51
ORIGINAL ARTICLE
Can the Six-Minute Walk Test Predict Peak Oxygen Uptake
in Men With Heart Transplant?
Stéphane Doutreleau, MD, PhD, Paola Di Marco, MD, Samy Talha, MD, Anne Charloux, MD, PhD,
François Piquard, PhD, Bernard Geny, MD, PhD
ABSTRACT. Doutreleau S, Di Marco P, Talha S, Charloux
A, Piquard F, Geny B. Can the six-minute walk test predict
peak oxygen uptake in men with heart transplant? Arch Phys
Med Rehabil 2009;90:51-7.
Objective: To determine whether the six-minute walk test
(6MWT) might predict peak oxygen consumption (VO2peak)
after heart transplantation.
Design: Case-control prospective study.
Setting: Public hospital.
Participants: Patients with heart transplant (n⫽22) and
age-matched sedentary male subjects (n⫽13).
Interventions: Not applicable.
Main Outcome Measures: Exercise performance using a
maximal exercise test, distance walked using the 6MWT, heart
rate, and VO2peak.
Results: Compared with controls, exercise performance was
decreased in patients with heart transplant with less distance
ambulated (516⫾13m vs 592⫾13m; P⬍.001) and a decrease
in mean VO2peak (23.3⫾1.3 vs 29.6⫾1mL·min⫺1·kg⫺1;
P⬍.001). Patients with heart transplant showed an increased
resting heart rate, a response delayed both at the onset of
exercise and during recovery. However, the patient’s heart rate
at the end of the 6MWT was similar to that obtained at the
ventilatory threshold. The formula did not predict measured
V̇O2, with a weak correlation observed between the six-minute
walk distance and both VO2peak (r⫽.53; P⬍.01) and ventila-
tory threshold (r⫽.53; P⬍.01) after heart transplantation. In-
terestingly, when body weight was considered, correlations
coefficient increased to .74 and .77, respectively (P⬍.001).
Conclusions: In heart transplant recipients, the 6MWT is a
safe, practical, and submaximal functional test. The distance-
weight product can be used as an alternative method for as-
sessing the functional capacity after heart transplantation but
cannot totally replace maximal V̇O2 determination.
Key Words: Exercise; Functional residual capacity; Reha-
bilitation; Transplantation.
© 2009 by the American Congress of Rehabilitation
Medicine
LTHOUGH BOTH FUNCTIONAL status and exercise
A performance progressively increase during the first 2 years
1,2
after surgery, patients with heart transplant still present low
activity level and exercise capacity compared with matched
From the Physiology Institute, Medicine Faculty and Hospital, University Hospital
of Strasbourg, Strasbourg, France.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Reprint requests to Stéphane Doutreleau, MD, PhD, Service de Physiologie et
d’Explorations Fonctionnelles, 1 place de l’hôpital, 67000 Strasbourg, France, e-mail:
stephane.doutreleau@chru-strasbourg.fr.
0003-9993/09/9001-00167$36.00/0
doi:10.1016/j.apmr.2008.07.010
sedentary subjects.3-7 This can be, in part, explained by both
central and peripheral limitation, leading to a reduced quality
of life in patients with heart transplant.8-12 Thus, cardiac dia-
stolic dysfunction6 and chronotropic insufficiency10,13 on the
one hand and muscular11,14 and endothelial dysfunction15 on
the other hand appear to be the main limiting factors of exercise
capacity after heart transplantation.
Standardized laboratory maximal exercise test with oxygen
uptake measurement can, noninvasively and objectively, quan-
tify this limitation by measuring VT and VO2peak. Thus, a
maximal cardiopulmonary exercise test is considered a crite-
rion standard, used in order to prescribe appropriate and indi-
vidualized physical rehabilitation, allowing a complete assess-
ment of all systems involved in exercise performance.16
However, laboratory tests of maximal exercise performance
require sophisticated equipment and specially trained people.
They are costly and time-consuming. Furthermore, these tests
are not always well accepted, and some participants may have
difficulties achieving a maximal exercise test.
Therefore, easier modalities to assess exercise capacities
have been developed. Particularly, the 6MWT is the most
popular and commonly used submaximal exercise test. Indeed,
it is easy to perform, is well tolerated, and better reflects daily
life activities of the subjects than other walk tests.17 The
6MWT can predict functional change resulting from disease
progression or therapeutic intervention, morbidity and mortal-
ity in heart18 or lung disease,19 and capacity in older, healthy,
sedentary people.20 The 6MWT can also be used to assess
functional exercise performance across various subjects like
young21 or older, sedentary people,22 patients with heart fail-
ure,18,23,24 and patients with a wide variety of pulmonary
alterations.25,26
The 6MWT performance has previously been shown to be
reduced in kidney transplant recipients.27 Interestingly, a weak
but significant correlation between the 6MWD and the
VO2peak has been reported in patients with heart18,28,29 or lung
failure.19 But curiously, whereas this test is commonly used in
patients with heart failure needing cardiac transplantation,30
data on the 6MWT characteristics and usefulness in heart
transplant recipients are lacking.
The main objective of the present investigation was therefore
to determine whether the 6MWT could predict VO2peak in
patients with heart transplant. Other objectives were to deter-
mine whether the 6MWT is a submaximal or a maximal exer-
cise test, and to compare the VO2peak predicted by formula
with the measured VO2peak after heart transplantation.
List of Abbreviations
6MWD six-minute walk distance
6MWT six-minute walk test
SEM standard error of the mean
V̇O2 oxygen uptake
VO2peak peak oxygen uptake
VT ventilatory threshold
Arch Phys Med Rehabil Vol 90, January 2009
52 WALK TEST AFTER HEART TRANSPLANTATION, Doutreleau
Table 1: Resting Clinical, Hemodynamic, and Echocardiographic
Characteristics of Both the Control Subjects and the Subjects
With Heart Transplant
Characteristics Control (n⫽13) Heart Transplant (n⫽22)
Age (y) 57.70⫾1.50 56.00⫾1.70
Height (cm) 179.20⫾1.10 174.50⫾1.30
BMI, (kg.m⫺2) 25.80⫾0.50 26.00⫾0.70
Heart rate (b.min⫺1) 73.00⫾3.20 95.10⫾2.40*
Blood pressure (mmHg)
Systolic 125.00⫾2.30 143.00⫾2.80*
Diastolic 81.00⫾1.50 88.00⫾1.70†
EF (%) 65.00⫾3.00 64.00⫾2.00
E/A ratio 1.55⫾0.08 1.49⫾0.09
Abbreviations: BMI, body mass index; E/A, ratio of peak early (E) and
late (A) transmitral filling velocities; EF, ejection fraction.
Differences between groups: *P⬍.001; †P⫽.01.
METHODS
Participants
The study was carried out between January 2005 and May
2006. During this period, the chirurgical team transplanted 8
patients. Eight heart transplant recipients were excluded: 3
refused to perform a maximal exercise test, and 5 were enrolled
in exercise rehabilitation or in sport. Twenty-two male seden-
tary patients with heart transplant, at least 6 months since
transplant, in sinus rhythm, and clinically stable (free of rejec-
tion with no sign of heart failure and without cardiac allograft
vasculopathy on the coronary arteriography) participated in the
study. Thirteen healthy sedentary age-matched people served
as controls. Patients with diabetes, pulmonary dysfunction, or
conditions that might impair a successful completion of the
6MWT or of the maximal exercise test, such as orthopedic or
muscular problems, were excluded. All patients with heart trans-
plant took their usual immunosuppressive therapy composed of
cyclosporine (189⫾12mg/d), prednisolone (6.9⫾0.8mg/d), and
mycophenolate mofetil (909⫾170mg/d). All of them had a sys-
temic hypertension treated with angiotensin-converting enzyme
inhibitor (n⫽15) and/or calcium antagonist (n⫽9), but none of
them took beta-blockers.
Clinical, hemodynamic, and echocardiographic characteris-
tics of the subjects are presented in table 1. Systolic and
diastolic left heart functions were obtained through the left
ventricular ejection fraction and the mitral ratio of peak early
and late transmitral filling velocities, respectively, following
the recommendations of the American Society of Echocardi-
ography.31 All patients gave written informed consent, and the
study was approved by the hospital and university review board
for human studies.
Interventions
Both patients with heart transplant and control groups per-
formed, 1 hour after a standardized meal, a 6MWT followed
after a 2-hour resting period by a maximal upright bicycle
cardiopulmonary exercise test in a quiet air-conditioned room
(21°C). To avoid circadian variation, all exercise tests were
performed between 2 PM and 4 PM.
Exercise Testing Protocol
Six-minute walk test. The 6MWT was coached by the
same physicians, according to the American Thoracic Society
recommendations.32 Briefly, patients were instructed to walk
the most distance possible in 6 minutes in a 13-m straight
Arch Phys Med Rehabil Vol 90, January 2009
calibrated track. Standardized encouragements were given ev-
ery minute. Before the test, patients rested in a chair, located
near the starting position, for 10 minutes. After 6 minutes, the
distance walked was recorded to the nearest meter. Results are
expressed as actual distance walked in meters.
Heart rate (b.min⫺1) and pulse oxygen saturation (%) were
continuously measured before the walk, during the test, and
during the first 5 minutes of recovery by using a lightweight
pulse oximetera on the finger.
A reference equation for healthy adults33 was used to com-
pute the percent predicted of 6MWD for individual adult pa-
tients with the following formula:
6MWD (m) ⫽ [7.57 ⫻ height(cm)] ⫺ [1.76 ⫻ weight(kg)]
⫺ [5.02 ⫻ age(y)] ⫺ 309
Predicted VO2peak from the 6MWT was calculated by using
the following formula from Cahalin et al:18
VO2peak (mL · min⫺1) ⫽ [0.03 ⫻ 6MWD (m) ⫹ 3.98]
Because the body weight of the patient directly affects the
work/energy required to perform the walk, whereas it is of
minor importance during cycling exercise, we used the body
weight-walking distance (body weight ⫻ walking distance)
product to assess the walking capacity of the subject (6-minute
walk work ⫽ kg.m).34-36
We also compared the 6MWD ⫻ body weight product to the
maximal workload (maximal power tolerated), the oxygen up-
take on the VT, and the VO2peak reached during the maximal
bicycle exercise test.
Maximal cardiopulmonary bicycle exercise test. All pa-
tients performed a symptom-limited exercise test in the upright
position using an electronically braked bicycle ergometer.b The
protocol was the same for all patients, and after a warm-up on
the bicycle for 3 minutes at 30W, exercise workload was
increased by 15W every minute. Exhaustion was defined as the
inability to maintain the pedal frequency above 50rev/min
because of leg fatigue and/or dyspnea.
Breath-by-breath V̇O2 (mL.min⫺1), carbon dioxide output
(mL.min⫺1), and minute ventilation (L.min⫺1) were measured
throughout using a Vmax 229.c The system was calibrated
before each test using known gas concentrations, and a 3-L
calibrated syringe was used to ensure the accuracy of the
pneumotach.
Peak values of VO2 were averaged on the last 30 seconds of
the exercise test (VO2peak). The VT was manually determined
by 2 blinded examiners, using the V-slope and ventilatory
equivalents methods.37 The interobserver variability for VT
determination was 4.8⫾1.64%. VO2peak was compared with
age/sex-adjusted peak oxygen uptake (peak % VO2).38
Electrocardiographic activity was monitored continuously
using a standard 12-lead configuration,d and systemic arterial
blood pressure was registered every 2 minutes using a sphyg-
momanometer. Maximal exercise heart rate was defined as the
maximal value reach at the end of the test.
Statistical Analysis
Sigma-Stat Softwaree was used for statistical analysis. All
data are presented as mean ⫾ standard error of the mean.
Differences between predicted V̇O2, 6MWD, and measured
values were evaluated using paired t tests. For comparison of
chronotropic response between groups, a 2-way analysis of
variance with repeated measures was performed. When the F
value indicated significant differences between means at dif-
ferent time, a Student-Neman-Keuls test for multiple compar-
 WALK TEST AFTER HEART TRANSPLANTATION, Doutreleau 53

isons was performed. A Pearson correlation analysis was used

to determine whether there was a significant association be-
tween the 6MWD and the 6-minute walk work with measured
VO2peak, maximal power tolerated, and VT. Correlation was
also determined between V̇O2 from predicted equations versus
the measured VO2peak. A P value less than .05 was considered
significant.
RESULTS
All 35 men completed the 6MWT and the cycle ergometry
with gas exchange. No complication occurred during both tests.
Resting Characteristics of the 2 Groups
The reason for cardiac transplantation was a dilated cardio-
myopathy for 14 and an ischemic cardiomyopathy for the other Fig 2. Chronotropic response at rest, exercise, and during the re-
covery period (R1 to R5). *P<.001 between heart transplant (black
8. The subjects were similar concerning their age and body point) and control groups (white point).
mass index. The delay between transplantation and the study
was 60.2⫾6.9 months, and the mean number of rejection
episodes was 1.3⫾0.2.
As expected, patients with heart transplant presented an 73.0⫾3.2b.min⫺1 and 123.4⫾3.0b.min⫺1 in the heart trans-
increased heart rate and blood pressure compared with control plant and control groups, respectively. Interestingly, despite
values. Both systolic and diastolic cardiac functions were in the reaching similar absolute values during exercise, the chrono-
normative range as inferred from the left ventricular ejection tropic response, calculated as peak heart rate minus resting
fraction and the mitral ratio of peak early and late transmitral heart rate, was significantly decreased in transplanted patients
filling velocities, respectively (see table 1). compared with the control group (28.4⫾2.9 and 50.4⫾2.8,
respectively; P⬍.001).
Distance Walked, Oxygen Saturation, and Heart Rate The peak heart rate reached during the 6MWT was similar to
Responses to the Six-Minute Walk Test the heart rate reached at the VT during the maximal exercise
The mean distance covered during the 6MWT was test, suggesting that the 6MWT is a submaximal test. It was
516.5⫾12.8m and 596.2⫾13.0m in patients with heart trans- significantly (P⬍.001) lower than the maximal heart rate (fig 3)
plant and control group, respectively (P⬍.001). When com- in both groups.
pared as a percentage of the predicted normative age-specific
and sex-specific values, patients with heart transplant presented Cardiorespiratory Responses to the Maximal Bicycle
with a significant (–14.7⫾2.5%; P⬍.001) reduction in the total Exercise Test
walk distance compared with the control group, which was in All patients also performed a maximal exercise test with an
normative range (– 0.2⫾2.2%) (fig 1). end-exercise respiratory exchange ratio of 1.16⫾0.03 and
Work for the 6MWT, calculated as the product of the walk 1.14⫾0.02 in the heart transplant and control groups, respec-
distance (m) ⫻ body weight (kg), was significantly reduced in tively. Patients stopped exercise because of leg fatigue (n⫽28)
patients with heart transplant compared with the control group or dyspnea (n⫽7). None of the exercise tests had to be termi-
(40,861.2⫾1883.1kg.m and 49,329.8⫾1447.8kg.m in patients nated prematurely because of an abnormal hemodynamic re-
with heart transplant and control group, respectively; P⫽.004). sponse. No subject had a ventilatory limitation. Ventilatory
Oxygen saturation remained unaltered throughout the walk reserves were 27.5⫾5.3% and 32.4⫾6.4% in heart transplant
and mean resting period and end-walking values were respec- and control subjects, respectively.
tively 97.3⫾0.2% and 97.2⫾0.1% in the 2 groups.
The chronotropic response is shown in figure 2. The heart
rate significantly increased during the walk test in the 2 groups
(P⬍.001). The mean resting and end-walking heart rate
values were 95.1⫾2.4b.min⫺1 and 123.5⫾2.8b.min⫺1 and

Fig 3. Comparison of heart rate measured at the end of the 6MWT

and during the incremental exercise test (IET) at the VT and at the
Fig 1. Distance walked in meters during the 6MWT in both control peak exercise both in the heart transplant (grey) and control groups
and heart transplant (HTx) groups. (white). Abbreviation: NS, not significant. *P<.001.

Arch Phys Med Rehabil Vol 90, January 2009

54 WALK TEST AFTER HEART TRANSPLANTATION, Doutreleau

Table 2: Cycle Ergometry Gas Exchange Data on VT and at DISCUSSION

Peak Exercise
The main results of this study performed in heart transplant
Variables Controls (n⫽13) Heart Transplant (n⫽22) recipients are the following: (1) the 6MWT is a submaximal
VT test, safe, and easy to perform; (2) the VO2peak predicted by
Work (W) 116.3⫾8.5 92.7⫾3.9§ equations does not correspond well enough with the measured
V̇O2 VO2peak after heart transplantation; and (3) unlike the simple
mL.min⫺1.kg⫺1 17.9⫾0.7 15.7⫾0.6‡ distance walked, the weight-distance product (6-minute walk
% predicted 61.0⫾2.8 55.3⫾1.9 work) might be a useful approach of patients’ VO2peak after
VCO2 (mL.min⫺1) 1520.6⫾78.4 1179.3⫾63.9* heart transplantation.
SpO2 (%) 97.1⫾0.3 96.7⫾0.3
HR (beats.min⫺1) 126.1⫾4.3 128.8⫾2.3 Exercise Intolerance After Heart Transplantation
Peak exercise As expected, patients with heart transplant showed a tight
Work (W) 194.2⫾7.2 135.0⫾9.1† but significant reduction of their exercise capacity in both
Exercise time (min) 14.5⫾0.4 10.1⫾0.6† maximal bicycle exercise test (82.5⫾3.5% of the predicted
V̇O2 values) and 6MWT (88.7⫾2.5% of the predicted values) com-
mL.min⫺1.kg⫺1 29.6⫾1.0 23.3⫾1.3* pared with control values. After cardiac transplantation, central
% predicted 100.2⫾3.5 82.5⫾3.5* factors (cardiac diastolic dysfunction and cardiac denervation
VCO2 (mL.min⫺1) 2749.8⫾185.2 2130.1⫾144.6‡ resulting in chronotropic incompetence) and peripheral factors
V̇E (L.min⫺1) 94.2⫾15.5 79.3⫾4.4 such as endothelial and muscular dysfunctions (progressive
SpO2 (%) 96.7⫾0.3 96.1⫾0.5 reduction in muscular fibers, greater contribution of glycolytic
SBP (mmHg) 171.5⫾5.8 177.3⫾4.2 metabolism despite the oxidative one) likely contribute to the
DBP (mmHg) 85.1⫾3.6 93.7⫾2.1‡ reduced exercise capacity.4,10,39-42 The values of the VO2peak
HR (beats.min⫺1) 168.4⫾2.7 148.7⫾3.4† were greater than values found in the literature.1-3,6,7 Such a
difference could be explained, in part, by the inclusion of
Abbreviations: DBP, diastolic blood pressure; HR, heart rate; SBP, patients without cardiac allograft vasculopathy6 and only the
systolic blood pressure; SpO2, pulse oxygen saturation; V̇CO2, carbon
dioxide output; V̇E, minute ventilation. bicaval surgical technique.43
Differences between groups: *P⫽.002; †P⬍.001; ‡P⬍.05. In our well patients, it is unlikely that central factors have
played a significant limiting role. Indeed, both cardiac systolic
and diastolic functions were similar to those of control sub-
The heart transplant population presented with a moderate jects. The normative diastolic function in our population late
exercise capacity limitation compared with the age-matched after heart transplantation could probably be explained by the
control values (table 2). Overall, the mean VO2peak during inclusion of patients without cardiac allograft vasculopathy.6
cycle ergometry was 23.3⫾1mL.min⫺1.kg⫺1 at a mean work- Furthermore, although a reduced heart rate reserve was
load of 135.0⫾9.1W. This represented 82.5⫾3.5% of the pre- shown—mainly because of the increased resting heart rate
dicted maximal V̇O2. A similar reduction in other gas exchange secondary to the surgical cardiac denervation—no relationship
indexes was noted (see table 2). The VT was determined in all was observed in our patients with heart transplant between
patients and tended to occur earlier in heart transplant patients heart rate reserve and exercise capacity. This is not unexpected,
than in control groups. VT correlated with the measured because such a relationship has been previously observed
VO2peak (r⫽.64; P⬍.001) in both groups. mainly in highly trained patients with heart transplant, support-
ing that greater exercise intensity might be necessary to reveal
Relationship Between Six-Minute Walk Test the central limitation of exercise capacity after heart transplan-
and Measured Oxygen Uptake tation.3,10
There were relatively weak but significant correlations (fig Concerning peripheral factors, both vascular and muscular
4A) between 6MWD and measured VO2peak, VT, and maximal alterations are important to consider. Indeed, besides a possible
power in the 2 groups. influence of the amino acid taurine,41 muscular alterations
When body weight was considered, correlations between might be a result of a direct deleterious effect of deconditioning
6MWD ⫻ body weight product (6-minute walk work) and the and/or the immunosuppressive therapy. Thus, both glucocorti-
measured maximal power tolerated, VT, and VO2peak became coids and cyclosporine have been shown to damage the mus-
stronger (fig 4B). Thus, for example, 28% of the variance in cles of patients with heart transplant. Skeletal muscle dysfunc-
V̇O2 on VT was accounted for by the distance walked in 6 tion might also result from relative hypoxia secondary to
minutes in the heart transplant group, while 59% was ac- inadequate perfusion; thus, vascular dysfunction is related to
counted for when the 6-minute walk work calculation was exercise capacity reduction after heart transplantation.41,42,44
applied, representing an improvement of 31% in the variance
for the same patients. Similar improvements were noted for the Exercise Capacity Determination After
VO2peak and maximal power tolerated. Heart Transplantation
The maximal power tolerated estimated from performance To quantify the aerobic performance of patients with heart
on the 6MWT (see equation in fig 3) was 133.8⫾6.8W and did transplant, we used both a maximal exercise test and a walk
not differ significantly from the measured maximal power test. A maximal bicycle exercise test with oxygen uptake
tolerated (135⫾9W; P⫽.89). measurement is the best test used to identify the limiting factor
The V̇O2 predicted by the equation by Cahalin et al18 was of aerobic performance. This test measured the global and
significantly lower than the measured VO2peak (19.6⫾0.4 integrated response involved in exercise performance, includ-
vs 23.3⫾1mL.min ⫺1 .kg ⫺1 ; P⬍.001), with an SEM of ing the potential limitations observed in heart transplant recip-
3.4mL.min⫺1.kg⫺1. However, there was a moderate but signif- ients: cardiovascular system and muscle metabolism.
icant correlation between predicted and measured VO2peak Walk tests are typically administered as a means of evalu-
(r⫽.50; P⬍.02). ating functional status, monitoring treatment effectiveness, and

Arch Phys Med Rehabil Vol 90, January 2009

 WALK TEST AFTER HEART TRANSPLANTATION, Doutreleau
Fig 4. Relationship between
both distance walked during
6MWT (6MWD) (A, left) or dis-
tance walked during the
6MWD (m) multiplied by the
body weight (kg) (B, right),
with measured VO2peak, the
VT, and peak exercise work-
load (Wpeak) in subjects with
heart transplant.
establishing prognosis.17,45 Indeed, walking is the most com-
mon, practical, and convenient form of exercise. Functional
walk tests measure particularly the ability to undertake physi-
cally demanding activities of daily living.17,46 Because most
activities of daily living are performed at submaximal levels of
exertion, the distance walked may better reflect the functional
exercise level for daily physical activities. Thus, the 6MWT
has been shown to correlate well with formal measures of
quality of life.47 Among walk tests, we chose the 6MWT
because it is easier to administer, is better tolerated, and better
reflects daily life activity than other walk tests.17
Is the Six-Minute Walk Test a Submaximal or Maximal
Test After Heart Transplantation?
This issue appeared controversial in previous studies be-
cause authors proposed that the 6MWT corresponded either to
a submaximal21,48 or a maximal exercise test,22 mainly depend-
ing on the type of patients investigated. This is not surprising,
because in people with an important exercise limitation factor,
the walking metabolic demand can approach their maximal
capacity and walk speed. Conversely, when people do not have
any important limiting factor, such as in sedentary people, the
6MWD mainly depends on the walk speed (they cannot run)
with its sex, age, and weight dependence. In our patients with
heart transplant, several arguments suggest that the 6MWT was
a submaximal test.
First, considering the values obtained in healthy subjects, the
distance walked by our healthy patients with heart transplant
55
remained in the sedentary predicted range. Indeed, healthy
subjects have been shown to walk about 400 to 700m during
the 6MWT, with the main predictors of the distance walked
being sex, age, and height.21
Second, we determined the heart rate response to the 6MWT
in our patients with heart transplant. This parameter deserves
discussion after heart transplantation because patients pre-
sented with a cardiac denervation secondary to the surgical
procedure.9 Accordingly, their resting heart rate was increased
and, during exercise, cardiac denervation resulted primarily in a
chronotropic incompetence characterized mainly by delays in the
heart rate response both at the beginning of exercise and during
recovery. However, even if denervated, the transplanted heart
remains under hormonal control and thus, during exercise, its
increase is related to exercise intensity.4,8,48 Thus, the end exercise
heart rate is similar in patients with heart transplant and controls at
the end of the 6MWT and, importantly, the heart rate of the
patients with heart transplant at the end of the 6MWT was com-
parable to that observed at the VT during the maximal exercise
test (124⫾3 and 129⫾2b.min⫺1, respectively in the heart trans-
plant group) (see fig 4).
Thus, it appeared likely that the 6MWT was a submaximal
test in these patients with heart transplant.
Can the Six-Minute Walk Test Predict Peak Oxygen
Uptake After Heart Transplantation?
In heart failure with systolic dysfunction18 or in patients with
end-stage lung diseases,19 the distance ambulated during the
Arch Phys Med Rehabil Vol 90, January 2009
56 WALK TEST AFTER HEART TRANSPLANTATION, Doutreleau
6MWT predicts the maximal oxygen consumption. Using the
heart failure prediction equation,18 we found higher values than
predicted with an SEM of 3.4mL.min⫺1.kg⫺1. Our results are
similar to those reported recently in older patients with systolic
and diastolic heart failure, supporting the idea that such equations
might not always be clinically useful.23
What about the direct determination of V̇O2 at the VT and at
the end of exercise (VO2peak)? Although positively correlated, the
relationship between the 6MWT distance and V̇O2 both at the VT
and at peak were relatively weak. Thus, the distance walked
during the 6MWT did not predict V̇O2 after heart transplantation
accurately.
However, the energy cost of walking depends on both
weight and walking speed,49 and the preferred minimum walk-
ing speed (to minimize the energy cost for walking) of healthy-
weight adults is higher than that of obese adults who prefer to
walk more slowly.50 In fact, overweight persons expend much
more metabolic energy during walking than healthy-weight
persons,50,51 and the distance walked during the 6MWT is
weight-dependent.
Accordingly, the correlation between performance on timed
walking tests and VO2peak from a cycle test becomes stronger
if distance walked is multiplied by body weight (distance ⫻
weight ⫽ work of walking at horizontal level).34,36 To take into
account this effect of weight on the distance walked by the
patients, we compared the distance-weight product during the
6MWT and the patients’ V̇O2. Very interestingly, the significant
relationship between this parameter and V̇O2 at the VT and at peak
exercise was much stronger than that obtained with the 6MWD.
Such data increase the clinical relevance of the 6MWT in patients
with heart transplant and suggest that the distance walked multi-
plied by the body weight might be used as a reasonable approach
to the patients’ VO2peak after heart transplantation.
Study Limitations
This study has several limitations. We included only a low
number of men without cardiac allograft vasculopathy, late
after heart transplantation. A greater number of all kinds of
patients are required to analyze the relation between the 6MWT
and the maximal V̇O2.
CONCLUSIONS
The 6MWT is a safe and practical test, easy to use in patients
with heart transplant. The heart rate response analysis support
that this walk test is a submaximal test after heart transplanta-
tion. Like the equation, the use of the walking distance alone
does not allow accurate prediction of the patients’ V̇O2. How-
ever, the distance-weight product obtained during the 6MWT
might be used as a clinically relevant approach to the patients’
VO2peak after heart transplantation. This will allow a broader
use of exercise testing after heart transplantation and might
help convince more patients to perform exercise training, the
beneficial effects of which have been largely demonstrated.
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