Cardiopulmonary Exercise Testing Following Open Repair for a Proximal Thoracic Aortic Aneurysm or Dissection Purpose: There are limited data on cardiopulmonary exercise testing (CPX) and cardiorespiratory fitness (CRF), following open repair for a proximal thoracic aortic aneurysm or dissection. The aim was to evaluate serious adverse events, abnormal CPX event rate, CRF (peak oxygen uptake, Vo2peak), and blood pressure. Methods: Patients were retrospectively identified from cardiac rehabilitation participation or prospectively enrolled in a research study and grouped by phenotype: (1) bicuspid aortic valve/thoracic aortic aneurysm, (2) tricuspid aortic valve/thoracic aortic aneurysm, and (3) acute type A aortic dissection. Results: Patients (n = 128) completed a CPX a median of 2.9 mo (interquartile range: 1.8, 3.5) following repair. No serious adverse events were reported, although 3 abnormal exercise tests (2% event rate) were observed. Eighty-one percent of CPX studies were considered peak effort (defined as respiratory exchange ratio of ≥1.05). Median measured Vo2peak was <36% predicted normative values (19.2 mL·kg−1.min−1 vs 29.3 mL·kg−1·min−1, P < .0001); the most marked impairment in Vo2peak was observed in the acute type A aortic dissection group (<40% normative values), which was significantly different from other groups (P < .05). Peak exercise systolic and diastolic blood pressures were 160 mm Hg (144, 172) and 70 mm Hg (62, 80), with no differences noted between groups. Conclusions: We observed no serious adverse events with an abnormal CPX event rate of only 2% 3 mo following repair for a proximal thoracic aortic aneurysm or dissection. Vo2peak was reduced among all patient groups, especially the acute type A aortic dissection group, which may be clinically significant, given the well-established prognostic importance of reduced cardiorespiratory fitness. Correspondence: Bo Yang, MD, PhD, Department of Cardiac Surgery, University of Michigan, Michigan Medicine, 1500 East Medical Center Dr, 5155 Frankel Cardiovascular Center, Ann Arbor, MI, 48109 (boya@med.umich.edu). External financial support: Bo Yang is supported by the National Institutes of Health (K08HL130614 and R01HL141891) and The Phil Jenkins and Darlene & Stephen J. Szatmari Funds. Cristen J. Willer is supported by the National Institutes of Health (R01-HL127564, R35-HL135824, and R01-HL142023). Himanshu J. Patel is supported by The Joe D. Morris Collegiate Professorship, the David Hamilton Fund, and the Phil Jenkins Breakthrough Fund in Cardiac Surgery. Kim A. Eagle is consultant for NHLBI and has a research grant from Gore. Lee W. Jones is supported by the National Cancer Institute, AKTIV Against Cancer, and the Kavli Trust. Sara Saberi is the site principal investigator for 2 clinical trials funded by Myokardia and receives financial support from Myokardia. Internal financial support: Whitney E. Hornsby, Bo Yang, Cristen J. Willer, and Sara Saberi are supported by the University of Michigan, Michigan Medicine, Frankel Cardiovascular Center, Aikens Fund for Aortic Research. Himanshu J. Patel is a consultant for WL gore Edwards and Medtronic. All other authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Aerobic Exercise Effects on Quality of Life and Psychological Distress After an Implantable Cardioverter Defibrillator Purpose: The purpose of this study was to evaluate quality of life (QOL), psychological function, and self-efficacy outcomes in the Anti-Arrhythmic Effects of Exercise After an ICD Trial. Methods: In the Anti-Arrhythmic Effects of Exercise After an ICD Trial, 160 patients (124 men and 36 women) who had an implantable cardioverter defibrillator for primary (43%) or secondary (57%) prevention were randomized to exercise (EX, n = 84) or usual care (UC, n = 76). The EX consisted of 8 wk of home walking 1 hr/d 5 d/wk, followed by 16 wk of maintenance home walking for 150 min/wk. Adherence was determined from exercise logs, ambulatory HR recordings, and phone calls. Assessments were conducted at baseline, 8, and 24 wk for QOL: Patient Concerns Assessment and Short Form-36; anxiety: State Trait Anxiety Inventory; depression: Physician Health Questionnaire-Depression; and self-efficacy: Self-Efficacy for Walking Scale. Results: Participants averaged 55 ± 12 yr of age with ejection fraction = 40.6 ± 15.7%. The EX significantly decreased depression severity (EX: 1.33 ± 0.64; UC: 1.51 ± 0.86, P = .05) and improved self-efficacy (EX: 7.65 ± 1.97; UC: 6.85 ± 2.40, P = .05) at 8 wk. There were no significant effects at 24 wk. Adherent exercisers had significant improvements in QOL, psychological, and self-efficacy outcomes at 8 and 24 wk compared with those who were nonadherent. There were no implantable cardioverter defibrillator shocks associated with exercise. Conclusions: The EX conferred significant effects on depression and self-efficacy at 8 wk, without effects on QOL. Adherent exercisers experienced significant improvements in outcomes over those who were nonadherent or received UC. Correspondence: Cynthia M. Dougherty, ARNP, PhD, University of Washington, School of Nursing, Box 357266, 1959 NE Pacific St, HSB T615A, Seattle, WA 98195 (cindyd@uw.edu). The authors declare no conflicts of interest. Clinical Trial Registration Information: ClinicalTrials.gov number: NCT 00522340, https://trialbulletin.com/lib/entry/ct-00522340 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Exercise Rehabilitation Improves Cardiac Volumes and Functional Capacity in Patients With Endomyocardial Fibrosis: A RANDOMIZED CONTROLLED TRIAL Purpose: Endomyocardial fibrosis (EMF) is a restrictive cardiomyopathy associated with low functional capacity and high mortality rates. Exercise training has been proved to be a nonpharmacological treatment of cardiovascular diseases. Therefore, the purpose of this study was to determine the effects of exercise rehabilitation in EMF patients. Methods: Twenty-two EMF patients, functional classes II and III (New York Heart Association [NYHA]), were randomized to the control (C-EMF) or exercise rehabilitation (Rehab-EMF) group. Patients in the Rehab-EMF group underwent 4 mo of exercise rehabilitation, whereas patients in the C-EMF group were instructed to maintain their usual daily routine. Peak oxygen uptake (Vo2), cardiac function, and quality of life were evaluated. All assessments were performed at baseline and after 4 mo. Results: After 4 mo of rehabilitation, peak Vo2 increased in the Rehab-EMF group (17.4 ± 3.0 to 19.7 ± 4.4 mL/kg/min, P < .001), whereas the C-EMF group showed no difference (15.3 ± 3.0 to 15.0 ± 2.0 mL/kg/min, P = .87). Also, post-intervention, peak Vo2 in the Rehab-EMF group was greater than that in the C-EMF group (P < .001). Furthermore, the Rehab-EMF group, when compared to the C-EMF group, showed an increase in left ventricular end-diastolic volume (102.1 ± 64.6 to 136.2 ± 75.8 mL vs 114.4 ± 55.0 to 100.4 ± 49.9 mL, P < .001, respectively) and decrease in left atrial diastolic volume (69.0 ± 33.0 to 34.9 ± 15.0 mL vs 44.6 ± 21.0 to 45.6 ± 23.0 mL, P < .001, respectively). Quality-of-life scores also improved in the Rehab-EMF group, whereas the C-EMF group showed no change (45 ± 23 to 27 ± 15 vs 47 ± 15 to 45 ± 17, P < .001, respectively). Conclusion: Exercise rehabilitation is a nonpharmacological intervention that improves functional capacity, cardiac volumes, and quality of life in EMF patients after endocardial resection surgery. In addition, exercise rehabilitation should be prescribed to EMF patients to improve their clinical condition. Correspondence: Ana Luiza Carrari Sayegh, PhD, Clinical Unit of Cardiomyopathy, Heart Institute, University of São Paulo Medical School, Av. Dr. Eneas de Carvalho Aguiar, 44 Cerqueira Cesar, Sao Paulo, SP 05403-000, Brazil (ana_luizas@hotmail.com). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effect of Cardiac Rehabilitation on Sexual Satisfaction Among Patients After Coronary Artery Bypass Graft Surgery Purpose: After coronary artery bypass graft (CABG) surgery, many patients experience diminished sexual function and satisfaction. The present study aimed to investigate the effect of outpatient cardiac rehabilitation (OCR) on the level of sexual satisfaction among post-CABG patients. Methods: A clinical trial was performed at the Al-Zahra Hospital, Shiraz, Iran, from July 2017 to January 2018. Based on the inclusion criteria, 104 post-CABG patients were recruited into the study. The participants were randomly assigned to the intervention (OCR) group (n = 52) or the usual care group (n = 52). The intervention group received 20 sessions of OCR, whereas the usual care group received the routine hospital care and education. Data were collected using the Index of Sexual Satisfaction and a demographic data sheet. The data were analyzed using the SPSS software, v23.0 (IBM) and the independent sample t test, paired-samples t test, and χ2 test. Results: There was no statistically significant difference in the mean pre-intervention score for sexual satisfaction between the groups. However, a statistically significant difference in the mean post-intervention score for sexual satisfaction was observed between the groups (P < .001). The difference in the mean pre- and post-intervention scores for sexual satisfaction in the intervention group was statistically significant (P < .001), whereas there was no significant difference in the usual care group. Conclusion: Post-CABG patients who completed the OCR program experienced an increased level of sexual satisfaction. It is, therefore, recommended to include an OCR program as part of the patient treatment and aftercare following CABG surgery. Correspondence: Mahnaz Rakhshan, PhD, Community Based Psychiatric Care Research Center, Shiraz University of Medical Sciences, Shiraz 71936-13119, Iran (mzrakhshan@ymail.com). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

A Randomized Study Examining the Effects of Mild-to-Moderate Group Exercises on Cardiovascular, Physical, and Psychological Well-Being in Patients With Heart Failure Purpose: To compare 2 mild-to-moderate group exercises and treatment as usual (TAU) for improvements in physical function and depressive symptoms. Methods: Patients with heart failure (n = 70, mean age = 66 yr, range = 45-89 yr) were randomized to 16 wk of tai chi (TC), resistance band (RB) exercise, or TAU. Results: Physical function differed by group from baseline to follow-up, measured by distance walked in the 6-min walk test (F = 3.19, P = .03). Tai chi participants demonstrated a nonsignificant decrease of 162 ft (95% confidence interval [CI], 21 to −345, P = .08) while distance walked by RB participants remained stable with a nonsignificant increase of 70 ft (95% CI, 267 to −127, P = .48). Treatment as usual group significantly decreased by 205 ft (95% CI, −35 to −374, P = .02) and no group differences occurred over time in end-systolic volume (P = .43) and left ventricular function (LVEF) (P = .67). However, groups differed over time in the Beck Depression Inventory (F = 9.2, P < .01). Both TC and RB groups improved (decreased) by 3.5 points (95% CI, 2-5, P < .01). Treatment as usual group decreased insignificantly 1 point (95% CI, −1 to 3, P = .27). Conclusions: Tai chi and RB participants avoided a decrease in physical function decrements as seen with TAU. No groups changed in cardiac function. Both TC and RB groups saw reduced depression symptoms compared with TAU. Thus, both TC and RB groups avoided a decrease in physical function and improved their psychological function when compared with TAU. Correspondence: Laura S. Redwine, PhD, College of Nursing, University of South Florida, 12901 Bruce B. Downs Blvd, MDC22, Tampa, FL 33612 (lredwine@health.usf.edu). This research was supported by R01HL096784. The protocol for the parent study can be found at clinicaltrial.gov. The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Clinical Trial number: NCT01625819. ORCID#: 0000-0001-7633-2034. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Functional and Cardiovascular Measurements in Patients With Peripheral Artery Disease: COMPARISON BETWEEN MEN AND WOMEN Purpose: To compare functional and cardiovascular variables of men and women with peripheral artery disease (PAD). Methods: This observational, cross-sectional study included 67 women and 144 men (age 66 ± 9 and 67 ± 10 yr, respectively) with PAD. Patients were submitted to a clinical evaluation, 6-min walk test (6MWT) and cardiovascular evaluation, including blood pressure, arterial stiffness variables, and heart rate variability. Results: Women had lower claudication onset distance (P = .033) and 6MWT distance (P < .001), and similar percentage of the predicted 6MWT distance (P > .05). Women had higher pulse pressure (P = .002), augmentation index (P < .001), augmentation index corrected by 75 bpm (P < .001), and brachial and central systolic blood pressure (P = .041 and P = .029). Diastolic blood pressure, pulse wave velocity, and heart rate variability were similar between sexes (P > .05). Conclusion: Although predicted 6MWT performance was similar between sexes, women had higher blood pressure and wave reflection variables compared with men. Interventions to reduce blood pressure and wave reflection should be emphasized in women with PAD. Correspondence: Raphael M. Ritti-Dias, PhD, Universidade Nove de Julho, São Paulo, SP, Brazil (raphaelritti@gmail.com) The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Wearable Cardioverter Defibrillator–Guided 6-Min Walk Test Performed at Home Is Accurate and Reliable: RESULTS OF THE TRENDS STUDY Purpose: The 6-min walk test (6MWT) is broadly used to evaluate the functional ability of patients with heart failure (HF). The purpose of this study was to evaluate the accuracy and reliability of the wearable cardioverter defibrillator (WCD)–guided 6MWT performed at home by patients with HF versus in-clinic testing. Methods: Patients (n = 197) with HF and a low ejection fraction prescribed a WCD were randomized to 2 groups. Group 1 completed an in-clinic clinician-guided 6MWT while wearing the WCD; results were recorded by the clinician. Group 2 completed a WCD-guided 6MWT, also performed in the clinic; results were recorded by the WCD accelerometer. Both groups performed weekly unsupervised WCD-guided 6MWTs at home, with results recorded by the WCD. Results: The initial in-clinic 6MWT showed no significant group difference in distance walked (group 1 = 306 m; group 2 = 297 m). For patients in group 2 who completed at least one 6MWT at home, there was a 15-step decrease between the in-clinic WCD-guided 6MWT and the first at-home 6MWT, 558 and 543 median steps (P = .001), respectively. Among patients with at least 8 weekly home WCD-guided 6MWTs (n = 70), there was no significant difference in the number of steps walked during the 6MWT from week to week. Conclusions: Results of the in-clinic 6MWT are similar between clinician-guided and WCD-guided patients across objective distances. Distances walked with a WCD-guided walk test were consistent whether conducted in the clinic or at home and were reliable over time. Correspondence: Ashley E. Burch, PhD, Department of Psychology, East Carolina University, 104 Rawl Bldg, Greenville, NC 27858 (burchas15@ecu.edu). Ashley E. Burch, PhD: research grants: Medtronic, ZOLL Medical. All funds are directed to East Carolina University. Andreas J. Rieth, MD: research grants: Pfizer, directed to Kerckhoff-Klinik Forschungs GmbH; Biotest, directed to Kerckhoff Herzforschungsinstitut; speaker fees and/or honoraria: St Jude Medical, Actelion, Novartis, and Orion Pharma. Nicole R. Bianco, PhD, Employee, ZOLL Medical. Samuel F. Sears, PhD: honoraria/consulting fees: Medtronic, Boston Scientific, St Jude Medical, ZOLL Medical; research grants: Medtronic, ZOLL Medical. All funds are directed to East Carolina University. The rest of the authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Effects of Different Rehabilitation Protocols in Inpatient Cardiac Rehabilitation After Coronary Artery Bypass Graft Surgery: A RANDOMIZED CLINICAL TRIAL Purpose: Patients undergoing coronary artery bypass graft (CABG) surgery typically experience loss of cardiopulmonary capacity in the post-operative period. The purpose of this study was to evaluate the effects of different rehabilitation protocols used in inpatient cardiac rehabilitation on functional capacity and pulmonary function in patient status post-CABG surgery. Methods: This was a single-blind randomized controlled trial. The primary endpoint of functional capacity and secondary endpoints of lung capacity and respiratory muscle function were assessed in patients scheduled to undergo CABG. After surgery, 40 patients were randomly assigned across 1 of 4 inpatient cardiac rehabilitation groups: G1, inspiratory muscle training, active upper limb and lower limb exercise training, and early ambulation; G2, same protocol as G1 without inspiratory muscle training; G3, inspiratory muscle training alone; and G4, control. All groups received chest physical therapy and expiratory positive airway pressure. Patients were reassessed on post-operative day 6 and post-discharge day 30 (including cardiopulmonary exercise testing). Results: The 6-min walk distance on post-operative day 6 was significantly higher in groups that included exercise training (G1 and G2), remaining higher at 30 d post-discharge (P < .001 between groups). Peak oxygen uptake on day 30 was also higher in G1 and G2 (P = .005). All groups achieved similar recovery of lung function. Conclusion: Protocols G1 and G2, which included a systematic plan for early ambulation and upper and lower limb exercise, attenuated fitness losses while in the hospital and significantly enhanced recovery 1 mo after CABG. Correspondence: Maurice Zanini, ScD, PT, Exercise Cardiology Research Group, Hospital de Clinicas de Porto Alegre, Rua Ramiro Barcelos, 2350, Térreo (Serviço de Fisiatria e Reabilitação) 90035-007, Porto Alegre, RS, Brazil (mauricezanini@gmail.com). The authors declare no conflicts of interest. Supplemental digital content is available for this article. Direct URL citation appears in the printed text and is provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com). Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Interval Endurance and Resistance Training as Part of a Community-Based Secondary Prevention Program for Patients With Diabetes Mellitus and Coronary Artery Disease Purpose: High-intensity interval training (HIIT) has been observed to improve health and fitness in patients with cardiovascular disease. High-intensity interval training may not be appropriate in community-based settings. Moderate-intensity interval training (MIIT) and resistance training (RT) are emerging as effective alternatives to HIIT. These have not been well investigated in a community-based cardiac maintenance program. Methods: Patients with coronary artery disease and/or diabetes mellitus participated in clinical examinations and a 6-mo exercise program. Center-based MIIT and home-based moderate continuous intensity exercise were performed for 3-5 d/wk for 30-40 min/session. RT, nutritional counseling, coping, and behavioral change strategies were offered to all patients. Within-group changes in clinical metrics and exercise performance were assessed on a per-protocol basis after 6 mo. Results: Two hundred ninety-two patients (74%) concluded the 6-mo program. There were no serious adverse events. The peak oxygen uptake and peak workload increased significantly, 21.8 ± 6.1 to 22.8 ± 6.3 mL/kg/min and 128 ± 39 to 138 ± 43 W, respectively (both P < .001). Submaximal exercise performance increased from 68 ± 19 to 73 ± 22 W (P < .001). Glycated hemoglobin decreased from 6.57 ± 0.93% to 6.43 ± 0.12%, (P = .023). Daily injected insulin dosage was reduced from 42 IU (interquartile range: 19.0, 60.0) to 26 IU (interquartile range: 0, 40.3, P < .001). Conclusions: MIIT and RT were feasible and effective in a community-based cardiac maintenance program for patients with cardiovascular disease, improving exercise performance, and blood glucose control. Correspondence: Jeffrey W. Christle, PhD, Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Falk Cardiovascular Research Building, 870 Quarry Road Ext, Palo Alto, CA 94304 (christle@stanford.edu). The authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

Higher Anxiety and Will to Live Are Associated With Poorer Adherence to Cardiac Rehabilitation Purpose: Cardiac rehabilitation (CR) session attendance and rates of completion remain suboptimal. Greater distress (ie, depression and anxiety) has been associated with both better and poorer adherence. Will to live (ie, desire, determination and effort to survive) has been associated with survival among cardiac patients and thus may be relevant for CR adherence. It was hypothesized that depression and anxiety would be negatively associated with adherence, and that will to live would moderate these relationships. Methods: Sixty patients (mean age = 56.9 ± 10.8 yr; 38 males) entering outpatient CR completed self-report measures of will to live (Wish to Prolong Life Questionnaire) and distress (Hospital Anxiety and Depression Scale). Hierarchical regression analyses were performed to predict CR session attendance (%) and program completion (yes/no) from depression and anxiety, as well as the interaction of those variables with will to live. Results: Neither depression nor anxiety was associated with CR adherence (Ps > .33). However, there was a significant interaction of will to live with anxiety in predicting attendance (β = −0.31, P = .03, Model R2 = .19, P = .01), reflecting that anxiety predicted lower attendance only among patients reporting greater will to live. Conclusions: These data help clarify the complex relationship between distress and CR adherence. Findings suggest that higher anxiety is associated with poorer adherence, but only in combination with greater motivation for living. Patients higher in anxiety and will to live may benefit from additional strategies to make actionable behavioral change in the context of CR. Correspondence: Charles F. Emery, PhD, Department of Psychology, The Ohio State University, 1835 Neil Ave, Columbus, OH 43210 (emery.33@osu.edu). All authors declare no conflicts of interest. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.