Clinicians Call for Post Left Ventricular Assist Device Implantation Physical Activity Guidelines

Specific guidelines for cardiac rehabilitation and physical activity (PA) in left ventricular assist device (LVAD) recipients are lacking. The European Society of Cardiology (ESC) published a position statement on early mobilization (defined as 7–10 days postimplant) and exercise training in patients with LVAD that provides basic advice for PA and exercise.1 The statement cites several studies that support the safety of postimplant PA; however, cautions that measures be taken to reduce risk including: incorporation of warm-up and cool down periods, close monitoring, and protecting the sternotomy site for a minimum of 6 weeks and driveline with a stabilization belt during PA.1 The ESC paper did not identify specific parameters to guide PA post-LVAD implantation and identified a critical need for evidence to support guidelines.1 Given the lack of research evidence upon which to base specific guidelines for cardiac rehabilitation and PA in the postimplantation period, our team initiated a web-based survey. Our objective was to gain information from LVAD clinicians concerning current practice, barriers, and perceived need for evidence-based PA guidelines. Methods Our survey was distributed in 2019 to LVAD clinicians through the International Society for Heart and Lung Transplantation (ISHLT) Connect membership portal, via email to the membership of the Heart Failure Society of America (HFSA), in-person at a targeted international conference, and through targeted emails sent to primary, secondary, and senior authors of manuscripts describing exercise or PA in LVAD recipients. We attempted to reach potential participants twice via email or membership community (maximum allowed by the organization). Clinicians were considered eligible if they currently worked with LVAD recipients. They demonstrated informed consent by completing the survey. The 53 item survey was assessed for face and content validity by a team of experts including a cardiothoracic surgeon, a cardiology fellow, and two heart failure advance practice providers. We collected individual and center demographics, and post-LVAD implantation outpatient PA recommendations, the use of cardiac rehabilitation in LVAD recipients, and the use of guidelines for PA. Responses included a 5 point Likert scale, categorical options, or open-ended questions that explored patient and institutional barriers to initiating and sustaining PA. Sixty clinicians representing LVAD implanting centers from 10 countries including Israel, the United Kingdom, Germany, Italy, Canada, Spain, Australia, and 24 states in the United States completed the survey. Clinician and facility demographics are reported in Table 1, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A580. To preserve clinician anonymity, we did not record the city or name of the facility. Figure 1, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A580 (included in supplementary material) shows the distribution of clinicians by country. Clinicians were predominately cardiologists or cardiothoracic surgeons (48.3%) and LVAD coordinators or Advanced Practice Providers (38.4%) and reported a mean of 31.5 (±20.1) LVAD implantations per year. Most strongly agreed or agreed that they recommend patients participate in PA post-LVAD (86.7%) in the outpatient setting. Importantly, 91.7% of clinicians indicated they strongly agreed or agreed with the statement “Guidelines for PA post-LVAD are needed” (Figure 1). Responses were compared across countries and US states; no differences were noted.Figure 1.: Responses to PA in advanced heart failure survey. Responses were formulated on a 5 point Likert scale ranging from “strongly agree” to “strongly disagree.” PA, physical activity.Clinicians indicated frequency, duration, and intensity recommendations for PA post-LVAD. Less than 2 weeks was the most common wait time to resume daily PA, whereas a few clinicians (5%) recommended a wait time greater than 6 weeks. Most clinicians recommended ≥4 PA sessions/week of 21–30 minutes at an intensity of 11–13 on the Borg rating of perceived exertion post-LVAD. Nearly, all clinicians (57/60) recommended walking as a form of PA for their LVAD patients, followed by stationary bike (45/60), and strength training (33/60). Thirty-one clinicians (51.7%) indicated their facility either currently uses a cardiac rehabilitation program designed for patients with LVADs or has a program under development. The remaining clinicians reported there was not a specific program in place or planned (20/60, 33.3%) or were unsure (8/60, 13.3%). Four open-ended questions assessed perceptions of patient and institutional barriers in initiating and sustaining PA. More than 90% (55/60) of clinicians provided responses to at least one of the open-ended questions. Physical limitations and deconditioning were the most common perceived patient barriers to initiating PA. Motivation, fear, lack of guidelines, and access were commonly mentioned patient barriers to both initiating and sustaining PA. Table 2, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A580 (included in supplementary material) highlights the frequency of each of these facilitators/barriers and exemplars from clinicians. Clinicians mentioned the importance of personnel training to monitor patients’ responses to PA, device care while being physically active, and guidelines for best practices (e.g., goals for someone with continuous flow therapy). Cost, access, lack of reimbursement, lack of guidelines, and lack of appropriately trained staff were noted institutional barriers. Barriers specific to accessing outpatient cardiac rehabilitation in rural areas were also noted—“Rural patients have trouble finding a cardiac rehab center with staff trained for LVADs and/or rural cardiac rehab centers are terrified and will not accept LVAD patients.” Discussion Overall, our findings indicate global practice of PA post-LVAD implantation is variable without specific guidelines. A summary of inpatient and outpatient practices reported by clinicians in our survey is included in Table 3, Supplemental Digital Content 1, https://links.lww.com/ASAIO/A580. Although clinicians in our sample agreed that PA is important in the post-LVAD implantation period, there is little specific guidance or evidence to support best practices.2,3 Further research is needed to develop evidence-based guidelines to direct PA for patients post-LVAD implantation. The ESC position statement on early mobilization and exercise training in patients with LVAD identified a lack of evidence to support PA beyond aerobic training, the optimal timing, frequency, duration, and intensity of training sessions. Exercise prescriptions, target heart rates, how to increase patient self-efficacy in PA, and the role of the caregiver were identified as targets for future research.1 As evidence accumulates to support PA in LVAD therapy, the need for guidelines will grow. Our findings indicate that clinicians desire more direct guidance to help patients, clinicians, and rehabilitation providers to improve PA in patients with LVADs. More interventional and outcomes research is needed to help LVAD recipients initiate and sustain a PA regimen and support funding for post-LVAD PA and cardiac rehabilitation programs. The clinicians surveyed represented a diverse, global pool; however, our sample was not all inclusive and some LVAD implanting centers/regions of the world were not represented. We recognize this important limitation in the generalizability of our findings. Although our findings did not identify a precise guide for best practices, they should be taken as a call to action. This survey aimed to validate that LVAD clinicians perceive a need for specific PA guidelines in the postimplantation period. Our results indicate this is the case. Guideline development requires multidisciplinary, global collaboration, and research to provide a robust evidence base to identify appropriate timing, intensity, and setting for the initiation and continuation of PA in patients with LVADs. More specific information on current protocols and where they are being used would be an important first step in summarizing current practice.