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López-Hernández A, Gimeno-Santos E, Navarro-Ripoll R, Arguis MJ, Romano-Andrioni B, López-Baamonde M, Teres S, Sanz-de la Garza M, Martinez-Palli G. Differential response to preoperative exercise training in patients candidates to cardiac valve replacement. BMC Anesthesiol 2024; 24:280. [PMID: 39123146 PMCID: PMC11311913 DOI: 10.1186/s12871-024-02671-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 08/01/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND There is lack of evidence regarding safety, effectiveness and applicability of prehabilitation on cardiac surgery population, particularly in patients candidates to cardiac valve replacement. The aim of the study is to assess and compare the effect of a multimodal prehabilitation program on functional capacity in patients with severe aortic stenosis (AoS) and severe mitral regurgitation (MR) proposed for valve replacement surgery. METHODS Secondary analysis from a randomised controlled trial whose main objective was to analyze the efficacy of a 4-6 weeks multimodal prehabilitation program in cardiac surgery on reducing postoperative complications. For this secondary analysis, only candidates for valve replacement surgery were selected. The primary outcome was the change in endurance time (ET) from baseline to preoperative assessment measured by a cycling constant work-rate cardiopulmonary exercise test. RESULTS 68 patients were included in this secondary analysis, 34 (20 AoS and 14 MR) were allocated to the prehabilitation group and 34 (20 AoS and 14 MR) to control group. At baseline, patients with AoS had better left systolic ventricular function and lower prevalence of atrial fibrillation compared to MR (p = 0.022 and p = 0.035 respectively). After prehabilitation program, patients with MR showed greater improvement in ET than AoS patients (101% vs. 66% increase from baseline). No adverse events related to the prehabilitation program were observed. CONCLUSIONS A 4-6 week exercise training program is safe and overall improves functional capacity in patients with severe AoS and MR. However, exercise response is different according to the cardiac valve type disfunction, and further studies are needed to know the factors that predispose some patients to have better training response. TRIAL REGISTRATION The study has been registered on the Registry of National Institutes of Health ClinicalTrials.gov (NCT03466606) (05/03/2018).
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Affiliation(s)
- Antonio López-Hernández
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Elena Gimeno-Santos
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Barcelona of Global Health Institute (ISGlobal) - Universitat Pompeu Fabra (UPF), Barcelona, Spain
- CIBER de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain
| | - Ricard Navarro-Ripoll
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - María José Arguis
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Bárbara Romano-Andrioni
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Nutrition and Clinical Dietetics, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Manuel López-Baamonde
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Silvia Teres
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - María Sanz-de la Garza
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
- Cardiovascular Institute, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Graciela Martinez-Palli
- Anesthesiology Department, Hospital Clínic de Barcelona, Barcelona, Spain.
- Prehabilitation Unit, Hospital Clínic de Barcelona, Barcelona, Spain.
- August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain.
- CIBER de Enfermedades Respiratorias (CIBERES), Carlos III Health Institute, Madrid, Spain.
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Verwijmeren L, Noordzij PG, Daeter EJ, Emmelot-Vonk MH, Vernooij LM, van Klei WA, van Dongen EPA. Preoperative frailty and one-year functional recovery in elderly cardiac surgery patients. J Thorac Cardiovasc Surg 2023; 166:870-878.e6. [PMID: 35272845 DOI: 10.1016/j.jtcvs.2022.01.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 12/27/2021] [Accepted: 01/18/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Frailty increases risk for morbidity and mortality after cardiac surgery. Its influence on functional outcome is largely unknown. We studied the association of frailty with health-related quality of life and disability after cardiac surgery. METHODS A prospective 2-center observational cohort of 555 patients aged 70 years or more undergoing cardiac surgery. A comprehensive frailty assessment was performed before surgery based on 11 individual assessments in physical, mental, and social domains. Frailty was defined as at least 1 positive test in each domain. The primary outcome was health-related quality of life over 1 year, and the secondary outcomes were severe in-hospital complications and disability over 1 year. Adverse functional outcome was defined as the composite of a decreased health-related quality of life and disability. RESULTS Physical frailty was most common (91%) compared with mental (39%) or social frailty (42%). Adverse functional outcome occurred in 257 patients (46%) and consisted of decreased physical health-related quality of life in 134 (24%), decreased mental health-related quality of life in 141 (25%), and disability in 120 (22%). Frailty was more common in patients with adverse functional outcome (29%) compared with patients without adverse functional outcome (16%, P < .001). Poor mobility, malnutrition, and polypharmacy were associated with a decreased health-related quality of life over time, whereas impaired physical functioning and higher self-rated health were related to increased health-related quality of life. Disability after cardiac surgery was associated with poor mobility, polypharmacy, dependent living, living alone, and lower self-rated mental health before surgery. CONCLUSIONS Mobility, nutrition, medication use, physical functioning, and self-rated health before surgery are associated with health-related quality of life in elderly patients 1 year after cardiac surgery.
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Affiliation(s)
- Lisa Verwijmeren
- Department of Anesthesiology, Intensive Care, and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter G Noordzij
- Department of Anesthesiology, Intensive Care, and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands.
| | - Edgar J Daeter
- Department of Cardiothoracic Surgery, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marielle H Emmelot-Vonk
- Department of Geriatric Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Anesthesiology, Intensive Care, and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands; Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wilton A van Klei
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Eric P A van Dongen
- Department of Anesthesiology, Intensive Care, and Pain Medicine, St Antonius Hospital, Nieuwegein, The Netherlands
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Rombey T, Eckhardt H, Kiselev J, Silzle J, Mathes T, Quentin W. Cost-effectiveness of prehabilitation prior to elective surgery: a systematic review of economic evaluations. BMC Med 2023; 21:265. [PMID: 37468923 PMCID: PMC10354976 DOI: 10.1186/s12916-023-02977-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/11/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Prehabilitation aims at enhancing patients' functional capacity and overall health status to enable them to withstand a forthcoming stressor like surgery. Our aim was to synthesise the evidence on the cost-effectiveness of prehabilitation for patients awaiting elective surgery compared with usual preoperative care. METHODS We searched PubMed, Embase, the CRD database, ClinicalTrials.gov, the WHO ICTRP and the dissertation databases OADT and DART. Studies comparing prehabilitation for patients with elective surgery to usual preoperative care were included if they reported cost outcomes. All types of economic evaluations (EEs) were included. The primary outcome of the review was cost-effectiveness based on cost-utility analyses (CUAs). The risk of bias of trial-based EEs was assessed with the Cochrane risk of bias 2 tool and the ROBINS-I tool and the credibility of model-based EEs with the ISPOR checklist. Methodological quality of full EEs was assessed using the CHEC checklist. The EEs' results were synthesised narratively using vote counting based on direction of effect. RESULTS We included 45 unique studies: 25 completed EEs and 20 ongoing studies. Of the completed EEs, 22 were trial-based and three model-based, corresponding to four CUAs, three cost-effectiveness analyses, two cost-benefit analyses, 12 cost-consequence analyses and four cost-minimization analyses. Three of the four trial-based CUAs (75%) found prehabilitation cost-effective, i.e. more effective and/or less costly than usual care. Overall, 16/25 (64.0%) EEs found prehabilitation cost-effective. When excluding studies of insufficient credibility/critical risk of bias, this number reduced to 14/23 (60.9%). In 8/25 (32.0%), cost-effectiveness was unclear, e.g. because prehabilitation was more effective and more costly, and in one EE prehabilitation was not cost-effective. CONCLUSIONS We found some evidence that prehabilitation for patients awaiting elective surgery is cost-effective compared to usual preoperative care. However, we suspect a relevant risk of publication bias, and most EEs were of high risk of bias and/or low methodological quality. Furthermore, there was relevant heterogeneity depending on the population, intervention and methods. Future EEs should be performed over a longer time horizon and apply a more comprehensive perspective. TRIAL REGISTRATION PROSPERO CRD42020182813.
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Affiliation(s)
- Tanja Rombey
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, Berlin, 10623, Germany.
| | - Helene Eckhardt
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, Berlin, 10623, Germany
| | - Jörn Kiselev
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Health Sciences, Fulda University of Applied Sciences, Fulda, Germany
| | - Julia Silzle
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, Berlin, 10623, Germany
| | - Tim Mathes
- Department for Medical Statistics, University Medical Centre Goettingen, Goettingen, Germany
| | - Wilm Quentin
- Department of Health Care Management, Technische Universität Berlin, Straße des 17. Juni 135, Berlin, 10623, Germany
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Efficacy of supervised exercise prehabilitation programs to improve major abdominal surgery outcomes: A systematic review and meta-analysis. J Clin Anesth 2023; 86:111053. [PMID: 36736208 DOI: 10.1016/j.jclinane.2023.111053] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/15/2022] [Accepted: 01/08/2023] [Indexed: 02/04/2023]
Abstract
The optimal package of components for a prehabilitation intervention remains unclear. The aim was to determine the efficacy of supervised exercise prehabilitation programs to enhance patient fitness and improve surgical outcomes. The protocol was preregistered (PROSPERO: CRD42020180693). PubMed, MEDLINE, CINAHL, AMED, CENTRAL, PeDro, ClinicalTrials.gov and the WHO International Clinical Trials Registry were searched. Randomized controlled trials (RCTs) of supervised prehabilitation programs before major abdominal surgery were included. Physical function, cardiorespiratory capacity and surgical outcomes were the primary outcomes measures. Risk of bias was assessed according to the Cochrane Risk of Bias 1.0 tool for RCTs. Data are summarized narratively, and where possible, quantitavely. Meta-analyses results are reported as risk ratios (RR), mean difference of changes between baseline and follow-up time points or mean difference between groups and 95% confidence interval (CI). Twenty RCTs were included in the analysis with a total of 1258 patients. The average 6-min walking distance change was +33 m in the prehabilitation group compared to the usual care (UC) group after prehabilitation (95% CI: [13, 53], P < 0.01). Only in studies with more than one supervised session per week changes in 6-min-walk distance were significantly higher in the prehabilitation group compared to the UC group after prehabiliatation (Mean difference: 47 m, 95% [CI]: [20-75], P < 0.01). The change in peak volume of oxygen uptake during a maximum cardiopulmonary test was +1.47 mL·kg-1·min-1 in the prehabilitation group compared to the UC group (95% CI: [0.68, 2.25], P < 0.01). There was no significant difference in the change in oxygen uptake at anaerobic threshold between groups (Mean differences: 0.47, 95% CI: [-0.16, 1.10], P:0.14). Post-operative complications incidence was similar between groups (RR: 0.80, 95% CI: [0.61, 1.05], P:0.11), irrespective of the frequency of supervised session per week (RR: 0.67, 95% CI: [0.43, 1.03], P:0.07). In conclusion, prehabilitation programmes with more than one supervised session per week improved physical function but did not enhance surgical outcomes.
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Jetten WD, Hogenbirk RNM, Van Meeteren NLU, Cuperus FJC, Klaase JM, De Jong R. Physical Effects, Safety and Feasibility of Prehabilitation in Patients Awaiting Orthotopic Liver Transplantation, a Systematic Review. Transpl Int 2022; 35:10330. [PMID: 36157271 PMCID: PMC9492850 DOI: 10.3389/ti.2022.10330] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 08/24/2022] [Indexed: 11/13/2022]
Abstract
Prehabilitation improves surgical outcomes in patients undergoing surgery. However, patients preparing for orthotopic liver transplantation (OLT) are physically “frail” and suffer from comorbidities that generally hamper physical activity. This systematic review aims to evaluate the physical effects, safety and feasibility of prehabilitation in OLT candidates. Relevant articles were searched, in Embase, Web of Science, Cochrane, Medline and Google Scholar, to December 2021. Studies reporting on specified preoperative exercise programs, including adult OLT candidates with end-stage liver disease, with a model for end-stage liver disease (MELD) score ≥12 or Child-Pugh classification B/C, were included. This resulted in 563 potentially eligible studies, out of which eight were selected for inclusion, consisting of 1,094 patients (male sex 68%; mean age 51–61 years; mean MELD score 12-21). Six of the included studies were classified as low-quality by the GRADE system, and three studies had high risk for ineffectiveness of the training program according to the i-CONTENT tool. Significant improvement was observed in VO2 peak, 6-minute walking distance, hand grip strength, liver frailty index and quality of life. Feasibility ranged from an adherence of 38%–90% in unsupervised-to >94% in supervised programs. No serious adverse events were reported. In conclusion, prehabilitation in patients awaiting OLT appears to improve aerobic capacity, and seems feasible and safe. However, larger clinical trials are required to accurately examine the preoperative and postoperative effects of prehabilitation in this specific patient population.
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Affiliation(s)
- Wesley D. Jetten
- Department of Anesthesiology, Erasmus University Medical Center, Erasmus University Rotterdam, Rotterdam, Netherlands
- *Correspondence: Wesley D. Jetten,
| | - Rianne N. M. Hogenbirk
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Nico L. U. Van Meeteren
- Department of Anesthesiology, Erasmus University Medical Center, Erasmus University Rotterdam, Rotterdam, Netherlands
- Top Sector Life Sciences and Health (Health∼Holland), The Hague, Netherlands
| | - Frans J. C. Cuperus
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Joost M. Klaase
- Department of Surgery, Division of Hepatopancreatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Renate De Jong
- Department of Anesthesiology, Erasmus University Medical Center, Erasmus University Rotterdam, Rotterdam, Netherlands
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Emmert DA, Arcario MJ, Maranhao B, Reidy AB. Frailty and cardiac surgery: to operate or not? Curr Opin Anaesthesiol 2022; 35:53-59. [PMID: 34669613 DOI: 10.1097/aco.0000000000001075] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW With an aging cardiac surgery population, prefrail and frail patients are becoming more common. Anesthesiologists will be faced with the decision of how best to provide care to frail patients. Identification, management, and outcomes in frail patients will be discussed in this review. RECENT FINDINGS Frailty is associated with a variety of poor outcomes, such as increased hospital length of stay, medical resource utilization, readmission rates, and mortality. Prehabilitation may play a greater role in the management of frail cardiac surgery patients. SUMMARY As frailty will likely only increase amongst cardiac surgery patients, it is important to develop multicenter trials to study management and treatment options. Until those studies are performed, the care of frail cardiac surgery patients may be best provided by high-volume surgical centers with expertise in the management of frail patients.
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Affiliation(s)
- Daniel A Emmert
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri, USA
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Reynolds A, Hamidian Jahromi A. Improving Postoperative Care Through Mindfulness-Based Cognitive Therapy and Isometric Exercise Interventions: A Systematic Review (Preprint). JMIR Perioper Med 2021; 5:e34651. [PMID: 35687415 PMCID: PMC9233259 DOI: 10.2196/34651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/21/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022] Open
Abstract
Background Mindfulness-based cognitive therapy and isometric exercise training (IET) interventions are relatively new approaches to maintain physical functioning, alleviate pain, prevent joint stiffness and muscular atrophy, and positively influence other postoperative care outcomes. Objective The aim of this review was to identify the impacts of mindfulness-based interventions (MBIs) and IET and, more specifically, their combination, which have not previously been assessed to our knowledge. Methods Studies were identified by searching the PubMed and Cochrane databases within the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) algorithm format and using relevant keyword combinations, which resulted in 39 studies meeting the inclusion criteria. Results In general, MBI was shown to positively impact both pain relief and physical functioning, while IET positively impacted physical functioning. Numerous other benefits, including improved quality of life and decreased postoperative opioid use, were also described from both interventions; however, further research is needed to confirm these findings as well as to determine other possible benefits. No studies were found that combined MBI and IET. Conclusions Despite many positive results from each individual intervention, there is a lack of information about how the combination of MBI and IET might impact postoperative care. The combination of these two interventions might prove to be more effective than each individual intervention alone, and the findings from this review show that they could even be complementary. Going forward, research should be expanded to study the possible benefits of the combination of MBI and IET in postoperative care routines as well as other possible combinations.
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Affiliation(s)
- Allie Reynolds
- Biological Sciences Division, University of Chicago Medicine, Chicago, IL, United States
| | - Alireza Hamidian Jahromi
- Department of Plastic and Reconstructive Surgery, Temple University Medical Center, Philadelphia, PA, United States
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