Artigo Coração Artificial e Reabilitação Cardíaca

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Atsuko Ueno, MD, PhD · Yasuko Tomizawa, MD, PhD
Cardiac rehabilitation and artifi cial heart devices
Abstract Recently, cardiac rehabilitation has gained popu-
larity in Japan because benefi cial effects on patients’ prog-
nosis have been reported. Another reason is that cardiac 
rehabilitation has been covered by health insurance since 
1988 in Japan. Currently, cardiac rehabilitation is covered 
for the diseases of angina pectoris, acute myocardial infarc-
tion, chronic heart failure (CHF), peripheral arterial disease, 
and diseases of the aorta and after open-heart surgery. Left 
ventricular assist devices (LVADs) are sometimes used in 
patients with progressive CHF symptoms to provide circu-
latory support, because in most of these patients heart 
failure does not improve with application of medical 
therapy, intra-aortic balloon pumping, or a percutaneous 
cardiopulmonary system. Modern VAD control systems are 
compact, allowing patients to carry them around without 
diffi culty. Since patient management at the outpatient clinic 
has become possible, patients are able to expand the scope 
of their activities. Early active rehabilitation in patients 
implanted with a LVAD improves their condition, favor-
ably impacts the clinical course while they await heart trans-
plantation, and also improves posttransplant recovery. 
Exercise therapy is one of the important components in 
comprehensive cardiac rehabilitation. Exercise therapy is 
important to improve the quality of life of patients with 
LVADs. Appropriate exercise therapy is effective for 
patients with various cardiac conditions who undergo 
diverse treatments and is practiced actively by many 
patients. In order to facilitate cardiac rehabilitation safely 
and effectively for patients with serious conditions, educa-
tion for health care professionals is essential. In this review, 
we describe the concept of rehabilitation followed by cardiac 
rehabilitation for patients with heart failure, patients after 
open-heart surgery, and patients with implanted LVADs.
Key words Cardiac rehabilitation · Exercise · Ischemic 
heart diseases · Heart failure · Ventricular assist device
Introduction
Recently, the benefi t of cardiac rehabilitation in improving 
the prognosis of patients with heart diseases has been estab-
lished. Since health insurance coverage for cardiac rehabili-
tation has been expanded to a variety of diseases since 2006 
in Japan, many health care professionals are actively pre-
scribing cardiac rehabilitation for more patients. Heart dis-
eases such as heart failure (HF) are included in health 
insurance coverage. Along with advances in medicine, 
various artifi cial devices such as heart valves, circulatory 
assist devices, and hemodialyzers have been developed 
and used for treatment.1,2 Left ventricular assist devices 
(LVADs) for patients with serious cardiac failure is one 
such device. In this review, we describe the concept of reha-
bilitation followed by cardiac rehabilitation for patients 
with HF, patients after open-heart surgery, and patients 
implanted with a LVAD.
Rehabilitation and therapeutic exercise
The word “rehabilitation” originates from the Latin reha-
bilitare: “re-” means “again”, “-ation” means “do”, and 
habilitare means “to fi t” or “to qualify.”3 Rehabilitation has 
come to mean the process of recovery of the patient’s abili-
ties and restoration (rehabilitation into society) of a social 
life.
The defi nition of rehabilitation varies, and the defi nition 
of the World Health Organization (WHO) in 1981 was as 
follows: “Rehabilitation includes all measures aimed at 
reducing the impact of disabling and handicapping con-
ditions, and at enabling the disabled and handicapped to 
J Artif Organs (2009) 12:90–97 © The Japanese Society for Artificial Organs 2009
DOI 10.1007/s10047-009-0461-8
Received: October 2, 2008 / Accepted: April 4, 2009
A. Ueno
Department of Cardiology, Tokyo Women’s Medical University, 
Tokyo, Japan
Y. Tomizawa (*)
Department of Cardiovascular Surgery, Tokyo Women’s Medical 
University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo 162-8666, Japan
Tel. +81-3-3353-8111; Fax +81-3-3356-0441
e-mail: 4CRNRY@hij.twmu.ac.jp
MINIREVIEW
 91
achieve social integration. Rehabilitation aims not only at 
training disabled and handicapped persons to adapt to their 
environment, but also at intervening in their immediate 
environment and society as a whole in order to facilitate 
their social integration. The disabled and handicapped 
themselves, their families, and the communities they live in 
should be involved in the planning and implementation of 
services related to rehabilitation.”4
Rehabilitation consists of four fi elds: medical rehabilita-
tion, occupational rehabilitation, social rehabilitation, and 
educational rehabilitation. Medical rehabilitation is divided 
into three phases: the acute phase, convalescence phase, 
and maintenance phase. Rehabilitation targets all impair-
ments or disorders in all people. It is used not only for those 
who have disorders of the nerves, bones, and muscles, but 
also for those who have visceral disorders such as respira-
tory, circulatory, and renal dysfunctions.
Therapeutic exercise is the core of rehabilitation. Exer-
cise therapy recognizes “exercise” as a form of medical 
treatment. The systematization of therapeutic exercise as it 
is known today was developed by a Swedish fencing instruc-
tor named Pehr Henri Ling (1776–1839) in the 19th 
century,5,6 although therapeutic exercise in its modern 
meaning was introduced at the end of the 18th century. Ling 
was careful in distinguishing movements of potential cura-
tive effect from the concept of exercise in a general sense.6 
His concept contributed greatly to therapeutic exercise. He 
defi ned the direction and duration as well as the velocity 
and rhythm of exercise. He explained the importance of the 
starting and terminating points of the movement and the 
moving line which all parts of the body must follow. He also 
coined some terminology of movement. In the early 20th 
century, an outbreak of poliomyelitis in England directed 
the attention of therapeutic exercise to the improvement of 
paralysis. Therapeutic exercise was used throughout World 
Wars I and II to rehabilitate wounded soldiers back into 
society. As a result, systematization of rehabilitation was 
established.
When patients suffer from cerebral infarction and brain 
hemorrhage resulting in paralysis of the hands and feet, 
appropriate rehabilitation including therapeutic exercise 
restores their ability to move their hands and feet because 
a new nerve system develops in the brain.7 The mechanism 
of function recovery has been elucidated as a result of 
recent brain research. A new nerve system may develop in 
the brain as a result of rehabilitation because of plasticity 
(the characteristic of changing the role of neurons fl exibly 
according to the situation) of the brain. Nudo et al.8 dem-
onstrated brain plasticity in an in vivo experiment. Various 
studies in the fi elds of neuroscience and diseases of the 
nervous system are in progress, and the rehabilitation fi eld 
is expected to advance signifi cantly.
History of cardiac rehabilitation
Cardiac rehabilitation has been developed over the years 
for the management of patients with acute myocardial 
infarction. In the era when early recanalization therapy was 
not available, “bed rest” was important until the infarct 
layer became steady. Prolonged bed rest was the main 
therapy in Europe and the United States until the 1960s. 
The main purpose of cardiac rehabilitation was the preven-
tion of adverse effects from prolonged bed rest and the 
improvement of deconditioning.
Research on the safety of early mobilization and early 
stage exercise was conducted in the latter half of the 1960s, 
and therapeutic exercise for early mobilization and early 
hospital discharge became the mainstream approach. The 
early defi nition of cardiac rehabilitation was providedby 
the WHO in 1964 as “the sum of activities required to 
ensure them the best possible physical, mental, and social 
conditions so that they may, by their own efforts, resume as 
normal a place as possible in the life of community . . . and 
that . . . rehabilitation cannot be regarded as an isolated 
form of therapy, but must be integrated into the whole 
treatment of which it constitutes only one facet.”9 Patient 
education is an integral part of any cardiac rehabilitation 
program. What a patient should learn in order to improve 
prognosis and quality of life (QOL) begins with the patient’s 
recognition of what they need to learn; in other words, the 
patient’s own efforts are essential.
Cardiac rehabilitation was perceived as simply a synonym 
for “exercise.” Such perception has changed after the intro-
duction of percutaneous coronary intervention (PCI) as a 
treatment for patients with myocardial infarction or angina 
pectoris, and cardiac rehabilitation has been practiced in 
earnest since the 1990s. Especially, early hospital discharge 
and early rehabilitation into society were accelerated after 
the introduction of PCI with stents, and the degree of 
deconditioning has ameliorated. The purpose of cardiac 
rehabilitation has moved toward secondary prevention.
In an updated statement in 1994, the American Heart 
Society10,11 defi ned cardiac rehabilitation as the “coordi-
nated sum of interventions required to ensure the best 
physical, psychological, and social conditions so that patients 
with chronic or post-acute cardiovascular disease may, 
by their own efforts, preserve or resume optimal function-
ing in society and, through improved health behaviors, 
slow or reverse progression of disease”. Thus cardiac reha-
bilitation consists of all the elements of comprehensive 
rehabilitation.
In the fi eld of comprehensive cardiac rehabilitation, 
Japan has lagged far behind Europe and the United States. 
It was therefore a surprise to fi nd that as early as 1956, Dr. 
Noboru Kimura of Kurume University had in fact advo-
cated “positive therapeutic exercise for acute myocardial 
infarction convalescence” at a lecture of the Japanese Inter-
nal Medicine Association Meeting.12 More than 20 years 
later, a research group funded by the Ministry of Health 
and Welfare was organized in 1980,13 and this marks the fi rst 
step toward the establishing of cardiac rehabilitation in 
clinical cardiology in Japan. Cardiac rehabilitation was 
covered by health insurance for the fi rst time in 1988, and 
the conditions covered were expanded to include post-
coronary artery bypass grafting (CABG) and angina pecto-
ris, in addition to cardiac infarction. Thereafter, the 
92 
conditions covered by health insurance were revised many 
times. In 2006, chronic heart failure (CHF), peripheral arte-
rial diseases, and diseases of the aorta were added to the 
former list of diseases covered by health insurance for 
cardiac rehabilitation.14 The scope of cardiac rehabilitation 
is expected to expand further in the future.
The effect and practice of therapeutic exercise
Exercise should be recognized as one component within a 
comprehensive plan to lower cardiovascular risks (including 
plans to mitigate obesity, hypertension, dyslipidemia, and 
diabetes) and improve overall outcome. Exercise may 
reduce various HF symptoms in daily life, such as breathing 
diffi culties and fatigue or angina attack, and as a result, 
improve the patient’s QOL. Endurance exercise (such as 
aerobic exercises, e.g., walking, running, and cycling) is a 
critical component in cardiac rehabilitation. Patients achieve 
optimal functional outcome with a well-balanced exercise 
program that includes muscle endurance, fl exibility, and 
resistance training aimed at reducing cardiovascular disease 
risk factors while improving physiological responses to 
physical challenges. As an overall effect, exercise training 
has been reported to decrease the occurrence of coronary 
events and the frequency of hospitalization due to progres-
sion of HF, and to improve the prognosis.15
In preparing exercise prescriptions, clinicians should 
consider a variety of factors: safety factors (clinical history, 
risk stratifi cation and exercise risk, degree of left ventricular 
impairment, ischemic and anginal threshold, and any 
cognitive or psychological impairment that may impede 
adherence to exercise limits), associated factors (vocational 
and avocational requirements, orthopedic limitations, 
premorbid state before onset, current activities, and per-
sonal health and fi tness goals), and other noncardiac 
considerations.16–18
The guidelines of the American College of Sports Medi-
cine on exercise programs for cardiac patients recommend 
a warm up of 5–10 min, continuous or intermittent aerobics 
for 30–45 min (resistance training added depending on con-
ditions), and a cool down of 5–10 min. It is necessary to 
consider safety, and the heart rate should be monitored 
initially.19
Several approaches are adopted to prescribe exercise 
intensity, such as percentage of peak heart rate (PHR), 
heart rate reserve (HRR), metabolic equivalent (MET), 
and rate of perceived exertion (RPE). The target heart rate 
(HR) is calculated as a percentage of PHR from the exer-
cise test, and is set between 40% and 85%, and varies 
depending on the patient’s condition. HRR is defi ned based 
on the peak HR and resting HR. The target HR is calcu-
lated based on the reserve HR and is adjusted for the resting 
HR, e.g., reserve HR = PHR − resting HR, or 150 − 70 = 
80. If the target is 60% of PHR, 80 × 0.6 = 48. Then the 
resting HR is added to 48 to provide a target HR of 118.17 
This method gives a result that is usually close to the equiva-
lent oxygen consumption value. The exercise prescription 
can be written using the workload and exercise intensity 
expressed in MET.
It is best to perform exercise training in an environment 
with controlled temperature, humidity, altitude, and pollu-
tion level, since these environmental factors may infl uence 
HR and RPE, and to use ergometers or treadmills as exer-
cise modalities. For patients who can reliably use the RPE 
scale, this can be an excellent adjunct to HR data, and is 
especially useful when medication changes affect HR or 
when HR cannot be assessed accurately. It is important to 
use standardized RPE instructions and to verify the RPE 
ratings during the actual exercise practice, because they 
may differ slightly from those obtained during the exercise 
test. The above approaches may be used independently or 
in combination (for example, using the RPE at the HR or 
MET level observed during evaluation), but in any case 
they should result in exercise training parameters that are 
below all the criteria indicating a need for lowering the 
upper limit of exercise intensity. The peak exercise HR 
should be set at a minimum of 10 bpm below the HR that 
has been associated with any sign or symptom specifi ed in 
the criteria. The corresponding systolic blood pressure 
response and perceived exertion should also be considered 
when establishing the exercise intensity.16 The frequency, 
intensity, and duration of exercise training may be modifi ed 
to achieve specifi c fi tness or health-related outcomes.
Rehabilitation for ischemic heart diseases
Approximately 170 000 people die of heart diseases every 
year in Japan. Heart disease ranks second among all causes 
of death, after malignant neoplasm. In Japan, the mortality 
rate of ischemic heart disease including acute myocardial 
infarction was 59.8 per 100 000 people in 2006.20
Acute myocardial infarction occurs when the blood fl ow 
to the cardiac muscle is interrupted due to blockage of the 
coronary arteries. Necrosis of the cardiac muscle occurs, 
which may be fatal as a result of serious complications such 
as ventricular fi brillation, pump failure, or cardiac rupture. 
Acute myocardial infarction infl uences cardiac function, 
body condition, andpsychological state. Therefore, the goal 
of medical treatment for ischemic heart diseases is twofold: 
promotion of health-related QOL and improvement of 
prognosis.
Therapeutic exercise for ischemic heart disease is classi-
fi ed into three phases, depending on the time from onset. 
Phase I targets the period from admission (onset of cardiac 
infarction) until discharge. The main goal of therapeutic 
exercise during this period is to protect the residual myo-
cardium and to facilitate the performance activities of daily 
living safely following discharge. Phase II targets the period 
from when the patient leaves hospital to rehabilitation into 
society. During this period, the aims are for the patient to 
increase the range of physical activities at home and in the 
community, and to return to work or other social activities 
with the best possible physical and mental conditions. Phase 
III is the period after the patient returns to society, and the 
 93
aim is for the patient to maintain mobility and self-
management.
Up to now, therapeutic exercise has been reported to be 
effective in reducing total deaths, cardiovascular deaths, 
and fatal myocardial re-infarction and in increasing event-
free survival and exercise capacity in patients with stable 
angina pectoris.21,22 Lifestyle-related diseases such as diabe-
tes, obesity, high blood pressure, and hyperlipidemia 
increase the risk of ischemic heart disease. Therapeutic 
exercise should also be effective for secondary prevention 
of these coronary risk factors.23,24 In summary, recent cardiac 
rehabilitation for ischemic heart disease includes an element 
of therapeutic exercise in the early stage for early mobiliza-
tion and social reintegration, as well as primary and second-
ary prevention of ischemic heart disease.
Rehabilitation after open-heart surgery
Gibbon25 developed the extracorporeal circulation tech-
nique in 1953, and used it clinically in an open-heart surgery. 
Postoperative rehabilitation had already been reported by 
around 1960.26,27 With the advances in minimally invasive 
surgery, CABG has been performed without extracardial 
circulation in recent years. However, most cardiovascular 
surgeries are performed through a median sternotomy inci-
sion. Therefore, these surgeries remain highly invasive for 
the whole body, including the chest. The importance of 
postoperative rehabilitation, including physiotherapy, is 
increasing. The aim of postoperative cardiac rehabilitation 
is to provide positive support to improve QOL28 and to 
improve prognosis from early after the operation.
The specifi c objectives are: (1) prevention of respiratory 
complications after surgery, (2) maintenance and improve-
ment of myocardium function, (3) wound protection, (4) 
improvement of cardiac symptoms, (5) improvement of 
physical function and exercise capacity, (6) secondary pre-
vention of coronary artery disease and prevention of cardiac 
events, (7) stabilization of mental and psychological states, 
(8) improvement of QOL, and (9) improvement of progno-
sis of patients.29
Patients with heart disease and postoperative patients 
are recommended to do a minimum level of muscle training 
needed for the performance of activities of daily living, and 
range-of-motion (ROM) exercises of the upper and lower 
extremities are considered appropriate. ROM is the extent 
of osteokinematic motion available for movement activi-
ties, functional or otherwise, with or without assistance. The 
purpose of ROM exercise is to improve the motor functions 
of joints with restricted ROM caused by contracture or 
decreased muscle strength through active, active-assistive, 
or passive exercises to increase the ROM of the joints and 
to prevent a decrease in tissue pliability. Postoperative 
patients should avoid resistance training exercise within 3 
months of sternotomy because it may cause pulling of the 
sternum.30
The programs of cardiac rehabilitation after cardiac 
surgery differ among individuals because of the differences 
in etiology, severity of symptoms, and operating methods. 
The majority of heart surgeries include CABG, valve 
replacement, or valvuloplasty. Patients undergoing these 
procedures are indicated for cardiac rehabilitation. The 
number of patients who participate in cardiac rehabilitation 
after undergoing surgeries for acute aortic dissociation and 
thoracic or abdominal aortic aneurysm is expected to 
increase because of the medical fee revisions of April 2006. 
Rehabilitation programs should be planned with under-
standing of patients’ clinical conditions according to the 
underlying diseases.
Rehabilitation of chronic heart failure
Heart failure is a complex syndrome. It may be caused by 
any structural or functional cardiac disorder that impairs 
fi lling of the ventricle or ejection of the blood from the 
ventricle. The symptoms of HF are dyspnea and fatigue, 
which may limit exercise tolerance, and fl uid retention, 
which may lead to pulmonary congestion and peripheral 
edema.31 Exercise capacity decreases in patients suffering 
from HF. Factors that may limit exercise are insuffi cient 
oxygen transfer due to reduced cardiac output and anemia; 
shortness of breath and dyspnea due to hyperventilation, 
elevated lung capillary pressure, increased sensitivity of 
chemoreceptors, or fatigability of respiratory muscles; and 
easy fatigue and dyspnea on effort due to reduced skeletal 
muscle.
The effectiveness of therapeutic exercise in patients with 
CHF has been reported recently.32,33 Appropriate therapeu-
tic exercise corrects the abnormal conditions of CHF and 
consequently improves QOL and survival. Therefore thera-
peutic exercise is classifi ed as a class I in classifi cation of 
recommendations in the 2005 guidelines of the American 
College of Cardiology/American Heart Association, along 
with diuretics and other treatments.34
The effects of therapeutic exercise in patients with CHF 
as reported by various studies are as follows: (1) improve-
ments in peak VO2, exercise capacity, and quality of life;
35,36 
(2) increase of oxidative capacity of skeletal muscles;37,38 (3) 
enhancement of endothelium-dependent vasodilation;39 (4) 
decrease of neurohormonal activation and sympathetic 
nervous system activity;40 (5) improvement of ventilatory 
responses;41 and (6) reduction of mortality and hospitaliza-
tion.35,42 These pieces of evidence show that therapeutic 
exercise is effective for CHF patients, and an appropriate 
therapeutic exercise program for compensated cardiac 
failure patients is recommended. CHF was also added to 
the list of medical insurance coverage for cardiac rehabilita-
tion in April 2006, and more active rehabilitation for patients 
with HF is expected.
LVAD and cardiac rehabilitation
Circulatory support with a left ventricular assist device 
(LVAD) is needed for patients with serious HF that does 
94 
not improve with medical therapy, intra-aortic balloon 
pump therapy, or percutaneous cardiopulmonary support. 
LVADs are used mostly to support left ventricular function. 
When heart failure progresses, LVADs are used as a bridge 
to cardiac transplantation or as chronic support.43,44 When 
the condition is complicated by right heart failure, a right 
ventricular assist device (RVAD) may be used together 
with a LVAD. The guidelines of the Japanese Circulation 
Society defi ne the indication of a LVAD for severe refrac-
tory chronic heart failure as a patient showing the following 
hemodynamic indices: cardiac index ≤2.0 l/min/m2 or sys-
tolic arterial pressure ≤80 mmHg and pulmonary capillary 
wedge pressure ≥20 mmHg.45 When the functional disorder 
of the major organs progresses, implantation of a VAD is 
considered.
In patients implanted with a LVAD for acute heart 
failure, the priority is focused on the resting state to reduce 
the load to the patient’s heart. In patients implanted with a 
LVAD, early initiation of exercise therapy has been 
reported to be associated with improvementsin exercise 
capacity and survival rate.46,47 Therefore, exercise therapy 
has been used in stable patients. Long-term support by 
LVAD has become possible as a result of improvement of 
the assist device systems and anticoagulant therapy,48 and 
exercise capacity is improved during long-term LVAD 
management.49–51 The early VAD systems were extracorpo-
real and large, but recent systems are more compact and 
can be carried around without diffi culty.52 Furthermore, 
patients can now be managed at outpatient clinics,53–56 
making it possible for the patients to expand the scope their 
of activities. To improve the QOL of patients with a LVAD, 
the time of initiation and the method of exercise therapy 
should be carefully considered.57,58 Early progressive mobi-
lization of patients implanted with a LVAD improves their 
overall condition and favorably impacts the clinical course 
while they are waiting for heart transplantation; it also opti-
mizes posttransplant recovery.59
In 2001, Rose et al.60 demonstrated that LVAD (Heart-
Mate VE, Thoratec, Pleasanton, CA, USA) implantation in 
patients with end-stage heart failure who were not consid-
ered candidates for heart transplantation signifi cantly 
improved survival rate and QOL compared with those of 
the optimal medical therapy group. Since then, the LVAD 
has been considered an option of destination therapy. 
Thereafter, Lietz et al.61 and Long et al.62 showed that 1-year 
survival after LVAD (HeartMate XVE, Thoratec) implan-
tation as destination therapy reached 56% and 60%, respec-
tively. As for the status of VADs, their role as a bridge to 
transplantation was the mainstream approach.63 VAD 
implantation as a bridge to transplantation has increased in 
Japan after the introduction of the Brain Death Organ 
Transplant Law in 1997.64 The role of the LVAD as destina-
tion therapy is expected to increase in Japan. Therefore, 
exercise therapy will become more important.
When the hemodynamics of a patient is stable after 
LVAD implantation, cardiac rehabilitation including exer-
cise training for early mobilization is necessary. Walking in 
the hospital ward as well as quantitative aerobic exercises 
on an ergometer and a treadmill are performed with the aim 
of improving exercise capacity.65 However, no standard 
exercise volume in terms of quantitative training load has 
been set for patients implanted with a LVAD.
Various institutions have designed their own exercise 
training programs and have reported benefi cial results. 
Mettauer et al.65 in France performed an exercise test on a 
patient 3 weeks after LVAD (Thermo Cardiosystems 
HeartMate 1000 IP, Woburn, MA, USA) implantation. The 
patient continued exercise training consisting of 20–30 min 
of constant rate stationary bicycle exercise daily and a daily 
walk along the hallway with his portable console. The 
maximum oxygen intake and the cardiac output increased, 
while the left ventricular fi lling pressure decreased with 
the exercise training. This result may show that exercise 
improves hemodynamic and exercise capacity in patients 
with LVADs. Perme et al.66 started physical therapy in a 
patient within 48 h after LVAD implantation (MicroMed 
DeBakey VAD, MicroMed Cardiovascular, Houston, TX, 
USA) in the ICU, with or without ventilation. At the 
beginning, they evaluated treatment history, general status, 
mental status, and motor function. The goal of physical 
therapy was set, and an individualized treatment plan was 
outlined. Criteria for discontinuation of physical therapy 
included a signifi cant drop in LVAD fl ow, symptoms associ-
ated with low LAVD fl ow, and a patient request to stop. 
The ultimate goals of early physical therapy intervention 
are to prevent postoperative complications due to bed rest, 
minimize loss of mobility, maximize independence, and 
facilitate weaning from the ventilator. It may also improve 
the prognosis after heart transplantation.
Makita et al.67 measured the anaerobic threshold levels 
during cardiopulmonary exercise tests performed by nine 
patients implanted with LVADs (Toyobo-NCVC VAD, 
Toyobo-National Cardiovascular Center, Osaka, Japan; 
HeartMate, Thoratec) when they were able to walk in the 
ward. A training program of 10–30 min of bicycle exercise 
at the anaerobic threshold level two to three times a week 
plus walking in the ward on other days led to a signifi cant 
increase in peak work rate. This result demonstrates an 
increase in exercise effi cacy by improving peripheral circu-
lation. Takagi et al.68 conducted cardiac rehabilitation with 
11 patients implanted with LVADs (Toyobo-NCVC VAD) 
using a series of progressive exercises starting with breath-
ing exercises, followed by joint range of motion and muscle 
strength exercises, sitting exercises, and standing exercises. 
During exercise, the change in pump fl ow volume as a result 
of the change in posture was observed carefully. Bicycle 
exercise was started at the anaerobic threshold level after 
walking exercise was performed using the Borg scales to 
rate perceived exertion. In their institute, physical thera-
pists play an important role in cardiac rehabilitation because 
they ensure that cardiac rehabilitation is conducted safely 
and effectively.
In patients receiving long-term support with an LVAD, 
Jaski et al.69 and Schima et al.70 reported that LVAD output 
increased during exercise. Additionally, Humphrey et al.47,71 
observed that both the LVAD output and the patient’s own 
left ventricular output contribute to the total output during 
exercise. Although there are individual differences in physi-
 95
ologic responses to exercise, the appropriate level of train-
ing and setting of the LVAD should be considered 
individually to maximize the effectiveness of the LVAD.
Risk management in patients implanted with an LVAD 
during the course of cardiac rehabilitation should be con-
ducted carefully. Marrone et al.59 reported that the limiting 
factors for exercise were a decrease in pump fl ow, infection, 
right heart failure, hemorrhage, and ventricular arrhythmia. 
The most common causes of death in patients with an 
LVAD are sepsis and device failure.45 Device failure and 
problems of the coagulation system, including periopera-
tively bleeding, cerebrovascular events such as infarction 
and hemorrhage, and pulmonary embolism, have been 
reported as causes of death associated with LVADs. There-
fore, before conducting cardiac rehabilitation for patients 
with an LVAD implanted, it is preferable to confi rm the 
patient’s general condition, including blood pressure and 
the state of anticoagulant therapy.
In Japan, the number of patients implanted with an 
LVAD had exceeded 750 by September 2007, over 300 of 
whom were patients with cardiomyopathy.64 Various types 
of LVAD have been developed. Cardiac rehabilitation 
should be designed according to the characteristics of each 
LVAD, with special attention paid to the condition of heart 
diseases and the state of the LVAD.
Cardiac rehabilitation for the future
Cardiac rehabilitation has been added to the list of proce-
dures covered by health insurance in Japan and the number 
of heart diseases covered by health insurance has increased. 
Therefore, it is good news that the number of cardiac reha-
bilitation facilities has increased. However, some institu-
tions fail to be approved as certifi ed cardiac rehabilitation 
facilities because they do not fulfi ll the revised standards for 
facility certifi cation. The numbers of patients with implant-
able cardioverter defi brillators and patients on cardiac 
resynchronization therapy have also increased. Education 
for health care professionals on how to perform cardiac 
rehabilitation safely and effectively is essential to obtain the 
best results.
Conclusion
Currently, cardiac assist devices can be implanted in only a 
limited number of facilities in Japan. When the number of 
implantations increases, the level of medical treatment will 
be advanced. Forpatients with heart disease, cardiac reha-
bilitation can be used as an adjunct to both invasive and 
noninvasive treatments, and improvements in QOL and 
prognosis are expected.
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 /KOR <FEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020be44c988b2c8c2a40020bb38c11cb97c0020c548c815c801c73cb85c0020bcf4ace00020c778c1c4d558b2940020b3700020ac00c7a50020c801d569d55c002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002e>
 /NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken waarmee zakelijke documenten betrouwbaar kunnen worden weergegeven en afgedrukt. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.)
 /NOR <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>
 /PTB <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>
 /SUO <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>
 /SVE <FEFF0041006e007600e4006e00640020006400650020006800e4007200200069006e0073007400e4006c006c006e0069006e006700610072006e00610020006f006d002000640075002000760069006c006c00200073006b006100700061002000410064006f006200650020005000440046002d0064006f006b0075006d0065006e007400200073006f006d00200070006100730073006100720020006600f60072002000740069006c006c006600f60072006c00690074006c006900670020007600690073006e0069006e00670020006f006300680020007500740073006b007200690066007400650072002000610076002000610066006600e4007200730064006f006b0075006d0065006e0074002e002000200053006b006100700061006400650020005000440046002d0064006f006b0075006d0065006e00740020006b0061006e002000f600700070006e00610073002000690020004100630072006f0062006100740020006f00630068002000410064006f00620065002000520065006100640065007200200035002e00300020006f00630068002000730065006e006100720065002e>
 /ENU <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>
 >>
>> setdistillerparams
<<
 /HWResolution [2400 2400]
 /PageSize [595.276 841.890]
>> setpagedevice