Which patients should be adressed to cardiac rehabilitation centers ? PATIENTS WITH VALVULAR HEART DESEASE Bernard PIERRE Déclaration de Relations Professionnelles Disclosure Statement of Financial Interest J'ai actuellement, ou j'ai eu au cours des deux dernières années, une affiliation ou des intérêts financiers ou intérêts de tout ordre avec une société commerciale ou je reçois une rémunération ou des redevances ou des octrois de recherche d'une société commerciale : I currently have, or have had over the last two years, an affiliation or financial interests or interests of any order with a company or I receive compensation or fees or research grants with a commercial company : Affiliation/Financial Relationship • • Grant/Research Support Consulting Fees/Honoraria Company • • • • • • • • • • Bayer BMS Bouchara – Recordati Daïchii MSD Novartis Pfizer Pierre Fabre Sanofi Servier A PARADOX ! • The cardiac rehabilitation : a program mostly indicated by cardiac surgeons • Nevertheless, their validation and recommendation level remains inferior to other indications • WHY ? Maladie Coronaire (hors chirurgie) Classe Niveau SCA « stabilisé » - Évaluation à l’effort -Prévention II -Education thérapeutique -Ambulatoire si possible I A Après ATL programmée -Évaluation à l’effort -Pas de sur-risque -Prévention II -Education thérapeutique -Ambulatoire si possible I B Angor stable -Évaluation à l’effort -Optimisation du traitement -Prévention II -Education thérapeutique -Ambulatoire si possible I B Management of ACS by cardiac rehabilitation Regional disparities de Peretti C.InVS. BEH 2014 Insuffisance Cardiaque Dysfonction systolique VG -Prise en charge globale -Programmes + longs Education thérapeutique -Ajustement traitement Fonction systolique préservée -Amélioration qualité de vie -Réduction hospitalisations Resynchronisati on cardiaque -Potentialisation effets de resynchronisation -Evaluation de la resynchronisation Assistances ventriculaires -Reconditionnement physique -Education : appareillage et AVK Transplantation Cardiaque -Pré-transplantation -Spécificités chirurgie, physiologie, immunologie -Aides psycho-sociales Classe Niveau I A II b C I B IIa C I B Artériopathie des membres inférieurs IPS < 0.9 Claudication ou Ischémie chronique Revascularisation -Améliore rhéologie, fonction endothéliale et extraction O2 -Améliore rendement -Marche -Exercices analytiques -Education thérapeutique -Sevrage tabagique -Appareillage Classe Niveau I A I A I B Autres indications Classe Niveau DAI - Évaluation à l’effort -Education thérapeutique -Aides psychologiques IIa B Cardiopathies congénitales -Amélioration des capacités fonctionnelles post-opératoire -Souvent IC, tr rythme, HTAP IIa C Haut risque CV -Évaluation à l’effort -Optimisation du traitement -Prévention II -Education thérapeutique -Ambulatoire+++ I A Chirurgie cardiaque Classe Niveau Pontages aortocoronaires - Prise en charge précoce en Centre privilégiée -Surveillance et SS - Type entraînement: IT I B Chirurgie valvulaire - Prise en charge précoce I B Chirurgie aorte thoracique - Prise en charge après dissection efficace bien tolérée - Surveillance PA II a C Pré-opératoire -Education - Ventilation, préparation à chirurgie coronaire IIb C en Centre privilégiée -Surveillance et SS -Type d’entraînement : combiné Cardiac surgeons have a better understanding of… • • • • Short hospitalization, but… Danger in home care (pericardial tamponade…) p-value < 0.05 for mortality is not α and Ω Better quality of life, lesser need of (re)hospitalization, morbidity reduction, rather than life expectancy • Cardiac rehabilitation center : ideal facility « Life is movement » Aristotle (4th century before Christ) Gohlke-Barwolf study 1200 patients 120 100 80 1 mois 6 mois 60 40 20 0 Rehabilitation program ? How ? RVM sur RVM sur RVA sur RVA sur IM RM IA RA 1 mois 55 40 76 70 6 mois 72 65 105 105 Exercise tolerance after valve replacement. Journal of Heart valve Dis. 1992;1:189-95 Per-cutaneous transluminal mitral stenosis plasty 10 days after •15 patients •VO2 peak : 952 + 271 to 1029 + 342 ml/mn (p = NS) Takaki et al. Heart Vessels. 1995;10(6):323-7 Exercise tolerance after mitral valve repair 216 + 80 days after MVR; n = 16 Exercise duration 700 680 660 640 620 600 580 560 Exercise duration peak VO2 * Before Surgery 7 months after 678 605 22 21,5 21 20,5 20 19,5 19 Before Surgery Le Tourneau et al. Circulation. 2000;36:2263-69 7 months after Hemodynamics abnormalities • Persist from 6 to 12 months after surgery Carstens V et al. Exercise capacity before and after cardiac valve surgery. Cardiology. 1983;70:41-49 • LVEF deterioration at exercises persists after 3months for many patients Jairath N et al. The effect of moderate exercise training on oxygen uptake post-aortic/mitralvalve surgery. Jcardiopulm Rehabil. 1995;15:424-430 Per-cutaneous transluminal mitral stenosis plasty • 26 patients Evolution VO2 * 26,6* 19,9 21,1 18,9 Avant chir 90j post chir Contrôle réadaptés w atts 29 27 25 23 21 19 17 15 Puissance d'effort 150 140 130 120 110 100 90 80 70 125* 94,6 108 96,1 Avant chir Douard H. Eur Heart J. 1997;18(3):464-9 90j post chir Contrôle Réadaptés • Improvement by 19% of VO2 peak after mitral valve replacement and 8 weeks rehabilitation program (while no positive evolution was noticed regarding the blank sample) Habel-Verge C et al. Cmaj. 1987;136:142-147 • Same results for aortic valve replacement Borg G et al. Int J Sports Med. 1982;3:153-158 • Whatever the age of the patient Ades PA et al. Am Heart J. 1990;120:585-589 Grands Prés Ph Meurin Broussais MC Iliou B Pierre IRIS S Corone Bligny Château Lemoine M Fischbach Kugler Beauvallon Ghannem Ollencourt L'Heritier Callian Ross Abreshviller Henry Recor Feige Rhone Durance Paemelaere Cambo Borgat Carquefou Cardiopulmonary Exercise Tests Evolution Early exercise training after mitral valv repair. CHEST 2005 % increase p Peak VO2 + 22 % 10-4 AT + 16 % 10-4 O2 pulse + 18 % 10-4 Ex duration + 34 % 10-4 Chron reserve + 18 % 10-4 PHYSICAL ACTIVITY AND MORTALITY 6 213 males referred to EFX ; 6 years Myers J et al. N Engl J Med. 2002;346:793-801 The most powerful life expectancy predictive factor • Excluding the age factor, VO2 pic: Stronger predictive value than classic risk factors (all death causes) Winning 1 MET = life expectancy increase of 12% Myers JN et al.N Engl. J. Med. 2002 • Physical condition = modifiable factor Gaining 1 min of effort = mortality reduction of 7.9% Blair SN et al. JAMA. 1995 GOALS 1 - Detect and treat complications and other pathologies 2 - Functional and risk evaluation 3 - Conform the therapy 4 - Optimize the secondary prevention : B.A.S.I.C. 5 - Make work resumption possible ; elderly ’s autonomy 6 - Attention, information, anti-overdramatization; teach self-evaluation 7 - Cost reduction 8 - Convey the « analysis » to correspondants * QoL and PRONOSTIC improvement* - ambulatory if possible: 2 to 5/week- ~ 20 days - hospitalization (recent surgeries, complications or associated desorders , seniors, unfavourable socio-psychologic conditions, high risk, severe HF) MEANS Global, Positive, pluridisciplinary treatment Medical (compulsory cardiologic presence) Paramedical . Occupational therapy . Physical therapy . Endurance training . Balneotherapy, hydrotherapy . Relaxation, support psycho-therapy, stress-management assistance . Anti-tobacco struggle . Dietetics . Professional reinsertion INITIAL & FINAL EVALUATION • Risk and capacities stratification – Clinical examination- ECG - biology- Chest X-ray - echocardiography- Holter – Patient and desease story – Pronostic factors (LVEF - ischemia - arrhythmia) – Associated comorbidities (pneumo - ortho - neuro) – Treatment to adapt – Initial motivation – Psychological impact – Work station – EFX(i) - 6 min walk test – To specify the rehabilitation program SPECIFICITIES • Elderly (TAVI) • Frequent comorbidities • Frequent complications : *arhythmias (AF +++, 50 %) with high risk of thomboembolic events *high degrees of A-V blocks *postoperative pericardial effusion (50 – 85 %), late tamponade : 60 % during cardiac rehabilitation *infectious *heart failure *psychological disorders • Therapeutic education : septic endocarditis, VKA • 3 – 4 weeks Return to work ? • One of the main goals of cardiac rehabilitation • Several studies show that RTW predictive factors after valve surgery are closely linked to functional exercise capacity, pre-operative pofessional status and psycho-sociological factors Gohlke-Barwolf C et al. J Heart Valve Dis. 1992;1:189-95 Sire S et al. Eur Heart J. 1987;8:1215-20 Hedback B et al. Eur Heart J. 1993; 14:831-35 PHYSICAL ACTIVITY: A FANTASTIC THERAPY? • « An agent with lipid-lowering, antihypertensive,positive inotropic,negative chronotropic, vasodilatating, diuretic, anorexigenic, weight reducing, hypoglycemic, tranquilizing, hypnotic and antidepressive. » • Williams C. Roberts, editor-in-chief Am J Cardiol. 1984;53:251 THANK YOU For your kind attention