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World J Transplant. Nov 18, 2021; 11(11): 466-479
Published online Nov 18, 2021. doi: 10.5500/wjt.v11.i11.466
Exercise training in heart transplantation
Christos Kourek, Eleftherios Karatzanos, Serafim Nanas, Andreas Karabinis, Stavros Dimopoulos
Christos Kourek, Eleftherios Karatzanos, Serafim Nanas, Stavros Dimopoulos, Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, Athens 10676, Attica, Greece
Andreas Karabinis, Stavros Dimopoulos, Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens 17674, Greece
Author contributions: Kourek C and Karatzanos E reviewed the literature; and Kourek C drafted the manuscript; Nanas S and Karabinis A revised the manuscript; Dimopoulos S designed the research study and revised the drafted manuscript; and all authors have read and approve the final manuscript.
Conflict-of-interest statement: Authors declare no conflict of interests for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Stavros Dimopoulos, MD, PhD, Consultant Physician-Scientist, Doctor, Postdoc, Research Scientist, Senior Researcher, Staff Physician, Clinical Ergospirometry, Exercise & Rehabilitation Laboratory, Evaggelismos Hospital, 45-47 Ipsilantou str., Athens 10676, Attica, Greece. stdimop@gmail.com
Received: March 1, 2021
Peer-review started: March 1, 2021
First decision: July 29, 2021
Revised: August 12, 2021
Accepted: October 27, 2021
Article in press: October 27, 2021
Published online: November 18, 2021
Processing time: 256 Days and 3 Hours
Abstract

Heart transplantation remains the gold standard in the treatment of end-stage heart failure (HF). Heart transplantation patients present lower exercise capacity due to cardiovascular and musculoskeletal alterations leading thus to poor quality of life and reduction in the ability of daily self-service. Impaired vascular function and diastolic dysfunction cause lower cardiac output while decreased skeletal muscle oxidative fibers, enzymes and capillarity cause arteriovenous oxygen difference, leading thus to decreased peak oxygen uptake in heart transplant recipients. Exercise training improves exercise capacity, cardiac and vascular endothelial function in heart transplant recipients. Pre-rehabilitation regular aerobic or combined exercise is beneficial for patients with end-stage HF awaiting heart transplantation in order to maintain a higher fitness level and reduce complications afterwards like intensive care unit acquired weakness or cardiac cachexia. All hospitalized patients after heart transplantation should be referred to early mobilization of skeletal muscles through kinesiotherapy of the upper and lower limbs and respiratory physiotherapy in order to prevent infections of the respiratory system prior to hospital discharge. Moreover, all heart transplant recipients after hospital discharge who have not already participated in an early cardiac rehabilitation program should be referred to a rehabilitation center by their health care provider. Although high intensity interval training seems to have more benefits than moderate intensity continuous training, especially in stable transplant patients, individualized training based on the abilities and needs of each patient still remains the most appropriate approach. Cardiac rehabilitation appears to be safe in heart transplant patients. However, long-term follow-up data is incomplete and, therefore, further high quality and adequately-powered studies are needed to demonstrate the long-term benefits of exercise training in this population.

Keywords: Heart transplantation; Endothelial dysfunction; Exercise training; High intensity interval training; Moderate intensity continuous training; Cardiac rehabilitation

Core Tip: Heart transplantation is the gold standard treatment of end-stage heart failure (HF). Heart transplantation patients present lower exercise capacity due to cardiac, vascular and skeletal muscle abnormalities. Exercise training improves exercise capacity, cardiac and vascular endothelial function in heart transplant recipients. Pre-rehabilitation regular aerobic or combined exercise is beneficial for patients with end-stage HF awaiting heart transplantation. All heart transplant recipients either hospitalized or after hospital discharge should be referred to a cardiac rehabilitation program. Individualized training still remains the most applicable approach despite the fact that high intensity interval training seems to have more benefits than moderate intensity continuous training.