Heart Valve Surgery Exercise Guidelines

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No doubt about it, heart valve replacement (or repair) is scary stuff.

If you’re an active person, it may come as even more of a shock.

You might be asking yourself, “how could this happen to me?”

You just want this nightmare behind you so you can get your life back to normal.

Common questions I hear from heart clients are: 

• Can I exercise after heart valve replacement or repair?
• How hard can I exercise?
• When can I get back to running after a mitral valve repair?
• Can I lift weights after an aortic valve replacement?

The short answer to these questions is a resounding YES!

In fact, exercise is highly recommended after heart valve surgery, but you DO need to bear in mind some precautions and safety guidelines to reduce your risk of post-operative complications.

If you’ve had a previous myocardial infarction (heart attack), bypass surgery, or angioplasty with a stent then you may need to tailor your approach with your cardiologist.

Therefore the purpose of this article is to:

1. Give you a brief overview of valvular disease;
2. Discuss the main heart valve surgical procedures (Skip directly to this part);
3. Provide guidelines for the immediate post-operative recovery period (Skip directly to this part); and
4. Discuss key exercise recommendations for valve surgery patients (Skip directly to this part)

1) Overview: What is heart valve disease?

The normal heart

First, you have to understand that the heart is a pump.

There are two upper chambers called atria and two lower chambers called ventricles.

In between the atria and ventricles are one-way valves which allow blood to pass from the atria on top down to the ventricles at the bottom of the heart.

The mitral valve regulates blood flow from the left atrium to the left ventricle and the tricuspid valve regulates blood flow from the right atrium to the right ventricle.

The two valves that regulate the passage of blood away from the heart are called the pulmonic valve (to the lungs) and the aortic valve (to the rest of the body).

Normal valves close tightly to prevent blood flow from passing backwards through the heart.

The image below shows the normal anatomy of the heart valves.

Types of heart valve disease

• Valvular stenosis – in valvular stenosis, your heart valves become stuck together or stiffened from calcification. In this case, the heart has to work harder to pump blood through it. Over time, this can contribute to heart failure where the ticker wears out from the increased pressures.
• Valvular insufficiency – in this case, your heart valves become leaky and can allow blood to “regurgitate” backwards. This means your heart has to work harder to maintain a normal blood flow out to your body.

Causes of heart valve disease

There are a number of reasons why heart valves become insufficient or fail altogether including:

• Congenital defects – “congenital” is a fancy way of saying you were born with a valve abnormality.

• Disease or illness – two common causes of valve disease are rheumatic fever and bacterial or viral endocarditis.  The latter is frequently attributed to dental procedures where bacteria from the mouth enter the blood stream and colonise the area around the valve.

• Unknown causes – in some cases, there is no identifiable cause for the valve problem.

Symptoms

No matter what the cause of your disease, there are a number of common symptoms which are associated with bad valves:

• Shortness of breath – if your heart is unable to pump sufficient blood to your body and lungs, then shortness of breath, fatigue, weakness, or an inability to keep up with your usual activities are logical outcomes.
• Lightheadedness – your heart’s inability to pump sufficient oxygenated blood to the brain might make you feel a bit woozy and even cause you to faint.
• Swelling – fluid accumulation around your lower extremities may occur due to the heart’s inability to adequately circulate blood not just to the body but also back up to itself.
• Chest pain or arrhythmia – in some cases, people complain of chest discomfort or may feel palpitations in their chest.

2) Common surgical procedures

So you’ve been to your cardiologist and it’s confirmed you need surgery to either repair or replace your leaky valve.

You will receive either a tissue or mechanical prosthetic heart valve depending on a number of factors including your particular condition, age, or ability or willingness to take blood-thinning medications the rest of your life.

Aortic and mitral valve surgeries are more common likely due to greater pressures found on the left side of the heart.

And it doesn’t discriminate, as even well known celebrities like Arnold Schwarzenegger and Barbara Walters have both had aortic valve replacement surgery.

Tricuspid and pulmonic valve surgery does occur but is comparatively less common.

The decision to repair or replace your valve will depend on your particular condition.

Most cardiothoracic surgeons prefer to repair the native valve (your own valve) if feasible since there is less risk of rejection.

The St Jude Medical has a short and informative article on surgery options.

Heart valve surgery video

The following short video shows a 3D animated video of aortic valve replacement surgery.

3) Post-operative activity guidelines

These guidelines refer to what I’ll phrase as “physical activity.”  

I differentiate this from “exercise” because, in the post-operative phase, it’s just about getting up on your feet, puttering around, and putting some gravitational load on your body (not on flogging yourself back to health in a gym).

Remember the effect of heart valve surgery on your body is something like a controlled car wreck. It is a trauma on your body and you DO need to rest.

Give yourself permission to be human during the inpatient recovery phase which generally tends to last between four to seven days.

Full recovery from the surgery can last six to eight weeks.

You’ll probably spend a couple days in the intensive care unit for the first day or two after your surgery.

The team will diligently monitor your heart rate and rhythm, blood pressure, oxygen saturation, temperature, blood biomarkers, etc.

Once you’ve been cleared to leave the ICU, you’ll end up in one of the wards where they’ll get you up walking around the nurses’ station a few times a day.

Aside from getting your rest, one of the most important things you can do at this stage is early mobilisation.

It will help you shake off the effects of the surgery and bed rest and help you get back to feeling normal again.

If your hospital has on-site exercise physiologists or physiotherapists, have them work with you to get you moving around safely, even if you don’t feel like it!

Sternal incision site

Your chest incision is going to be sore and sensitive at this point.

Once cleared by your doctor, you should start doing some stretches and mobilisation of the shoulder girdle.

This will help promote range of motion and minimise stiffness around the neck, shoulders, chest, and back.

Also remember to be VERY diligent about keeping your sternal incision site clean.

Speak to your medical management team about their wound care procedures.

Failure to keep it clean can result in infection and another unexpected stay in the hospital.

Early activity program after discharge from hospital

Four to seven days have passed and you’ve finally been discharged from the hospital. Now what?

At this point, you’re now in the in-between stage between in-patient recovery and your regular exercise (i.e., the gym, running, sport).

During the immediate post-discharge phase, you MUST remember that even if you’re starting to feel better, there IS still healing happening on the inside.

The table below provides a graduated activity program to help you transition towards the exercise phase.

The overarching theme is that you do more frequent exercise bouts each day but for very short as-tolerated intervals.

Each week, you challenge yourself by adding about five to ten minutes to each activity bout but reducing the number of times per day you do them.

Your goal should be to graduate up to longer and longer continuous exercise bouts for fewer times per day (i.e, 1-2 bouts).

Week	Min	Times x day
1	3-5	6-8
2	5-10	4-5
3	10-15	3-4
4	15-20	3
5	25-30	2
6	30-45	2
7	60	1

4) Heart valve surgery exercise guidelines

Aerobic exercise

First and foremost, get your cardiologist’s clearance before you get back to the gym or your regular workouts.  

Everyone’s case is different, so you need some assurance that you are medically stable before you start your quest for Olympic gold!

If you’re an athlete that had to go under the knife, then I can appreciate you want to get back to your training schedule.

In this case, I would suggest asking your cardiologist to do a maximal treadmill stress test.

If everything looks stable (i.e., no rhythm abnormalities, shortness of breath, or other complications), then you’ll likely be safe to get back to your routine.

Frequency – how many times per week can I exercise?

Coming off your graduated activity program I mentioned above, you should be able to do some exercise most days of the week.  

I would suggest a minimum of three (3) days per week but ideally five (5) or more.

Listen to your body and remember to ease yourself back into it.

Heart valve surgery is hard on the body and you won’t be leaping tall buildings in a single bound overnight.

Intensity – how hard can I exercise?

When I work with clients, my aim is to figure out what their current exercise tolerance is.

I will put them on a treadmill and ask “if you were walking through your neighbourhood on a flat surface, how fast would you be walking?”

We then do some experimentation to find out what that speed is.

Once the initial habitual speed is established, say 4 kph (or 2.5 mph), then the goal is to match or slightly improve upon that intensity with each session.

So if you feel tired, try to match it. If you’re feeling particularly well, then try to bump up the speed by 0.2 to 0.3 kmh (0.1 to 0.2 mph).

I reference a treadmill in the example above, but you can apply the same concept to a bike, rower, elliptical trainer, or any other piece of equipment.

I’m not necessarily a massive fan of exercise equipment per se, but it is valuable in a rehab context because it allows you to QUANTIFY your progress.

If you don’t have any exercise equipment, then you can still get out and do the same thing by walking around your neighbourhood.

You can monitor your exercise intensity by heart rate or the talk test or rating of perceived exertion discussed below.

If you have a hard time finding your pulse, get yourself a heart rate monitor or a Fitbit (which also tracks your non-exercise movement habits).

Talk test

Medications like beta-blockers will blunt your heart rate response to exercise so the use of a heart rate monitor might not help you gauge your true intensity.

In this case, you can rely on what’s known as the “talk test.”

The aim is to be able to have a conversation with the person next to you while exercising.

You can huff and puff a little bit, but if you’re huffing and puffing and can no longer speak, then the intensity is probably too much.

Rating of perceived exertion

The Borg rating of perceived exertion (RPE) 6 to 20 point scale is also quite helpful if you’re on beta-blockers (as in the talk test example above).

Counterintuitive as it may sound, a 6 to 20 scale is meant to correspond to a heart rate range of 60 to 200 (i.e., just add a zero).

So at rest, most people have a resting heart rate of around 60 beats per minute.

When you’re really pushing yourself, your heart rate would be up around 160 to 200.

The RPE scale requires a bit of a learning curve.

It trains you be become self-conscious of your subjective effort and more in-tune with your body (something a lot of people lose throughout their lifetimes). 

If you’re participating in a cardiac rehab program, ask the staff to teach you the ins and outs of this scale.

Duration – how long can I exercise?

As with frequency and intensity, you need to ease into it.

Depending on how well you felt during your graduated activity program (discussed above in section 3), you can just continue on from where you left off.

Pay attention to how you feel the following day. A little bit of fatigue the following day is a good thing since it lets you know you pushed yourself.

But if you feel shattered and can barely get out of bed, then you probably went a little too long.

Gradually increase and adjust your duration by 5 to 10 minutes (as tolerated).

Types – what type of aerobic exercise is best?

There is no special or preferred aerobic exercise for heart valve surgery, but to answer this, I refer to a question I pose to my audiences during seminars: “what’s the best exercise in the world?” 

Answer: “the one that you enjoy and will stick with!”

Whether you like to run, cycle, or swim doesn’t really matter.

All will challenge your heart and body to become more fit and efficient at delivering oxygen and nutrients to where they’re needed most (exercising muscles!).

From a recovery standpoint, try and do aerobic exercises that incorporate the large muscles of your body like your legs and hips.

Compound movements like these will give you more exercise “bang for the buck” and will put more stress on your body to improve as compared to movements which only work the smaller muscles of the upper body.

Aerobic exercise cautions

Warm-up

Make sure to give yourself a 5 to 10 minute warm up and cool down phase before and after each session (particularly if you live in an extremely hot or cold environment).

Medications

Blood thinning medications are frequently prescribed after heart valve surgery to reduce the risk of blood clots (which can lead to heart attack or stroke).

If you feel a bit wobbly on your feet after surgery, try to avoid movements which increase the likelihood of falling. If you bang your head, you are at increased risk of internal bleeding.

Environment

Following on from above, beware of environmental stressors like extreme heat, cold, or strong head winds.

All these can make exercise a LOT harder and really knock the stuffing out of you.

Be patient

Remember that even if you feel great, there is still healing happening on the inside.

Surgery is a trauma on the heart and the body so be nice to yourself and try not to overdo it with too much exercise too soon.  

Your sternum might take up to a year to heal and get its strength back.

Signs and symptoms

Watch out for any out of the ordinary signs and symptoms.

Seek immediate medical attention if you experience chest pain, dizziness, light-headedness, shortness of breath or difficulty breathing, swelling in the ankles, extreme redness and oozing pus from your incision site, or anything else that is just doesn’t quite look right.

Early treatment can catch complications and stop them in their tracks.

Weight training (resistance exercise)

You should speak with your cardiologist or surgeon to find out if weight training is right for you and to get final clearance.

Lifting weights, particularly heavy weights, can cause a sharp spike in your blood pressure which, depending on your individual condition, may or may not be safe.

Provided there are no surgical complications or limitations in your particular condition, then you should be able to ease back into weight training.

Frequency – how many days per week can I lift weight?

Don’t try to be superman (or superwoman) after valve surgery. Start off with two to three times per week and gradually increase as tolerated.

If doing regular aerobic exercise, then remember the accumulated effect of aerobic and weight training might leave you drained.

Try to experiment to see how you can fit them together into a training regimen.

Intensity – how much weight can I lift and how hard?

If you’re just getting back into the weight room, start off with light weights and gradually progress from there.

Sets and reps will also need to be adjusted as tolerated.

Start with 4 or 5 kg (10 lb) or less during the first four to six weeks of recovery.

For example, you might use light dumbbells for your upper body exercises and maybe just body weight for squats and lunges.  

Monitor for extreme soreness and adjust the weights up or down by 1-2% as tolerated.

Sternum and weight lifting

One of the main concerns most people have is whether or not the sternum can handle it.

In this case, there is an element of common sense.  The sternum can take a year before it’s quite strong and ready to withstand heavy resistance placed on it (i.e., bench press).  

In the immediate post-op phase, you can probably get away with lower weights and intensities and

Use light resistance in the beginning. It is far better to use light weights and learn proper form up front than start off with heavy weights and sloppy form.

Duration – how long can I lift weights?

Start off with shorter weight sessions of approximately 20 minutes and gradually progress as tolerated.

Long, drawn-out sessions can leave you exhausted and less likely to be compliant with your regimen.

And, as I mentioned above, if you’re doing aerobic training, then you’re going to have to fit it all into your schedule.

Types

There are no shortage of weight training options on the market: circuit training, Cross-Fit, high intensity interval training (HIIT), free weights, machines, body weight training using the TRX.

How do you know which one is right for you after surgery?

If you’re still in the early phases of recovery, err on the side of caution and do lighter weights and more reps.

As you get stronger (and with your doc’s approval), you can graduate to the more intense workouts.

Weight training cautions

Weight training requires proper form and breathing technique to help minimise sharp spikes in heart rate and blood pressure.

Remember to exhale on the exertion and avoid excessive breath holding and straining.

I would suggest working with a clinical exercise physiologist or trainer with experience working with cardiac clients.

As with aerobic training, you might be prescribed blood thinning medications to reduce your risk of blood clots.

You will need to be extra careful if there is any risk of your being hit by weights or someone else since these meds can increase your risk of internal bleeding.

Take home message

You can exercise safely and effectively after heart valve surgery provided you are medically-stable and have received full clearance from your doctor.

With proper precautions and a slow and gradual approach, you will be able to work yourself back to full health.

Be on the look out for any signs or symptoms that could be early warning signs for complications.  

Now get back to living!!

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