiate with exercise in a conservative fashion . Exercise intensities may vary according to the patient´s needs using interval training such as in heart failure patients or a steady state modus in the light or light to moderate domains and it should be supervised by the target heart rate and the rate of perceived exertion . Heart rate is often higher than after coronary artery bypass grafting because of absence of systematic betablocking therapy and higher incidences of atrial fibrillation and no formula allows the calculation of the heart rate at the anaerobic threshold, which is often used as a target during the training sessions .
Conflict of Interest
Can A Heart Valve Replacement Go Bad Because Of Extensive Exercise Asks Joe
By Adam Pick on August 14, 2012
I just received a great question from Joe about heart valve replacement durability and exercise after heart valve surgery.
In his email, Joe writes, Adam GOD Bless you for all the work youve done for people like us. You made your TEST, your Testimonial. That will never be forgotten. I just celebrated my 1 year anniversary since my aortic valve replacement performed by Dr. Craig Smith at NewYork-Presbyterian. I opted for a tissue valve bovine to be exact. Thank GOD Ive made a full recovery. I play 2-3 hours of tennis both singles and doubles 3 times a week. Im also jogging again and working out vigorously in the gym to keep myself strong and healthy to play competitive tennis. My question to you and your community is, can a replacement valve go bad because of extensive use during exercise? EDWARDS claims the valve can last 20+ years, perhaps longer. But is that projection for a sedentary individual or an athlete? Id like to know. Thanks, Joe
To provide Joe an expert opinion, I contacted his surgeon, Dr. Craig Smith.
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Causes Of Heart Valve Disease
There are a number of reasons why heart valves become insufficient or fail altogether including:
- Congenital defectscongenital is a fancy way of saying you were born with a valve abnormality.
- Disease or illness two common causes of valve disease are rheumatic fever and bacterial or viral endocarditis. The latter is frequently attributed to dental procedures where bacteria from the mouth enter the blood stream and colonise the area around the valve.
- Unknown causes in some cases, there is no identifiable cause for the valve problem.
Recovery Time From Surgery
Full recovery time after or valve surgery can last between six to eight weeks, but you may have residual pain at the chest incision site that persists a little bit longer.
Because each case is different, you should adhere to the specific guidelines provided by your surgeon, cardiologist, or other associated health care provider.
Most open-heart surgery patients are discharged from the hospital and return home between four and six days.
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Climbing Stairs And Steps
Remember that open heart surgery surgery is a trauma to your body and the combination of muscle mass loss and a cocktail of cardiac medications might make climbing stairs feel particularly tiring.
Begin with a graduated approach by starting with a single flight of stairs. If you find yourself short of breath, simply stop and rest before resuming.
As you start to regain your strength, gradually increase the number of stairs you climb and reduce breaks.
Rehabilitation Following Percutaneous Replacement Of Heart Valves And Mitral Clip Procedure
In recent years improved valve technologies with fewer complications such as permanent AV block III and paravalvular leaks have led to a 20-fold increase since 2008 with a total of 48,353 TAVI procedures that have been performed in Germany .
Several controlled studies were published regarding rehabilitation after TAVI.
Russo examined 78 TAVI and 80 patients with conventional aortic valve replacement, all of them octogenerians not differing neither in age, gender or duration of rehabilitation. Although TAVI patients had more comorbidities, rehabilitation was safe either after TAVI or surgical valve replacement with no difference in exercise capacity .
Pressler conducted a small, randomized controlled trial of 30 TAVI patients. The maximum oxygen uptake increased by 3.7 ml/min kg, as well as the muscle strength in all five major muscle groups investigated. The same was true for the sum scales of the quality of life questionnaires proving that structured strength-endurance training can be safely and effectively used even in patients with a median age of 81 years .
In a meta-analysis of 5 trials with 292 TAVI patients, the 6-minute walk test and the Barthel Index were found to improve significantly as they did after surgical aortic valve replacement .
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Is It Safe To Run A Marathon After Heart Surgery
Each week students in Professor Ian Shriers Massive Open Online Course ask questions. One questions is answered by our world expert panel on the BJSM blog. This weeks question is from a MOOC student who used to run marathons.
Q: I used to be a marathon runner currently has 2+ mitral regurgitation and had past heart surgery including tricuspid valve repair. I am not asking your medical opinion but I wonder what principles underpin a cardiologists advice to runners who have had surgery and wonder if it will ever be safe to run a marathon again? (Underscore this is an example for discussion, it is NOT medical advice for one person.
Answer by Associate Professor André La Gerche, MBBS, PhD, FRACP, FCSANZ, FESC. Sports Cardiologist, Cardiology Department, St Vincents Hospital, Melbourne, Australia in high volume exercisers or listen to him chat to Dr Michael Turner).
Note: Legal caveat. BJSM underscores that this is not patient advice but discussion of a general question.
There are many different ways a heart valve may not be working well. Each has its own particular challenges that would influence recommendations for exercise, as well as personal history of previous heart surgery and other past medical or surgery history. However, there are some basic principles that are usually followed.
First, we want to avoid any factors that may exacerbate the condition and increase the chance of needing re-do surgery. The complexity of re-do surgery is always greater.
Types Of Strength Training
Resistance bands or tubing
Resistance bands or tubing can be a great way to perform resistance exercise because its simple, easy to use, and does not require expensive equipment.
Resistance machines
Resistance machines found in gyms work your muscles but keep your body within a safe guided range of motion.
Free weights
Free weights include dumbbells and barbells and require you to balance and stabilize the weights through the range of motion. If youre a new exerciser, it may be advisable to hire a trainer to help you with correct technique.
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Exercise After Cardiac Surgery
For six to eight weeks:
- DO NOT LIFT, PUSH, OR PULL objects heavier than 10 pounds .
- Avoid trunk twisting.
- Use the incentive spirometer four to five times a day.
- Each session, do 10 slow, deep breaths. Be sure to relax your shoulders.
- Take your time between breaths.
- Placing your hands over your chest incision, perform two or three strong coughs.
- BMC also offers Breathing Exercise classes.
Mobility and Flexibility Exercises
- Do these exercises before and after walking.
- Do not hold your breath .
- Do 10 repetitions of each exercise two times a day.
Walking Program
- For the next four to six weeks before starting cardiac rehabilitation, you will be doing a walking program twice a day.
- Measure walking in terms of time not distance .
- If you have chest pain, shortness of breath, lightheadedness, or palpitations, STOP YOUR ACTIVITY!
Helpful hints about walking
- Wear comfortable clothing and shoes.
- Wait at least one hour after meals to do your exercise and walking program.
- Avoid hilly areas and excessive stair climbing. Pace yourself when climbing stairs.
- Exercising in cold and windy or hot and humid weather puts stress on your heart. If temperatures outside are below 40 degrees or above 75 degrees, then exercise indoors.
- Riding a stationary bike or walking on a treadmill is an acceptable alternative to walking.
Cardiac Rehabilitation
Cardiac Rehabilitation consists of:
Rest
What Is Open Heart Surgery
Open heart surgery can take the form of a coronary artery bypass graft procedure to reestablish blood flow in blocked arteries , and/or heart valve surgery to repair or replace a faulty valve.
In the case of coronary artery disease, surgery may be indicated when blockages are too widespread for angioplasty and stenting or if a blood vessel is too difficult or risky to access with a coronary catheter.
Mitral and/or aortic valve repair or replacement are also common open heart surgery procedures and may stem from a case of childhood rheumatic fever, or perhaps valve damage associated with viral or bacterial endocarditis.
Other reasons for open heart surgery may stem from a congenital heart condition or a heart transplant in those with advanced heart failure.
No matter what the reason for your surgery, the recovery time and subsequent exercise prescription are quite similar.
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