The left ventricular assist device 'skeleton man': case report-simple tools for skeletal muscle evaluation and very early aerobic/resistance/inspiratory training in cardiac cachexia.

Background: Skeletal muscle wasting (SMW) is highly prevalent in patients with heart failure (HF) at left ventricular assist device (LVAD) implantation and is associated with morbidity and mortality. At the same time, SMW is clinically under-recognized, while exercise training (ET) studies in weak LVAD patients are lacking.

Case Summary: A 60-year-old man with advanced HF, SMW, cardiac cachexia, and frailty was confined in bed for 6 months initially supported with intravenous inotropes and subsequently with an intra-aortic balloon pump.

Combined aerobic/resistance/inspiratory muscle training as the 'optimum' exercise programme for patients with chronic heart failure: ARISTOS-HF randomized clinical trial.

Aims: An 'optimum' universally agreed exercise programme for heart failure (HF) patients has not been found. ARISTOS-HF randomized clinical trial evaluates whether combined aerobic training (AT)/resistance training (RT)/inspiratory muscle training (IMT) (ARIS) is superior to AT/RT, AT/IMT or AT in improving aerobic capacity, left ventricular dimensions, and secondary functional outcomes.

Methods And Results: Eighty-eight patients of New York Heart Association II-III, left ventricular ejection fraction  ≤ 35% were randomized to an ARIS, AT/RT, AT/IMT, or AT group, exercising 3 times/week, 180 min/week for 12 weeks.

Restoring pulsatility and peakVO in the era of continuous flow, fixed pump speed, left ventricular assist devices: 'A hypothesis of pump's or patient's speed?'.

Despite significant improvement in survival and functional capacity after continuous flow left ventricular assist device implantation, the patient's quality of life may remain limited by complications such as aortic valve insufficiency, thromboembolic episodes and gastrointestinal bleeding attributed to high shear stress continuous flow with attenuated or absence of pulsatile flow and by a reduced peak oxygen consumption (peakVO) primarily associated with a fixed pump speed operation. Revision of current evidence suggests that high technology pump speed algorithms, a 'hypothesis of decreasing pump's speed' to promote pulsatile flow and a 'hypothesis of increasing pump's speed' to increase peakVO, may only partially reverse these barriers. A 'hypothesis of increasing patient's speed' is introduced, suggesting that exercise training may further contribute to the patient's recovery, enhancing peakVO and pulsatile flow by improving skeletal muscle oxidative capacity and strength, peripheral vasodilatory and ventilatory responses, favour changes in preload/afterload and facilitate native flow, formulating the rationale for further studies in the field.

Exercise training in patients with ventricular assist devices: a review of the evidence and practical advice. A position paper from the Committee on Exercise Physiology and Training and the Committee of Advanced Heart Failure of the Heart Failure Association of the European Society of Cardiology.

Exercise training (ET) and secondary prevention measures in cardiovascular disease aim to stimulate early physical activity and to facilitate recovery and improve health behaviours. ET has also been proposed for heart failure patients with a ventricular assist device (VAD), to help recovery in the patient's functional capacity. However, the existing evidence in support of ET in these patients remains limited.

The 'aerobic/resistance/inspiratory muscle training hypothesis in heart failure'.

Evidence from large multicentre exercise intervention trials in heart failure patients, investigating both moderate continuous aerobic training and high intensity interval training, indicates that the 'crème de la crème' exercise programme for this population remains to be found. The 'aerobic/resistance/inspiratory (ARIS) muscle training hypothesis in heart failure' is introduced, suggesting that combined ARIS muscle training may result in maximal exercise pathophysiological and functional benefits in heart failure patients. The hypothesis is based on the decoding of the 'skeletal muscle hypothesis in heart failure' and on revision of experimental evidence to date showing that exercise and functional intolerance in heart failure patients are associated not only with reduced muscle endurance, indication for aerobic training (AT), but also with reduced muscle strength and decreased inspiratory muscle function contributing to weakness, dyspnoea, fatigue and low aerobic capacity, forming the grounds for the addition of both resistance training (RT) and inspiratory muscle training (IMT) to AT.

Inspiratory work capacity is more severely depressed than inspiratory muscle strength in patients with heart failure: Novel applications for inspiratory muscle training.

Background: We hypothesized that the ability to sustain maximal inspiratory pressure (SPImax) over time as a measure of work capacity may be more severely affected than inspiratory muscle strength (PImax) in patients with heart failure (HF).

Methods: We retrospectively investigated eighty patients with HF, NYHA II/III/ ambulatoryIV and a (mean±SD) LVEF 27±8%, and compared them to 25 healthy subjects (HS). During a maximal inspiratory manoeuvre from residual volume (RV) to total lung capacity, PImax was measured as the maximum mouth pressure at RV, inspiratory contraction time (ICT) as the time from RV to end of inspiration and SPImax as the area under a pressure-time curve using an electronic pressure manometer with designed-purpose software (Trainair(®), Project Electronics Ltd.

Combined aerobic/inspiratory muscle training vs. aerobic training in patients with chronic heart failure: The Vent-HeFT trial: a European prospective multicentre randomized trial.

Aims: Vent-HeFT is a multicentre randomized trial designed to investigate the potential additive benefits of inspiratory muscle training (IMT) on aerobic training (AT) in patients with chronic heart failure (CHF).

Methods And Results: Forty-three CHF patients with a mean age of 58 ± 12 years, peak oxygen consumption (peak VO2 ) 17.9 ± 5 mL/kg/min, and LVEF 29.

Thyroid hormone signalling is altered in response to physical training in patients with end-stage heart failure and mechanical assist devices: potential physiological consequences?

Objectives: The present study investigated the potential of the failing myocardium of patients with ventricular assist devices (VAD) to respond to physiological growth stimuli, such as exercise, by activating growth signalling pathways. This may be of therapeutic relevance in identifying novel pharmacological targets for therapies that could facilitate recovery after VAD implantation.

Methods: Twenty-two patients bridged to heart transplantation (HTx) with VAD were included in the study.

Benefits of combined aerobic/resistance/inspiratory training in patients with chronic heart failure. A complete exercise model? A prospective randomised study.

Background: We hypothesised that combined aerobic training (AT) with resistance training (RT) and inspiratory muscle training (IMT) could result in additional benefits over AT alone in patients with chronic heart failure (CHF).

Methods: Twenty-seven patients, age 58 ± 9 years, NYHA II/III and LVEF 29 ± 7% were randomly assigned to a 12-week AT (n=14) or a combined AT/RT/IMT (ARIS) (n=13) exercise program. AT consisted of bike exercise at 70-80% of max heart rate.

Prognostic value of NT-proBNP at rest and peak exercise in patients with impaired left ventricular function.

We aimed to identify whether N-terminal fragment of pro-brain natriuretic peptide (NT-proBNP) at peak exercise can provide incremental clinical information over resting levels. A total of 90 patients with systolic heart failure were prospectively studied. Levels of plasma NT-proBNP were assessed at rest and at peak exercise during a cardiopulmonary exercise test.

Prognostic significance of blood pressure response to exercise in patients with systolic heart failure.

High systolic blood pressure (SBP) has been linked to worse cardiovascular outcomes. However, emerging data suggest that in patients with heart failure (HF), low SBP correlates with increased mortality. The purpose was to examine the impact of baseline and post-exercise systolic and diastolic blood pressure (DBP), as well as pulse pressure (PP), on cardiac mortality in patients with systolic HF.

Benefits of physical training on exercise capacity, inspiratory muscle function, and quality of life in patients with ventricular assist devices long-term postimplantation.

Background: Capacity to exercise may not be fully restored in patients with heart failure even in the long term after ventricular assist device (VAD) implantation. The benefits of exercise training in patients with VAD are unknown.

Design And Methods: Fifteen patients, aged 38.

High plasma adiponectin is related to low functional capacity in patients with chronic heart failure.

We evaluated the association between plasma adiponectin and functional capacity in patients with chronic heart failure (CHF). Similarly to NT-proBNP, plasma adiponectin was elevated in CHF compared to healthy controls. Adiponectin correlated inversely with peak oxygen consumption and 6-minute walking distance and was able to identify CHF patients with impaired exercise capacity.

Incremental value of N-terminal pro-brain natriuretic peptide over left ventricle ejection fraction and aerobic capacity for estimating prognosis in heart failure patients.

Background: N-terminal pro-brain natriuretic peptide (NT-proBNP) plasma levels have been associated with indices of left ventricular (LV) function and aerobic capacity in heart failure.

Methods: We prospectively followed-up 149 patients with impaired left ventricular function for 30 +/- 10 months. During this period, 22 patients died and 5 underwent heart transplantation.

N-terminal prohormone brain natriuretic peptide plasma levels in heart failure are affected both directly and indirectly by carvedilol.

N-terminal prohormone brain natriuretic peptide (NT Pro BNP) is a sensitive marker of left ventricular function in patients with heart failure. The influence of carvedilol on NT Pro BNP plasma levels was analyzed in 21 heart failure patients. Blood samples were taken before administration and after 12 months of treatment with low-dose carvedilol.

Effects of inspiratory muscle training on autonomic activity, endothelial vasodilator function, and N-terminal pro-brain natriuretic peptide levels in chronic heart failure.

Purpose: To assess the effects of inspiratory muscle training (IMT) on autonomic activity, endothelial function, and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in patients with chronic heart failure.

Methods: Using age- and sex-matched controlled study, 23 patients (mean left ventricular ejection fraction 29 +/- 2%) were assigned to either a high-intensity training group (n = 14), New York Heart Association (NYHA) class II (n = 9)/III (n = 5), or a low-intensity training group (n = 9), NYHA class II (n = 6)/III (n = 3), exercising at 60% and 15% of sustained maximum inspiratory pressure (SPImax), respectively, 3 times per week for 10 weeks. Before and following IMT, patients underwent cardiopulmonary exercise testing and dyspnea evaluation on exertion.

Chronotropic and neurohumoral markers for the evaluation of functional capacity in patients with impaired left ventricular function.

Introduction: Brain natriuretic peptide (BNP) levels correlate with functional capacity in patients with heart failure. Autonomic dysfunction and baro-chemo reflex balance play a role in conditioning exercise tolerance and chronotropic competence in heart failure. In this study we examined the relationship between N-terminal pro-brain natriuretic peptide (NT-pro-BNP) and heart rate (HR) response during cardiopulmonary exercise testing and the ability of those two markers to detect low functional class patients.

Immune response to inspiratory muscle training in patients with chronic heart failure.

Background: The effects of inspiratory muscle training on plasma cytokines, C-reactive protein and the soluble apoptosis mediators Fas and Fas ligand in chronic heart failure are unknown.

Design And Methods: Thirty-eight patients with chronic heart failure, age 57+/-2 years, New York Heart Association classification II-III, were assigned to either a high intensity training group (n=15, age 53+/-2 years) exercised at 60% of sustained maximal inspiratory pressure, or a low intensity training group (n=23, age 59+/-2 years), exercised at 15% of sustained maximal inspiratory pressure, three times per week for 10 weeks. Patients in the high intensity training group and low intensity training group were matched for age, sex and New York Heart Association functional class.

N-terminal prohormone brain natriuretic peptide as a marker for detecting low functional class patients and candidates for cardiac transplantation: linear correlation with exercise tolerance.

Background: N-terminal prohormone brain natriuretic peptide (NT Pro BNP) plasma levels have been associated with indices of left ventricular (LV) function and aerobic capacity in heart failure. The aim of our study was to use NT Pro BNP for the prediction of low functional class patients and also to detect candidates for cardiac transplantation.

Methods: We studied 100 patients with impaired left ventricular (LV) function.

Inspiratory muscle training in a patient with left ventricular assist device.

The use of mechanical assist devices as a 'bridge' to cardiac transplantation, as a "bridge" to recovery, or as a destination therapy in end-stage heart failure, is increasing. Studies of different modes of rehabilitation in this population are lacking. We report the benefits of inspiratory muscle training on the exercise capacity and quality of life in the recipient of a left ventricular assist device.