Evolution of Early Postoperative Cardiac Rehabilitation in Patients with Acute Type A Aortic Dissection.

INTRODUCTION: Surgically treated acute type A aortic dissection (ATAAD) patients are often restricted from physical exercise due to a lack of knowledge about safe blood pressure (BP) ranges. The aim of this study was to describe the evolution of early postoperative cardiac rehabilitation (CR) for patients with ATAAD. METHODS: This is a retrospective study of 73 patients with ATAAD who were referred to the CR department after surgery. An incremental symptom-limited exercise stress test (ExT) on a cyclo-ergometer was performed before and after CR, which included continuous training and segmental muscle strengthening (five sessions/week). Systolic and diastolic blood pressure (SBP and DBP) were monitored before and after all exercise sessions. RESULTS: The patients (78.1% male; 62.2 ± 12.7 years old; 54.8% hypertensive) started CR 26.2 ± 17.3 days after surgery. During 30.4 ±11.6 days, they underwent 14.5 ± 4.7 sessions of endurance cycling training, and 11.8 ± 4.3 sessions of segmental muscle strengthening. At the end of CR, the gain of workload during endurance training and functional capacity during ExT were 19.6 ± 10.2 watts and 1.2 ± 0.6 METs, respectively. The maximal BP reached during endurance training was 143 ± 14/88 ± 14 mmHg. The heart rate (HR) reserve improved from 20.2 ± 13.9 bpm to 33.2 ± 16.8 bpm while the resting HR decreased from 86.1 ± 17.4 bpm to 76.4 ± 13.3 bpm. CONCLUSION: Early post-operative exercise-based CR is feasible and safe in patients with surgically treated ATAAD. The CR effect is remarkable, but it requires a close BP monitoring and supervision by a cardiologist and physical therapist during training.

Responses to exercise training in patients with heart failure. Analysis by oxygen transport steps.

BACKGROUND: Exercise training (ET) increases exercise tolerance, improves quality of life and likely the prognosis in heart failure patients with reduced ejection fraction (HFrEF). However, some patients do not improve, whereas exercise training response is still poorly understood. Measurement of cardiac output during cardiopulmonary exercise test might allow ET response assessment according to the different steps of oxygen transport. METHODS: Fifty-three patients with HFrEF (24 with ischemic cardiomyopathy (ICM) and 29 with dilated cardiomyopathy (DCM) had an aerobic ET. Before and after ET program, peak oxygen consumption (VO2peak) and cardiac output using thoracic impedancemetry were measured. Oxygen convection (QO2peak) and diffusion (DO2) were calculated using Fick's principle and Fick's simplified law. Patients were considered as responders if the gain was superior to 10%. RESULTS: We found 55% VO2peak responders, 62% QO2peak responders and 56% DO2 responders. Four patients did not have any response. None baseline predictive factor for VO2peak response was found. QO2peak response was related to exercise stroke volume (r = 0.84), cardiac power (r = 0.83) and systemic vascular resistance (SVRpeak) (r = -0.42) responses. Cardiac power response was higher in patients with ICM than in those with DCM (p < 0.05). Predictors of QO2peak response were low baseline exercise stroke volume and ICM etiology. Predictors of DO2 response were higher baseline blood creatinine and prolonged training. CONCLUSION: The analysis of the response to training in patients with HFrEF according to the different steps of oxygen transport revealed different phenotypes on VO2peak responses, namely responses in either oxygen convection and/or diffusion.

Cardiac rehabilitation in patients with pacemakers and implantable cardioverter defibrillators.

Large subsets of patients admitted in cardiac rehabilitation centers are having a pacemaker, cardiac resynchronization (CRT) or implantable cardiac defibrillator (ICD). Cardiac rehabilitation for patients, mostly with heart failure, with implanted electronic devices as pacemakers or ICD is a unique opportunity not only to optimize the medical treatment, to increase their exercise capacity and improves their clinical condition but also to supervise the correct functioning of the device. CRT reduces clinical symptoms and increases slightly the exercise capacity. But in these patients, the clinical improvements are likely to be explained by both the enhancement of cardiac function induced by the device and by the improved peripheral (muscular and vascular) and cardiac effects of exercise. The additional expected gain by exercise in this population is between 14 to 25%. In patients implanted with an ICD, exercise training is safe, without increasing shocks or anti-tachycardia pacing therapy. The comprehensive cardiac rehabilitation combining exercise training and a psycho-educational intervention improves exercise capacity, quality of life, general and mental health. Nevertheless, further large scale studies was needed to evaluate the most appropriate management and demonstrate definitively the role of cardiac rehabilitation in this particular group of patients.

La anemia influye en la capacidad de ejercicio sin comprometer el beneficio de la rehabilitación cardíaca en pacientes con insuficiencia cardíaca / Anemia affects exercise capacity without compromising the benefits of cardiac rehabilitation in patients with heart failure / Anemia afeta a capacidade de exercício, sem comprometer os benefícios da reabilitação cardíaca em pacientes com insuficiência cardíaca

Introducción. La anemia en los pacientes con insuficiencia cardíaca (IC) crónica es un factor predictivo independiente de mortalidad y su prevalencia aumenta con la severidad de la IC. Objetivo. Evaluar en forma prospectiva el impacto de los valores de hemoglobina (Hb) sobre la capacidad de ejercicio basal y los resultados del reentrenamiento físico en pacientes con disfunción sistólica de ventrículo izquierdo. Material y métodos. Se incluyeron 246 pacientes con IC de diferentes etiologías con una edad media de 56 ± 12 años con una fracción de eyección <40%. Se consideraron anémicos todos los pacientes de sexo masculinos con una Hb <13 g/L y menor a <12g/L en las mujeres. Todos los pacientes realizaron un programa de entrenamiento físico en cicloergómetro con una media de 20 sesiones. Resultados. El 55,7% de los pacientes era anémico. Las tasas de Hb no difirieron antes ni después del programa de rehabilitación en ninguno de los dos grupos. La presencia de la anemia influyó de manera negativa en la capacidad de esfuerzo medida por la duración del esfuerzo (5,08 ± 2,4 vs 5,9 ± 2,9 minutos; p=0,001), la carga máxima (68,3 ± 22,8 vs 80,2 ± 27,7 watts; p=0,0005) o el pico de consumo de oxígeno (14,9 ± 4,4 vs 16,9 ± 5,4 ml/kg/min; p=0,0001). El porcentaje de ganancia de capacidad de esfuerzo por entrenamiento es comparable en los dos grupos: 20,1± 22,1% y 18,9 ± 22,8%. Conclusión. En pacientes con IC, la anemia es responsable de modificaciones metabólicas, bioquímicas y funcionales que conducen a un agravamiento de la disfunción ventricular izquierda, a una reducción de las capacidades físicas y consecuentemente a un empeoramiento de la calidad de vida. Sin embargo, los beneficios obtenidos por la rehabilitación son similares en pacientes anémicos y no anémicos.

Introduction. Anemia in chronic heart failure (HF) patients is an independent predictor of mortality and its prevalence increases with the severity of HF. Objectives. Prospectively assess the impact of hemoglobin (Hb) levels on the baseline exercise capacity and physical retraining results in patients with left ventricular systolic dysfunction. Methods and material. We included 246 patients with heart failure of different etiologies with a mean age 56 ± 12 years with an ejection fraction <40%. All were considered anemic male patients with Hb <13 g/L and less than <12 g/L in women. All patients underwent a physical training program in cycloergometer with an average of 20 sessions. Results. The 55.7% of patients was anemic. Hb rates did not differ before or after the rehabilitation program in any of the two groups. The presence of anemia negatively influenced in exercise capacity measured by the exercise duration (5.08 ± 2.4 vs 5.9 ± 2.9 minutes, P=0.001), maximum load (68.3 ± 22.8 vs 80.2 ± 27.7 watts, p=0.0005) or peak oxygen consumption (14.9 ± 4.4 vs 16.9 ± 5.4 ml/kg/min, P=0.0001). The percentage gain in exercise capacity by training is comparable in both groups: 20.1 ± 22.1% and 18.9 ± 22.8%. Conclusion. In patients with HF, anemia is responsible for metabolic, biochemical, and functional modifications, leading to a worsening of left ventricular dysfunction, a reduction of physical capacities and consequently deterioration in the quality of life. However, the rehabilitation benefits are similar in anemic and non anemic patients.

Introdução. A Anemia em pacientes com insuficiência cardíaca (IC) crônica é um preditor independente de mortalidade e sua prevalência aumenta com a gravidade da IC. Objetivos. Prospectivamente avaliar o impacto dos níveis de hemoglobina (Hb) na capacidade de exercício de referência e resultados de reciclagem física em pacientes com disfunção sistólica ventricular esquerda. Material e métodos. Foram incluídos 246 pacientes com insuficiência cardíaca de diferentes etiologias, com idade média de 56 ± 12 anos, com fração de ejeção <40%. Foram considerados anêmicos todos os pacientes do sexo masculino com uma Hb <13 g/L, e menos de <12 g/L em mulheres. Todos os pacientes foram submetidos a um programa de treinamento físico em cicloergômetro com uma média de 20 sessões. Resultados. O 55,7% dos pacientes estava anêmico. As taxas de Hb não diferiram antes ou depois do programa de reabilitação em qualquer um dos dois grupos. A presença de anemia afeta negativamente na capacidade de exercício medida pela duração do esforço (5,08 ± 2,4 vs 5,9 ± 2,9 minutos, P=0,001) de carga, máxima (68,3 ± 22,8 vs 80,2 ± 27,7 watts, p=0,0005) ou pico de consumo de oxigênio (14,9 ± 4,4 vs 16,9 ± 5,4 ml/kg/min, P=0,0001). O ganho percentual da capacidade de exercício de treinamento é comparável em ambos os grupos: 20,1 ± 22,1% e 18,9 ± 22,8%. Conclusão. Em pacientes com insuficiência cardíaca, a anemia é responsável por alterações metabólicas, bioquímicas e funcionais, levando a um agravamento da disfunção ventricular esquerda, uma redução de capacidades físicas e, conseqüentemente, a um declínio na qualidade de vida. No entanto, os benefícios de reabilitação são semelhantes em anêmicos e não anêmicos.

Nonsteroidal anti-inflammatory drug treatment for postoperative pericardial effusion: a multicenter randomized, double-blind trial.

BACKGROUND: The incidence of asymptomatic pericardial effusion is high after cardiac surgery. Nonsteroidal anti-inflammatory drugs (NSAIDs) are widely prescribed in this setting, but no study has assessed their efficacy. OBJECTIVE: To assess whether the NSAID diclofenac is effective in reducing postoperative pericardial effusion volume. DESIGN: Multicenter randomized, double-blind, placebo-controlled study. (Clinical trials.gov registration number: NCT00247052) SETTING: 5 postoperative cardiac rehabilitation centers. PATIENTS: 196 patients at high risk for tamponade because of moderate to large persistent pericardial effusion (grade 2, 3, or 4 on a scale of 0 to 4, as measured by echocardiography) more than 7 days after cardiac surgery. INTERVENTION: Random assignment at each site in blocks of 4 to diclofenac, 50 mg, or placebo twice daily for 14 days. MEASUREMENTS: The main end point was change in effusion grade after 14 days of treatment. Secondary end points included frequency of late cardiac tamponade. RESULTS: The initial mean pericardial effusion grade was 2.58 (SD, 0.73) for the placebo group and 2.75 (SD, 0.81) for the diclofenac group. The 2 groups showed similar mean decreases from baseline after treatment (-1.08 grades [SD, 1.20] for the placebo group vs. -1.36 (SD, 1.25) for the diclofenac group). The mean difference between groups was -0.28 grade (95% CI, -0.63 to 0.06 grade; P = 0.105). Eleven cases of late cardiac tamponade occurred in the placebo group and 9 in the diclofenac group (P = 0.64). These differences persisted after adjustment for grade of pericardial effusion at baseline, treatment site, and type of surgery. LIMITATION: The sample was not large enough to find small beneficial effects of diclofenac or assess the cardiovascular tolerance of diclofenac. CONCLUSION: In patients with pericardial effusion after cardiac surgery, diclofenac neither reduced the size of the effusions nor prevented late cardiac tamponade. PRIMARY FUNDING SOURCE: French Society of Cardiology.

Thromboembolic events early after mitral valve repair: incidence and predictive factors.

BACKGROUND AND OBJECTIVES: The incidence of thromboembolic events (TE) in the early period following mitral valve repair (MV repair) is poorly documented. The aim of this prospective study was to evaluate it, and to determine predictive factors. METHODS AND RESULTS: In this prospective multicenter non-randomized study, 350 consecutive patients were included after MV repair and monitored until post-operative day 44+/-6. 65.7% received Vitamin K antagonists (VKA), 18.8% aspirin (ASA), 5.4% ASA+VKA and 10% received no antithrombotic therapy (AT). All patients with AF received VKA or VKA+ASA. Twelve patients had a cerebral TE during follow-up:14.3% among untreated patients, 3.0% in the VKA group, and 0% in the ASA and in the ASA+VKA groups (p=0.03 for comparison no AT group versus the three other combined groups; p=NS for VKA versus ASA). In univariate analysis, only the absence of post-operative AT was related to the risk of TE (HR=6.7, CI 95%[2.1-21], p=0.0002). In a prespecified subgroup (n=185) of patients with sinus rhythm and without concomitant cardiac surgery (in which the choice of AT is not influenced by these associate conditions), only the absence of post-operative AT remained related to the risk of TE (HR=10.0, CI 95%[2.45-40], p=0.001). CONCLUSION: In the first six weeks following MV repair, the incidence of thromboembolic events is far from negligible (3.5%), even in patients with sinus rhythm. The main predictive factor for thromboembolic event determined in this study is the absence of an antithrombotic therapy.

Early exercise training after mitral valve repair: a multicentric prospective French study.

BACKGROUND: Surgical mitral valve (MV) repair is now the best technique to correct mitral regurgitation (MR). However, clinical studies have shown that without exercise training (ET), there is no significant postoperative exercise tolerance improvement. Moreover, healing duration of the MV wound is not well known; thus, the feasibility of an early ET program (ETP) may be discussed. OBJECTIVES: To evaluate safety and feasibility of an early ETP after MV repair. METHODS AND RESULTS: All patients hospitalized in 13 postoperative centers after MV repair from September 2002 to June 2003 were included in this prospective study. They underwent an ETP during 3 weeks on average. Transthoracic echocardiography and a cardiopulmonary exercise test were performed before and after the ETP. PATIENTS: Two hundred fifty-one consecutive patients (male gender, 70%; mean age, 59 +/- 14 years [+/- SD]) were included 16 +/- 10 days after MV repair. There was no MR occurrence or worsening after the ETP. Left ventricular ejection fraction slightly increased (53 +/- 10% vs 55 +/- 9%, p = 0.004). Peak oxygen consumption and anaerobic threshold increased from 16.3 +/- 4.5 to 20.0 +/- 6.0 mL/kg/min (22% increase) and from 12.2 +/- 3.8 to 14.2 +/- 4.3 mL/kg/min (16% increase) respectively, (p < 0.0001). CONCLUSION: ET after MV repair does not deteriorate the outcome of recent surgery and seems efficient.

Impact of time to treatment on mortality after prehospital fibrinolysis or primary angioplasty: data from the CAPTIM randomized clinical trial.

BACKGROUND: CAPTIM was a randomized trial comparing prehospital thrombolysis with transfer to an interventional facility (and, if needed, percutaneous intervention) with primary percutaneous coronary intervention (PCI) in patients with ST-segment-elevation myocardial infarction (STEMI). Because the benefit of thrombolysis is maximal during the first 2 hours after symptom onset, and because prehospital thrombolysis can be implemented earlier than PCI, this analysis studied the relationship between the effect of assigned treatment and the time elapsed from symptom onset. METHODS AND RESULTS: Randomization within 2 hours (n=460) or > or =2 hours (n=374) after symptom onset had no impact on the effect of treatment on the 30-day combined primary end point of death, nonfatal reinfarction, and disabling stroke. However, patients randomized <2 hours after symptom onset had a strong trend toward lower 30-day mortality with prehospital thrombolysis compared with those randomized to primary PCI (2.2% versus 5.7%, P=0.058), whereas mortality was similar in patients randomized > or =2 hours (5.9% versus 3.7%, P=0.47). There was a significant interaction between treatment effect and delay with respect to 30-day mortality (hazard ratio 4.19, 95% CI 1.033 to 17.004, P=0.045). Among patients randomized in the first 2 hours, cardiogenic shock was less frequent with lytic therapy than with primary PCI (1.3% versus 5.3%, P=0.032), whereas rates were similar in patients randomized later. CONCLUSIONS: Time from symptom onset should be considered when one selects reperfusion therapy in STEMI. Prehospital thrombolysis may be preferable to primary PCI for patients treated within the first 2 hours after symptom onset.