**4.1 Sarcopenia and indication for HTx**

The donor heart shortage restricts HTx to a small portion of potential recipients. Moreover, serious complications accompanied with patients with end-stage HF, such as sarcopenia, systemic infection, and irreversible renal and hepatic dysfunction, more greatly affect patient prognosis after HTx than other cardiac surgery, because HTx recipients need immunosuppressive medication to prevent allograft rejection. Therefore, HTx is a treatment option for a few carefully selected patients with end-stage HF. The number of patients above the age of 60 years being transplanted has increased over the past 10 years. And recent post-HTx survival in patients aged between 60 and 69 years has been satisfactory. However, 5-year mortality in those aged 70 years and older are significantly poorer compared with

*Sarcopenia in Patients with End-Stage Cardiac Failure Requiring Ventricular Assist Device or… DOI: http://dx.doi.org/10.5772/intechopen.100612*

those aged between 18 and 59 years. Therefore, recipients aged older than 70 years are less acutely ill, have fewer comorbidities, and are less likely to have durable LVAD support for BTT [42]. Therefore, usually moderate or severe sarcopenia, as well as frailty, might be a contraindication for HTx. However, LVAD implantation in patients with frailty could be applicable as a bridge to candidacy. Patients who can recover from a frail state after LVAD implantation presumably after a certain period of physical rehabilitation and nutrition supplementation would then be considered eligible for HTx. This means that a sarcopenia patient who is firstly likely to survive LVAD implantation and secondly to reverse his/her frailty or sarcopenia can be a potential candidate for HTx [43]. For these reasons, there has been no published data concerning the impacts of real sarcopenia on outcomes after HTx.

## **4.2 Impact of malnutrition and physical rehabilitation at before and after HTx on exercise capacity post-HTx**

Although previous studies have shown that the recipients exhibit improvements in exercise capacity and physical performance after HTx, the recipients often have a lower exercise capacity than normal healthy controls of the same age and gender soon and long after HTx.

Yanase et al. [44] investigated the effects of the recipient and donor predictive risk factors on the patient's exercise capacity early after HTx. In this study, 3-month rehabilitation exercise training significantly increased peak VO2 irrespective of the main recipient or donor risk predictive factors on post-HTx survival, which included paracorporeal or implantable LVAD, and several marginal donor heart risk factors. Only younger recipient age and better several nutrition factors, such as higher choline esterase and higher blood lymphocyte count, at the entry of 3-month exercise program were significantly associated with higher peak VO2 at the entry and the end of the 3-month training program. These data suggested that nutrition management and rehabilitation at the bedside prior to starting the exercise training program play a significant role in increasing peak VO2 at the entry of the rehabilitation program.
