14.2 Evidence review
All patients after LT-MCS implantation should undergo cardiac rehabilitation in a rehabilitation centre familiar with the special challenges of MCS [71, 345]. To achieve independence and mobility in daily life, a multimodal rehabilitation programme consisting of endurance and strength training should be combined with education on handling the device and peripherals as well as anticoagulation self-management. Patients with neurological complications after VAD implantation should undergo rehabilitation in a centre with combined cardiac and neurological rehabilitation facilities.
Exercise and strength training should be performed in accordance with the recommendations for patients with HF and has repeatedly been shown to be safe in patients with LT-MCS [346–348]. During the index rehabilitation, exercise training should be performed using bicycle ergometry to minimise the risk of falls or other accidents. Exercise training can be guided by the perceived level of exertion as measured by the modified Borg Scale and should be performed at a higher level (around 13), which accounts for training between the anaerobic threshold and the respiratory compensation point [348–350]. Alternatively, a baseline cardiopulmonary stress test can be used to guide exercise training. This approach has been shown to significantly improve peak VO2 in several series of patients with LT-MCS from baseline values as low as 10 to >14 ml/kg/min at discharge [348, 350, 351]. Strength training should focus on the muscle groups of the lower extremities, which are important for mastering the activities of daily life (standing up, walking performance) and are also prone to early deconditioning in critical illness [352]. Specifically, leg press, leg extensor, leg flexor, lower limb abductors and adductors should be trained [352]. Similar to exercise training, the appropriate level of exertion can be determined using the modified Borg Scale [348, 351, 353]. Structured walks and other group activities can complement exercise and strength training. These should further be complemented by physiotherapy and occupational therapy that are tailored to the individual patient’s needs.
Patients should be educated about the importance of fluid balance and treatment compliance. In addition, patients should be educated about home INR monitoring and INR self-management to promote independence after discharge (see Chapter 13).
Patients and caregivers should be educated about handling the assist device as well as the required actions to typical alarms.