Exercise training is the core component of cardiac rehabilitation in patients with coronary artery disease (CAD) and the positive effects have been studied extensively (see Chapter 17).1-5 Markedly less information is available concerning the results of exercise training in patients with valvular heart disease (VHD). This is mainly due to the fact that patients with native VHD have rarely been considered candidates for exercise training. In the guidelines on the management of patients with VHD no comments are made on this topic in patients with native VHD or after valve surgery.6 In the new recommendation by the working group on valvular heart disease of the European Society of Cardiology suggestions for exercise training after valve surgery are outlined.7

As long as patients are asymptomatic or mildly symptomatic with VHD they are usually not included in medically supervised exercise training programs as part of the conservative management. Therefore experience in patients with VHD and exercise training is limited.

Recommendations for exercise training in athletes with asymptomatic VHD have been dealt with by Pelliccia et al.8 and Bonow et al.9

Until recently patients came to the attention of cardiologists after development of symptoms. At this point training was usually not an option, because symptomatic patients need valve surgery or valve interventions. Thus also in these patients little experience with exercise training is available.

In patients with asymptomatic significant mitral stenosis, exercise training may acutely increase heart rate, particularly in patients with atrial fibrillation, and thus cause symptoms acutely. Studies on chronic exercise training in these patients are not available.

In women with documented mitral valve prolapse, a 12-week aerobic exercise program improved symptoms and functional capacity. Compared with the control group, the exercise group showed a significant decrease in anxiety, as well as increases in general well-being, functional capacity, and a decline in symptoms such as chest pain, fatigue, dizziness, and mood swings.10 Thus a supervised program may be recommended for these patients. Contraindications for exercise training are present in patients with a history of syncope, documented to be arrhythmogenic in origin, family history of sudden death associated with mitral valve prolapse, repetitive forms of sustained and non-sustained supraventricular arrhythmias, particularly if exaggerated by exercise, and severe mitral regurgitation.

In asymptomatic patients with severe aortic stenosis, careful evaluation with exercise testing is required before embarking on a training program. Exercise training is not an option, if during exercise testing a pathological response occurs (see Chapter 16). These patients require surgery, unless contraindications exist. Whether exercise training may be helpful or harmful in aggravating left ventricular hypertrophy in these patients has not been studied.

In patients with aortic regurgitation, dynamic exercise acutely increases heart rate, which short ens diastole and the time available for aortic regurgitation. Yet bradycardia, induced in the chronic state of exercise training, prolongs diastole and may increase aortic regurgitation, and may theoretically aggravate left ventricular dysfunction. There are no studies examining the long-term effects of endurance training in aortic regurgitation.

In patients with severe symptoms, exercise training is usually not possible or feasible prior to surgery, although one could argue that a specially designed exercise training program, similar to programs used in patients with heart failure, might be of value prior to surgery to counteract the deconditioning that is usually present at the time of operation. But studies concerning this topic are not available.

Thus medically supervised exercise training was mainly started in the postoperative or post-interventional period as part of the management after valve surgery or valve interventions.

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