Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Cardiac rehabilitation for patients with assistive devices is very important, given the improvement in quality of life and survival rates. 
I recommend that the authors of the article briefly address the following issues: 1. The timeliness of device implantation, as the outcome of the intervention will depend on this.
2. In addition to physical rehabilitation, social rehabilitation, particularly psychological rehabilitation, is very important, so attention should also be focused on this.
3. Regarding physical exercise. The main focus is on cardiopulmonary testing, but there are other methods, so they should also be briefly listed.

Author Response

1. The timeliness of device implantation, as the outcome of the intervention, will depend on this.

Response: Thank you to the reviewer for this comment.  We concur that the optimal timing of implantation is closely related to the post-implantation outcomes. However, in this study, our primary objective was to provide practical guidance on cardiac rehabilitation following LVAD implantation; therefore, we deem it inappropriate to include a dedicated section on this topic.

2. In addition to physical rehabilitation, social rehabilitation, particularly psychological rehabilitation, is very important, so attention should also be focused on this.

Response: We appreciate the reviewer's comment. While we concur that social and psychological rehabilitation are crucial following LVAD implantation, our article primarily focuses on cardiac rehabilitation post-LVAD; therefore, we believe that incorporating a section on this topic would be unsuitable.

3. Regarding physical exercise. The main focus is on cardiopulmonary testing, but there are other methods, so they should also be briefly listed.

We appreciate the reviewer's comment. We have added some sentences on the improvement of 6MWDT after CR.

Reviewer 2 Report

Comments and Suggestions for Authors

The article addresses a relevant and growing topic. Despite the value of the narrative review, I suggest developing more concrete practical clinical recommendations.

Although reviewing many studies, the discussion does not clearly explain where there is consensus and where the data are still conflicting. In some passages, the text assumes universal benefits of post-LVAD cardiac rehabilitation without distinguishing between patient types or clinical contexts.

As it is a narrative review, it would be useful for the authors to justify this choice and explicitly state the inclusion/exclusion criteria for the cited studies.

The title could indicate that it is a narrative review, and the abstract could more clearly mention the main findings and gaps.

Review the spelling and typing structure of the text: punctuation, spacing, misuse of commas, and some sentences with confusing structure.

Author Response

The article addresses a relevant and growing topic. Despite the value of the narrative review, I suggest developing more concrete practical clinical recommendations.

Response: We express our gratitude to the reviewer for their appreciation of our work.

Although reviewing many studies, the discussion does not clearly explain where there is consensus and where the data are still conflicting. In some passages, the text assumes universal benefits of post-LVAD cardiac rehabilitation without distinguishing between patient types or clinical contexts.

Response: We appreciate the reviewer's comment. In the new version of the paper, we have highlighted areas of consensus and indicated where the data remain conflicting regarding CR in LVAD recipients.

As it is a narrative review, it would be useful for the authors to justify this choice and explicitly state the inclusion/exclusion criteria for the cited studies.

Response: We appreciate the reviewer's comment. In the revised version of the paper, we clarify why we chose a narrative review. However, since narrative reviews have less strict research criteria than systematic reviews, we did not use prespecified inclusion and exclusion criteria.

The title could indicate that it is a narrative review, and the abstract could more clearly mention the main findings and gaps.

Response: We appreciate the reviewer’s comment. The title and abstract have been revised accordingly.

Review the spelling and typing structure of the text: punctuation, spacing, misuse of commas, and some sentences with confusing structure.

Response: We appreciate the reviewer’s comment. In the new version of the manuscript, we have carefully revised the text.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors, 
Congratulations on your proposal and the work reflected in the manuscript. However, there are a few aspects that should be considered: 

Abstract

A well-structured and clinically relevant abstract is presented that adequately summarises the pathophysiology, justification for CR, and practical aspects.

Although some sentences are long and dense, simplifying the syntax is recommended to improve readability. The abstract could benefit from a clearer final sentence summarising the main clinical message (take-home message). The use of expressions such as “probably also to reduced mortality” should be qualified (e.g., “may be associated with”) to avoid potentially speculative statements.

Introduction

An adequate contextualisation of the increase in LVAD use is highlighted, with appropriate use of recent INTERMACS data. The gap between survival and functional capacity is also correctly addressed.
It is recommended that the knowledge gap be reinforced more explicitly: what is still unclear about CR in patients with LVAD? The introduction could conclude with a more formalised objective.

Physiology and pathophysiology of LVAD during exercise
This section is very solid from a scientific point of view, with excellent integration of invasive studies, CPET, and haemodynamic data. Table 1 is clear and useful.
However, the section is long and very dense; it could benefit from internal substructuring (short subheadings). Some paragraphs combine results from multiple studies with strong conclusions; it is recommended to separate results from interpretation. It is suggested to add a brief summary sentence at the end of the section to facilitate reading for the non-expert clinician.

Cardiac Rehabilitation in HF: General Principles
Correct contextualisation of CR as a pillar of HFrEF treatment
Some of the content is very general and not specific to LVAD; it could be condensed slightly to avoid redundancy with widely known literature.
It is recommended to explicitly reinforce the conceptual transition from ‘classic’ HFrEF to the LVAD subgroup.

Post-LVAD CR: Rationale and Results
Excellent selection of key studies (Rehab-VAD, multicentre studies) and appropriate use of functional and quality of life endpoints. The added value of CR compared to LVAD alone is clearly conveyed.
Some results present non-significant p-values; it would be advisable to clarify their clinical interpretation. A summary table of the main CR studies in LVAD (design, n, intervention, outcomes) could be added. The causal relationship between CR and mortality should be presented with more caution, emphasising the observational nature of some studies.

Practical aspects of CR after LVAD implantation
Section of high clinical and educational value, well aligned with actual practice.
Review some stylistic aspects (spacing, punctuation, minor grammatical inconsistencies). It could be structured into clear subsections (safety, haemodynamics, volume, device). It would be useful to add a brief algorithm or practical figure.

Conclusions
Consistent with the content of the manuscript, clear clinical message and well aligned with the evidence.
Avoid overly categorical statements about mortality. A brief mention of future lines of research (randomised trials, standardised protocols) could be added.

Author Response

Abstract

A well-structured and clinically relevant abstract is presented that adequately summarises the pathophysiology, justification for CR, and practical aspects.

Although some sentences are long and dense, simplifying the syntax is recommended to improve readability. The abstract could benefit from a clearer final sentence summarising the main clinical message (take-home message). The use of expressions such as “probably also to reduced mortality” should be qualified (e.g., “may be associated with”) to avoid potentially speculative statements.

Response: Thank you to the reviewer for this comment. We have revised the abstract accordingly.

Introduction

An adequate contextualisation of the increase in LVAD use is highlighted, with appropriate use of recent INTERMACS data. The gap between survival and functional capacity is also correctly addressed.
It is recommended that the knowledge gap be reinforced more explicitly: what is still unclear about CR in patients with LVAD? The introduction could conclude with a more formalised objective.

Response: Thank you to the reviewer for this comment. We have revised the introduction accordingly.

Physiology and pathophysiology of LVAD during exercise
This section is very solid from a scientific point of view, with excellent integration of invasive studies, CPET, and haemodynamic data. Table 1 is clear and useful.
However, the section is long and very dense; it could benefit from internal substructuring (short subheadings). Some paragraphs combine results from multiple studies with strong conclusions; it is recommended to separate results from interpretation. It is suggested to add a brief summary sentence at the end of the section to facilitate reading for the non-expert clinician.

Thank you to the reviewer for this comment. We have revised the section accordingly.

 

Cardiac Rehabilitation in HF: General Principles
Correct contextualisation of CR as a pillar of HFrEF treatment
Some of the content is very general and not specific to LVAD; it could be condensed slightly to avoid redundancy with widely known literature.
It is recommended to explicitly reinforce the conceptual transition from ‘classic’ HFrEF to the LVAD subgroup.

Response: Thank you to the reviewer for this comment. In the revised manuscript, we have shortened the section on Cardiac Rehabilitation in HF and emphasized the need for addressing specific issues to ensure proper conduct of CR in LVAD recipients.

Post-LVAD CR: Rationale and Results
Excellent selection of key studies (Rehab-VAD, multicentre studies) and appropriate use of functional and quality of life endpoints. The added value of CR compared to LVAD alone is clearly conveyed.
Some results present non-significant p-values; it would be advisable to clarify their clinical interpretation. A summary table of the main CR studies in LVAD (design, n, intervention, outcomes) could be added. The causal relationship between CR and mortality should be presented with more caution, emphasising the observational nature of some studies.

Response: Thank you to the reviewer for this comment. In the revised manuscript, we have added a table of the main study of CR in LVAD recipients.  Moreover, we have modified the text accordingly. 

Practical aspects of CR after LVAD implantation
Section of high clinical and educational value, well aligned with actual practice.
Review some stylistic aspects (spacing, punctuation, minor grammatical inconsistencies). It could be structured into clear subsections (safety, haemodynamics, volume, device). It would be useful to add a brief algorithm or practical figure.

Response: Thank you to the reviewer for this comment. We have revised the text accordingly; however, since CR protocols differ across centers, we believe adding a figure would not be helpful.

Conclusions
Consistent with the content of the manuscript, clear clinical message and well aligned with the evidence.
Avoid overly categorical statements about mortality. A brief mention of future lines of research (randomised trials, standardised protocols) could be added.

Response: Thank you to the reviewer for this comment. We have revised the conclusion accordingly.