- Email: [email protected]
Cardiac Rehabilitation After Heart Valve Surgery
Clinical Review: Focused
Cardiac Rehabilitation After Heart Valve Surgery Martin K. Kiel, MD Cardiac rehabilitation (CR) is approved by the Centers for Medicare and Medicaid Services for patients who have had heart valve surgery. Analysis of data shows that CR increases exercise capacity and quality of life, and facilitates return to work, with minimal risk of significant adverse effects. In spite of this, CR is vastly underused. Recommendations to improve this include an automatic referral system, liaison assistance to speak with inpatients about CR, and establishment of CR programs in areas that have poor access to the large hospital-based facilities. Components of CR for patients who have had heart valve surgery also are discussed in this review. PM R 2011;3:962-967
INTRODUCTION Cardiac rehabilitation (CR) is a long-term program that involves prescribed exercise, education, and counseling to limit physiological and psychological effects of cardiac disease and to enhance the psychosocial and vocational status of selected patients [1]. CR starts in the hospital, before discharge; continues after discharge, in a supervised setting, usually with telemetry monitoring initially; and transitions to a home-based program to be continued indefinitely. CR began in the 1950s with early inpatient mobilization of patients who had had a myocardial infarction [2]. CR has predominately been directed toward patients with coronary artery disease (CAD), and its benefits are summarized by Wenger et al [3] in their guide for clinicians. Results of a meta-analysis show 15%-28% reductions in all-cause mortality and 26%-31% reductions in cardiac mortality for patients with CAD who received CR [4]. Within the past decade, CR has broadened to include patients who have had heart valve (HV) surgery [1]. A decision memorandum in 2006 from the Centers for Medicare and Medicaid Services concludes that the evidence is adequate that CR is reasonable and necessary after HV repair or replacement [5]. This memo focuses on phase 2, outpatient CR, which recommends up to 36 sessions and 2-3 sessions per week. The sessions should include prescribed exercise, education, and counseling. In spite of CR being approved for patients who have experienced the consequences of CAD and patients who have had HV surgery, CR is widely underused. Suaya et al [4] studied the use of CR by Medicare beneficiaries and found that only 14.2% of patients with an acute myocardial infarction, who had undergone procedures related to CAD, who also had valvular heart disease used CR. The primary purpose of this review is to draw more attention to CR. Strategies to improve CR use are discussed. There have been relatively few articles that address CR for patients who received HV surgery compared with patients with CAD. This review will summarize the articles that studied the effect of CR on patients who had HV surgery. Even though outpatient CR is now an approved part of post–HV surgery care, it is instructive to review the literature that relates to this decision. In addition, some of the components of the CR program for patients who had HV surgery will be discussed.
METHODS The method used for selecting articles that address the effect of CR on patients who had HV surgery was a PubMed journal search for all articles from 1980 to the present that included the following elements: PM&R
962
1934-1482/11/$36.00 Printed in U.S.A.
M.K.K. Member, Massachusetts Medical Society; fellow member, American Academy of Physical Medicine and Rehabilitation. Bedford, MA. Address correspondence to: M.K.K.; e-mail: [email protected] Disclosure: nothing to disclose Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org Submitted for publication December 7, 2010; accepted June 23, 2011.
© 2011 by the American Academy of Physical Medicine and Rehabilitation Vol. 3, 962-967, October 2011 DOI: 10.1016/j.pmrj.2011.06.007
PM&R
1. Patients who had HV surgery. 2. Patients who received either an outpatient comprehensive CR program or an outpatient exercise training program. 3. Articles that were evidence based. 4. Full-length articles available in English.
LITERATURE REVIEW Outcomes of CR in Patients with HV Surgery Gladkova and Kassirsky [6] studied 209 patients who had either aortic valve (AV) or mitral valve (MV) replacement. The patients received physical rehabilitation for 2 years, which included therapeutic exercises, controlled walking, stair climbing, and/or bicycle ergometry. The heart rate (HR) was kept to 40%-50% of submaximal aerobic capacity. CR also included psychotherapeutic talks, sedatives, tranquilizers, or antidepressants as needed. Return to work after MV replacement was 52% in the patients in CR and 37.5% in the patients not in CR. Return to work after AV replacement was 77.4% in the patients in CR and 56.1% for the patients not in CR. Rimington et al [7] studied the outcome of early outpatient CR in 200 patients; 90% had AV replacement or AV replacement plus coronary artery bypass grafting (CABG). The 6-minute walk test improved in both the patients in CR and the patients not in CR, without a significant difference between them. That study also evaluated outcomes in 43 patients who completed a long-term outpatient CR program. The 6-minute walk test and quality of life (QOL) questionnaire showed greater improvement in the patients who received long-term outpatient CR than in patients who received only short-term CR. Newell et al [8] studied 24 patients who had AV or MV replacement. CR was composed of the Canadian Air Force Exercise Program, which included calisthenics and stationary running 12 minutes per day for 24 weeks. There was greater improvement in the ratio of HR to submaximal oxygen consumption (VO2) in the CR group than in the non-CR group. Sire [9] studied 44 patients who had AV replacement. CR included calisthenics, volleyball, and stationary bicycle 3-4 hours per day for 1 month. At 6 months, work capacity, in watts, was 38% greater in patients in CR than in patients not in CR; and, at 1 year, it was 37% higher in the patients in CR. Return to work at 1 year was 81% in patients in CR and 65% in patients not in CR. Meurin et al [10] studied 251 patients who had MV replacement. The outpatient exercise program included dynamic and isometric arm and leg exercises for 30-40 minutes per session, and stationary bicycle for 30 minutes at approximately 70% of maximum HR for 3 days per week for 5 weeks. Peak VO2 increased 22%. Vanhees et al [11] studied 69 patients who had valve replacements. These patients received 3 months of super-
Vol. 3, Iss. 10, 2011
963
vised outpatient CR, 3 sessions per week for 90 minutes per session. Activities included cycling, running, arm ergometry, rowing, calisthenics. and relaxation techniques. Initial exercise intensity was derived from resting HR plus 60% (peak HR minus resting HR), which was progressively increased to 90% HR reserve. Peak VO2 increased 25.9%. Ueshima et al [12] studied 64 patients who underwent AV or MV repair or replacement. Exercise training was 2-3 sessions per week for 6 months. There was greater improvement in the anaerobic threshold and QOL questionnaire in the exercise group than in the nonexercise group. Toyomasu et al [13] studied 71 patients who underwent MV commissurotomy, MV or AV replacement, double valve replacement, or MV commissurotomy plus AV replacement. The outpatient exercise program was stationary bicycle riding, 6 minutes twice daily for 1 month. Peak VO2 improved in the exercise group but not in the nonexercise group. Ruttenberg et al [14] studied 5 patients who required surgery for AV stenosis. They received a 9-week exercise program of walking or jogging with HR at 65%-75% of maximal, 3 times per week. Session duration was gradually increased to 30 minutes. The exercise group showed an increased peak VO2 at a level of borderline significance. The nonexercise group showed no significant change in peak VO2. Gohlke-Barwolf et al [15] studied 1270 patients who had AV or MV replacement. Patients received CR and showed improved exercise tolerance (measured in watts). Jairath et al [16] studied 49 patients who had AV or MV repair or replacement. The outpatient exercise program included 10 minutes of warm-up exercises, 30 minutes of walking, and 10 minutes of cool-down exercise 3 times per week for 3 months. Peak VO2 increased in both the exercise and nonexercise groups, without significant differences between them. The outcome parameters used in these studies [6-16] include return to work, a 6-minute walk, QOL questionnaires, the ratio of HR to VO2, exercise tolerance or work capacity achieved on a bicycle ergometer (measured in watts), peak VO2, and anaerobic threshold. The results show that CR improves these outcome parameters to varying degrees. In the studies that used a control group that did not receive formal CR [6-9,12-14,16], outcomes were better in the group that did receive formal CR, except the study by Jairath et al [16], which demonstrated equivalent improvement in both groups. In the study by Rimington et al [7], the first part of the study evaluated outcome for early CR, and both the CR group and control group improved without a significant difference between them; however, the second part of the study looked at the outcome of long-term outpatient CR, and here the CR group improved significantly over the control group.
964
Kiel
Adverse Effects Related to CR Among the evidence-based studies described above [6-16], which included 2299 patients, adverse clinical events associated with CR included the following: one patient developed worsening heart failure [8], which was treated, and the patient then completed CR and showed improvement in the ratio of HR to VO2 at 26 weeks after surgery. One patient developed a hematoma in his abdominal wall [9] and resumed CR 3 months later. In the study by Meurin et al [10], 52 patients had permanent atrial fibrillation (AF) before surgery. During CR, 66 patients had a least one episode of AF that lasted more than 24 hours. Among those, 32 patients had AF at the completion of CR. The researchers did not specify what percentage of these patients had new-onset AF. The incidence of sustained atrial tachyarrhythmias after CABG is approximately 30%, after valve surgery is 40%, and after combined CABG and valve surgery is 50% [17]. These dysrhythmias usually occur in the immediate postoperative period, facilitated by atrial trauma, hypoxia, electrolyte abnormality, and increased sympathetic activity [17]. Data for the risk of AF occurring during outpatient CR, which typically begins 6-8 weeks after HV surgery, is not available. None of the studies, except for that by Vanhees et al [11], reported an episode in which a patient required cardiopulmonary resuscitation, developed new neurologic deficits, experienced a fall, or developed a new or worsening heart murmur. Vanhees et al [11] evaluated the incidence of adverse effects during CR that required resuscitation, but they did not determine this incidence in the subset of patients (3.61%) who had HV surgery.
Recommendations for CR After HV Surgery Core Components of CR. Core components of CR and secondary prevention programs are outlined in the 2007 Scientific Statement by the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) [18]. Patients referred to CR require a thorough medical evaluation and symptomlimited exercise test before starting the program. Secondary prevention aspects of CR are particularly important for those patients with concomitant CAD. More than 33% of patients with aortic stenosis who need AV replacement have concomitant CAD [19]. The prevalence of CAD in patients with mitral stenosis averages 20% [19]. Secondary prevention includes nutritional counseling, tobacco cessation, blood pressure management, diabetes management, and lipid management. The patients attend group sessions to receive instruction in these areas, including information about their medications. These group sessions also can be helpful, even for those patients without CAD, to re-enforce the benefits of a healthy lifestyle to minimize the development of CAD. Although it is difficult to obtain precise figures,
CARDIAC REHABILITATION AFTER HEART VALVE SURGERY
analysis of the data suggests that most patients who undergo valve surgery are in their 50s and 60s [7,10,11,15,19]. Blood pressure and HR are monitored during CR, and problems are reported to the physician. Telemetry monitoring is available during exercise training based on the patient’s risk for dysrhythmias [18]. Patients can check their own blood glucose levels before and after exercise, and can take glucose supplements if needed, which will help them to be independent once they complete supervised outpatient CR. Psychosocial management should be part of CR, which can provide a support group for sharing experiences and concerns, and counseling to help adjust to heart disease and the impact that it will have on them for the rest of their lives. Ideally, family members are included. Individualized exercise prescription by the referring physician includes aerobic and resistance training. The symptom limited or submaximal exercise test helps to determine the target HR range and is recommended before beginning CR [18]. Other factors to consider include musculoskeletal conditions and peripheral artery disease. General recommendations for aerobic exercise are frequency of 3-5 sessions per week; intensity of 50%-80% of the HR achieved in exercise testing; and session duration of 30-60 minutes [18]. Walking on a treadmill or riding a stationary bicycle is commonly used. General recommendations for dynamic resistance exercise are frequency of 2-3 times per week; intensity of 10-15 repetitions; and 1-3 sets for upper and lower extremities. Elastic bands with increasing strengths can be used by starting with the lightest and then progressing. Hand weights (starting at 1 lb [0.45 kg]) can be used [18]. Isometric exercise is generally not recommended, because it might increase the blood pressure [20]. Warm-up and cool-down activities also are recommended, as well as relaxation techniques at the end of the session. Typically, phase 2 CR begins at a low enough intensity to accommodate most patients who have had HV surgery. In an assessment from the U.S. Department of Health and Human Services regarding CR programs, the patients who benefited the most were those who began CR at an exercise capacity level of 3-5 metabolic equivalents [21], which is a low level of activity sufficient to perform basic activities of daily living, to walk 2-4 miles per hour, and to drive a car. Detailed records should be kept of what is accomplished during each session so that the program can be increased gradually on a weekly basis. Along with telemetry monitoring for the initial sessions, blood pressure and pulse are monitored, and the patient is asked for his or her subjective rating of exertion according to the Borg Scale [22]. A weekly body weight measurement is recommended not only for monitoring compliance with nutritional recommendations but also for monitoring patients at risk for heart failure. The AACVPR offers a certification process for CR programs that meet their standards of practice. The AACVPR and the American Heart Association encourage all CR programs
PM&R
Vol. 3, Iss. 10, 2011
965
to meet these standards; however, as of October 2006, only 973 of an estimated 2621 CR programs in the United States have received AACVPR certification (37%) [1]. Certification is voluntary and does not mean that other programs are substandard, but it can add to patients’ confidence and can help to develop the most efficacious CR programs. In the 11 studies summarized in the literature review [6-16], a variety of different CR regimens were used. Further studies are needed to determine which programs produce the best results.
of CR. These recommendations apply to most of the patients who attend CR, the majority of whom have problems related to CAD. Exercise recommendations derived from evidencebased studies specifically directed to patients who had HV surgery are not available. Bonow et al [27] provide general consensus recommendations regarding participation in competitive sports for asymptomatic athletes who had HV surgery. Even though this is not the typical patient population seen in most CR programs, their recommendations may still be helpful for the nonathletes:
CR Issues Specific to Patients With Valve Surgery. In addition to the general guidelines for CR, there are further considerations, depending on each patient’s unique history. For those patients who had open heart surgery with a median sternotomy, which includes most patients who had valve surgery, sternotomy precautions are important. The strongest force that challenges the sternotomy is the pectoralis muscles [23]. These muscles pull in opposite direction to the holding power of the wire sutures [23]. Sternal disruption occurs in 2%-8% of patients with median sternotomy [23]. Predisposing factors include conditions that hinder bone healing, such as smoking, osteoporosis, obesity, and steroids. Patients receive instruction in sternal precautions within the first few days after surgery, which includes the proper method for going from supine to sitting position, which is rolling to one side and propping oneself up on an elbow, rather than attempting a partial sit-up, which uses the rectus abdominis muscles, and which can exert unequal pull on the sternum [23]. Patients are taught the proper way to rise from a chair, which is by using one’s legs rather than pushing down with the arms, which can stress the incision. Selfhugging or hugging a pillow when coughing or sneezing can help to brace the incision. Coughing can produce a greater disruptive force to the incision than lifting 40 lb (18 kg) [24]. These techniques are begun on an inpatient basis but should be continued after discharge to minimize sternal stress and pain. Resistance exercises for the shoulders, especially internal rotation and adduction with elastic bands should be minimal initially and progressed according to the patient’s pain level. Pushing doors and opening car doors can produce 11-13 lb force (5-6 kg) on the sternum [24]. Sternal protection precautions should be rigorously followed for at least the first 3 months after surgery, and lifting should be limited to less than 10 lb (4.5 kg) [24,25]. Patients with a mechanical prosthesis require lifelong warfarin medication. Patients who receive a bioprosthesis or MV repair should receive warfarin for 3 months after surgery [26]. Even though phase 2 CR exercise modalities are not high impact, patients should still be counseled to use caution with home activities that could cause a high-impact injury, such as falls. General recommendations for aerobic and resistance exercises were given in the discussion of the core components
1. Athletes with a bioprosthetic MV and who are not taking anticoagulants, and who have normal valve function and normal or near-normal left ventricular (LV) function can participate in low and moderate static and dynamic competitive sports. 2. Athletes with a mechanical or bioprosthetic AV and with normal valve function and normal LV function can engage in low and moderate static and dynamic competitive sports. Athletes who participate in more than low-intensity competitive sports should undergo exercise testing to at least the level of activity achieved in competition. 3. For patients with mitral stenosis and who have undergone successful open or closed commissurotomy, participation in competitive sports should be based on the residual severity of mitral stenosis or regurgitation. The capacity to engage in physical exercise should be evaluated with a exercise tolerance test at least to the level of anticipated activity. Patients with LV dysfunction should be restricted from athletic participation in the same context as those without surgery. 4. Athletes who have undergone MV repair for regurgitation should not engage in sports that involve risk of bodily contact that might disrupt the repair. They can participate in low-intensity competitive sports and, in selected athletes, in low and moderate static and dynamic sports. In these recommendations for participation in sports, the main determinants are valve function, LV function, performance on exercise testing, and use of anticoagulants. Echocardiography and exercise testing are routinely performed within 1-2 months after HV surgery [26]. The referring physician can use these evaluations to help determine the appropriateness and intensity of CR. For patients who had MV reconstruction, which is most commonly secondary to myxomatous degeneration, there are insufficient data to determine whether exercise could hasten further degeneration of the valve [26]. Flameng et al [28] discuss the biochemical abnormalities in the myxomatous leaflets from patients with degenerative MV regurgitation. The leaflets are more extensible and less stiff than in normal valves. Barber et al [29] reported that chordae tendinae from patients with degenerative MV regurgitation were significantly weaker than normal chordae tendinae. Madaric et al [30] performed exercise echocardiography with 26 patients
966
Kiel
who had endoscopic MV repair, and did not find increased regurgitation. Meurin et al [10] evaluated 251 patients after MV repair who received CR, and there was no increased regurgitation. However, more studies are needed, particularly for long-term effects of more strenuous activities once the patient graduates from phase 2 CR and begins phase 3 CR at home or at a community fitness center. Most prosthetic valves are at least mildly stenotic [31]. Bleiziffer et al [32] found that patients with patient–prosthesis mismatch (PPM) of a bioprosthetic aortic valve had a lower predicted exercise capacity than patients without PPM. They suggest that PPM may limit the increase in cardiac output during exercise, similar to native aortic stenosis. This illustrates the need for individualized exercise prescriptions based on the cardiologist’s assessment of the patient before starting CR. PPM also has been studied in patients with MV prostheses but to a lesser extent than in patients with AV prostheses. Sakamoto and Watanabe [33] did not find significant differences in heart failure or pulmonary artery pressure between patients with PPM MV and patients without PPM MV. They recommend further evaluations of hemodynamics with exercise testing.
Underuse of CR Suaya et al [4] analyzed use of phase 2 CR by 267,427 Medicare beneficiaries who had an acute myocardial infarction or CABG. One part of the study included patients who also had a variety of comorbidities. One of the comorbidities was valvular heart disease, and the rate of CR use was only 14.2% for this patient group. Data for CR use by patients with HV surgery only are not available. One of the predictors of CR use was the distance to the nearest CR facility [4]. The researchers suggest that community or home-based CR programs be considered as supplements or alternatives for facility-based programs, particularly for low-risk patients who live in rural areas. The researchers also propose that CR use could be increased by improving methods of patient referral to CR, such as routine standing orders [4]. Grace et al [34] studied CR referral strategies on use rates in 2635 inpatients with CAD; 7.6% of these patients also had valve repair or replacement. The researchers compared 4 different referral strategies: (1) automatic referral in the discharge orders for eligible patients, (2) liaison referral whereby a nurse or physical therapist or a former patient who attended CR spoke with the inpatient, (3) a combination of both, and (4) referral at the discretion of the attending physician. The main results included percentage referral, percentage enrollment, and percentage of CR sessions attended. Enrollment was attending a CR intake assessment. The combination strategy achieved the greatest referral and enrollment rates, followed by the automatic referral strategy,
CARDIAC REHABILITATION AFTER HEART VALVE SURGERY
the liaison referral strategy, and, finally, referral at the physician’s discretion. The number of CR sessions attended did not differ significantly based on referral strategy. The researchers also report that the Ontario Cardiac Rehabilitation Pilot Project in 2002 established a target goal that at least 40% of eligible cardiac patients are referred to CR [34]. The referral rate in 1999 was less than 10% [35].
CONCLUSION CR should be part of the care plan for patients who have had HV surgery. CR is approved by the Centers for Medicare and Medicaid and is endorsed by numerous professional medical organizations, including the AACVPR and the American Heart Association. Although more large-scale studies are needed, analysis of data shows that CR improves exercise capacity and QOL and facilitates return to work, with minimal risk of significant adverse effects. In spite of this, CR is vastly underused. Proposals to remedy this include an automatic referral system and liaison referral assistance, and improvement in the availability of CR in communities that have poor access to the larger hospital-based facilities. Setting a target goal for CR referrals and CR attendance and a monitoring system also might improve CR use. Morbidity and mortality data should be gathered on patients who receive CR after HV surgery and those who do not.
REFERENCES 1. Thomas RJ, King M, Lui K, Oldridge N, Pina IL, Spertus J. AACVPR/ ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. Circulation 2007;116:1611-1642. 2. Fuster V, Walsh RA, O’Rourke RA, et al, eds. Hurst’s the Heart. 12th ed. New York: McGraw Hill, 2008, 2230. 3. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation as Secondary Prevention. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and National Heart Lung, and Blood Institute. AHCPR Pub. No. 96-0673. October 1995. 4. Suaya JA, Shepard DS, Normand SLT, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007;116:16531662. 5. Decision Memo for Cardiac Rehabilitation Programs (CAG-00089R). Washington, DC: Centers for Medicare and Medicaid Services. U.S. Department of Health and Human Services; 2006. Available at http:// www.cmms.hhs.gov/medicare-coverage-database/details/nca-decisionmemo.aspx?NCAId⫽164&ver⫽12&NCDId⫽36&ncdver⫽3& NcaName⫽Cardiac⫹Rehabilitation⫹Programs&IsPopup⫽y&bc⫽ AAAAAAAAIAAA& ? Accessed July 6, 2011. 6. Gladkova MA, Kassirsky GI. Topical problems in rehabilitation following valve replacement. Cor Vasa 19 84;26:394-399. 7. Rimington H, Weinman J, Chambers JB. Predicting outcome after valve replacement. Heart 2010;96:118-123. 8. Newell JP, Kappagoda CT, Stoker JB, Deverall PB, Watson DA, Linden RJ. Physical training after heart valve replacement. Br Heart J 1980;44: 638-649.
PM&R
9. Sire S. Physical training and occupational rehabilitation after aortic valve replacement. Eur Heart J 1987;8:1215-1220. 10. Meurin P, Illiou MC, Ben Driss A, et al. Early exercise training after mitral valve repair: A multicentric prospective French study. Chest 2005;128:1638-1644. 11. Vanhees L, Stevens A, Schepers D, Defoor J, Rademakers F, Fagard R. Determinants of the effects of physical training and of the complications requiring resuscitation during exercise in patients with cardiovascular disease. Eur J Cardiovasc Prev Rehabil 2004;11:304-312. 12. Ueshima K, Kamata J, Kobayashi N, et al. Effects of exercise training after open heart surgery on quality of life and exercise tolerance in patients with mitral regurgitation or aortic regurgitation. Jpn Heart J 2004;45:789-797. 13. Toyomasu K, Nishiyama Y, Yoshida N, et al. Physical training in patients with valvular heart disease after surgery. Jpn Circ J 1990;54: 1451-1458. 14. Ruttenberg HD, Adams TD, Orsmond GS, Conlee RK, Fisher AG. Effects of exercise training on aerobic fitness in children after open heart surgery. Pediatr Cardiol 1983;4:19-24. 15. Gohlke-Barwolf C, Gohlke H, Samek L, et al. Exercise tolerance and working capacity after valve replacement. J Heart Valve Dis 1992;1: 189-195. 16. Jairath N, Salerno T, Chapman J, Dornan J, Weisel R. The effect of moderate exercise training on oxygen uptake post-aortic/mitral valve surgery. J Cardiopulm Rehabil 1995;15:424-430. 17. Mitchell BL, Exner DV, Wyse GD, et al. Prophylactic oral amiodarone for the prevention of arrhythmias that begin early after revascularization, valve replacement, or repair. JAMA 2005;294:3093-3100. 18. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. Circulation 2007;115:2675-2682. 19. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). Circulation 2008;118:e523-e661. 20. Sparling PB, Cantwell JD, Dolan CM, Niederman RK. Strength training in a cardiac rehabilitation program: A six-month follow-up. Arch Phys Med Rehabil 1990;71:148-152.
Vol. 3, Iss. 10, 2011
967
21. Hotta SS. Cardiac rehabilitation programs. Health Technol Assess Rep 1991;3:1-10. 22. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-381. 23. Robicsek F, Fokin A, Cook J, Bhatia D. Sternal instability after midline sternotomy. Thorac Cardiov Surg 2000;48:1-8. 24. Brocki BC, Thorup CB, Andreasen JJ. Precautions related to midline sternotomy in cardiac surgery: A review of mechanical stress factors leading to sternal complications. Eur J Cardiovasc Nurs 2010;9:77-84. 25. Westerdahl E, Moller M. Physiotherapy-supervised mobilization and exercise following cardiac surgery: A national questionnaire survey in Sweden. J Cardiothorac Surg 2010;5:67 [Epub ahead of print]. 26. Butchart EG, Gohlke-Barwolf C, Antunes MJ, et al. Recommendations for the management of patients after heart valve surgery. Eur Heart J 2005;26:25632471. 27. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: Valvular heart disease. J Am Coll Cardiol 2005;45:1334-1340. 28. Flameng W, Herijers P, Bogaerts K. Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease. Circulation 2003;107:1609. 29. Barber EJ, Kasper KF, Ratliff NB, Cosgrove DM, Griffin BP, Vesely I. Mechanical properties of myxomatous mitral valves. J Thorac Cardiovasc Surg 2001;122:955-962. 30. Madaric J, Watripont P, Bartunek J, et al. Effect of mitral valve repair on exercise tolerance in asymptomatic patients with organic mitral regurgitation. Am Heart J 2007;154:180-185. 31. Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol 2000;36:1131-1141. 32. Bleiziffer S, Eichinger WB, Hettich I, et al. Impact of patient-prosthesis mismatch on exercise capacity in patients after bioprosthetic aortic valve replacement. Heart 2008;94:637-641. 33. Sakamoto H, Watanabe Y. Does patient-prosthesis mismatch affect long-term results after mitral valve replacement? Ann Thorac Cardiovasc Surg 2010;16:163-167. 34. Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization rates. Arch Intern Med 2011;171:235241. 35. Ontario Cardiac Rehabilitation Pilot Project Report and Recommendations, 2002. Cardiac Care Network Web Site. Available at: http:// www.ccn.on.ca/pdfs/Rehab-Pilot-Project-Sep2002.pdf. Accessed June 10, 2011.
Cardiac Rehabilitation After Heart Valve Surgery Martin K. Kiel, MD Cardiac rehabilitation (CR) is approved by the Centers for Medicare and Medicaid Services for patients who have had heart valve surgery. Analysis of data shows that CR increases exercise capacity and quality of life, and facilitates return to work, with minimal risk of significant adverse effects. In spite of this, CR is vastly underused. Recommendations to improve this include an automatic referral system, liaison assistance to speak with inpatients about CR, and establishment of CR programs in areas that have poor access to the large hospital-based facilities. Components of CR for patients who have had heart valve surgery also are discussed in this review. PM R 2011;3:962-967
INTRODUCTION Cardiac rehabilitation (CR) is a long-term program that involves prescribed exercise, education, and counseling to limit physiological and psychological effects of cardiac disease and to enhance the psychosocial and vocational status of selected patients [1]. CR starts in the hospital, before discharge; continues after discharge, in a supervised setting, usually with telemetry monitoring initially; and transitions to a home-based program to be continued indefinitely. CR began in the 1950s with early inpatient mobilization of patients who had had a myocardial infarction [2]. CR has predominately been directed toward patients with coronary artery disease (CAD), and its benefits are summarized by Wenger et al [3] in their guide for clinicians. Results of a meta-analysis show 15%-28% reductions in all-cause mortality and 26%-31% reductions in cardiac mortality for patients with CAD who received CR [4]. Within the past decade, CR has broadened to include patients who have had heart valve (HV) surgery [1]. A decision memorandum in 2006 from the Centers for Medicare and Medicaid Services concludes that the evidence is adequate that CR is reasonable and necessary after HV repair or replacement [5]. This memo focuses on phase 2, outpatient CR, which recommends up to 36 sessions and 2-3 sessions per week. The sessions should include prescribed exercise, education, and counseling. In spite of CR being approved for patients who have experienced the consequences of CAD and patients who have had HV surgery, CR is widely underused. Suaya et al [4] studied the use of CR by Medicare beneficiaries and found that only 14.2% of patients with an acute myocardial infarction, who had undergone procedures related to CAD, who also had valvular heart disease used CR. The primary purpose of this review is to draw more attention to CR. Strategies to improve CR use are discussed. There have been relatively few articles that address CR for patients who received HV surgery compared with patients with CAD. This review will summarize the articles that studied the effect of CR on patients who had HV surgery. Even though outpatient CR is now an approved part of post–HV surgery care, it is instructive to review the literature that relates to this decision. In addition, some of the components of the CR program for patients who had HV surgery will be discussed.
METHODS The method used for selecting articles that address the effect of CR on patients who had HV surgery was a PubMed journal search for all articles from 1980 to the present that included the following elements: PM&R
962
1934-1482/11/$36.00 Printed in U.S.A.
M.K.K. Member, Massachusetts Medical Society; fellow member, American Academy of Physical Medicine and Rehabilitation. Bedford, MA. Address correspondence to: M.K.K.; e-mail: [email protected] Disclosure: nothing to disclose Disclosure Key can be found on the Table of Contents and at www.pmrjournal.org Submitted for publication December 7, 2010; accepted June 23, 2011.
© 2011 by the American Academy of Physical Medicine and Rehabilitation Vol. 3, 962-967, October 2011 DOI: 10.1016/j.pmrj.2011.06.007
PM&R
1. Patients who had HV surgery. 2. Patients who received either an outpatient comprehensive CR program or an outpatient exercise training program. 3. Articles that were evidence based. 4. Full-length articles available in English.
LITERATURE REVIEW Outcomes of CR in Patients with HV Surgery Gladkova and Kassirsky [6] studied 209 patients who had either aortic valve (AV) or mitral valve (MV) replacement. The patients received physical rehabilitation for 2 years, which included therapeutic exercises, controlled walking, stair climbing, and/or bicycle ergometry. The heart rate (HR) was kept to 40%-50% of submaximal aerobic capacity. CR also included psychotherapeutic talks, sedatives, tranquilizers, or antidepressants as needed. Return to work after MV replacement was 52% in the patients in CR and 37.5% in the patients not in CR. Return to work after AV replacement was 77.4% in the patients in CR and 56.1% for the patients not in CR. Rimington et al [7] studied the outcome of early outpatient CR in 200 patients; 90% had AV replacement or AV replacement plus coronary artery bypass grafting (CABG). The 6-minute walk test improved in both the patients in CR and the patients not in CR, without a significant difference between them. That study also evaluated outcomes in 43 patients who completed a long-term outpatient CR program. The 6-minute walk test and quality of life (QOL) questionnaire showed greater improvement in the patients who received long-term outpatient CR than in patients who received only short-term CR. Newell et al [8] studied 24 patients who had AV or MV replacement. CR was composed of the Canadian Air Force Exercise Program, which included calisthenics and stationary running 12 minutes per day for 24 weeks. There was greater improvement in the ratio of HR to submaximal oxygen consumption (VO2) in the CR group than in the non-CR group. Sire [9] studied 44 patients who had AV replacement. CR included calisthenics, volleyball, and stationary bicycle 3-4 hours per day for 1 month. At 6 months, work capacity, in watts, was 38% greater in patients in CR than in patients not in CR; and, at 1 year, it was 37% higher in the patients in CR. Return to work at 1 year was 81% in patients in CR and 65% in patients not in CR. Meurin et al [10] studied 251 patients who had MV replacement. The outpatient exercise program included dynamic and isometric arm and leg exercises for 30-40 minutes per session, and stationary bicycle for 30 minutes at approximately 70% of maximum HR for 3 days per week for 5 weeks. Peak VO2 increased 22%. Vanhees et al [11] studied 69 patients who had valve replacements. These patients received 3 months of super-
Vol. 3, Iss. 10, 2011
963
vised outpatient CR, 3 sessions per week for 90 minutes per session. Activities included cycling, running, arm ergometry, rowing, calisthenics. and relaxation techniques. Initial exercise intensity was derived from resting HR plus 60% (peak HR minus resting HR), which was progressively increased to 90% HR reserve. Peak VO2 increased 25.9%. Ueshima et al [12] studied 64 patients who underwent AV or MV repair or replacement. Exercise training was 2-3 sessions per week for 6 months. There was greater improvement in the anaerobic threshold and QOL questionnaire in the exercise group than in the nonexercise group. Toyomasu et al [13] studied 71 patients who underwent MV commissurotomy, MV or AV replacement, double valve replacement, or MV commissurotomy plus AV replacement. The outpatient exercise program was stationary bicycle riding, 6 minutes twice daily for 1 month. Peak VO2 improved in the exercise group but not in the nonexercise group. Ruttenberg et al [14] studied 5 patients who required surgery for AV stenosis. They received a 9-week exercise program of walking or jogging with HR at 65%-75% of maximal, 3 times per week. Session duration was gradually increased to 30 minutes. The exercise group showed an increased peak VO2 at a level of borderline significance. The nonexercise group showed no significant change in peak VO2. Gohlke-Barwolf et al [15] studied 1270 patients who had AV or MV replacement. Patients received CR and showed improved exercise tolerance (measured in watts). Jairath et al [16] studied 49 patients who had AV or MV repair or replacement. The outpatient exercise program included 10 minutes of warm-up exercises, 30 minutes of walking, and 10 minutes of cool-down exercise 3 times per week for 3 months. Peak VO2 increased in both the exercise and nonexercise groups, without significant differences between them. The outcome parameters used in these studies [6-16] include return to work, a 6-minute walk, QOL questionnaires, the ratio of HR to VO2, exercise tolerance or work capacity achieved on a bicycle ergometer (measured in watts), peak VO2, and anaerobic threshold. The results show that CR improves these outcome parameters to varying degrees. In the studies that used a control group that did not receive formal CR [6-9,12-14,16], outcomes were better in the group that did receive formal CR, except the study by Jairath et al [16], which demonstrated equivalent improvement in both groups. In the study by Rimington et al [7], the first part of the study evaluated outcome for early CR, and both the CR group and control group improved without a significant difference between them; however, the second part of the study looked at the outcome of long-term outpatient CR, and here the CR group improved significantly over the control group.
964
Kiel
Adverse Effects Related to CR Among the evidence-based studies described above [6-16], which included 2299 patients, adverse clinical events associated with CR included the following: one patient developed worsening heart failure [8], which was treated, and the patient then completed CR and showed improvement in the ratio of HR to VO2 at 26 weeks after surgery. One patient developed a hematoma in his abdominal wall [9] and resumed CR 3 months later. In the study by Meurin et al [10], 52 patients had permanent atrial fibrillation (AF) before surgery. During CR, 66 patients had a least one episode of AF that lasted more than 24 hours. Among those, 32 patients had AF at the completion of CR. The researchers did not specify what percentage of these patients had new-onset AF. The incidence of sustained atrial tachyarrhythmias after CABG is approximately 30%, after valve surgery is 40%, and after combined CABG and valve surgery is 50% [17]. These dysrhythmias usually occur in the immediate postoperative period, facilitated by atrial trauma, hypoxia, electrolyte abnormality, and increased sympathetic activity [17]. Data for the risk of AF occurring during outpatient CR, which typically begins 6-8 weeks after HV surgery, is not available. None of the studies, except for that by Vanhees et al [11], reported an episode in which a patient required cardiopulmonary resuscitation, developed new neurologic deficits, experienced a fall, or developed a new or worsening heart murmur. Vanhees et al [11] evaluated the incidence of adverse effects during CR that required resuscitation, but they did not determine this incidence in the subset of patients (3.61%) who had HV surgery.
Recommendations for CR After HV Surgery Core Components of CR. Core components of CR and secondary prevention programs are outlined in the 2007 Scientific Statement by the American Heart Association (AHA) and the American Association of Cardiovascular and Pulmonary Rehabilitation (AACVPR) [18]. Patients referred to CR require a thorough medical evaluation and symptomlimited exercise test before starting the program. Secondary prevention aspects of CR are particularly important for those patients with concomitant CAD. More than 33% of patients with aortic stenosis who need AV replacement have concomitant CAD [19]. The prevalence of CAD in patients with mitral stenosis averages 20% [19]. Secondary prevention includes nutritional counseling, tobacco cessation, blood pressure management, diabetes management, and lipid management. The patients attend group sessions to receive instruction in these areas, including information about their medications. These group sessions also can be helpful, even for those patients without CAD, to re-enforce the benefits of a healthy lifestyle to minimize the development of CAD. Although it is difficult to obtain precise figures,
CARDIAC REHABILITATION AFTER HEART VALVE SURGERY
analysis of the data suggests that most patients who undergo valve surgery are in their 50s and 60s [7,10,11,15,19]. Blood pressure and HR are monitored during CR, and problems are reported to the physician. Telemetry monitoring is available during exercise training based on the patient’s risk for dysrhythmias [18]. Patients can check their own blood glucose levels before and after exercise, and can take glucose supplements if needed, which will help them to be independent once they complete supervised outpatient CR. Psychosocial management should be part of CR, which can provide a support group for sharing experiences and concerns, and counseling to help adjust to heart disease and the impact that it will have on them for the rest of their lives. Ideally, family members are included. Individualized exercise prescription by the referring physician includes aerobic and resistance training. The symptom limited or submaximal exercise test helps to determine the target HR range and is recommended before beginning CR [18]. Other factors to consider include musculoskeletal conditions and peripheral artery disease. General recommendations for aerobic exercise are frequency of 3-5 sessions per week; intensity of 50%-80% of the HR achieved in exercise testing; and session duration of 30-60 minutes [18]. Walking on a treadmill or riding a stationary bicycle is commonly used. General recommendations for dynamic resistance exercise are frequency of 2-3 times per week; intensity of 10-15 repetitions; and 1-3 sets for upper and lower extremities. Elastic bands with increasing strengths can be used by starting with the lightest and then progressing. Hand weights (starting at 1 lb [0.45 kg]) can be used [18]. Isometric exercise is generally not recommended, because it might increase the blood pressure [20]. Warm-up and cool-down activities also are recommended, as well as relaxation techniques at the end of the session. Typically, phase 2 CR begins at a low enough intensity to accommodate most patients who have had HV surgery. In an assessment from the U.S. Department of Health and Human Services regarding CR programs, the patients who benefited the most were those who began CR at an exercise capacity level of 3-5 metabolic equivalents [21], which is a low level of activity sufficient to perform basic activities of daily living, to walk 2-4 miles per hour, and to drive a car. Detailed records should be kept of what is accomplished during each session so that the program can be increased gradually on a weekly basis. Along with telemetry monitoring for the initial sessions, blood pressure and pulse are monitored, and the patient is asked for his or her subjective rating of exertion according to the Borg Scale [22]. A weekly body weight measurement is recommended not only for monitoring compliance with nutritional recommendations but also for monitoring patients at risk for heart failure. The AACVPR offers a certification process for CR programs that meet their standards of practice. The AACVPR and the American Heart Association encourage all CR programs
PM&R
Vol. 3, Iss. 10, 2011
965
to meet these standards; however, as of October 2006, only 973 of an estimated 2621 CR programs in the United States have received AACVPR certification (37%) [1]. Certification is voluntary and does not mean that other programs are substandard, but it can add to patients’ confidence and can help to develop the most efficacious CR programs. In the 11 studies summarized in the literature review [6-16], a variety of different CR regimens were used. Further studies are needed to determine which programs produce the best results.
of CR. These recommendations apply to most of the patients who attend CR, the majority of whom have problems related to CAD. Exercise recommendations derived from evidencebased studies specifically directed to patients who had HV surgery are not available. Bonow et al [27] provide general consensus recommendations regarding participation in competitive sports for asymptomatic athletes who had HV surgery. Even though this is not the typical patient population seen in most CR programs, their recommendations may still be helpful for the nonathletes:
CR Issues Specific to Patients With Valve Surgery. In addition to the general guidelines for CR, there are further considerations, depending on each patient’s unique history. For those patients who had open heart surgery with a median sternotomy, which includes most patients who had valve surgery, sternotomy precautions are important. The strongest force that challenges the sternotomy is the pectoralis muscles [23]. These muscles pull in opposite direction to the holding power of the wire sutures [23]. Sternal disruption occurs in 2%-8% of patients with median sternotomy [23]. Predisposing factors include conditions that hinder bone healing, such as smoking, osteoporosis, obesity, and steroids. Patients receive instruction in sternal precautions within the first few days after surgery, which includes the proper method for going from supine to sitting position, which is rolling to one side and propping oneself up on an elbow, rather than attempting a partial sit-up, which uses the rectus abdominis muscles, and which can exert unequal pull on the sternum [23]. Patients are taught the proper way to rise from a chair, which is by using one’s legs rather than pushing down with the arms, which can stress the incision. Selfhugging or hugging a pillow when coughing or sneezing can help to brace the incision. Coughing can produce a greater disruptive force to the incision than lifting 40 lb (18 kg) [24]. These techniques are begun on an inpatient basis but should be continued after discharge to minimize sternal stress and pain. Resistance exercises for the shoulders, especially internal rotation and adduction with elastic bands should be minimal initially and progressed according to the patient’s pain level. Pushing doors and opening car doors can produce 11-13 lb force (5-6 kg) on the sternum [24]. Sternal protection precautions should be rigorously followed for at least the first 3 months after surgery, and lifting should be limited to less than 10 lb (4.5 kg) [24,25]. Patients with a mechanical prosthesis require lifelong warfarin medication. Patients who receive a bioprosthesis or MV repair should receive warfarin for 3 months after surgery [26]. Even though phase 2 CR exercise modalities are not high impact, patients should still be counseled to use caution with home activities that could cause a high-impact injury, such as falls. General recommendations for aerobic and resistance exercises were given in the discussion of the core components
1. Athletes with a bioprosthetic MV and who are not taking anticoagulants, and who have normal valve function and normal or near-normal left ventricular (LV) function can participate in low and moderate static and dynamic competitive sports. 2. Athletes with a mechanical or bioprosthetic AV and with normal valve function and normal LV function can engage in low and moderate static and dynamic competitive sports. Athletes who participate in more than low-intensity competitive sports should undergo exercise testing to at least the level of activity achieved in competition. 3. For patients with mitral stenosis and who have undergone successful open or closed commissurotomy, participation in competitive sports should be based on the residual severity of mitral stenosis or regurgitation. The capacity to engage in physical exercise should be evaluated with a exercise tolerance test at least to the level of anticipated activity. Patients with LV dysfunction should be restricted from athletic participation in the same context as those without surgery. 4. Athletes who have undergone MV repair for regurgitation should not engage in sports that involve risk of bodily contact that might disrupt the repair. They can participate in low-intensity competitive sports and, in selected athletes, in low and moderate static and dynamic sports. In these recommendations for participation in sports, the main determinants are valve function, LV function, performance on exercise testing, and use of anticoagulants. Echocardiography and exercise testing are routinely performed within 1-2 months after HV surgery [26]. The referring physician can use these evaluations to help determine the appropriateness and intensity of CR. For patients who had MV reconstruction, which is most commonly secondary to myxomatous degeneration, there are insufficient data to determine whether exercise could hasten further degeneration of the valve [26]. Flameng et al [28] discuss the biochemical abnormalities in the myxomatous leaflets from patients with degenerative MV regurgitation. The leaflets are more extensible and less stiff than in normal valves. Barber et al [29] reported that chordae tendinae from patients with degenerative MV regurgitation were significantly weaker than normal chordae tendinae. Madaric et al [30] performed exercise echocardiography with 26 patients
966
Kiel
who had endoscopic MV repair, and did not find increased regurgitation. Meurin et al [10] evaluated 251 patients after MV repair who received CR, and there was no increased regurgitation. However, more studies are needed, particularly for long-term effects of more strenuous activities once the patient graduates from phase 2 CR and begins phase 3 CR at home or at a community fitness center. Most prosthetic valves are at least mildly stenotic [31]. Bleiziffer et al [32] found that patients with patient–prosthesis mismatch (PPM) of a bioprosthetic aortic valve had a lower predicted exercise capacity than patients without PPM. They suggest that PPM may limit the increase in cardiac output during exercise, similar to native aortic stenosis. This illustrates the need for individualized exercise prescriptions based on the cardiologist’s assessment of the patient before starting CR. PPM also has been studied in patients with MV prostheses but to a lesser extent than in patients with AV prostheses. Sakamoto and Watanabe [33] did not find significant differences in heart failure or pulmonary artery pressure between patients with PPM MV and patients without PPM MV. They recommend further evaluations of hemodynamics with exercise testing.
Underuse of CR Suaya et al [4] analyzed use of phase 2 CR by 267,427 Medicare beneficiaries who had an acute myocardial infarction or CABG. One part of the study included patients who also had a variety of comorbidities. One of the comorbidities was valvular heart disease, and the rate of CR use was only 14.2% for this patient group. Data for CR use by patients with HV surgery only are not available. One of the predictors of CR use was the distance to the nearest CR facility [4]. The researchers suggest that community or home-based CR programs be considered as supplements or alternatives for facility-based programs, particularly for low-risk patients who live in rural areas. The researchers also propose that CR use could be increased by improving methods of patient referral to CR, such as routine standing orders [4]. Grace et al [34] studied CR referral strategies on use rates in 2635 inpatients with CAD; 7.6% of these patients also had valve repair or replacement. The researchers compared 4 different referral strategies: (1) automatic referral in the discharge orders for eligible patients, (2) liaison referral whereby a nurse or physical therapist or a former patient who attended CR spoke with the inpatient, (3) a combination of both, and (4) referral at the discretion of the attending physician. The main results included percentage referral, percentage enrollment, and percentage of CR sessions attended. Enrollment was attending a CR intake assessment. The combination strategy achieved the greatest referral and enrollment rates, followed by the automatic referral strategy,
CARDIAC REHABILITATION AFTER HEART VALVE SURGERY
the liaison referral strategy, and, finally, referral at the physician’s discretion. The number of CR sessions attended did not differ significantly based on referral strategy. The researchers also report that the Ontario Cardiac Rehabilitation Pilot Project in 2002 established a target goal that at least 40% of eligible cardiac patients are referred to CR [34]. The referral rate in 1999 was less than 10% [35].
CONCLUSION CR should be part of the care plan for patients who have had HV surgery. CR is approved by the Centers for Medicare and Medicaid and is endorsed by numerous professional medical organizations, including the AACVPR and the American Heart Association. Although more large-scale studies are needed, analysis of data shows that CR improves exercise capacity and QOL and facilitates return to work, with minimal risk of significant adverse effects. In spite of this, CR is vastly underused. Proposals to remedy this include an automatic referral system and liaison referral assistance, and improvement in the availability of CR in communities that have poor access to the larger hospital-based facilities. Setting a target goal for CR referrals and CR attendance and a monitoring system also might improve CR use. Morbidity and mortality data should be gathered on patients who receive CR after HV surgery and those who do not.
REFERENCES 1. Thomas RJ, King M, Lui K, Oldridge N, Pina IL, Spertus J. AACVPR/ ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services. Circulation 2007;116:1611-1642. 2. Fuster V, Walsh RA, O’Rourke RA, et al, eds. Hurst’s the Heart. 12th ed. New York: McGraw Hill, 2008, 2230. 3. Wenger NK, Froelicher ES, Smith LK, et al. Cardiac Rehabilitation as Secondary Prevention. Clinical Practice Guideline. Quick Reference Guide for Clinicians, No. 17. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research and National Heart Lung, and Blood Institute. AHCPR Pub. No. 96-0673. October 1995. 4. Suaya JA, Shepard DS, Normand SLT, Ades PA, Prottas J, Stason WB. Use of cardiac rehabilitation by Medicare beneficiaries after myocardial infarction or coronary bypass surgery. Circulation 2007;116:16531662. 5. Decision Memo for Cardiac Rehabilitation Programs (CAG-00089R). Washington, DC: Centers for Medicare and Medicaid Services. U.S. Department of Health and Human Services; 2006. Available at http:// www.cmms.hhs.gov/medicare-coverage-database/details/nca-decisionmemo.aspx?NCAId⫽164&ver⫽12&NCDId⫽36&ncdver⫽3& NcaName⫽Cardiac⫹Rehabilitation⫹Programs&IsPopup⫽y&bc⫽ AAAAAAAAIAAA& ? Accessed July 6, 2011. 6. Gladkova MA, Kassirsky GI. Topical problems in rehabilitation following valve replacement. Cor Vasa 19 84;26:394-399. 7. Rimington H, Weinman J, Chambers JB. Predicting outcome after valve replacement. Heart 2010;96:118-123. 8. Newell JP, Kappagoda CT, Stoker JB, Deverall PB, Watson DA, Linden RJ. Physical training after heart valve replacement. Br Heart J 1980;44: 638-649.
PM&R
9. Sire S. Physical training and occupational rehabilitation after aortic valve replacement. Eur Heart J 1987;8:1215-1220. 10. Meurin P, Illiou MC, Ben Driss A, et al. Early exercise training after mitral valve repair: A multicentric prospective French study. Chest 2005;128:1638-1644. 11. Vanhees L, Stevens A, Schepers D, Defoor J, Rademakers F, Fagard R. Determinants of the effects of physical training and of the complications requiring resuscitation during exercise in patients with cardiovascular disease. Eur J Cardiovasc Prev Rehabil 2004;11:304-312. 12. Ueshima K, Kamata J, Kobayashi N, et al. Effects of exercise training after open heart surgery on quality of life and exercise tolerance in patients with mitral regurgitation or aortic regurgitation. Jpn Heart J 2004;45:789-797. 13. Toyomasu K, Nishiyama Y, Yoshida N, et al. Physical training in patients with valvular heart disease after surgery. Jpn Circ J 1990;54: 1451-1458. 14. Ruttenberg HD, Adams TD, Orsmond GS, Conlee RK, Fisher AG. Effects of exercise training on aerobic fitness in children after open heart surgery. Pediatr Cardiol 1983;4:19-24. 15. Gohlke-Barwolf C, Gohlke H, Samek L, et al. Exercise tolerance and working capacity after valve replacement. J Heart Valve Dis 1992;1: 189-195. 16. Jairath N, Salerno T, Chapman J, Dornan J, Weisel R. The effect of moderate exercise training on oxygen uptake post-aortic/mitral valve surgery. J Cardiopulm Rehabil 1995;15:424-430. 17. Mitchell BL, Exner DV, Wyse GD, et al. Prophylactic oral amiodarone for the prevention of arrhythmias that begin early after revascularization, valve replacement, or repair. JAMA 2005;294:3093-3100. 18. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update. Circulation 2007;115:2675-2682. 19. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease). Circulation 2008;118:e523-e661. 20. Sparling PB, Cantwell JD, Dolan CM, Niederman RK. Strength training in a cardiac rehabilitation program: A six-month follow-up. Arch Phys Med Rehabil 1990;71:148-152.
Vol. 3, Iss. 10, 2011
967
21. Hotta SS. Cardiac rehabilitation programs. Health Technol Assess Rep 1991;3:1-10. 22. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-381. 23. Robicsek F, Fokin A, Cook J, Bhatia D. Sternal instability after midline sternotomy. Thorac Cardiov Surg 2000;48:1-8. 24. Brocki BC, Thorup CB, Andreasen JJ. Precautions related to midline sternotomy in cardiac surgery: A review of mechanical stress factors leading to sternal complications. Eur J Cardiovasc Nurs 2010;9:77-84. 25. Westerdahl E, Moller M. Physiotherapy-supervised mobilization and exercise following cardiac surgery: A national questionnaire survey in Sweden. J Cardiothorac Surg 2010;5:67 [Epub ahead of print]. 26. Butchart EG, Gohlke-Barwolf C, Antunes MJ, et al. Recommendations for the management of patients after heart valve surgery. Eur Heart J 2005;26:25632471. 27. Bonow RO, Cheitlin MD, Crawford MH, Douglas PS. Task Force 3: Valvular heart disease. J Am Coll Cardiol 2005;45:1334-1340. 28. Flameng W, Herijers P, Bogaerts K. Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease. Circulation 2003;107:1609. 29. Barber EJ, Kasper KF, Ratliff NB, Cosgrove DM, Griffin BP, Vesely I. Mechanical properties of myxomatous mitral valves. J Thorac Cardiovasc Surg 2001;122:955-962. 30. Madaric J, Watripont P, Bartunek J, et al. Effect of mitral valve repair on exercise tolerance in asymptomatic patients with organic mitral regurgitation. Am Heart J 2007;154:180-185. 31. Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol 2000;36:1131-1141. 32. Bleiziffer S, Eichinger WB, Hettich I, et al. Impact of patient-prosthesis mismatch on exercise capacity in patients after bioprosthetic aortic valve replacement. Heart 2008;94:637-641. 33. Sakamoto H, Watanabe Y. Does patient-prosthesis mismatch affect long-term results after mitral valve replacement? Ann Thorac Cardiovasc Surg 2010;16:163-167. 34. Grace SL, Russell KL, Reid RD, et al. Effect of cardiac rehabilitation referral strategies on utilization rates. Arch Intern Med 2011;171:235241. 35. Ontario Cardiac Rehabilitation Pilot Project Report and Recommendations, 2002. Cardiac Care Network Web Site. Available at: http:// www.ccn.on.ca/pdfs/Rehab-Pilot-Project-Sep2002.pdf. Accessed June 10, 2011.