Exercise training improves exercise capacity and quality of life after transcatheter aortic valve implantation: A randomized pilot trial

doi:10.1016/j.ahj.2016.08.007

American Heart Journal

Volume 182, December 2016, Pages 44-53

https://doi.org/10.1016/j.ahj.2016.08.007 Get rights and content

Background

Transcatheter aortic valve implantation (TAVI) is increasingly applied for aortic stenosis in elderly patients with impaired mobility and reduced quality of life. These patients may particularly benefit from postinterventional exercise programs, but no randomized study has evaluated the safety and efficacy of exercise in this population.

Methods

In a prospective pilot study, 30 patients after TAVI (mean age, 81 ± 6 years, 44% female, 83 ± 34 days postintervention) were randomly allocated 1:1 to a training group (TG) performing 8 weeks of supervised combined endurance and resistance exercise or to usual care. The formal primary efficacy end point was between-group difference in change in peak oxygen uptake assessed by cardiopulmonary exercise testing; secondary end points included muscular strength, 6-minute walk distance, and quality of life (Kansas City Cardiomyopathy Questionnaire and Medical Outcomes Study 12-Item Short-Form Health Survey questionnaires). Safety was assessed by documenting training-related adverse events, prosthesis, and renal function.

Results

Significant changes in favor of TG were observed for peak oxygen uptake (group difference, 3.7 mL/min per kg [95% CI, 1.1-6.3; P = .007]), muscular strength (bench press, 6 kg [95% CI, 3-10; P = .002]; rowing, 7 kg [95% CI, 3-11; P < .001]; pulldown, 9 kg [95% CI, 4-14; P = .001]; shoulder press, 5 kg [95% CI, 1-8; P = .008]; leg press, 17 kg [95% CI 6-28; P = .005]), components of quality of life (Kansas City Cardiomyopathy Questionnaire physical limitation, 19.2 [95% CI, 4.1-34.2; P = .015]; symptom burden, 12.3 [95% CI, 0.5-24.0; P = .041]; clinical summary, 12.4 [3.4-21.4; P = .009]), but not for other questionnaire subscales and 6-minute walk distance (15 m [95% CI, −23 to 53; P = .428]). Three dropouts unrelated to exercise occurred (TG = 2; usual care, = 1); prosthesis and renal function were not affected by the exercise intervention.

Conclusions

In patients after TAVI, exercise training appears safe and highly effective with respect to improvements in exercise capacity, muscular strength, and quality of life.

Clinical Trial Registration: Clinicaltrials.gov NCT01935297.

Section snippets

Study design and population

Safety, applicability, and outcome of regular exercise training after SPORT:TAVI was a prospective, randomized controlled pilot trial that was conducted by 3 centers in Munich, Germany, between October 2012 and April 2014. Patients underwent TAVI either at the German Heart Center Munich or at the University Hospital Munich of the Ludwig-Maximilians-Universität, whereas the supervised exercise training was performed at the Department of Prevention, Rehabilitation and Sports Medicine, Technical

Participant flow and baseline data

The flow of participants through the study is summarized in Figure 1. The mean age of the study population was 81 ± 6 years (range, 71-92), and patients were included 83 ± 34 days (range, 42-132) after intervention. No differences for TG and UC with respect to age, proportion of females, The Society of Thoracic Surgeons mortality risk score, NYHA class, preexisting conditions, and medication were observed (see Table I). No patient had clinically relevant chronic lung disease. Participants had

Discussion

This pilot study showed that an exercise intervention in patients after TAVI, consisting of gradually increasing moderate combined endurance and strength training over 8 weeks, was safe and had no negative effects on prosthesis, renal, or neurohumoral function. It resulted in significant improvements in exercise capacity, muscular strength as well as important aspects of quality of life related to physical function, and symptom burden as compared with usual care.

Alongside interventional and

Conclusions

In this pilot study on exercise after TAVI, 8 weeks of combined endurance and resistance exercise resulted in significant improvements in exercise capacity, muscular strength, and quality of life compared with usual care without affecting cardiac adverse events or prosthesis function. The findings indicate that exercise after TAVI may strongly add to improved functional outcomes beyond the effects of the TAVI procedure itself. Adequately powered randomized trials are warranted to evaluate

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Efficacy of exercise training-based cardiac rehabilitation programmes after transcatheter aortic valve implantation: A systematic review and meta-analysis
2024, International Journal of Cardiology: Cardiovascular Risk and Prevention
The beneficial effects of exercise training-based cardiac rehabilitation (CR) in different cardiac conditions have been previously studied. In this meta-analysis, we focused on the potential impact of CR on patients undergoing transcatheter aortic valve implantation (TAVI).
Multiple databases were searched in a systematic approach to find the eligible studies. All the studies investigating the potential impact of exercise training-based CR programmes on exercise capacity and health-related quality of life in patients undergoing TAVI were retrieved. The primary endpoint of interest was 6-min walk test (6MWT). The pooled standardized mean difference (SMD) and 95 % confidence interval (CI) were measured to compare the improvement or worsening the endpoints using a random- or fixed-effects model, as appropriate.
A total of eleven studies (685 patients) were considered eligible for quantitative synthesis. The results showed that performing exercise training-based CR after TAVI is associated with significant improvement in 6MWT (SMD 0.59, 95 % CI (0.48; 0.71), p < 0.01), Barthel index (SMD 0.73, 95 % CI (0.57; 0.89), p < 0.01), 12-item Short Form (SF-12) physical (SMD 0.30, 95 % CI (0.08; 0.52), p < 0.01) and mental (SMD 0.27, 95 % CI (0.05; 0.49), p = 0.02) survey scores, and hospital anxiety and depression scale – depression (HADS-D) score (SMD -0.26, 95 % CI (−0.42; −0.10), p < 0.01).
Performing exercise training-based CR following TAVI has significant benefits regarding physical capacity and health-related quality of life irrespective of the programme duration.
Efficacy and Safety of Moderate-Intensity Continuous Training on the Improvement of Cardiopulmonary Function in Patients After Transcatheter Aortic Valve Replacement (ENERGY): A Randomized Controlled Trial
2023, Journal of the American Medical Directors Association
To investigate the effect of moderate-intensity continuous training (MICT) on the improvement of cardiopulmonary function for patients undergoing transcatheter aortic valve replacement (TAVR).
Randomized controlled study.
Between August 20, 2021, and February 28, 2022, a total of 66 patients after TAVR were screened for inclusion and randomly divided into the MICT and control groups at a ratio of 1:1. MICT was scheduled 3 times per week for 3 months in the intervention group. Patients in the control group received one-time advice on physical activity according to the current guideline.
The primary endpoint was the 3-month change in peak oxygen consumption (peak VO₂) assessed by cardiopulmonary exercise testing. The secondary endpoints included the 3-month change in 6-minute walk test (6MWT), the 12-Item Short Form Health Survey (SF-12), New York Heart Association (NYHA) class, echocardiographic parameters, and laboratory parameters.
After 3 months, the change in peak VO₂ was higher in the MICT group than that in the control group (1.63 mL/kg/min, 95% CI 0.58-2.67, P = .003). Change in 6MWT (21.55 m, 95% CI 0.38-42.71, P = .046) was higher in the MICT group compared with the control group. A significant change in favor of MICT was also observed for low-density lipoprotein cholesterol (−0.62 mmol/L, 95% CI –1.00 to −0.23, P = .002). However, there were no significant changes in other echocardiographic indices, laboratory parameters, and SF-12 between the 2 groups (all P > .05).
MICT had a positive effect on the cardiopulmonary function and physical capacity of patients after TAVR.
Cardiac Rehabilitation After TAVI –A Systematic Review and Meta-Analysis
2023, Current Problems in Cardiology
Citation Excerpt :
The overall increase was from 4.7 ± 1.2 at baseline to 5.0 ± 0.8 at discharge and was even sustained at the follow up after 6 months. The two studies11,12 excluded from the meta-analysis, that did not utilize the BI used the Short Form 12 (SF-12) questionnaire instead. Both reported very similar results and measured an overall positive improvement.
Despite the increasing popularity of Transcatheter aortic valve implantation (TAVI) in patients with high surgical risk, there is no current guideline for the management of patients following the intervention. This systematic review and meta-analysis aims to summarize and analyse all clinical data and evidence regarding the effectiveness and outcomes of CR following TAVI. The first meta-analysis measured the walked distance in the Six-Minute Walk Test (6MWT) and the second meta-analysis included studies that showed the Barthel Index (BI) before and after CR. The mean distance walked prior to CR was 235.88 ± 69.36 m increased to 292.12 ± 54.92 m after rehabilitation, signifying a moderate clinically relevant effect size (0.593 (0.42, 0.76); P=0.00). The mean BI score before CR was 76.6 ± 11.5 which increased to 89.8 ± 5.5 after the programme and similarly demonstrated a significant standardized mean improvement (0.75 (0.57, 0.93); I= 0.00). Exercise-based CR in patients with aortic stenosis treated with TAVI demonstrated a significant improvement in exercise tolerance and functional independence shown by the 6MWT and BI.
Interventions for Frailty Among Older Adults With Cardiovascular Disease: JACC State-of-the-Art Review
2022, Journal of the American College of Cardiology
With the aging of the world’s population, a large proportion of patients seen in cardiovascular practice are older adults, but many patients also exhibit signs of physical frailty. Cardiovascular disease and frailty are interdependent and have the same physiological underpinning that predisposes to the progression of both disease processes. Frailty can be defined as a phenomenon of increased vulnerability to stressors due to decreased physiological reserves in older patients and thus leads to poor clinical outcomes after cardiovascular insults. There are various pathophysiologic mechanisms for the development of frailty: cognitive decline, physical inactivity, poor nutrition, and lack of social supports; these risk factors provide opportunity for various types of interventions that aim to prevent, improve, or reverse the development of frailty syndrome in the context of cardiovascular disease. There is no compelling study demonstrating a successful intervention to improve a global measure of frailty. Emerging data from patients admitted with heart failure indicate that interventions associated with positive outcomes on frailty and physical function are multidimensional and include tailored cardiac rehabilitation. Contemporary cardiovascular practice should actively identify patients with physical frailty who could benefit from frailty interventions and aim to deliver these therapies in a patient-centered model to optimize quality of life, particularly after cardiovascular interventions.
Comprehensive Geriatric Assessment and Exercise Capacity in Cardiac Rehabilitation for Patients Referred to Transcatheter Aortic Valve Implantation
2021, American Journal of Cardiology
Comprehensive geriatric assessment (CGA)-based cardiac rehabilitation (CR) program is essential for patients before and after transcatheter aortic valve implantation (TAVI). This study aimed to explore the values of CGA and exercise capacity in CR for patients referred to TAVI. A retrospective analysis was conducted in 90 patients referred to TAVI from January to October 2019. CR strategies started before TAVI. The association between clinical characteristics, CGA, and change in six-minute walk distance (Δ6MWD) was analyzed with multivariate regression models. Most of patients had cognitive impairment (50%), malnutrition (61%), and frailty (83%). After the CR, the proportion of cognitive impairment, malnutrition, and frail patients was significantly decreased by 21%, 40%, and 57%, respectively (p = 0.002, p <0.001, p <0.001). The 6MWD at a month after discharge (291.9 ± 98.8 m) was significantly improved than that at discharge after TAVI (218.8 ± 114.3m, p <0.001). The multivariate regression analysis indicated body mass index (BMI; Δ6MWD:12.0, 95% confidence interval [CI] 0.3 to 23.8, p = 0.045), frailty (Δ6MWD: −57.9, 95% CI −81.8 to −34.1, p <0.001) and malnutrition (Δ6MWD: −25.1, 95% CI −47.0 to −3.2, p = 0.026) as the associated predictors of Δ6MWD. In conclusion, functional status in patients referred to TAVI could be improved by CGA-based CR. BMI, frailty, and malnutrition were associated with the efficacy of CR on exercise capacity. CGA can play the important role in the evaluation and making strategies for CR in patients.
Implementing the physical activity vital sign in an academic preventive cardiology clinic
2021, Preventive Medicine Reports
The aims were to implement physical activity (PA) screening as part of the electronic kiosk check-in process in an adult preventive cardiology clinic and assess factors related to patients’ self-reported PA. The 3-question physical activity vital sign (PAVS) was embedded in the Epic electronic medical record and included how many days, minutes and intensity (light, moderate, vigorous) of PA patients conducted on average. This is a data analysis of PAVS data over a 60-day period. We conducted multivariable logistic regression to identify factors associated with not meeting current PA recommendations. Over 60 days, a total of 1322 patients checked into the clinic using the kiosk and 72% (n = 951) completed the PAVS at the kiosk. The majority of those patients were male (58%) and White (71%) with a mean age of 64 ± 15 years. Of the 951 patients completing the PAVS, 10% reported no PA, 55% reported some PA, and 35% reported achieving at least 150 min moderate or 75 min vigorous PA/week. In the logistic model, females (AOR = 1.4, 95%CI: 1.002–1.8, p = .049) vs. males, being Black (AOR = 2.0, 95%CI: 1.04–3.7, p = .038) or ‘Other’ race (AOR = 1.5, 95%CI: 1.02–2.3, p = .035) vs. White, unknown or other types of relationships (AOR = 0.0.26, 95%CI: 0.10–0.68, p = .006) vs. being married/partnered, and those who were retired (AOR = 1.9, 95% CI: 1.4–2.8, p < .001) or unemployed (AOR = 2.2, 95%CI: 1.3–3.7, p = .002) vs. full-time workers were associated with not achieving recommended levels of PA.
The PAVS is a feasible electronic tool for quickly assessing PA and may prompt providers to counsel on this CVD risk factor.

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: All authors have approved the final article.

: Conflicts of interest: none.

: Grant support: This study received grant support by the German Heart Foundation/German Foundation of Heart Research (Frankfurt, Germany; F/14/12). Author BL received financial support from the German Cardiac Society (Düsseldorf, Germany) via the Otto-Hess-Research-Grant.

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Clinical InvestigationExercise training improves exercise capacity and quality of life after transcatheter aortic valve implantation: A randomized pilot trial

Background

Methods

Results

Conclusions

Section snippets

Study design and population

Participant flow and baseline data

Discussion

Conclusions

Lancet

Lancet

J Am Coll Cardiol

J Am Coll Cardiol

JACC Cardiovasc Interv

J Am Coll Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

J Am Coll Cardiol

J Heart Lung Transplant

J Am Coll Cardiol

J Am Coll Cardiol

Int J Cardiol

Am J Cardiol

Transcatheter aortic valve replacement: current perspectives and future implications

Heart

Registry of transcatheter aortic-valve implantation in high-risk patients

N Engl J Med

Clinical Investigation
Exercise training improves exercise capacity and quality of life after transcatheter aortic valve implantation: A randomized pilot trial