Antiarrhythmic effect of 9-week hybrid cardiac telerehabilitation - subanalysis of the TELEREHabilitation in Heart Failure patients - TELEREH-HF randomized clinical trial

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The National Centre for Research and Development, Warsaw, Poland. Background. Cardiac rehabilitation is a component of heart failure (HF) management but its effect on ventricular arrhythmias is not well recognized. Purpose. We analyzed the antiarrhythmic effect of a 9-week hybrid cardiac telerehabilitation (HCTR) and its influence on long term cardiovascular mortality in HF patients taken from the TELEREH-HF trial. Methods. We evaluated the presence of non-sustained ventricular tachycardia (nsVT) and frequent premature ventricular complexes ≥10 beats/hour (PVCs ≥10) with 24-hour ECG monitoring at the baseline and after 9-week HCTR or usual care (UC) of 773 HF patients (NYHA I-III, LVEF ≤ 40%). Results. Among 143 patients with nsVT, arrhythmia subsided in 30.8% after HCTR, similarly among 165 patients randomized to UC who had nsVT 34.5% did not show them after 9 weeks (p = 0.481). There was no significant difference in the decrease in PVC ≥10 over 9 weeks between randomization arms (14.9% vs. 17.8%, respectively p = 0.410). Functional response for HCTR (Δ peak oxygen consumption [pVO2] in cardiopulmonary exercise test >2.0 ml/kg/min) did not affect occurrence of arrhythmias. The multivariable analysis of the entire population did not identify HCTR as an independent factor determining improvement in terms of nsVT or PVCs >10. However, only in the HCTR group, the achievement of the antiarrhythmic effect significantly reduced the cardiovascular mortality in 2 years follow-up (Logrank p = 0.0009) (Figure). Conclusions. Significant improvement in physical capacity after 9 weeks of HCTR did not correlate with the antiarrhythmic effect in terms of incidence of nsVT or PVCs ≥10. An antiarrhythmic effect after the 9-week HCTR affected long term cardiovascular mortality in HF patients. Abstract Figure

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Antiarrhythmic effect of 9-week hybrid comprehensive telerehabilitation and its influence on cardiovascular mortality in long term follow-up - subanalysis of the TELEREHabilitation in Heart Failure Patients - TELEREH-HF Randomized Clinical Trial.

Archives of Medical Science ◽

10.5114/aoms/136563 ◽

2021 ◽

Author(s):

Piotr Orzechowski ◽

Ryszard Piotrowicz ◽

Wojciech Zareba ◽

Michael J. Pencina ◽

Ilona Kowalik ◽

...

Keyword(s):

Heart Failure ◽

Functional Response ◽

Cardiovascular Mortality ◽

Multivariable Analysis ◽

Antiarrhythmic Effect ◽

Peak Oxygen Consumption ◽

Significant Difference ◽

Long Term Follow Up

IntroductionCardiac rehabilitation is a component of heart failure (HF) management but its effect on ventricular arrhythmias is not well recognized. We analyzed the antiarrhythmic effect of a 9-week hybrid comprehensive telerehabilitation (HCTR) and its influence on long term cardiovascular mortality in HF patients taken from TELEREH-HF trial.Material and methodsWe evaluated the presence of non-sustained ventricular tachycardia (nsVT) and frequent premature ventricular complexes≥10 beats/hour (PVCs≥10) in 24-hour ECG monitoring at baseline and after 9-week HCTR or usual care(UC) of 773 HF patients (NYHA I-III, LVEF≤40%). Functional response for HCTR was assessed by changes-delta(Δ) in peak oxygen consumption(pVO2) as a result of comparing pVO2 from the beginning and the end of the program.ResultsAmong 143 patients with nsVT, arrhythmia subsided in 30.8% after HCTR, similarly among 165 patients randomized to UC who had nsVT 34.5% did not show them after 9 weeks (p=0.481). There was no significant difference in the decrease in PVC≥10 over 9 weeks between randomization arms (14.9%vs17.8%, respectively p=0.410). Functional response for HCTR in ΔpVO2>2.0 ml/kg/min did not affect occurrence of arrhythmias. Multivariable analysis did not identify HCTR as an independent factor determining improvement of nsVT or PVCs≥10. However, only in HCTR group, the achievement of the antiarrhythmic effect significantly reduced the cardiovascular mortality in 2-year follow-up (p<0.001).ConclusionsSignificant improvement in physical capacity after 9 weeks of HCTR did not correlate with the antiarrhythmic effect in terms of incidence of nsVT or PVCs≥10. An antiarrhythmic effect after the 9-week HCTR affected long term cardiovascular mortality in HF patients.

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Improvement of exercise tests and reduction of heart failure biomarkers in short term follow up after comprehensive rehabilitation program of patients with implanted LVAD

European Heart Journal ◽

10.1093/eurheartj/ehab724.0929 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

T Chwyczko ◽

E Smolis-Bak ◽

L Zalucka ◽

A Segiet-Swiecicka ◽

E Piotrowicz ◽

...

Keyword(s):

Heart Failure ◽

Cardiopulmonary Exercise Test ◽

Rehabilitation Program ◽

Exercise Tests ◽

National Budget ◽

Funding Sources ◽

6Mwt Distance ◽

Galectin 3 ◽

Comprehensive Rehabilitation ◽

Public Grant

Abstract Background There is increasing recognition of the importance of rehabilitating patients after LVAD implantation. The novel method of comprehensive rehabilitation starting directly after LVAD implantation was designed for our LVAD patients population. Aim of the study The study aimed to determine, if novel rehabilitation program improves functional and biochemical parameters in patients after recent LVAD implantation. Study group 37 recent LVAD (22 Heart Mate III, 15 HeartWare) recipients (19–67, mean 58.7 years, 35 men) participated in specially designed rehabilitation program. The program included 4–5 weeks of sationary rehabilitation: supervised endurance training on cycloergometer (5 times per week), resistance training, general fitness exercises with elements of equivalent and coordination exercises (every day). It was followed by individual exercises performed at home. At the beginning and at the end of rehabilitation program the patients performed 6 minute walking test (6MWT), cardiopulmonary exercise test (CPET). Following prognostic biomarkers of heart failure: NT-proBNP, galectin-3 and ST2 were also measured. Results See table 1. Increase of 6MWT distance, higher maximal workload, peak VO2 and upward shift of anaerobic threshold in CPET were observed in all patients. Significant reductions of NTproBNP, ST2 and galectin-3 levels were observed. There were no major adverse events during rehabilitation. Conclusions Comprehensive novel rehabilitation in LVAD recipients is safe and results in significant improvement of functional tests and biomarkers of heart failure. FUNDunding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Center for Research and Development: National grant - STRATEGMED II,

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Differences in long-term all-cause and cardiovascular mortality according to heart failure aetiology in ambulatory patients

European Heart Journal ◽

10.1093/eurheartj/ehab724.0805 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

Author(s):

G Spitaleri ◽

G Cediel ◽

E Santiago-Vacas ◽

P Codina ◽

M Domingo ◽

...

Keyword(s):

Heart Failure ◽

Cardiovascular Mortality ◽

Lower Risk ◽

Cox Regression ◽

Multivariable Analysis ◽

Real Life ◽

Cardiovascular Death ◽

Number Of Patients

Abstract Background Heart failure (HF) is the final stage of many cardiac disorders. Mortality in heart HF remains challenging despite improvement in outcomes proved in clinical trials in HF with reduced ejection fraction and it can be influenced by the aetiology of HF. Purpose To assess differences in long-term mortality (up to 18 years) in a real-life cohort of HF outpatients according to the aetiology of HF. Methods Consecutive patients with HF admitted at the HF Clinic from August 2001 to September 2019 were included. Follow-up was closed at 30.9.2020. HF aetiology was divided into ischemic heart disease (IHD), dilated cardiomyopathy (CM) –including non-compaction CM–, hypertensive CM, alcohol-derived CM, drug-derived CM, valvular disease, hypertrophic CM and others. For the present analysis, this latter group was excluded due to the big heterogeneity and limited number of patients in each subtype of aetiology. All-cause death and cardiovascular death were the primary end-points. Fine & Gray method for competing risk was used for cardiovascular mortality analysis. Results Out of 2387 patients included (age 66.5±12.5 years, 71.3% men, LVEF 35.4%±14.2, mainly in NYHA class II [65.5%] and III [26.5%]), 1317 deaths were recorded (731 from cardiovascular cause) during a maximum follow-up of 18 years (median 4.1 years [IQR 2–7.8] for the total cohort, 5.3 years [IQR 2.6–9.7] for survivors). Figure 1 shows Cox regression multivariable analysis for all-cause death and cardiovascular mortality. Considering IHD aetiology as reference, only dilated CM showed significantly lower risk of all-cause death, and only drug-induced CM showed higher risk of all-cause death. However, when cardiovascular mortality was considered almost all aetiologies showed significant lower risk of cardiovascular death than IHD. Figure 2 shows adjusted survival curves (A) and adjusted incidence curves of cardiovascular death (B) based on HF aetiology. Conclusions After adjusting for multiple prognostic factors among the studied HF aetiologies, dilated CM and drug-related CM showed the lowest and the highest risk of all-cause death, respectively. Patients with IHD showed the highest adjusted risk of cardiovascular death. FUNDunding Acknowledgement Type of funding sources: None.

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Very early detection of low dose anti-cancer therapy-related cardiotoxicity in lymphoma patients

European Heart Journal ◽

10.1093/ehjci/ehaa946.3257 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

Y.W Liu ◽

H.Y Chang ◽

C.H Lee ◽

W.C Tsai ◽

P.Y Liu ◽

...

Keyword(s):

Heart Failure ◽

Cancer Therapy ◽

Cardiac Dysfunction ◽

Systolic Dysfunction ◽

Multivariable Analysis ◽

Cardiopulmonary Exercise Test ◽

Left Ventricular ◽

Funding Source ◽

Anti Cancer ◽

All Cause Mortality

Abstract Background and purpose Left ventricular (LV) global peak systolic longitudinal strain (GLS) by speckle-tracking echocardiography is a sensitive modality for the detection of subclinical LV systolic dysfunction and a powerful prognostic predictor. However, the clinical implication of LV GLS in lymphoma patients receiving anti-cancer therapy remains unknown. Methods We prospectively enrolled 74 patients (57.9±17.0 years old, 57% male) with lymphoma who underwent echocardiography prior to chemotherapy, post 3rd and 6th cycle and 1 year after chemotherapy. Cancer therapy-related cardiac dysfunction (CTRCD) is defined as the reduction of absolute GLS value from baseline of ≥15%. All the eligible patients underwent a cardiopulmonary exercise test (CPET) upon completion of 3 cycles of anti-cancer therapy. The primary outcome was defined as a composite of all-cause mortality and heart failure events. Results Among 36 (49%) patients with CTRCD, LV GLS was significantly decreased after the 3rd cycle of chemotherapy (20.1±2.6% vs. 17.5±2.3%, p<0.001). In the multivariable analysis, male sex and anemia (hemoglobin <11 g/dL) were found to be independent risk factors of CTRCD. Objectively, patients with CTRCD had lower minute oxygen consumption/kg (VO2/kg) and lower VO2/kg value at anaerobic threshold in the CPET. The incidence of the primary composite outcome was higher in the CTRCD group than in the non-CTRCD group (hazard ratio 3.21; 95% CI, 1.04–9.97; p=0.03). Conclusion LV GLS is capable of detecting early cardiac dysfunction in lymphoma patients receiving anti-cancer therapy. Patients with CTRCD not only had a reduced exercise capacity but also a higher risk of all-cause mortality and heart failure events. Change of LVEF and GLS after cancer Tx Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Ministry of Science and Technology (MOST), Taiwan

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Enhanced Inflammation is a Marker for Risk of Post-Infarct Ventricular Dysfunction and Heart Failure

International Journal of Molecular Sciences ◽

10.3390/ijms21030807 ◽

2020 ◽

Vol 21 (3) ◽

pp. 807 ◽

Cited By ~ 3

Author(s):

Iwona Świątkiewicz ◽

Przemysław Magielski ◽

Jacek Kubica ◽

Adena Zadourian ◽

Anthony N. DeMaria ◽

...

Keyword(s):

Heart Failure ◽

Left Ventricular Systolic Dysfunction ◽

Systolic Dysfunction ◽

Multivariable Analysis ◽

High Sensitivity ◽

Left Ventricular ◽

St Segment Elevation ◽

Reactive Protein

Acute ST-segment elevation myocardial infarction (STEMI) activates inflammation that can contribute to left ventricular systolic dysfunction (LVSD) and heart failure (HF). The objective of this study was to examine whether high-sensitivity C-reactive protein (CRP) concentration is predictive of long-term post-infarct LVSD and HF. In 204 patients with a first STEMI, CRP was measured at hospital admission, 24 h (CRP24), discharge (CRPDC), and 1 month after discharge (CRP1M). LVSD at 6 months after discharge (LVSD6M) and hospitalization for HF in long-term multi-year follow-up were prospectively evaluated. LVSD6M occurred in 17.6% of patients. HF hospitalization within a median follow-up of 5.6 years occurred in 45.7% of patients with LVSD6M vs. 4.9% without LVSD6M (p < 0.0001). Compared to patients without LVSD6M, the patients with LVSD6M had higher CRP24 and CRPDC and persistent CRP1M ≥ 2 mg/L. CRP levels were also higher in patients in whom LVSD persisted at 6 months (51% of all patients who had LVSD at discharge upon index STEMI) vs. patients in whom LVSD resolved. In multivariable analysis, CRP24 ≥ 19.67 mg/L improved the prediction of LVSD6M with an increased odds ratio of 1.47 (p < 0.01). Patients with LVSD6M who developed HF had the highest CRP during index STEMI. Elevated CRP concentration during STEMI can serve as a synergistic marker for risk of long-term LVSD and HF.

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P3453Gender difference in impact of ischemic heart disease on long-term outcome in patients with heart failure reduced ejection fraction

European Heart Journal ◽

10.1093/eurheartj/ehz745.0326 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

H J Kim ◽

M A Kim ◽

D I Lee ◽

H L Kim ◽

D J Choi ◽

...

Keyword(s):

Heart Failure ◽

Clinical Outcomes ◽

Survival Rates ◽

Free Survival ◽

Reduced Ejection Fraction ◽

Clinical Events ◽

Significant Difference ◽

Patients With Heart Failure

Abstract Background Ischemic heart disease (IHD) is a major underlying etiology in patients with heart failure (HF). Although the impact of IHD on HF is evolving, there is a lack of understanding of how IHD affects long-term clinical outcomes and uncertainty about the role of IHD in determining the risk of clinical outcomes by gender. Purpose This study aims to evaluate the gender difference in impact of IHD on long-term clinical outcomes in patients with heart failure reduced ejection fraction (HFrEF). Methods Study data were obtained from the nationwide registry which is a prospective multicenter cohort and included patients who were hospitalized for HF composed of 3,200 patients. A total of 1,638 patients with HFrEF were classified into gender (women 704 and men 934). The primary outcome was all-cause death during follow-up and the composite clinical events of all-cause death and HF readmission during follow-up were also obtained. HF readmission was defined as re-hospitalization because of HF exacerbation. Results 133 women (18.9%) were died and 168 men (18.0%) were died during follow-up (median 489 days; inter-quartile range, 162–947 days). As underlying cause of HF, IHD did not show significant difference between genders. Women with HFrEF combined with IHD had significantly lower cumulative survival rate than women without IHD at long-term follow-up (74.8% vs. 84.9%, Log Rank p=0.001, Figure 1). However, men with HFrEF combined with IHD had no significant difference in survival rate compared with men without IHD (79.3% vs. 83.8%, Log Rank p=0.067). After adjustment for confounding factors, Cox regression analysis showed that IHD had a 1.43-fold increased risk for all-cause mortality independently only in women. (odds ratio 1.43, 95% confidence interval 1.058–1.929, p=0.020). On the contrary to the death-free survival rates, there were significant differences in composite clinical events-free survival rates between patients with HFrEF combined with IHD and HFrEF without IHD in both genders. Figure 1 Conclusions IHD as predisposing cause of HF was an important risk factor for long-term mortality in women with HFrEF. Clinician need to aware of gender-based characteristics in patients with HF and should manage and monitor them appropriately and gender-specifically. Women with HF caused by IHD also should be treated more meticulously to avoid a poor prognosis. Acknowledgement/Funding None

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The Role of a “Treat-to-Target” Approach in the Long-Term Renal Outcomes of Patients with Gout

Journal of Clinical Medicine ◽

10.3390/jcm8071067 ◽

2019 ◽

Vol 8 (7) ◽

pp. 1067

Author(s):

Woo-Joong Kim ◽

Jung Soo Song ◽

Sang Tae Choi

Keyword(s):

Renal Function ◽

Kidney Disease ◽

Chronic Kidney Disease Stage ◽

Multivariable Analysis ◽

Serum Urate ◽

Disease Stage ◽

Treat To Target ◽

Renal Outcomes ◽

Significant Difference

Background: Although gout is accompanied by the substantial burden of kidney disease, there are limited data to assess renal function as a therapeutic target. This study evaluated the importance of implementing a “treat-to-target” approach in relation to renal outcomes. Methods: Patients with gout who underwent continuous urate-lowering therapy (ULT) for at least 12 months were included. The effect of ULT on renal function was investigated by means of a sequential comparison of the estimated glomerular filtration rate (eGFR). Results: Improvement in renal function was only demonstrated in subjects in whom the serum urate target of <6 mg/dL was achieved (76.40 ± 18.81 mL/min/1.73 m2 vs. 80.30 ± 20.41 mL/min/1.73 m2, p < 0.001). A significant difference in the mean change in eGFR with respect to serum urate target achievement was shown in individuals with chronic kidney disease stage 3 (−0.35 ± 3.87 mL/min/1.73 m2 vs. 5.33 ± 11.64 mL/min/1.73 m2, p = 0.019). Multivariable analysis predicted that patients ≥65 years old had a decreased likelihood of improvement (OR 0.31, 95% CI 0.13–0.75, p = 0.009). Conclusions: The “treat-to-target” approach in the long-term management of gout is associated with better renal outcomes, with a greater impact on those with impaired renal function.

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Relationship between worsening renal function and long-term cardiovascular mortality in heart failure patients

International Journal of Cardiology ◽

10.1016/j.ijcard.2016.12.101 ◽

2017 ◽

Vol 230 ◽

pp. 47-52 ◽

Cited By ~ 5

Author(s):

Toshitaka Okabe ◽

Tadayuki Yakushiji ◽

Takehiko Kido ◽

Yuji Oyama ◽

Wataru Igawa ◽

...

Keyword(s):

Heart Failure ◽

Renal Function ◽

Cardiovascular Mortality ◽

Heart Failure Patients ◽

Worsening Renal Function

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5951The impact of regulatory T lymphocytes on long-term survival in patients with ischemic heart failure with reduced ejection fraction

European Heart Journal ◽

10.1093/eurheartj/ehz746.0101 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

P Sulzgruber ◽

L Koller ◽

S Blum ◽

A Hammer ◽

N Kazem ◽

...

Keyword(s):

Heart Failure ◽

T Lymphocytes ◽

Ejection Fraction ◽

Cellular Immunity ◽

Cardiovascular Mortality ◽

Left Ventricular Ejection ◽

Term Survival ◽

Long Term Survival ◽

Regulatory T Lymphocytes

Abstract Background Heart failure with reduce ejection fraction (HFrEF) constitutes a global health issue representing a prevalent clinical syndrome. While pro-inflammatory cytokines proved to have a pivotal role in the development and progression of HFrEF, less attention has been paid to the cellular immunity. Regulatory T lymphocytes (Tregs) seem to have an important role in the induction and maintenance of immune homeostasis especially in patients after acute coronary syndrome and coronary vessel disease. Therefore, we aimed to investigate the impact of Tregs on the outcome of patients presenting with ischemic HFrEF. Methods We prospectively enrolled 112 patients with HFrEF defined by New York Heart Association (NYHA) functional class >II and left ventricular ejection fraction (LVEF) <40%. Patients were stratified in ischemic (iHFrEF, n=57) and dilated etiology (dHFrEF, n=55). Cells from fresh heparinized blood were stained and analyzed using BD FACS Canto II flow cytometry. Cox regression hazard analysis was used to assess the influence of Tregs on survival. The multivariate model was adjusted forage and gender. Results Comparing patients with iHFrEF to dHFrEF we found a significantly lower fraction of Tregs within lymphocytes in the ischemic subgroup (0.42% vs. 0.56%; p=0.009). After a mean follow-up time of 4.5 years 32 (28.6%) patients died due to cardiovascular causes. We found that Tregs were significantly associated with cardiovascular survival in the entire study cohort with an adjusted HR per one standard deviation (1-SD) of 0.60 (95% CI 0.39–0.92; p=0.017). Interestingly while there was no association with cardiovascular survival independently in the dHFrEFsubgroup (adj. HR per 1-SD of 0.62 (95% CI 0.17–2.31); p=0.486), we found a significant inverse association of Tregs and cardiovascular survival in patients with iHFrEFwith an adj. HR per 1-SD of 0.59 (95% CI 0.36–0.96; p=0.034). Figure 1. Survival Curves of Cardiovascular Mortality. Kaplan-Meier plots showing survival free of cardiovascular mortality in the total study collective (A) and patients stratified in ischemic CMP (B) as well dilative CMP (C) according to tertiles of frequencies of regulatory T cells. Tertile 1 = high; Tertile 2 = mid; Tertile 3 = low. Conclusion Our results indicate a potential influence of Tregs in the pathogenesis and progression of iHFrEF, fostering the implication of cellular immunity in iHFrEF pathophysiology and proving Tregs as a predictor for long-term survival among iHFrEF -patients.

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P6325Gas exchange improvements during exercise correlate with hemodynamic changes in heart failure patients with a left ventricular assist device

European Heart Journal ◽

10.1093/eurheartj/ehz746.0922 ◽

2019 ◽

Vol 40 (Supplement_1) ◽

Author(s):

K Seuthe ◽

M Morosin ◽

H Smail ◽

F Gerhardt ◽

A Simon ◽

...

Keyword(s):

Heart Failure ◽

Cardiac Output ◽

Cardiopulmonary Exercise Test ◽

Left Ventricular ◽

Peak Oxygen Consumption ◽

Ventricular Assist ◽

Heart Failure Patients ◽

Left Ventricular Assist

Abstract Background The implantation of left ventricular assist devices (LVAD) has established its role in therapy for patients with end stage heart failure. Benefits in survival as well as an improved quality of life, compared to optimized medical therapy (OMT) alone, has been proven. There are limited data in the literature on the metabolic changes during exercise in LVAD patients, and in most studies no increase in peak oxygen consumption on cardiopulmonary exercise test (CPET) could be shown early after surgery. However, recent data suggests an improvement in peak oxygen uptake (VO2) as a late effect after rehabilitation. To further investigate these findings we sought to analyse CPET data from patients before LVAD implantation as well as in the early and late follow up in correlation with hemodynamic changes at these times. Methods We collected and retrospectively analysed data of heart failure patients who had undergone LVAD implantation, and in whom a right heart catheterization, a cardiopulmonary exercise test and an echocardiography had been performed at time before, as well as 6 Months and 12 months after LVAD implantation, respectively. Results Data of 43 patients implanted with an LVAD between 2011 and 2017 were analysed. There was significant improvement in cardiac output (3,2 vs 4,3 L/min, p<0,001) and VE/VCO2 slope (46 vs 38, p=0,001) 6 months after LVAD implant as well as a significant reduction in PCWP (26 vs 11 mmHg, p<0,001), PAP mean (40 vs 22 mmHg, p<0,001), RA mean (12 vs 8 mmHg, p=0,002) and PVR (4,2 vs 2,5 WU, p<0,001). However, there was no significant increase in peak VO2 after 6 months. 12 months after LVAD implantation there were no further significant changes in cardiac output, intracardiac pressures or VE/VCO2 slope, which all remained similar to the 6 months follow up. However, at that point, a significant increase in peak VO2 was seen, compared to baseline (1060 vs 1410ml/min, p=0,001) and to 6 months after surgery (Figure 1). Conclusion Cardiac output increases in heart failure patients early after LVAD implantation. Consequently, permanent ventricular off loading results in the reduction of intracardiac pressures and improvement in the VE/VCO2 slope 6 months after surgery. However, a significant rise in peak oxygen consumption could only be noted 12 months after surgery, suggesting either a delayed long-term effect of improved hemodynamics or other causes such as enhanced mobility or training due to improved quality of life.

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