Our analysis suggests that EBCR results in significant improvements in functional capacity as measured by 6MWD and peak
The improvements noted with EBCR in our analysis appear comparable to those observed with other common interventions in advanced systolic HF such as cardiac resynchronization therapy. In a substudy of COMPANION (The Comparison of Medical Therapy, Pacing, and Defibrillation in Heart Failure),22 trial patients who underwent cardiac resynchronization therapy had an average improvement of 1.26 mL/kg/min (from a baseline of 12.7 mL/kg/min) in peak
The persistent functional impairment, despite adequate hemodynamic support after LVAD implantation, may be related to other peripheral mechanisms such as skeletal muscle deconditioning and apoptosis associated with advanced HF.28 Derangement of skeletal muscle structure and metabolic function is associated with exercise intolerance and fragility. These changes correlate poorly with central hemodynamics.29 Recruitment of skeletal muscle fibers during exercise is known to increase oxygen transport and uptake by skeletal muscles, upregulation of anabolic enzymes, and decrease in the catabolic catalysts. These favorable changes lead to an increase in peak muscle strength and could contribute to the additive benefits of EBCR in LVAD recipients.30 Furthermore, none of the included studies in our review reported serious adverse events related to EBCR. In 1 recent retrospective study, Marko et al18 identified only 1 training-related adverse event in 41 LVAD recipients undergoing a total of 1600 training sessions. Thus, participation in EBCR shortly after LVAD implantation appears safe, despite the limited nature of the available evidence.31 In addition, there are very limited data comparing the benefits of traditional EBCR to home-based rehabilitation programs in this patient population. Cinar et al32 demonstrated a greater improvement in peak
There were limitations with this review and analysis. As with any meta-analysis, our study inherits the intrinsic limitations of each of the included studies. Second, the limited number of studies (3 for meta-analysis and 6 for the review) and the overall small number of subjects limit the general applicability of our findings. In addition, we could not accurately assess the impact of EBCR on QOL in this cohort due to discrepancies between studies in the tools used for assessing QOL. Finally, all included studies were single-center trials and there was heterogeneity in the type of LVADs used and the protocols of EBCR among the included trials. This highlights the need for larger well-designed, multicenter studies on the impact of EBCR in LVAD recipients using standardized CR protocols.
We thank Kate Hayes, digital repository and reference librarian, at Creighton University Health Sciences Library for her support in conducting the search and article procurement.
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