Heart Valve Surgery Exercise Guidelines

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heart valve surgery

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.

heart valve surgery
Credit: http://www.cts.usc.edu/hpg-heartvalvesurgery.html

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 deleterious 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).

WeekMinTimes x day
13-56-8
25-104-5
310-153-4
415-203
525-302
630-452
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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). Click on each image to check out features and thousands of Amazon user reviews.

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.

borg-rpe_scale

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!!

11 COMMENTS

  1. Sir,
    I am M.S.Patil and I’ve had open heart surgery on 12 June 2015. My pulmonary valve was corrected by “Valvotomy” to get rid of severe pulmonary stenosis. It was 110 earlier and constant. Now, after surgery, I feel quite well. The pulmonary pressure is now 25mm. In your article, you answered my questions. I am doing regular exercise at home with an RPE of 12 to 13. My cardiologist has given clearance to do resistance training instead of going to the gym. Now, can you please advise me, I want to do safe exercise to build my strength. I’ve started doing this exercise only after surgery. Now I’m 51 years old. Is it possible for me to build strength after open heart surgery from doing regular exercise? Thanks.

    • Hi Maruti,
      Thank you for your comment. Whilst I cannot give you any specific routine or weight training regimen by way of the internet, I can say that it sounds like you have done everything right. In answer to your question, you can definitely build strength after your surgery, but I would advise working with an exercise physiologist or personal trainer to help show you safe exercise and breathing techniques. Once you have that, then you can go off on your own and build your strength. If you have any signs or symptoms, you should make sure to report them to your doctor to make sure there is nothing more sinister happening. Obviously if you’re having chest pain or anything else, go to the hospital. But safety first. I have worked with a lot of people who had heart attacks and open heart surgery and were able to lift weights and build strength, but you must always be safe first! Hope this is helpful. Kind regards, Bill

  2. Hi Dr. Bill Sukala
    One year is Passed, after my open heart surgery I was doing regular exercise as you have advised, (in your blog). Now I am feeling healthy, or I think now I can join gym for strength training.

    During my complete one year exercise Program, I have maintained, 25 minute Cardiac Rehab Exercise, 4 mins, Stair Climbing Exercise, I used to go up stairs to my House on the 9th floor, every day after finishing my 20 minites walking exercise.

    Initially I used to stop at 3rd floor then 6th floor, then 9th floor. Now I am in position to go up to 9th floor non stop. Nowadays I heard (read from internet) about HIIT exercise. Is it possible for me to do this HIIT. ?

    I am thinking of doing sit ups (Sit and Stand). With 20 sit ups My heart beats goes up to 168 bpm. This happens within 40 sec. time, and again I reapet this after resting for 2 minites, is it ok? Please advise.

    • Hi Maruti,
      Congratulations on feeling better after your open heart surgery. Regarding joining a gym and doing high intensity exercise, I would first advise you to speak with your cardiologist or whatever doctor is managing your cardiac care. I cannot legally give you a yes or know as to whether HIIT is right for you since I am not familiar with your entire medical history. Based on the information you have provided, it sounds like you have developed a good level of fitness. If your doctor can perform a treadmill stress test that pushes you to a high intensity and you do not have any abnormal changes in your ECG, then your doctor may give you clearance for performing HIIT. Keep up the good work. Kind regards, Bill

  3. Hi Dr Bill,

    I had my open heart surgery in 2013, i just wanted to know what kinda exercise i can do, im feeling abit over weight now and i want to lose it esp my tummy and love handles. can you give me advise please.

  4. Hi Dr. Bill Sukala,

    My name is Gabor Vasko. I am a 30 years old male and was doing sports my entire life. I had an aortic valve reconstruction on 20th of April in 2016. The surgery went well, I had zero regurgitation right after the operation then it progressed to minimal. 9months after surgery which was my 3rd follow up with my cardiologist they said the regurgitation is a little bit bigger but it’s normal. My fear is that the regurgitation will get worse quicker due to weight lifting, quicker than it would without me doing any exercise. I also run 10k once or twice a week and I do rock climb as well. My left ventricle was a little above 70mm before the surgery and now is 60mm. Is it possible that the regurgitation will get worse quicker due to weight lifting? I am also afraid that if the regurgitation gets worse then my left ventricle will start to get bigger again and I will have to go through another surgery a lot sooner than I was expecting. I go to the gym three times per week and either run or rock climb twice a week. Your answer is greatly appreciated. Best regards, Gabor Vasko

    • Hi Gabor,
      Thank you for taking the time to leave a comment. While I cannot provide any medical advice (I’m an exercise physiologist), I think it’s important that you discuss these specific concerns with your cardiologist and/or surgeon. You’re clearly an active person and this is a part of your quality of life. I can’t say for certain if the regurgitation will get worse, as that’s something that can only be answered by your docs who are most familiar with your specific situation. If we play devil’s advocate and your regurgitation does get “worse,” then the next question is if it is clinically meaningful to the extent that it will cause symptoms and require you to have another surgery. Perhaps if it does get worse, it could be a very small change over a very long time. But again, this is something you’ll need to ask your doc. Based on the information you’ve provided, the cardiologist still said the regurgitation was within normal limits. I think provided you have good communication with your docs and you go for regular check-ups along the way, then you will be able to live your usual active lifestyle. Kind regards, Bill

      • Thank you very much for taking the time and answering my question. The problem is that it’s hard to find someone who can tell me exactly what is ok and what is not considering sports and exercise. I guess it’s not possible to tell someone exactly what is too much exercise, or too heavy weights. My doctors are great and I do talk to them regularly but my problem is that they can’t give me these answers, only basic guidelines and I just want to make sure that whatever exercise I do will not worsen my symptoms quicker. Again, thank you very much for taking the time answering. Best regards, Gabor Vasko

        • Thanks Gabor,
          I can certainly understand your frustration, but when it comes to the ticker (or any medical condition for that matter), there are only guidelines but no catch all for every single person and condition. But there are people who break the mould and do some pretty incredible things despite underlying medical issues. I had a guy in my cardiac rehab program who was an elite cyclist, despite having had three heart attacks. He had so much damage to his heart muscle that he had developed congestive heart failure with a very low blood pressure. But amazingly, despite how sick his heart was, the rest of his body was so well-conditioned that it compensated for his heart. His blood pressures were anomalously low, like 60/40 at rest and during exercise he’d get up to a whopping 90/50 or so. The cardiac rehab staff talked to his docs and told them about how much exercise this guy could tolerate. They basically said under any other circumstances, they’d never recommend that amount of exercise, but in his case, it was “normal” for him.

          The moral of the story is, work closely with your docs and get on with your life. Exercise and go back for regular checkups. Remember that, as with the guy in the above example, it’s not a one-size-fits-all when it comes to exercise with heart valve surgery. The docs need to take on board the fact that you are young and athletic. Those factors change the landscape a bit for you as opposed to someone who is 65 years old, never exercised, and has other medical conditions.

          Hope this helps provide you some peace of mind.
          Kind regards
          Bill

  5. Hi Dr. Bill Sukala
    I am M.S. Patil, I have had my Open heart surgey on 12th June 2015. I am doing my Regular
    cardiac exercise & I tried to increase the intensity of my Home Exercise gradually, In my Last E-mail, in which I asked you my ambition to build a body strength. I was thinking to join Gym, but instead I tried to follow Cardiac Rehab Exercises by getting downloaded & doing it regularly at home. I found improvement in my capacity. I used to check my heart rate & Blood Pressure almost Daily, I am thinking that, slowly my heart capacity will increase, so I am Trying to Push myself hard but slowly. Today I just Read the E-mail queary of Mr. Gabor, & I feel Mine is also same case, The correction of Pulmonary Valve, One Day I checked all my reports, & found that, other than this ” main Pulmonary Stenosis” Which was corrected, there are still other problems present like Mild Mitral, tricuspid regurgitation & moderate Pulmonary Hypertention is Present, Also Grade I Diastolic dysfunction is present.
    My worry is, Is it possible to minimise this regurgatations by doing regular exercise. ? My regular HIIT Training includes 1) going up stairs non-stop up to 9th floor, it takes two minutes, & 2) doing Sit-ups ( sit & stand) fourty times in a length it takes 45 sec. & in both case my Heart beat reaches above 150 BPM. Please advise.
    BEST REGARDS M.S.Patil

    • Hi Maruti,
      As I mentioned to Gabor and most people who post questions in this forum, I cannot provide specific medical advice to anyone because I am not familiar with each person’s specific situation. It’s important to understand that there is no single “right vs wrong” answer that will apply to everyone. Yes, we do know that exercise is good for your health in most cases, but if your medical condition is not stable, then exercise can pose additional risks to your safety. So I would suggest speaking to your cardiologist and making sure that you are medically stable and that you have proper clearance from your doctor to participate in higher intensity exercise. I have worked with many patients who’ve had surgeries similar to yourself and Gabor and have gone on to lead very active lives. But again, it is very much dependent upon each person’s individual circumstances and must be cleared by the doctor. Also be aware that certain medications can have an effect on your body that may make higher intensity exercise safer (in terms of reducing exercising heart rate and blood pressure). Whilst I am not a fan of prescription medications, there are certain circumstances where they can be helpful to minimise risk and ensure your safety. Hope this helps. Kind regards, Bill

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