[Conservative treatment of valvular heart disease in adults]

Currently, there is no specific medication approved for the treatment of valvular heart disease per se. Except for secondary mitral valve insufficiency and tricuspid valve insufficiency in pulmonary hypertension, drug therapy for higher-grade valvular heart disease is limited to diuretic therapy for symptom control. Conservative therapy for comorbidities and potential heart failure can be beneficial regardless of the specific valve lesion. In cases of aortic valve stenosis or insufficiency, controlling arterial hypertension is important. Patients with mitral valve stenosis benefit from rhythm and rate control. Diuretics can help reduce regurgitant volume in patients with primary mitral valve insufficiency and tricuspid valve insufficiency. In addition to drug therapy, maintaining functional capacity is crucial for the outcome of patients. Therefore, it is recommended to engage in active physical activity whenever possible, despite the presence of valvular heart disease.

Outcome Heterogeneity in Prehabilitation Trials-Are We Comparing Apples and Oranges?

INTRODUCTION

Over the last decade, the number of prehabilitation randomised controlled trials (RCTs) has increased significantly. Therefore, this review aimed to describe the outcomes reported in prehabilitation RCTs in patients undergoing cancer surgery.

METHODS

A search was conducted in Embase, Allied and Complementary Medicine Database, The Cochrane Library, PsycINFO, MEDLINE, and Cumulated Index to Nursing and Allied Health Literature from inception to July 2021. We included RCTs evaluating the effectiveness of preoperative exercise, nutrition, and psychological interventions on postoperative complications and length of hospital stay in adult oncology patients who underwent thoracic and gastrointestinal cancer surgery. The verbatim outcomes reported in each article were extracted, and each outcome was assessed to determine whether it was defined and measured using a validated tool. Verbatim outcomes were grouped into standardized outcomes and categorized into domains. The quality of outcome reporting in each identified article was assessed using the Harman tool (score range 0-6, where 0 indicated the poorest quality).

RESULTS

A total of 74 RCTs were included, from which 601 verbatim outcomes were extracted. Only 110 (18.3%) of the verbatim outcomes were defined and 270 (44.9%) were labeled as either "primary" or "secondary" outcomes. Verbatim outcomes were categorized into 119 standardized outcomes and assigned into one of five domains (patient-reported outcomes, surgical outcomes, physical/functional outcomes, disease activity, and intervention delivery). Surgical outcomes were the most common outcomes reported (n = 71 trials, 95.9%). The overall quality of the reported outcomes was poor across trials (median score: 2.0 [IQR = 0.00-3.75]).

CONCLUSIONS

Prehabilitation RCTs display considerable heterogeneity in outcome reporting, and low outcome reporting quality. The development of standardized core outcome sets may help improve article quality and enhance the clinical utility of prehabilitation following cancer surgery.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS)

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

The prevalence and impact of sarcopenia in older cardiac patients undergoing inpatient cardiac rehabilitation - results from a prospective, observational cohort pre-study

BACKGROUND

The prevalence of sarcopenia and its impact in older patients undergoing inpatient cardiac rehabilitation (iCR) after cardiac procedure has been insufficiently studied. The main aim of this study was to evaluate the prevalence of sarcopenia and quantify the functional capacity of older sarcopenic and non-sarcopenic patients participating in iCR.

METHODS

Prospective, observational cohort study within the framework of the ongoing multicenter prehabilitation study "PRECOVERY". A sample of 122 patients ≥75 years undergoing iCR after cardiac procedure were recruited in four German iCR facilities and followed up 3 months later by telephone. At iCR (baseline), the Strength, Assistance with walking, Rise from a chair, Climb stairs and Falls (SARC-F) questionnaire was used to identify sarcopenic patients. In addition, Katz-Index, Clinical Frailty Scale (CFS), handgrip strength (HGS), Short Physical Performance Battery (SPPB) and 6-minute walk distance (6MWD) measured functional capacity and frailty at baseline. Outcomes were prevalence of sarcopenia and the correlation of sarcopenia to functional capacity and frailty at baseline as well as the SARC-F score at follow-up. The Wilcoxon test was applied for pre-post-test analysis. Correlation between sarcopenia and 6MWD, SPPB score and HGS was tested with the eta coefficient with one-way ANOVA.

RESULTS

Complete assessments were collected from 101 patients (79.9 ± 4.0 years; 63% male). At baseline, the mean SARC-F score was 2.7 ± 2.1; 35% with sarcopenia. Other baseline results were Katz-Index 5.7 ± 0.9, CFS 3.2 ± 1.4, HGS 24.9 ± 9.9 kg, SPPB score 7.5 ± 3.3 and 6MWD 288.8 ± 136.5 m. Compared to baseline, fewer patients were sarcopenic (23% versus 35%) at follow-up. In the subgroup of sarcopenic patients at baseline (n = 35), pre-post comparison resulted in a significant SARC-F improvement (p = 0.017). There was a significant correlation between sarcopenia measured by SARC-F and poor results in the assessments of functional capacity (p < 0.001; r > 0.546).

CONCLUSIONS

The prevalence of sarcopenia in older patients at iCR after cardiac procedure is high (35%) and remains high at follow-up (23%). Sarcopenia screening is important since the diagnosis of sarcopenia in these patients correlates significantly with poor functional capacity. The results indicate that these patients may benefit from prehabilitation aimed at improving perioperative outcomes, increasing functional capacity and mitigating adverse effects.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS; http://www.drks.de ; DRKS00032256). Retrospectively registered on 13 July 2023.

Feasibility of preoperative and postoperative physical rehabilitation for cardiac surgery patients - a longitudinal cohort study

BACKGROUND

This study aimed to determine the feasibility of a preoperative and postoperative (in- and outpatient) physical rehabilitation program, the Heart-ROCQ-pilot program.

METHODS

This cohort study included patients undergoing cardiac surgery (including coronary artery bypass graft surgery, valve surgery, aortic surgery, or combinations of these surgeries) and participated in the Heart-ROCQ-pilot program. Feasibility involved compliance and characteristics of bicycle and strength training sessions in the three rehabilitation phases.

RESULTS

Of the eligible patients, 56% (n = 74) participated in the program (41% of exclusions were due to various health reasons). On average across the rehabilitation phases, the compliance rates of bicycle and strength training were 88% and 83%, respectively. Workload to heart rate (W/HR) ratio and total absolute volume load for bicycle and strength training, respectively, improved in each rehabilitation phase (P < 0.05). The W/HR-ratio was higher during the last postoperative session compared to the first preoperative session (0.48 to 0.63 W/beat, P < 0.001) and similar to the last preoperative session (0.65 to 0.64 W/beat, P < 0.497). During less than 1% of the bicycle sessions, patients reported discomfort scores of 5 to 6 (scale 0-10, with higher scores indicating a higher level).

CONCLUSIONS

The Heart-ROCQ-pilot program was feasible for patients awaiting cardiac surgery. Patients were very compliant and were able to safely increase the training load before surgery and regained this improvement within eight weeks after surgery.

Impact of preoperative uni- or multimodal prehabilitation on postoperative morbidity: meta-analysis

BACKGROUND

Postoperative complications occur in up to 43% of patients after surgery, resulting in increased morbidity and economic burden. Prehabilitation has the potential to increase patients' preoperative health status and thereby improve postoperative outcomes. However, reported results of prehabilitation are contradictory. The objective of this systematic review is to evaluate the effects of prehabilitation on postoperative outcomes (postoperative complications, hospital length of stay, pain at postoperative day 1) in patients undergoing elective surgery.

METHODS

The authors performed a systematic review and meta-analysis of RCTs published between January 2006 and June 2023 comparing prehabilitation programmes lasting ≥14 days to 'standard of care' (SOC) and reporting postoperative complications according to the Clavien-Dindo classification. Database searches were conducted in PubMed, CINAHL, EMBASE, PsycINFO. The primary outcome examined was the effect of uni- or multimodal prehabilitation on 30-day complications. Secondary outcomes were length of ICU and hospital stay (LOS) and reported pain scores.

RESULTS

Twenty-five studies (including 2090 patients randomized in a 1:1 ratio) met the inclusion criteria. Average methodological study quality was moderate. There was no difference between prehabilitation and SOC groups in regard to occurrence of postoperative complications (OR = 1.02, 95% c.i. 0.93 to 1.13; P = 0.10; I2 = 34%), total hospital LOS (-0.13 days; 95% c.i. -0.56 to 0.28; P = 0.53; I2 = 21%) or reported postoperative pain. The ICU LOS was significantly shorter in the prehabilitation group (-0.57 days; 95% c.i. -1.10 to -0.04; P = 0.03; I2 = 46%). Separate comparison of uni- and multimodal prehabilitation showed no difference for either intervention.

CONCLUSION

Prehabilitation reduces ICU LOS compared with SOC in elective surgery patients but has no effect on overall complication rates or total LOS, regardless of modality. Prehabilitation programs need standardization and specific targeting of those patients most likely to benefit.

A 20-year bibliometric analysis of postoperative pulmonary complications: 2003-2022

Background

Postoperative pulmonary complications (PPCs) are known to adversely affect surgical outcomes and patient prognoses, yet no published study provides a qualitative and quantitative analysis of the latest trends and developments in the field of PPCs. Therefore, we conducted a bibliometric analysis of 20 years of publications related to PPCs.

Methods

We examined publications on PPCs published between 2003 and 2022 in the Web of Science Core Collection database to assess trends in the field in four dimensions: trends in publications, major research power, keywords, and co-cited publications.

Results

A total of 1881 articles were analyzed using CiteSpace and VOSviewer. Overall, the number of publications on PPCs has increased in the last two decades, with 42.72% of the publications being produced in the last five years. The United States of America had the highest number of articles, accounting for 21.91% of the total. The institution with the highest number of publications was the University of Genoa, which published 54 articles and showed a general lack of inter-institutional collaboration. The most productive author was Paolo Pelosi, with no core group of authors identified in the field of PPCs. The keyword co-occurrence analysis indicated that the focus of research has shifted over the past 20 years in terms of risk factors, type of surgery, and so on, while "enhanced recovery", "prehabilitation", "driving pressure" and "sugammadex" have received the most recent attention. In the analysis of co-cited literature, the most recent clusters that received attention were driving pressure, lung cancer patient, enhanced recovery, and neuromuscular blockade.

Conclusion

This bibliometric study suggests that pulmonary protective ventilation strategies, neuromuscular blockade reversal, and pulmonary prehabilitation strategy will be the focus of attention in the coming period. More large-scale studies and strengthened institutional collaboration are necessary to generate robust evidence for guiding individualized prevention of PPCs.

Postponing surgery to optimise patients with acute right-sided obstructing colon cancer - A pilot study

BACKGROUND

Right-sided obstructing colon cancer is most often treated with acute resection. Recent studies on right-sided obstructing colon cancer report higher mortality and morbidity rates than those in patients without obstruction. The aim of this study is to retrospectively analyse whether it is possible to optimise the health condition of patients with acute right-sided obstructing colon cancer, prior to surgery, and whether this improves postoperative outcomes.

METHOD

All consecutive patients with high suspicion of, or histologically proven, right-sided obstructing colon cancer, treated with curative intent between March 2013 and December 2019, were analysed retrospectively. Patients were divided into two groups: optimised group and non-optimised group. Pre-operative optimisation included additional nutrition, physiotherapy, and, if needed, bowel decompression.

RESULTS

In total, 54 patients were analysed in this study. Twenty-four patients received optimisation before elective surgery, and thirty patients received emergency surgery, without optimisation. Scheduled surgery was performed after a median of eight days (IQR 7-12). Postoperative complications were found in twelve (50%) patients in the optimised group, compared to twenty-three (77%) patients in the non-optimised group (p = 0.051). Major complications were diagnosed in three (13%) patients with optimisation, compared to ten (33%) patients without optimisation (p = 0.111). Postoperative in-hospital stay, 30-day mortality, as well as primary anastomosis were comparable in both groups.

CONCLUSION

This pilot study suggests that pre-operative optimisation of patients with obstructing right sided colonic cancer may be feasible and safe but is associated with longer in-patient stay.

Prehabilitation in older patients prior to elective cardiac procedures (PRECOVERY): study protocol of a multicenter randomized controlled trial

BACKGROUND

Previous studies have demonstrated the efficacy of rehabilitation after a cardiovascular procedure. Especially older and multimorbid patients benefit from rehabilitation after a cardiac procedure. Prehabilitation prior to cardiac procedures may also have positive effects on patients' pre- and postoperative outcomes. Results of a current meta-analysis show that prehabilitation prior to cardiac procedures can improve perioperative outcomes and alleviate adverse effects. Germany currently lacks a structured cardiac prehabilitation program for older patients, which is coordinated across healthcare sectors.

METHODS

In a randomized, controlled, two-arm parallel group, assessor-blinded multicenter intervention trial (PRECOVERY), we will randomize 422 patients aged 75 years or older scheduled for an elective cardiac procedure (e.g., coronary artery bypass graft surgery or transcatheter aortic valve replacement). In PRECOVERY, patients randomized to the intervention group participate in a 2-week multimodal prehabilitation intervention conducted in selected cardiac-specific rehabilitation facilities. The multimodal prehabilitation includes seven modules: exercise therapy, occupational therapy, cognitive training, psychosocial intervention, disease-specific education, education with relatives, and nutritional intervention. Participants in the control group receive standard medical care. The co-primary outcomes are quality of life (QoL) and mortality after 12 months. QoL will be measured by the EuroQol 5-dimensional questionnaire (EQ-5D-5L). A health economic evaluation using health insurance data will measure cost-effectiveness. A mixed-methods process evaluation will accompany the randomized, controlled trial to evaluate dose, reach, fidelity and adaptions of the intervention.

DISCUSSION

In this study, we investigate whether a tailored prehabilitation program can improve long-term survival, QoL and functional capacity. Additionally, we will analyze whether the intervention is cost-effective. This is the largest cardiac prehabilitation trial targeting the wide implementation of a new form of care for geriatric cardiac patients.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS; http://www.drks.de ; DRKS00030526). Registered on 30 January 2023.

Guidelines on perioperative optimization protocol for the adult patient 2023

OBJECTIVE

The French Society of Anesthesiology and Intensive Care Medicine [Société Française d'Anesthésie et de Réanimation (SFAR)] aimed at providing guidelines for the implementation of perioperative optimization programs.

DESIGN

A consensus committee of 29 experts from the SFAR was convened. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Four fields were defined: 1) Generalities on perioperative optimization programs; 2) Preoperative measures; 3) Intraoperative measures and; 4) Postoperative measures. For each field, the objective of the recommendations was to answer a number of questions formulated according to the PICO model (population, intervention, comparison, and outcomes). Based on these questions, an extensive bibliographic search was carried out using predefined keywords according to PRISMA guidelines and analyzed using the GRADE® methodology. The recommendations were formulated according to the GRADE® methodology and then voted on by all the experts according to the GRADE grid method. As the GRADE® methodology could have been fully applied for the vast majority of questions, the recommendations were formulated using a "formalized expert recommendations" format.

RESULTS

The experts' work on synthesis and application of the GRADE® method resulted in 30 recommendations. Among the formalized recommendations, 19 were found to have a high level of evidence (GRADE 1±) and ten a low level of evidence (GRADE 2±). For one recommendation, the GRADE methodology could not be fully applied, resulting in an expert opinion. Two questions did not find any response in the literature. After two rounds of rating and several amendments, strong agreement was reached for all the recommendations.

CONCLUSIONS

Strong agreement among the experts was obtained to provide 30 recommendations for the elaboration and/or implementation of perioperative optimization programs in the highest number of surgical fields.

Effectiveness of a short-term multimodal prehabilitation program in adult patients awaiting selective cardiac surgery: study protocol for an open-label, pilot, randomized controlled trial

Background

Prehabilitation has been demonstrated to positively impact postoperative recovery in patients undergoing selective cardiac surgery. However, the optimal modules included in prehabilitation programs are yet to be fully explored, as existing studies have primarily focused on exercise. This study will explore the effectiveness of a three-arm prehabilitation program among adult patients awaiting selective cardiac surgery.

Methods and analysis

A single-center, parallel-group randomized controlled trial will be conducted at the Second Affiliated Hospital of Zhejiang University School of Medicine (SAHZU). A total of 152 adult patients scheduled for elective cardiac surgery (coronary artery bypass grafting or valvular surgery) will be recruited from a tertiary teaching hospital. The patients will be randomly assigned to either the control group or the prehabilitation group. Patients assigned to the control group will receive standard care, which includes patient education and counseling as well as personal guidance on exercise, breathing, and coughing. Patients in the intervention group will be provided a multimodal prehabilitation program, including nutrition guidance, a diet journal, mindfulness training, and exercise guidance. The interventions will begin with home-based training and continue after hospital admission and before surgery. The primary outcome will be the perioperative 6-minute walk distance (6 MWD). The secondary outcomes will include preoperative readiness, postoperative recovery, and patient experience with the program.

Discussion

The purpose of the study is to examine whether a short-term multimodal prehabilitation program will be associated with improved preoperative readiness and postoperative outcomes. The findings of this study will provide evidence to support the development of a perioperative program aimed at enhancing patient recovery.

Clinical Trial Registration

www.ClinicalTrials.gov; identifier: NCT05503004.

Exploring barriers and facilitators of behavioural changes in dietary intake and physical activity: a qualitative study in older adults undergoing transcatheter aortic valve implantation

PURPOSE

The majority of older patients, scheduled for a cardiac procedure, do not adhere to international dietary intake and physical activity guidelines. The purpose of this study was to explore barriers and facilitators regarding dietary intake and physical activity behaviour change in older patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

We conducted a qualitative study using semi-structured interviews with patients undergoing TAVI. Interviews were analysed by two independent researchers using thematic analysis, the capability, opportunity and motivation behaviour model was used as a framework.

RESULTS

The study included 13 patients (82 ± 6 years old, 6 females) until data saturation was reached. Six themes were identified, which were all applicable to both dietary intake and physical activity. Three following themes were identified as barriers: (1) low physical capability, (2) healthy dietary intake and physical activity are not a priority at an older age and (3) ingrained habits and preferences. Three following themes were identified as facilitators: (1) knowledge that dietary intake and physical activity are important for maintaining health, (2) norms set by family, friends and caregivers and (3) support from the social environment.

CONCLUSION

Our study found that older patients had mixed feelings about changing their behaviour. The majority initially stated that dietary intake and physical activity were not a priority at older age. However, with knowledge that behaviour could improve health, patients also stated willingness to change, leading to a state of ambivalence. Healthcare professionals may consider motivational interviewing techniques to address this ambivalence.

Prehabilitation before elective coronary artery bypass grafting surgery: a scoping review

OBJECTIVE

The objective of this scoping review was to identify and map existing preoperative interventions, referred to as prehabilitation, in adult patients at home awaiting elective coronary artery bypass grafting surgery. This review also sought to report feasibility and patient experiences to shape clinical practice and underpin a future systematic review.

INTRODUCTION

As patients age, comorbidities become more common. Strategies to improve postoperative outcomes and to accelerate recovery are required in patients undergoing coronary artery bypass grafting. Prehabilitation refers to a proactive process of increasing functional capacity before surgery to improve the patient's ability to withstand upcoming physiologic stress and, thus, avoid postoperative complications.

INCLUSION CRITERIA

Studies that included adult patients awaiting coronary artery bypass grafting surgery at home and that described interventions optimizing preoperative physical and psychological health in any setting were included.

METHODS

The JBI methodology for conducting scoping reviews was used to identify relevant studies in MEDLINE, CINAHL, Cochrane Library, Embase, Scopus, SweMed+, PsycINFO, and PEDro. Gray literature was identified searching Google Scholar, ProQuest Dissertations and Theses, MedNar, OpenGrey, NICE Evidence search, and SIGN. Studies in Danish, English, German, Norwegian, and Swedish were considered for inclusion, with no geographical or cultural limitations, or date restrictions. Two independent reviewers screened titles and abstracts, and studies meeting the inclusion criteria were imported into Covidence. Sixty-seven studies from November 1987 to September 2022 were included. The data extraction tool used for the included papers was developed in accordance with the review questions and tested for adequacy and comprehensiveness with the first 5 studies by the same 2 independent reviewers. The tool was then edited to best reflect the review questions. Extracted findings are described and supported by figures and tables.

RESULTS

Sixty-seven studies were eligible for inclusion, representing 28,553 participants. Analyses of extracted data identified various preoperative interventions for optimizing postoperative and psychological outcomes for adult patients awaiting elective coronary artery bypass grafting surgery. Based on similarities, interventions were grouped into 5 categories. Eighteen studies reported on multimodal interventions, 17 reported on psychological interventions, 14 on physical training interventions, 13 on education interventions, and 5 on oral health interventions.

CONCLUSION

This scoping review provides a comprehensive summary of strategies that can be applied when developing a prehabilitation program for patients awaiting elective coronary artery bypass surgery. Although prehabilitation has been tested extensively and appears to be feasible, available evidence is mostly based on small studies. For patients undergoing elective coronary artery bypass grafting to derive benefit from prehabilitation, methodologically robust clinical trials and knowledge synthesis are required to identify optimal strategies for patient selection, intervention design, adherence, and intervention duration. Future research should also consider the cost-effectiveness of prehabilitation interventions before surgery. Finally, there is a need for more qualitative studies examining whether individual interventions are meaningful and appropriate to patients, which is an important factor if interventions are to be effective.

Feasibility and effects of prehabilitation in cardiac surgery. Preliminary study

Prehabilitation programs that combine exercise training, nutritional support, and emotional reinforcement have demonstrated efficacy as a strategy for preoperative optimization in abdominal surgery. The experience in cardiac surgery, one of those associated with greater morbidity and mortality, is anecdotal.

OBJECTIVE

evaluation of the feasibility of a multimodal prehabilitation program and its effect on functional capacity in patients candidates for elective cardiac surgery.

METHODS

Pilot study conducted from July 2017 to June 2018 in patients candidates to myocardial revascularization and/or valve replacement. The program consisted of: 1) supervised exercise training program, 2) breathing incentive exercises, 3) nutritional support, and 4) mindfulness training. An evaluation was carried out prior to the start of the program and at the end of it (preoperatively).

RESULTS

All patients except one who refused surgery, completed the program, which lasted an average of 45 days. No patients presented complications related to the program. The program induced a significantly increase in functional capacity measured by the six-minute walking test (510.7 + 62 m vs 534.3 + 71 m, p = 0.007) and the chair test (13.2 + 4, 7 vs 16.4 + 7 repetitions, p = 0.02), as well as an increase in the level of physical activity measured by the Yale physical activity questionnaire (37.6 + 20 vs 54.2 + 27; p = 00029).

CONCLUSIONS

Multimodal prehabilitation in patients candidates for elective cardiac surgery is feasible and it increases functional capacity preoperatively without being associated with complications. The presumed beneficial impact of this improvement on the incidence of postoperative complications and hospital stay, requires further investigation.

Perioperative Optimization of the Cardiac Surgical Patient

Perioperative optimization of cardiac surgical patients is imperative to reduce complications, utilize health care resources efficiently, and improve patient recovery and quality of life. Standardized application of evidence-based best practices can lead to better outcomes. Although many practices should be applied universally to all patients, there are also opportunities along the surgical journey to identify patients who will benefit from additional interventions that will further ameliorate their recovery. Enhanced recovery programs aim to bundle several process elements in a standardized fashion to optimize outcomes after cardiac surgery. A foundational concept of enhanced recovery is attaining a better postsurgical end point for patients, in less time, through achievement and maintenance in their greatest possible physiologic, functional, and psychological state. Perioperative optimization is a broad topic, spanning multiple phases of care and involving a variety of medical specialties and nonphysician health care providers. In this review we highlight a variety of perioperative care topics, in which a comprehensive approach to patient care can lead to improved results for patients, providers, and the health care system. A particular focus on patient-centred care is included. Although existing evidence supports all of the elements reviewed, most require further improvements in implementation, as well as additional research, before their full potential and usefulness can be determined.

The Role and Effect of Multimodal Prehabilitation Before Major Abdominal Surgery: A Systemic Review and Meta-Analysis

BACKGROUND

For patients undergoing abdominal surgery, multimodal prehabilitation, including nutrition and exercise interventions, aims to optimize their preoperative physical and physiological capacity. This meta-analysis aims to explore the impact of multimodal prehabilitation on surgical and functional outcomes of abdominal surgery.

METHODS

Medline, Embase and CENTRAL were searched for articles about multimodal prehabilitation in major abdominal surgery. Primary outcomes were postoperative complications with a Clavien-Dindo score ≥3, and functional outcomes, measured by the 6-Minute Walking Test (6MWT). Secondary outcome measures included the quality-of-life measures. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated, with DerSimonian and Laird random effects used to account for heterogeneity.

RESULTS

Twenty-five studies were included, analysing 4,210 patients across 13 trials and 12 observational studies. Patients undergoing prehabilitation had significantly fewer overall complications (RR = 0.879, 95% CI 0.781-0.989, p = 0.034). There were no significant differences in the rates of wound infection, anastomotic leak and duration of hospitalization. The 6MWT improved preoperatively in patients undergoing prehabilitation (SMD = 33.174, 95% CI 12.674-53.673, p = 0.005), but there were no significant differences in the 6MWT at 4 weeks (SMD = 30.342, 95% CI - 2.707-63.391, p = 0.066) and 8 weeks (SMD = 24.563, 95% CI - 6.77-55.900, p = 0.104) postoperatively.

CONCLUSIONS

As preoperative patient optimization shifts towards an interdisciplinary approach, evidence from this meta-analysis shows that multimodal prehabilitation improves the preoperative functional capacity and reduces postoperative complication rates, suggesting its potential in effectively optimizing the abdominal surgery patient. However, there is a large degree of heterogenicity between the prehabilitation interventions between included articles; hence results should be interpreted with caution.

The Trajectory of Nutritional Status and Physical Activity before and after Transcatheter Aortic Valve Implantation

It is suggested that older patients waiting for an elective surgical procedure have a poor nutritional status and low physical activity level. It is unknown if this hypothesis is true and if these conditions improve after a medical procedure. We aimed to determine the trajectory of both conditions before and after transcatheter aortic valve implantation (TAVI). Included patients (n = 112, age 81 ± 5 years, 58% male) received three home visits (preprocedural, one and six months postprocedural). Nutritional status was determined with the mini nutritional assessment—short form (MNA-SF) and physical activity using an ankle-worn monitor (Stepwatch). The median MNA-SF score was 13 (11−14), and 27% of the patients were at risk of malnutrition before the procedure. Physical activity was 6273 ± 3007 steps/day, and 69% of the patients did not meet the physical activity guidelines (>7100 steps/day). We observed that nutritional status and physical activity did not significantly change after the procedure (β 0.02 [95% CI −0.03, 0.07] points/months on the MNA-SF and β 16 [95% CI −47, 79] steps/month, respectively). To conclude, many preprocedural TAVI patients should improve their nutritional status or activity level. Both conditions do not improve naturally after a cardiac procedure.

PREPARE trial: a protocol for a multicentre randomised trial of frailty-focused preoperative exercise to decrease postoperative complication rates and disability scores

INTRODUCTION

Frailty is a strong predictor of adverse postoperative outcomes. Prehabilitation may improve outcomes after surgery for older people with frailty by addressing physical and physiologic deficits. The objective of this trial is to evaluate the efficacy of home-based multimodal prehabilitation in decreasing patient-reported disability and postoperative complications in older people with frailty having major surgery.

METHODS AND ANALYSIS

We will conduct a multicentre, randomised controlled trial of home-based prehabilitation versus standard care among consenting patients >60 years with frailty (Clinical Frailty Scale>4) having elective inpatient major non-cardiac, non-neurologic or non-orthopaedic surgery. Patients will be partially blinded; clinicians and outcome assessors will be fully blinded. The intervention consists of >3 weeks of prehabilitation (exercise (strength, aerobic and stretching) and nutrition (advice and protein supplementation)). The study has two primary outcomes: in-hospital complications and patient-reported disability 30 days after surgery. Secondary outcomes include survival, lower limb function, quality of life and resource utilisation. A sample size of 750 participants (375 per arm) provides >90% power to detect a minimally important absolute difference of 8 on the 100-point patient-reported disability scale and a 25% relative risk reduction in complications, using a two-sided alpha value of 0.025 to account for the two primary outcomes. Analyses will follow intention to treat principles for all randomised participants. All participants will be followed to either death or up to 1 year.

ETHICS AND DISSEMINATION

Ethical approval has been granted by Clinical Trials Ontario (Project ID: 1785) and our ethics review board (Protocol Approval #20190409-01T). Results will be disseminated through presentation at scientific conferences, through peer-reviewed publication, stakeholder organisations and engagement of social and traditional media.

TRIAL REGISTRATION NUMBER

NCT04221295.

Effectiveness of Preoperative Chest Physiotherapy in Patients Undergoing Elective Cardiac Surgery, a Systematic Review and Meta-Analysis

Background and Objectives: Patients undergoing cardiac surgery are particularly vulnerable for developing postoperative pulmonary complications (PPCs). This systematic review and meta-analysis aimed to evaluate the role of preoperative chest physiotherapy in such patients. Materials and Methods: All original articles that assessed patients undergoing elective cardiac surgery, with preoperative chest physiotherapy, and compared them to patients undergoing elective cardiac surgery, without preoperative chest physiotherapy, were included. Animal studies, studies conducted prior to the year 2000, commentaries, or general discussion papers whose authors did not present original data were excluded. Studies assessing physiotherapy regimens other than chest physiotherapy were also excluded. The search was performed using the following electronic resources: the Cochrane Central Register of Controlled Trials, the PubMed central database, and Embase. The included studies were assessed for potential bias using the Cochrane Collaboration’s tool for assessing the risk of bias. Each article was read carefully, and any relevant data were extracted. The extracted data were registered, tabulated, and analyzed using Review Manager software. Results: A total of 10 articles investigating 1458 patients were included in the study. The studies were published from 2006 to 2019. The populations were patients scheduled for elective CABG/cardiac surgery, and they were classified into two groups: the interventional (I) group, involving 651 patients, and the control (C) group, involving 807 patients. The meta-analysis demonstrated no significant differences between the interventional and control groups in surgery time and ICU duration, but a significant difference was found in the time of mechanical ventilation and the length of hospital stay, favoring the interventional group. A significant difference was shown in the forced expiratory volume in 1s (FEV1% _predicted), forced vital capacity (FVC% _predicted), and maximum inspiratory pressure (Pi-max), favoring the interventional group. Conclusions: This study is limited by the fact that one of the included ten studies was not an RCT. Moreover, due to lack of the assessment of certain variables in some studies, the highest number of studies included in a meta-analysis was the hospital stay length (eight studies), and the other variables were analyzed in a fewer number of studies. The data obtained can be considered as initial results until more inclusive RCTs are conducted involving a larger meta-analysis. However, in the present study, the intervention was proved to be protective against the occurrence of PPCs. The current work concluded that preoperative chest physiotherapy can yield better outcomes in patients undergoing elective cardiac surgery.

Quality of life following cardiac rehabilitation in cardiac surgery patients

BACKGROUND

Undergoing cardiac surgery often result in perioperative loss of health-related quality of life (HRQOL). Although participation rates in Australia is low, cardiac rehabilitation (CR) has been demonstrated to improve patient HRQOL in cardiac patients. Literature is unclear regarding the role of CR and HRQOL in the cardiac surgery (CS) patient population.

METHODS

A prospective non-randomised study was conducted on eligible cardiac surgery patients between December 2009 and March 2015. HRQOL was assessed using the Short Form 12 at baseline and post-operatively at 30 days and 180 days. CR participation was recorded and barriers to CR uptake was assessed using the Cardiac Rehabilitation Enrolment Obstacles (CREO) scale.

RESULTS

At 180 days, 107 patients participated in CR and 111 did not participate in CR. A significant improvement from baseline mental and physical HRQOL was observed in both groups at 30 days and 180 days (p < 0.002). No significant difference between group characteristics or HRQOL was observed at any time. A trend of superior improvement in mental QOL was observed in the CR group. The study is limited by poor initial uptake (218/1772 of eligible) and may be underpowered to observe a clinical difference. A significant difference in CREO scores were observed between the two groups at 30 days (13 out of 16 questions, p < 0.001) and 180 days (11 out of 16 questions, p < 0.011).

CONCLUSION

Literature has shown that CR may improve numerous health outcomes in cardiac and CS patients, however CR uptake in Australia is low. Mental and Physical QOL is demonstrated to improve following CS, however further research is required to delineate the role of CR and QOL in CS patients. The CREO tool utilised in this study identified numerous potentially modifiable barriers to CR uptake. Specific strategies related to the survey are suggested to improve awareness, uptake, and adherence to CR, including advocacy of home-based and telehealth services.

Physical activity and exercise recommendations for patients with valvular heart disease

There is a paucity of studies looking at the natural history of valvular heart disease (VHD) in exercising individuals, and exercise recommendations are largely based on expert consensus. All individuals with VHD should be encouraged to avoid sedentary behaviour by engaging in at least 150 min of physical activity every week, including strength training. There are generally no exercise restrictions to individuals with mild VHD. Regurgitant lesions are better tolerated compared with stenotic lesions and as such the recommendations are more permissive for moderate-to-severe regurgitant VHD. Individuals with severe aortic regurgitation can still partake in moderate-intensity exercise provided the left ventricle (LV) and aorta are not significantly dilated and the ejection fraction (EF) remains >50%. Similarly, individuals with severe mitral regurgitation can partake in moderate-intensity exercise if the LV end-diastolic diameter <60 mm, the EF ≥60%, resting pulmonary artery pressure <50 mm Hg and there is an absence of arrhythmias on exercise testing. Conversely, individuals with severe aortic or mitral stenosis are advised to partake in low-intensity exercise. For individuals with bicuspid aortic valve, in the absence of aortopathy, the guidance for tricuspid aortic valve dysfunction applies. Mitral valve prolapse has several clinical, ECG and cardiac imaging markers of increased arrhythmic risk; and if any are present, individuals should refrain from high-intensity exercise.

Sarcopenia and risk of infection in adult heart transplant recipients in Japan

AIMS

Heart transplantation (HT) is an effective therapeutic option for end-stage heart failure. Infection is a major cause of morbidity and mortality after HT. Sarcopenia, defined as the loss of muscle mass and strength, is a common comorbidity in HT candidates with end-stage heart failure. However, the effects of sarcopenia on the occurrence of post-HT infections are not well understood. Therefore, we explored the association between the skeletal muscle mass and post-transplant infections in adult HT recipients.

METHODS AND RESULTS

We retrospectively examined the records of 135 patients who underwent HT between August 2007 and November 2019 at our institution. Pre-transplant computed tomography was used to calculate the skeletal muscle index (SMI) at the level of the third lumbar vertebra. Muscle wasting was defined as the SMI of the lowest sex-based tertiles. The primary endpoint was infections within 6 months of HT. The study included 109 patients (80 men, mean age: 41.6 ± 12.0 years): 37 patients in the muscle wasting group and 72 patients in the non-muscle wasting group. The mean SMI values in the muscle wasting and non-muscle wasting groups were 29.9 ± 4.8 cm² /m² and 40.7 ± 6.7 cm² /m² , respectively. Prior to HT, 108 (99.1%) patients were on left ventricular assist device support, and during that support, the rate of late right heart failure was significantly higher in the muscle wasting group than non-muscle wasting group (P = 0.012). Sixteen infections occurred within 6 months of HT. The most common infection sites included the respiratory tract (n = 5) and the upper gastrointestinal tract (n = 5), followed by the urinary tract (n = 4). Overall, 10 patients experienced infections in the muscle wasting group (27.0%) and 6 in the non-muscle wasting group (8.3%) (P = 0.009). Two patients in the muscle wasting group required intensive care unit admission, compared to none in the non-muscle wasting group. Low skeletal muscle mass was associated with infections in the univariate and multivariate logistic regression models (hazard ratio: 3.68, 95% confidence interval: 1.19-11.3; P = 0.023). However, the duration of all-cause mortality within 3 years did not differ between the groups (P = 0.56).

CONCLUSIONS

Low skeletal muscle mass is a predictor of post-HT infections within 6 months of HT.

Frailty-aware care: giving value to frailty assessment across different healthcare settings

Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.

Prehabilitation in adult patients undergoing surgery: an umbrella review of systematic reviews

BACKGROUND

The certainty that prehabilitation improves postoperative outcomes is not clear. The objective of this umbrella review (i.e. systematic review of systematic reviews) was to synthesise and evaluate evidence for prehabilitation in improving health, experience, or cost outcomes.

METHODS

We performed an umbrella review of prehabilitation systematic reviews. MEDLINE, Embase, Cochrane, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Joanna Briggs Institute's database, and Web of Science were searched (inception to October 20, 2020). We included all systematic reviews of elective, adult patients undergoing surgery and exposed to a prehabilitation intervention, where health, experience, or cost outcomes were reported. Evidence certainty was assessed using Grading of Recommendations Assessment, Development and Evaluation. Primary syntheses of any prehabilitation were stratified by surgery type.

RESULTS

From 1412 titles, 55 systematic reviews were included. For patients with cancer undergoing surgery who participate in any prehabilitation, moderate certainty evidence supports improvements in functional recovery. Low to very low certainty evidence supports reductions in complications (mixed, cardiovascular, and cancer surgery), non-home discharge (orthopaedic surgery), and length of stay (mixed, cardiovascular, and cancer surgery). There was low to very low certainty evidence that exercise prehabilitation reduces the risk of complications, non-home discharge, and length of stay. There was low to very low certainty evidence that nutritional prehabilitation reduces risk of complications, mortality, and length of stay.

CONCLUSIONS

Low certainty evidence suggests that prehabilitation may improve postoperative outcomes. Future low risk of bias, randomised trials, synthesised using recommended standards, are required to inform practice. Optimal patient selection, intervention design, and intervention duration must also be determined.

Prehabilitation as an important stage before cardiac surgery

The review discusses the preparation of patients for surgery on the heart and other organs. We considered the importance of introducing a new stage of medical and cardiology rehabilitation — prehabilitation. The results of randomized clinical trials, systematic reviews and metaanalyzes evaluating the effectiveness of respiratory techniques and physical training during the prehabilitation are presented. Particular attention is paid to the involvement of patients in prehabilitation programs before the elective coronary artery bypass grafting. Methodological problems arising in the development of prehabilitation programs are discussed.

The social construction of the patient-physician relationship in the clinical encounter: Media frames on shared decision making in Germany

The literature on healthcare management has noted that shared decision-making (SDM) - a practice of organizing joint decisions between healthcare professionals and patients - should improve healthcare outcomes through patient engagement and autonomy, fostering patient-centeredness. While SDM projects are implemented across Europe and the US, the diffusion of the practice remains partial, and its' conceptualization scattered. Healthcare management literature explores SDM on the underlying assumption that its limited diffusion results from an information problem, implying objective criteria and rational behavior. The purpose of this research is to study the social construction of SDM within the clinical setting and the underlying rationales using the case of one of the largest healthcare markets worldwide - Germany. To capture the complexity of SDM, a frame analysis is conducted on its medial representations. News media is both influential in shaping public opinion, as well as in generating public discourse. This analysis enables one to elaborate different facets of the construct of SDM, to capture inherent patterns of facilitating and obstructing aspects and to explore consequences for the diffusion of SDM. Three facilitating and three obstructive frames on the implementation of SDM were identified. The polarities of these frames range from the questioning of one's decision-making authority to the perception of individual competence and decision-making agency. Moreover, this study reflects on how physicians' and patients' role for SDM is conceived.

The effectiveness of pre- and post-operative rehabilitation for lung cancer: A systematic review and meta-analysis on postoperative pulmonary complications and length of hospital stay

OBJECTIVE

To investigate the effects of rehabilitation either before or after operation for lung cancer on postoperative pulmonary complications and the length of hospital stay.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL Plus, SPORTDiscus, PsycInfo and Embase were searched from inception until June 2021.

REVIEW METHODS

Inclusion criteria were patients scheduled to undergo or had undergone operation for lung cancer, randomised controlled trials comparing rehabilitative interventions initiated before hospital discharge to usual care control. Two reviewers independently assessed eligibility, extracted data and risks of bias. Pooled odds ratios (ORs) or standardised mean differences (SMDs) with 95% Confidence Intervals (CI) were estimated using random-effects meta-analyses.

RESULTS

Twenty-three studies were included (12 preoperative, 10 postoperative and 1 perioperative), with 2068 participants. The pooled postoperative pulmonary complication risk and length of hospital stay were reduced after preoperative interventions (OR = 0.32; 95% CI = 0.22, 0.47; I² = 0.0% and SMD = -1.68 days, 95% CI = -2.23, -1.13; I² = 77.8%, respectively). Interventions delivered during the immediate postoperative period did not have any significant effects on either postoperative pulmonary complication or length of hospital stay (OR = 0.85; 95% CI = 0.56, 1.29; I² = 0.0% and SMD = -0.23 days, 95% CI = -1.08, 0.63; I² = 64.6%, respectively). Meta-regression showed an association between a higher number of supervised sessions and shorter hospital length of stay in preoperative studies (β = -0.17, 95% CI = -0.29, -0.05).

CONCLUSION

Preoperative rehabilitation is effective in reducing postoperative pulmonary complications and length of hospital stay associated with lung cancer surgery. Short-term postoperative rehabilitation in inpatient settings is probably ineffective.

Impact of prehabilitation on objectively measured physical activity levels in elective surgery patients: a systematic review

OBJECTIVE

To systematically review the impact of prehabilitation on objectively measured physical activity (PA) levels in elective surgery patients.

DATA SOURCES

Articles published in Web of Science Core Collections, PubMed, Embase (Ovid), CINAHL (EBSCOHost), PsycInfo (EBSCOHost) and CENTRAL through August 2020.

STUDY SELECTION

Studies that met the following criteria: (1) written in English, (2) quantitatively described the effect(s) of a PA intervention among elective surgery patients prior to surgery and (3) used and reported objective measures of PA in the study.

DATA EXTRACTION AND SYNTHESIS

Participant characteristics, intervention details, PA measurement, and clinical and health-related outcomes were extracted. Risk of bias was assessed following the revised Cochrane risk of bias tool. Meta-analysis was not possible due to heterogeneity, therefore narrative synthesis was used.

RESULTS

6533 unique articles were identified in the search; 21 articles (based on 15 trials) were included in the review. There was little evidence to suggest that prehabilitation is associated with increases in objectively measured PA, but this may be due to insufficient statistical power as most (n=8) trials included in the review were small feasibility/pilot studies. Where studies tested associations between objectively measured PA during the intervention period and health-related outcomes, significant beneficial associations were reported. Limitations in the evidence base precluded any assessment via meta-regression of the association between objectively measured PA and clinical or health-related outcomes.

CONCLUSIONS

Additional large-scale studies are needed, with clear and consistent reporting of objective measures including accelerometry variables and outcome variables, to improve our understanding of the impact of changes in PA prior to surgery on surgical and health-related outcomes.

PROSPERO REGISTRATION NUMBER

CRD42019151475.

The Essential Frailty Toolset in Older Adults Undergoing Coronary Artery Bypass Surgery

Background The Essential Frailty Toolset (EFT) was shown to be easy to use and predictive of adverse events in patients undergoing aortic valve replacement procedures. The objective of this study was to evaluate the EFT in patients undergoing coronary artery bypass grafting procedures. Methods and Results The McGill Frailty Registry prospectively included patients ≥60 years of age undergoing urgent or elective isolated coronary artery bypass grafting between 2011 and 2018 at 2 hospitals. The preoperative EFT was scored 0 to 5 points as a function of timed chair rises, Mini-Mental Status Examination, serum albumin, and hemoglobin. The primary outcome was all-cause mortality assessed by Cox proportional hazards regression. The cohort consisted of 500 patients with a mean age of 71.4 ± 6.4 years, of which 27% presented with acute coronary syndromes requiring urgent surgery. The mean EFT was 1.3 ± 1.1 points, 132 (26%) were nonfrail, 298 (60%) were prefrail, and 70 (14%) were frail. Over a median follow-up of 4.0 years, 78 deaths were observed. In nonfrail, prefrail, and frail patients, survival at 1 year was 98%, 95%, and 91%, and at 5 years was 89%, 83%, and 63% (P<0.001). After adjustment, each incremental EFT point was associated with a hazard ratio of 1.28 (95% CI, 1.05-1.56) and frail patients had a 3-fold increase in all-cause mortality. Conclusions The EFT is a pragmatic and highly prognostic tool to assess frailty and guide decisions for coronary artery bypass grafting in older adults. Furthermore, the EFT may be actionable through targeted interventions such as cardiac rehabilitation and nutritional optimization.

Perioperative digital behaviour change interventions for reducing alcohol consumption, improving dietary intake, increasing physical activity and smoking cessation: a scoping review

BACKGROUND

Evidence suggests that unhealthy lifestyle behaviours are modifiable risk factors for postoperative complications. Digital behaviour change interventions (DBCIs), for instance text messaging programs and smartphone apps, have shown promise in achieving lifestyle behaviour change in a wide range of clinical populations, and it may therefore be possible to reduce postoperative complications by supporting behaviour change perioperatively using digital interventions. This scoping review was conducted in order to identify existing research done in the area of perioperative DBCIs for reducing alcohol consumption, improving dietary intake, increasing physical activity and smoking cessation.

MAIN TEXT

This scoping review included eleven studies covering a range of surgeries: bariatric, orthopaedic, cancer, transplantation and elective surgery. The studies were both randomised controlled trials and feasibility studies and investigated a diverse set of interventions: one game, three smartphone apps, one web-based program and five text message interventions. Feasibility studies reported user acceptability and satisfaction with the behaviour change support. Engagement data showed participation rates ranged from 40 to 90%, with more participants being actively engaged early in the intervention period. In conclusion, the only full-scale randomised controlled trial (RCT), text messaging ahead of bariatric surgery did not reveal any benefits with respect to adherence to preoperative exercise advice when compared to a control group. Two of the pilot studies, one text message intervention, one game, indicated change in a positive direction with respect to alcohol and tobacco outcomes, but between group comparisons were not done due to small sample sizes. The third pilot-study, a smartphone app, found between group changes for physical activity and alcohol, but not with respect to smoking cessation outcomes.

CONCLUSION

This review found high participant satisfaction, but shows recruitment and timing-delivery issues, as well as low retention to interventions post-surgery. Small sample sizes and the use of a variety of feasibility outcome measures prevent the synthesis of results and makes generalisation difficult. Future research should focus on defining standardised outcome measures, enhancing patient engagement and improving adherence to behaviour change prior to scheduled surgery.

[Unresolved issues in the prevention of bronchopulmonary complications in a cardiac surgery patient from the standpoint of a rehabilitation therapist]

Bronchopulmonary complications are one of the leading causes of morbidity after cardiac surgery; they lengthen a patient's hospital stay and increase the cost of treatment. The most common postoperative bronchopulmonary complications include pneumonia, atelectasis, respiratory failure, pneumothorax, and bronchospasm. These complications are the consequences of anesthesia and surgical trauma aggravated by the presence of risk factors in the patient in the preoperative period such as any chronic disease involving the lungs, smoking history, persistent cough and / or wheezing, chest and spinal deformities, obesity, senior age. In addition, the presence of chronic heart failure, diabetes mellitus, and chronic kidney disease also increase the risk of developing bronchopulmonary complications. In the prevention and treatment of bronchopulmonary complications the clinical effectiveness of rehabilitation programs after coronary artery bypass grafting is undeniable. The effectiveness of the programs has been proven on the basis of both domestic and foreign long-term in-practice and scientific research. However, despite the significant advances in cardiac rehabilitation there are a number of unresolved issues. Is it possible in a short period of time of the first stationary rehabilitation stage to form the patient's skill to perform breathing exercises and, accordingly, to obtain the maximum effect in the prevention of bronchopulmonary complications? What factors can affect the speed of motor skill formation in the patient's mastering of breathing exercises? What should be the frequency of procedures per day and the number of exercises when a physical therapy instructor works with a patient to increase the effectiveness of the prevention of bronchopulmonary complications in the postoperative period? What category of patients is strictly required for the pre-rehabilitation stage? How should the pre-rehabilitation stage be organized and how long should it take? All these questions require the work-out and implementation of scientifically grounded individual rehabilitation programs with a step-by-step algorithm for managing the patient by a rehabilitation multi-team from the first hours after surgery with the mandatory inclusion of pre-rehabilitation and taking into account the social, anamnestic, clinical and psychological characteristics of the patient.

Personalized teleprehabilitation in elective cardiac surgery: a study protocol of the Digital Cardiac Counselling randomized controlled trial

Aims

Previous research has shown the possibility to use the pre-operative period to improve a patient's tolerance for surgery. However, there is limited experience with prehabilitation in cardiac surgery. The aim of this study is to evaluate the effect of a comprehensive personalized teleprehabilitation programme on major adverse cardiac events (MACE) in patients scheduled for elective cardiac surgery. Secondary outcomes are post-operative complications, cardiovascular risk factors, quality of life, and cost-effectiveness.

Methods and results

In this single-centre randomized controlled trial, patients are eligible for inclusion when they are ≥18 years of age and cardiac surgery is scheduled at least 8 weeks from informed consent. Participants will be randomized to the teleprehabilitation group or the control group. After a digital baseline screening for perioperative risk factors, patients in the intervention arm can pre-operatively be referred to one or more of the prehabilitation modules (functional exercise training, inspiratory muscle training, psychological support, nutritional support, and/or smoking cessation). The programme is targeted at a duration of at least 6 weeks. It is executed by a multidisciplinary team using (video)calls and supported by a custom-made digital platform. During the pre-operative period, the platform is also used to inform patients about their upcoming surgery and for telemonitoring.

Conclusion

Reducing perioperative risk factors might result in a reduction of MACE, post-operative complications, length of stay, and cardiovascular risk factors, as well as improved quality of life. Cost-effectiveness will be evaluated.

Current Prehabilitation Programs Do Not Improve the Postoperative Outcomes of Patients Scheduled for Lumbar Spine Surgery: A Systematic Review With Meta-analysis

OBJECTIVE

To assess the effectiveness of prehabilitation in patients with degenerative disorders of the lumbar spine who are scheduled for spine surgery.

DESIGN

Intervention systematic review with meta-analysis.

LITERATURE SEARCH

Seven electronic databases were systematically searched for randomized controlled trials or propensity-matched cohorts.

STUDY SELECTION CRITERIA

Studies that measured the effect of prehabilitation interventions (ie, exercise therapy and cognitive behavioral therapy [CBT]) on physical functioning, pain, complications, adverse events related to prehabilitation, health-related quality of life, psychological outcomes, length of hospital stay, use of analgesics, and return to work were included.

DATA SYNTHESIS

Data were extracted at baseline (preoperatively) and at short-term (6 weeks or less), medium-term (greater than 6 weeks and up to 6 months), and long-term (greater than 6 months) follow-ups. Pooled effects were analyzed as mean differences and 95% confidence intervals (CIs). Certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

RESULTS

Cognitive behavioral therapy interventions were no more effective than usual care for all outcomes. Pooled effect sizes were -2.0 (95% CI: -4.4, 0.4) for physical functioning, -1.9 (95% CI: -5.2, 1.4) for back pain, and -0.4 (95% CI: -4.1, 0.4) for leg pain. Certainty of evidence for CBT ranged from very low to low. Only 1 study focused on exercise therapy and found a positive effect on short-term outcomes.

CONCLUSION

There was very low-certainty to low-certainty evidence of no additional effect of CBT interventions on outcomes in patients scheduled for lumbar surgery. Existing evidence was too limited to draw conclusions about the effects of exercise therapy. J Orthop Sports Phys Ther 2021;51(3):103-114. Epub 25 Dec 2020. doi:10.2519/jospt.2021.9748.

The effect of short-term exercise prehabilitation on skeletal muscle protein synthesis and atrophy during bed rest in older men

BACKGROUND

Poor recovery from periods of disuse accelerates age-related muscle loss, predisposing individuals to the development of secondary adverse health outcomes. Exercise prior to disuse (prehabilitation) may prevent muscle deterioration during subsequent unloading. The present study aimed to investigate the effect of short-term resistance exercise training (RET) prehabilitation on muscle morphology and regulatory mechanisms during 5 days of bed rest in older men.

METHODS

Ten healthy older men aged 65-80 years underwent four bouts of high-volume unilateral leg RET over 7 days prior to 5 days of inpatient bed rest. Physical activity and step-count were monitored over the course of RET prehabilitation and bed rest, whilst dietary intake was recorded throughout. Prior to and following bed rest, quadriceps cross-sectional area (CSA), and hormone/lipid profiles were determined. Serial muscle biopsies and dual-stable isotope tracers were used to determine integrated myofibrillar protein synthesis (iMyoPS) over RET prehabilitation and bed rest phases, and acute postabsorptive and postprandial myofibrillar protein synthesis (aMyoPS) rates at the end of bed rest.

RESULTS

During bed rest, daily step-count and light and moderate physical activity time decreased, whilst sedentary time increased when compared with habitual levels (P < 0.001 for all). Dietary protein and fibre intake during bed rest were lower than habitual values (P < 0.01 for both). iMyoPS rates were significantly greater in the exercised leg (EX) compared with the non-exercised control leg (CTL) over prehabilitation (1.76 ± 0.37%/day vs. 1.36 ± 0.18%/day, respectively; P = 0.007). iMyoPS rates decreased similarly in EX and CTL during bed rest (CTL, 1.07 ± 0.22%/day; EX, 1.30 ± 0.38%/day; P = 0.037 and 0.002, respectively). Postprandial aMyoPS rates increased above postabsorptive values in EX only (P = 0.018), with no difference in delta postprandial aMyoPS stimulation between legs. Quadriceps CSA at 40%, 60%, and 80% of muscle length decreased significantly in EX and CTL over bed rest (0.69%, 3.5%, and 2.8%, respectively; P < 0.01 for all), with no differences between legs. No differences in fibre-type CSA were observed between legs or with bed rest. Plasma insulin and serum lipids did not change with bed rest.

CONCLUSIONS

Short-term resistance exercise prehabilitation augmented iMyoPS rates in older men but did not offset the relative decline in iMyoPS and muscle mass during bed rest.

Elements not Graded in the Cardiac Enhanced Recovery After Surgery Guidelines Might Improve Postoperative Outcome: A Comprehensive Narrative Review

Enhanced Recovery Programs (ERPs) are protocols involving the whole patient surgical journey. These protocols are based on multimodal, multidisciplinary, evidence-based, and patient-centered approaches aimed at improving patient recovery after a surgical intervention. Such programs have shown striking positive results in different surgical specialties. However, only a few research groups have incorporated preoperative, intraoperative, and postoperative evidence-based interventions in bundles used to standardize care and build cardiac surgery ERPs. The Enhanced Recovery After Surgery Society recently published evidence-based recommendations for perioperative care in cardiac surgery. Their recommendations included 22 perioperative interventions that may be part of any cardiac ERP. However, various components integrated in already-published cardiac ERPs were neither graded nor reported in these recommendations. The goals of the current review are to present published cardiac ERPs and their effects on patient outcomes and reported components incorporated into these ERPs and to discuss the objectives and scope of cardiac ERPs.

Perioperative care in cardiac surgery

As mortality is now low for many cardiac surgical procedures, there has been an increasing focus on patient centered outcomes such as recovery and quality of life. The Enhanced Recovery After Surgery (ERAS) cardiac society recently published the first set of guidelines for cardiac surgery which will be useful as a starting point to help translate this philosophy for the benefit of those undergoing cardiac surgery. At the same time there are many advances in other areas such as mechanical circulation, diagnostics and quality metrics. We intend here to present a balanced and evidenced based review of selected aspects of current practice, encompassing both UK and international perioperative care with a focus on recent advances. For the convenience of the reader we will adopt the conventional perioperative preoperative, intraoperative and postoperative phases of care. The focus of cardiac surgical practice needs to evolve from mortality to recovery. Those specialists who work in cardiac anaesthesia and critical care are well placed to contribute to these changes. Accompanying this work is the development of technologies to improve recognition of and intervention to prevent early organ dysfunction. Measuring, benchmarking and publishing quality outcomes from cardiac surgical centres is likely to improve services and benefit our patients.

Prehabilitation before elective coronary artery bypass grafting surgery: a scoping review protocol

OBJECTIVE

The objective of this scoping review is to identify and map existing preoperative interventions, referred to as prehabilitation, in adult patients at home awaiting coronary bypass grafting (CABG) surgery. This scoping review also seeks to examine the feasibility and patient experiences in order to inform clinical practice and underpin a future systematic review.

INTRODUCTION

As patients age, comorbidities become more common. Strategies to improve postoperative outcomes and to accelerate recovery are required in patients undergoing CABG. Prehabilitation refers to a proactive process of increasing functional capacity before surgery to improve the patient's capacity to withstand upcoming physiologic stress and thus avoid postoperative complications.

INCLUSION CRITERIA

This scoping review will consider any studies including adult patients at home awaiting CABG surgery. Studies will provide information on any prehabilitation intervention to optimize preoperative physical and psychological health status. Studies conducted in any setting will be included.

METHODS

The methodology will follow the JBI recommendations for scoping reviews. Any published or unpublished source of information will be considered. Studies published in English, German, Danish, Swedish, and Norwegian will be included, with no geographical or cultural limitations. Retrieved papers will be screened by two independent reviewers, and a standardized tool will be used to extract data from each included source. The results will be presented as a map of the data extracted in a tabular form together with a narrative summary to provide a description of the existing evidence.

Effect of preparative rehabilitation on recovery after cardiac surgery: A systematic review

BACKGROUND

Physical prehabilitation (preparative rehabilitation) programs may have beneficial effects on enhancing physical strength and functional status before surgery, but their effects on postoperative recovery are unclear.

OBJECTIVES

This systematic review investigated the effectiveness of physical prehabilitation programs before cardiac surgery on postoperative recovery and other perioperative outcomes.

METHODS

We searched for reports of randomised controlled trials of any prehabilitation programs that included physical activity or an exercise training component in adults undergoing elective cardiac surgery, published in any language, from six bibliographic databases (last search on June 20, 2019). We assessed trials for risk of bias, overall certainty of evidence and quality of intervention reporting using the Cochrane Risk of Bias Assessment Tool, GRADE system and the Template for Intervention Description and Replication checklist and guide, respectively.

RESULTS

All 7 studies (726 participants) were at high risk of bias because of lack of blinding. The quality of prehabilitation reporting was moderate because program adherence was rarely assessed. The timing of prehabilitation ranged from 5 days to 16 weeks before surgery and from face-to-face exercise prescription to telephone counselling and monitoring. We found uncertain effects of prehabilitation on postoperative clinical outcomes (among the many outcomes assessed): perioperative mortality (Peto odds ratio 1.30, 95% confidence interval [CI] 0.28 to 5.95; I²=0%; low-certainty evidence) and postoperative atrial fibrillation (relative risk 0.75, 95% CI 0.38 to 1.46; I²=50%; very low-certainty evidence). However, prehabilitation may improve postoperative functional capacity and slightly shorten the hospital stay (mean difference -0.66 days, 95% CI -1.29 to -0.03; I²=45%; low-certainty evidence).

CONCLUSION

Despite the high heterogeneity among physical prehabilitation trials and the uncertainty regarding robust clinical outcomes, physical prehabilitation before cardiac surgery seems to enhance selected postoperative functional performance measures and slightly reduce the hospital length of stay after cardiac surgery.

Electroencephalogram Burst-suppression during Cardiopulmonary Bypass in Elderly Patients Mediates Postoperative Delirium

BACKGROUND

Intraoperative burst-suppression is associated with postoperative delirium. Whether this association is causal remains unclear. Therefore, the authors investigated whether burst-suppression during cardiopulmonary bypass (CPB) mediates the effects of known delirium risk factors on postoperative delirium.

METHODS

This was a retrospective cohort observational substudy of the Minimizing ICU [intensive care unit] Neurological Dysfunction with Dexmedetomidine-induced Sleep (MINDDS) trial. The authors analyzed data from patients more than 60 yr old undergoing cardiac surgery (n = 159). Univariate and multivariable regression analyses were performed to assess for associations and enable causal inference. Delirium risk factors were evaluated using the abbreviated Montreal Cognitive Assessment and Patient-Reported Outcomes Measurement Information System questionnaires for applied cognition, physical function, global health, sleep, and pain. The authors also analyzed electroencephalogram data (n = 141).

RESULTS

The incidence of delirium in patients with CPB burst-suppression was 25% (15 of 60) compared with 6% (5 of 81) in patients without CPB burst-suppression. In univariate analyses, age (odds ratio, 1.08 [95% CI, 1.03 to 1.14]; P = 0.002), lowest CPB temperature (odds ratio, 0.79 [0.66 to 0.94]; P = 0.010), alpha power (odds ratio, 0.65 [0.54 to 0.80]; P < 0.001), and physical function (odds ratio, 0.95 [0.91 to 0.98]; P = 0.007) were associated with CPB burst-suppression. In separate univariate analyses, age (odds ratio, 1.09 [1.02 to 1.16]; P = 0.009), abbreviated Montreal Cognitive Assessment (odds ratio, 0.80 [0.66 to 0.97]; P = 0.024), alpha power (odds ratio, 0.75 [0.59 to 0.96]; P = 0.025), and CPB burst-suppression (odds ratio, 3.79 [1.5 to 9.6]; P = 0.005) were associated with delirium. However, only physical function (odds ratio, 0.96 [0.91 to 0.99]; P = 0.044), lowest CPB temperature (odds ratio, 0.73 [0.58 to 0.88]; P = 0.003), and electroencephalogram alpha power (odds ratio, 0.61 [0.47 to 0.76]; P < 0.001) were retained as predictors in the burst-suppression multivariable model. Burst-suppression (odds ratio, 4.1 [1.5 to 13.7]; P = 0.012) and age (odds ratio, 1.07 [0.99 to 1.15]; P = 0.090) were retained as predictors in the delirium multivariable model. Delirium was associated with decreased electroencephalogram power from 6.8 to 24.4 Hertz.

CONCLUSIONS

The inference from the present study is that CPB burst-suppression mediates the effects of physical function, lowest CPB temperature, and electroencephalogram alpha power on delirium.

Early Extubation in Enhanced Recovery from Cardiac Surgery

Prolonged intubation and mechanical ventilation following cardiac surgery have been associated with increased hospital and intensive care unit length of stays; higher health care costs; and morbidity resulting from atelectasis, intrapulmonary shunting, and pneumonia. Early extubation was developed as a strategy in the 1990s to reduce the high-dose opiate regimes and long ventilator times. Early extubation is a key component of the enhanced recovery pathway following cardiac surgery and enables early mobilization and early return to a normal diet. The plan to extubate should start as soon as the patient is scheduled for cardiac surgery and continue throughout the perioperative period.

Optimization of a Comprehensive Prehabilitation Program for Patients with Stable Coronary Artery Disease Undergoing Elective Coronary Artery Bypass Grafting

Aim. To evaluate the effectiveness of a comprehensive prehabilitation program including the optimization of drug therapy for patients undergoing elective coronary artery bypass grafting (CABG).

Material and methods. 56 male patients with stable angina referred to elective on-pump CABG were enrolled in a study. All patients were screened for eligibility according to the inclusion/exclusion criteria and then randomized into two groups. Group 1 patients (n=28) underwent preoperative management (prehabilitation) for 14 days, including patient education and physical rehabilitation. Trimetazidine in a dose of 80 mg per day was added to the standard drug therapy. Group 2 patients (n=28) underwent similar preoperative management, but with the standard drug therapy without trimetazidine. In addition to the routine methods of preoperative management, all patients underwent the 6-minute walk test (6MWT) to assess exercise tolerance and speckle tracking echocardiography to measure left ventricular (LV) longitudinal deformation. Serum troponin T was measured in all patients. The measurements were performed at admission and after the surgery.

Results. Patients did not differ in the main clinical and demographic data, as well as the main preoperative speckle tracking echocardiography findings. The intraoperative parameters were comparable in both groups. The rate of early postoperative complications was 61% (n=17) in Group 1 and 64% (n=18) in Group 2 (p>0.05). LV ejection fraction significantly decreased postoperatively in both groups (p<0.01) as well as LV longitudinal deformation as compared to the baseline. Patients receiving the standard therapy without trimetazidine reported a significant decrease in the longitudinal strain after CABG compared with the baseline (p=0.01). There were no statistically significant differences in most preoperative and postoperative indicators of longitudinal deformation among patients treated with trimetazidine. Postoperative values of GLPS-LAX and GLPS-Avg were significantly higher in the trimetazidine group than those in the control group (p=0.04). Group 1 patients reported longer distance covered in 6MWT than Group 2 patients while assessing exercise tolerance: 370.0 [260.0;415.0] vs 242.0 [202.0;350.0] m, respectively (p=0.0059).

Conclusion. The addition of trimetazidine in a dose of 80 mg daily in the prehabilitation program for patients undergoing elective CABG demonstrated better postoperative indicators of LV longitudinal deformation and an increase in exercise tolerance. Obtained findings allowed considering this approach to the preoperative management as an additional method of cardiac protection and optimization of the functional status of patients.

Managing Cardiovascular Risk Factors without Medications: What is the Evidence?

In this era of potent medications and interventional cardiovascular (CV) procedures, the importance of beginning with and including Therapeutic Lifestyle Changes (TLC) is frequently forgotten. A major goal of this review article is to show and emphasize that modification of CV risk with nonmedication approaches makes an essential contribution to CV risk reduction. Available information on TLC and modifiable CV risk factors was reviewed and assessed. Modifiable major CV risk factors include diabetes mellitus, hypertension, hyperlipidemia, tobacco abuse, obesity, stress, and a sedentary lifestyle. Age as a major CV risk factor is, of course, not susceptible to modification. A contribution to the control of CV risk factors can occur without the start of medications and there is proof of benefit for beginning with a non-pharmacological approach. TLC can benefit all of the major modifiable CV risk factors and there is good evidence for the additional benefit of supervised and group TLC. TLC includes physical activity, diet, and smoking cessation. Evidence for the benefits of TLC in reducing CV disease events is well established. However, medications must be added in those patients with higher CV risk to obtain maximum cholesterol reduction (lower is better for the low-density lipoprotein cholesterol) and good blood pressure control. The benefit of TLC is frequently forgotten in this era of potent medications and invasive procedures. The benefits of diet and physical activity are emphasized with supporting data. Many motivated patients can prolong their lives significantly by dedication to TLC. Therapeutic Lifestyle Change (TLC) especially encompasses increased physical activity, a healthy diet, and smoking cessation. There is extensive proof for the benefit of TLC in contributing to cardiovascular (CV) disease prevention. CV diseases have strong metabolic and inflammatory components, both of which can be improved by TLC.