ICF framework in cardiac rehabilitation: a real-life implementation in post-cardiac surgery and chronic heart failure patients.

BACKGROUND: The International Classification of Functioning, Disability, and Health (ICF) is growing in importance in cardiac rehabilitation (CR) as the number of elderly comorbid patients increases. AIM: To classify through the ICF framework a group of post-cardiac surgery (CS) and chronic heart failure (CHF) patients undergoing rehabilitation. Then, to compare the two groups and identify possible factors at admission that could affect ICF evaluations at discharge. DESIGN: Observational retrospective real-life study. SETTING: Two inpatient CR units. POPULATION: Consecutive CS and CHF patients admitted for CR (January-December 2019). METHODS: Clinical, anthropometric data and functional status at admission and discharge were extracted from patient health records. A set of 26 ICF codes regarding body functions (b) and activities (d) was analyzed to identify: 1) the qualifiers attributed (from 0=no impairment to 4=severe impairment) for each code, 2) the percent distribution of qualifiers (0/1/2/3/4) attributed per patient. We then evaluated changes in both (1) and (2 - defined as ICF Delta%) from admission to discharge. RESULTS: All patients (55% males; mean age 73±12 years) showed an improvement post-rehabilitation in the ICF qualifiers attributed (P<0.0001 for all codes). CS patients (N.=150) were less functionally impaired at admission than CHF (N.=194) (P<0.05 for all codes), and at discharge showed greater Delta% in the qualifiers 0/1/2 attributed than CHF (P<0.0001 for b codes; P<0.05 for d codes). Delta% for qualifiers 3 and 4 was similar in the two groups. No impairment at admission (qualifier 0), CS group, and presence/complexity of comorbidities were identified as possible covariates influencing ICF qualifiers at discharge, impacting the rate of both no/mild impairment (ICF% aggregate 0+1 - adjusted R2=0.627; P<0.0001) and moderate impairment (ICF% qualifier 2 - adjusted R2=0.507; P<0.0001). CONCLUSIONS: CHF patients showed a worse ICF picture at admission and less improvement at discharge than CS. The presence and complexity of comorbidities negatively influenced the ICF classification at discharge, especially in CHF patients. CLINICAL REHABILITATION IMPACT: This study shows the utility of ICF classification in CR as a means for describing, measuring, and comparing patient functioning across the care continuum.

Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve replacement (TAVR): a multicenter retrospective study.

BACKGROUND: The aim of this study was to evaluate cardiac rehabilitation (CR)-derived predictors of outcome in patients discharged from rehabilitation after transcatheter aortic valve replacement (TAVR). METHODS: We retrospectively analyzed data from 232 TAVR patients (aged 82±6 years, 55% females) discharged following an average 3-week residential CR program in the period January 2009 to December 2017. Comorbidities (cumulative illness rated state-comorbidity index, CIRS-CI), echocardiography on admission, disability (Barthel Index [BI]) and functional capacity (6-min walk distance, 6MWD) at discharge, and maximal training session intensity expressed in METs/min were collected. The endpoint was all-cause mortality. RESULTS: Seventy-four (32%) deaths occurred at 3-year follow-up. At discharge, non-survivors had a higher comorbidity rate (CIRS-CI 5.2±2.3 vs. 4.1±1.9, P=0.000), higher disability level (BI 80.4±24 vs. 88.8±17, P=0.000), and worse renal function (creatinine 1.6±0.9 vs. 1.2±0.4 mg/dL, P=0.000). They were also more often on diuretics (73% vs. 53.2%, P=0.003) and beta-blocker therapy (73% vs. 57.6%, P=0.042) and had a markedly reduced functional capacity (6MWD 221±100m vs. 265±105m, P=0.001). At multivariate Cox proportional hazards regression analysis, independent predictors of survival at follow-up were lower comorbidity rate, a better-preserved renal function, lower use of diuretics, and a higher 6MWD at discharge (Harrell's C = 0.707). CONCLUSIONS: Patients attending residential CR after TAVR are very old with significant comorbidity. The overall 3-year mortality rate after CR discharge is high. Our findings suggest the need for individually tailored follow-up care in patients discharged from CR after TAVR to address their residual exercise capacity, comorbidities, and renal function impairment.

Cardiac Rehabilitation for Transcatheter Aortic Valve Replacement.

More than 300,000 patients worldwide have undergone transcatheter aortic valve replacement (TAVR) for severe aortic stenosis (AS). The rise in TAVR as a treatment option is driven in large part by evidence showing its benefits compared with medical treatment in patients with symptomatic severe AS who were too ill to undergo surgical aortic valve replacement. Cardiac rehabilitation (CR) is recommended after valvular cardiac surgery for improving exercise capacity, with data also now showing its utility to improve quality of life, moderate frailty, and increase survival. This review describes the state of the art of CR for TAVR.

Predictors of survival in patients undergoing cardiac rehabilitation after transcatheter aortic valve implantation.

AIMS: Cardiac rehabilitation may improve physical and functional recovery after transcatheter aortic valve implantation (TAVI), but outcome predictors in TAVI patients are usually based on assessments made before or at the time of TAVI without regard to cardiac rehabilitation referral. We aimed to assess exercise-based cardiac rehabilitation-derived parameters that may predict 3-year outcome in TAVI patients undergoing residential cardiac rehabilitation. METHODS AND RESULTS: In 95 consecutive TAVI patients (82.7 ±â€Š4.9 years, 65% women) who underwent a 3-week cardiac rehabilitation program, at 3-year follow-up 35 deaths occurred. Compared with survivors, nonsurvivors had longer stay in cardiac rehabilitation (29.5 ±â€Š12.3 vs. 21.6 ±â€Š7.5 days, P = 0.0001), worse serum creatinine at admission/discharge (1.59 ±â€Š0.86 vs. 1.26 ±â€Š0.43 mg/dl, P = 0.0164; 1.52 ±â€Š0.61 vs. 1.23 ±â€Š0.44 mg/dl, P = 0.011), higher Cumulative Illness Rated State Comorbidity Index (5.4 ±â€Š1.5 vs. 4.6 ±â€Š1.8, P = 0.036) and Barthel Index at admission/discharge (51.8 ±â€Š24.5 vs. 68.1 ±â€Š23.2, P = 0.0016; 73.5 ±â€Š27.2 vs. 88.6 ±â€Š15.3, P = 0.0007), higher Morse Fall Risk score (35.6 ±â€Š24 vs. 24.3 ±â€Š14.1, P = 0.0056), and were less likely to train above the median exercise workload (fit) (11 vs. 35%, P = 0.008) or perform the 6-min walk test (6MWT) at admission/discharge (NO-6MWT: 34 vs. 12%, P = 0.008) and walked less distance on admission (6MWT: 129.6 ±â€Š88.3 vs. 193.3 ±â€Š69.8 m, P = 0.008). Univariate predictors of 3-year survival were cardiac rehabilitation duration, serum creatinine, Cumulative Illness Rated State Comorbidity Index, Barthel Index and NO-6MWT at admission/discharge, 6MWT at admission, Morse Fall Risk score at discharge and fit. Multivariate analysis confirmed exercise tolerance, Barthel Index and sCr at discharge as predictors. CONCLUSION: In TAVI patients who undergo cardiac rehabilitation, lower exercise tolerance, higher Barthel Index and sCr at discharge may predict 3-year mortality.

Cardiac rehabilitation after transcatheter aortic valve implantation compared to patients after valve replacement.

AIMS: To evaluate feasibility, safety, and outcome of an exercise-based residential cardiac rehabilitation program in transcatheter aortic valve implantation (TAVI) patients compared to elderly patients after surgical valve replacement (sAVR). METHODS: From January 2010 to January 2013, 65 consecutive TAVI and 70 sAVR older than 70 years were enrolled. Six-min walk test (6MWT) distance, Barthel index, Morse Fall Scale (MFS) on admission and discharge, Cumulative Illness Rated State-Comorbidity Index (CIRS-CI), and echocardiography were assessed. Patients underwent a 3-week intensive cardiac rehabilitation program. RESULTS: Compared with sAVR, TAVI had worse CIRS-CI (4.8 ±â€Š1.5 vs. 3.4 ±â€Š1.5; P = 0.00001), left ventricle ejection fraction (55.3 ±â€Š9 vs. 59.2 ±â€Š7.7; P = 0.008), Barthel index (67 ±â€Š24 vs. 79 ±â€Š21; P = 0.0018), and MFS (36 ±â€Š22 vs. 25 ±â€Š19; P = 0.002) on admission and at discharge (Barthel index 85 ±â€Š17 vs. 93 ±â€Š14; P = 0.005 and MFS 30 ±â€Š20 vs. 20 ±â€Š12; P = 0.0001), despite a significant improvement at discharge of Barthel index (85 ±â€Š17 vs. 67 ±â€Š24; P = 0.001) and MFS (36 ±â€Š22 vs. 30 ±â€Š20; P > 0.01). TAVI attended safely cardiac rehabilitation, but tolerated a significantly lower workload and had reduced 6MWT both on admission and discharge compared with sAVR (162 ±â€Š87vs. 216 ±â€Š82; P = 0.00001, and 240 ±â€Š92 vs. 33295; P = 0.00001, respectively), despite a net improvement at discharge in 6MWT (240 ±â€Š92 vs. 162 ±â€Š92; P < 0.001). CONCLUSION: Intensive cardiac rehabilitation after TAVI is safe, well tolerated, and leads to a net improvement in disability, risk of falls, and exercise capacity, similar to that observed in less disabled sAVR patients, favoring home discharge and relatively independent life at home. A persistent higher disability, comorbidity profile, and risk of falls at discharge characterize TAVI patients compared with sAVR patients of similar age.

Prognostic value of angiopoietin-2 in patients with chronic heart failure.

PURPOSE: The analysis of biomarkers with a prognostic value in chronic heart failure (CHF) is in constant progress. This study aimed to evaluate the short-term prognostic value of angiopoietin-2 (Ang2), galectin-3 (Gal-3), myeloperoxidase (MPO), endostatin (End), and pro-brain natriuretic peptide (pro-BNP) as a conventionally accepted prognosis biomarker in CHF patients. METHODS AND RESULTS: 146 consecutive patients with CHF due to left ventricular systolic dysfunction (LVEF<40% at echocardiography) were enrolled, and underwent serum/blood sample analysis after 12-h fasting. Within 1year, 25 (17%) patients died (D) or underwent heart transplantation (HT). D+HT patients showed higher values of Ang2 (Log Ang2: 8.97±0.52 vs. 8.45±0.69, p=0.0004), myeloperoxidase (MPO) (Log MPO: 5±1.1 vs. 4.2±1.3, p=0.005) and pro-BNP (Log pro-BNP: 8.70±0.9 vs. 7.45±1.3, p<0.00001). At univariate Cox regression, pro-BNP and Ang2 were the best predictors of 1-year mortality, with area under the curve (AUC)=0.78 for pro-BNP (68% sensitivity and 82% specificity to predict outcome for a cut-off value of 5109pg/mL, 95% confidence interval [CI] 0.70-0.85, p<0.0001) and AUC=0.73 for Ang2 (84% sensitivity and 61% specificity to predict outcome for a cut-off value of 5175pg/mL, 95% CI 0.65-0.80, p<0.0001). At multivariate analysis, pro-BNP was the only predictor of one-year D/HT. CONCLUSION: In our series of CHF patients, Ang2 and pro-BNP showed the best predictive value for 1-year outcome, while only pro-BNP could independently predict D/HT.

EaRly-start ExerciSe training afTer acute hemodynAmic decompensation in patients with chRonic hearT failure (RE-START). A multicenter, randomized, controlled trial on short-term feasibility and impact on functional capacity, symptoms and neurohumoral activation .

RE-START is a multicenter, randomized, prospective, open, controlled trial aiming to evaluate the feasibility and the short- and medium-term effects of an early-start AET program on functional capacity, symptoms and neurohormonal activation in chronic heart failure (CHF) patients with recent acute hemodynamic decompensation. Study endpoints will be: 1) safety of and compliance to AET; 2) effects of AET on i) functional capacity, ii) patient-reported symptoms and iii) AET-induced changes in beta-adrenergic receptor signaling and circulating angiogenetic and inflammatory markers. Two-hundred patients, randomized 1:1 to training (TR) or control (C), will be enrolled. Inclusion criteria: 1) history of systolic CHF for at least 6 months, with ongoing acute decompensation with need of intravenous diuretic and/or vasodilator therapy; 2) proBNP > 1000 pg/mI at admission. Exclusion criteria: 1) ongoing cardiogenic shock; 2) need of intravenous inotropic therapy; 3) creatinine > 2.5 mg/dl at admission. After a 72-hour run-in period, TR will undergo the following 12-day early-start AET protocol: days 1-2: active/passive mobilization (2 sessions/day, each 30 minutes duration); days 3-4: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 5-10 minutes duration); days 5-8: as days 1-2 + unloaded bedside cycle ergometer (3 sessions/day, each 15-20 minutes duration); days 9-12: as days 1-2 + bedside cycle ergometer at 10-20 W (3 sessions/day, each 15-20 minutes duration). During the same period, C will undergo the same activity protocol as in days 1-2 for TR. All patients will undergo a 6-min WT at day 1, 6, 12 and 30 and echocardiogram, patient-reported symptoms on 7-point Likert scale and measurement of lymphocyte G protein coupled receptor kinase, VEGF, angiopoietin, TNF alfa, IL-1, IL-6 and eNOS levels at day 1, 12 and 30.

Fibrosis markers and CRIM1 increase in chronic heart failure of increasing severity.

BACKGROUND: Fibrosis suppressors/activators in chronic heart failure (CHF) is a topic of investigation. AIM: To quantify serum levels of fibrosis regulators in CHF. METHODS: ELISA tests were used to quantify fibrosis regulators, procollagen type-(PIP)I, (PIP)III, collagen-I, III, BMP1,2,3,7, SDF1α, CXCR4, fibulin 1,2,3, BMPER, CRIM1 and BAMBI in 66 CHF (NYHA class I, n = 9; II, n = 34; III n = 23), and in 14 controls. RESULTS: In CHF, TGFßR2, PIPIII, SDF1α and CRIM1 were increased. PIPIII correlated with CRIM1. CONCLUSIONS: The BMPs inhibitor CRIM1 is increased and correlates with higher levels of serum PIPIII showing an imbalance in favor of pro-fibrotic mechanisms in CHF.

How to face emergencies in heart failure patients with ventricular assist device.

Ventricular assist device (VAD) technology has rapidly evolved, and VADs are now seen as a reliable lifesaving option to support the failing heart in the short- and long-term: in some cases, VAD therapy represents a well-accepted treatment option for advanced heart failure that can obviate the need for heart transplantation. In the near future, more and more cardiologists will encounter VAD patients in their clinical practice and need to know how to handle the inherent risks associated with VAD use. The emergency care of a VAD patient differs from that of conventional practice and specific expertise is required to avoid inappropriate management that could lead to inefficient treatment and/or dangerous consequences. Here, we describe two emergency scenarios in VAD patients, two paradigmatic clinical in-hospital situations, in different settings. Following a brief overview of the role of cardiopulmonary resuscitation maneuvers in VAD patients, we propose a working algorithm that might help to ensure a timely and efficient response to acute demands in this setting.

Flow-mediated dilation normalization predicts outcome in chronic heart failure patients.

BACKGROUND: Reduced flow-mediated dilation (FMD) is a known prognostic marker in heart failure (HF), but may be influenced by the brachial artery (BA) diameter. Aiming to adjust for this influence, we normalized FMD (nFMD) by the peak shear rate (PSR) and tested its prognostic power in HF patients. METHODS AND RESULTS: BA diameter, FMD, difference in hyperemic versus rest brachial flow velocity (FVD), PSR (FVD/BA), and nFMD (FMD/PSR × 1000) were assessed in 71 HF patients. At follow-up (mean 512 days), 19 HF (27%) reached the combined endpoint (4 heart transplantations [HTs], 1 left ventricle assist device implantation [LVAD], and 14 cardiac deaths [CDs]). With multivariate Cox regression analysis, New York Heart Association functional class ≥III (hazard ratio [HR] 9.36, 95% confidence interval [CI] 2.11-41.4; P = .003), digoxin use (HR 6.36, 95% CI 2.18-18.6; P = .0010), FMD (HR 0.703, 95% CI 0.547-0.904; P = .006), PSR (HR 1.01, 95% CI 1.005-1.022; P = .001), FVD (HR 1.04, 95% CI 1.00-1.06; P = .02), and nFMD (HR 0.535, 95% CI 0.39-0.74; P = .0001) were predictors of unfavorable outcome. Receiver operating characteristic curve for nFMD showed that patients with nFMD >5 seconds had significantly better event-free survival than patients with nFMD ≤5 seconds (log-rank test: P < .0001). CONCLUSIONS: nFMD is a strong independent predictor of CD, HT, and LVAD in HF with left ventricular ejection fraction <40%. Patients with nFMD >5 seconds have a better prognosis than those with lower values.

Prognostic relevance of a non-invasive evaluation of right ventricular function and pulmonary artery pressure in patients with chronic heart failure.

AIM: To determine the prognostic relevance of the echocardiographic evaluation of pulmonary artery systolic pressure (PASP) and tricuspid annular plane systolic excursion (TAPSE) in patients with chronic heart failure (CHF). Pulmonary hypertension (PH) and right ventricular (RV) dysfunction have both been associated with poor prognosis in CHF. METHODS AND RESULTS: A complete echocardiographic examination was performed in 658 outpatients with CHF and LVEF <45%. PASP was available in 544 (83%) patients, TAPSE in all patients, and E wave deceleration time (DT) in 643 (98%) patients. During a median follow-up period of 38 months, 125 patients died, 5 underwent urgent heart transplantation, and 5 had an appropriately detected and treated episode of ventricular fibrillation. At Cox survival analysis (composite endpoint was death, urgent heart transplantation, and ventricular fibrillation), patients with PASP ≥40 mmHg plus TAPSE ≤14 mm had a poorer prognosis than those with high PASP but preserved TAPSE; RV dysfunction associated with normal PASP did not carry additional risks. Similar results were obtained when patients were grouped on the basis of DT (restrictive vs. non restrictive) and TAPSE. CONCLUSIONS: A simple echocardiographic evaluation of PASP and RV function with TAPSE may improve risk stratification in patients with CHF. Importantly, if PASP cannot be recorded at echocardiography, a restrictive DT, measurable in the vast majority of patients, may be coupled with TAPSE to stratify patients.

Cardiovascular prevention and rehabilitation for patients with ventricular assist device from exercise therapy to long-term therapy. Part I: Exercise therapy.

In the present context of an aging population, limited donor heart availability, improved reliability of mechanical cardiac support and improved patient outcomes, ventricular assist device (VAD) options to support end-stage heart failure patients are rapidly expanding. In addition, both the smaller size and lighter weight of the pumps now produced and early evidence that these third generation devices may be associated with lower risk of infection and right ventricular failure will probably lead to greater physician and patient acceptability. This is the first of a two-part review on the role of cardiovascular prevention and rehabilitation in patients with VAD. In this first part, we will discuss the role of exercise therapy in VAD patients, while the second will focus on long-term management. One of the prerequisites for use of a VAD--whether permanent (as destination therapy) or semi-permanent (as an alternative to heart transplantation)--is that exercise capacity, although not normal, must be adequate for daily life activities. An intensive multidisciplinary rehabilitation program has the potential to increase exercise performance and improve the quality of life of VAD patients. Both early progressive mobilization and exercise training may improve the overall condition of VAD patients, and favorably impact their clinical course.

Stepwise increase of angiopoietin-2 serum levels is related to haemodynamic and functional impairment in stable chronic heart failure.

BACKGROUND: A reciprocal link between inflammation, oxidative/nitrosative stress, and endothelial dysfunction has been postulated in chronic heart failure (CHF). The endothelial repair mechanisms involved remain to be determined. Our aim was to investigate whether there are detectable signs of ongoing angiogenesis in serum of CHF patients and to evaluate the correlation with indexes of haemodynamic and functional impairment. METHODS AND RESULTS: Enzyme-linked immunosorbent assay tests were used to quantify angiogenin, angiopoietin-1, angiopoietin-2, vascular endothelial growth factor, Tie-2, and brain natriuretic peptide in serum of 87 patients with CHF of increasing severity according to New York Heart Association (NYHA; class I, n = 8; II, n = 45; and III, n = 34) and in 14 healthy subjects matched for age and sex. Angiogenin, angiopoietin-2, and Tie-2 were significantly increased in CHF of increasing severity (Kruskal-Wallis: p = 0.0004, p < 0.0001, and p = 0.017, respectively). Angiopoietin-2 was inversely correlated with the 6-min walking test (r = -0.65, p < 0.0001), peak oxygen consumption (VO(2max); r = -0.57, p = 0.0002), and deceleration time (r = -0.61, p < 0.0001). Multiple regression analysis showed that angiopoietin-2 was mainly associated with VO(2max) (p = 0.018). The angiopoietin-2 area under the receiver operating characteristic curve for CHF diagnosis was 0.94 (95% CI 0.88-0.99; p < 0.001). CONCLUSIONS: These data demonstrate that angiopoietin-2 and selected serum markers of angiogenesis progressively increase with haemodynamic and functional decline in CHF.

Cardiovascular prevention and rehabilitation for patients with ventricular assist device from exercise therapy to long-term therapy. Part II: long-term therapy.

Over the years left ventricular assist devices (VADs) have become more durable and reliable, smaller, simpler, easier to implant and more comfortable. The extensive experience now acquired shows successful hospital discharge with VAD use. We are entering an era in which long-term mechanical circulatory support will play an increasing role in the approach to end-stage heart failure (HF); at the same time, the extension of VADs into destination therapy has revealed the limitations of our understanding of these populations. This second paper on cardiovascular prevention and rehabilitation for patients with left VADs will deal with the management of patients outside the highly specialized HF centers and surgical setting, with particular focus on postoperative patient management. Outpatient management of VAD patients is time-intensive, and a multidisciplinary approach is ideal in long-term care. Although the new devices have definite advantages over the older pumps, some challenges still remain, i.e. infection, stroke, device thrombosis, gastrointestinal bleeding, recurrent HF symptomatology with or without multisystem organ failure, and occurrence of ventricular arrhythmias.

Flow mediated dilation in patient with Berlin Heart Incor left ventricle assist device.

Endothelial function measured with brachial ultrasound (BU) is a validated prognostic factor in heart failure patients. LVAD (left ventricle assist device) application is a promising surgical technique to treat refractory heart failure patients both as a bridge to heart transplantation or as destination therapy. Clinical recovery in such patients may be associated to normal endothelial function measured by BU but, as recently reported, only in pulsatile flow LVAD patients. The present paper report a case of normal endothelial function even in a axial LVAD patient.

Ultrasound-guided compression repair of femoral pseudoaneurysms complicating cardiac catheterization.

BACKGROUND: Femoral pseudoaneurysms complicate cardiac catheterizations in up to 3.2% of cases. Ultrasound-guided compression repair (UGCR) is a known valid alternative therapy to surgical and percutaneous repair. We evaluated its safety and efficacy in a series of patients. METHODS: Patients with clinical findings suggesting pseudoaneurysm after cardiac catheterization, underwent echo-color and duplex studies. When a pseudoaneurysm was diagnosed, the patient underwent UGCR until closure or for 50 min. A groin compression bandage was applied after the procedure and patients were put on bed rest for 12-18 hours; a new ultrasound study was performed the day after the procedure: when the UGCR procedure failed, patients were referred to a vascular surgeon or interventional radiologist. When possible, a third ultrasound study was performed 1 month after the procedure. RESULTS: Between January 2001 and June 2003, 15 pseudoaneurysms were diagnosed and treated by means of UGCR. The UGCR procedure (UGCR followed by groin bandage) was successful in 13 cases (87%); 1 patient underwent surgical repair and 1 patient underwent percutaneous repair. No local or systemic complications were observed following UGCR. CONCLUSIONS: Pseudoaneurysm UGCR constitutes a safe and valid procedure; it is less invasive and easier to perform than percutaneous and surgical repair.