Can resistance prehabilitation training bring additional benefits in valvular cardiac surgery? protocol for a randomized controlled trial

INTRODUCTION

Cardiovascular diseases (CVD) are a group of illnesses that include coronary heart disease, cerebrovascular disease, congenital heart disease and deep vein thrombosis. Major surgery is often chosen as the treatment of choice for CVD. The concept of fast-track rehabilitation after surgery appeared in the 1970s. Participation in these exercise-based prehabilitation programmes may decrease postoperative complications and length of hospital stay. The primary aim of the present study is to evaluate whether the implementation of an additional resistance training (RT) prehabilitation protocol within cardiac exercises based prehabilitation can reduce intensive care unit (ICU) length of stay, postoperative complications and hospital length of stay (LOS).

METHODS

A protocol of a prospective, parallel, randomised clinical trial includes 96 adult patients diagnosed with valvular pathology and who have been scheduled for surgery. The participants will be randomly assigned to two groups of 48. Control group will be treated with ventilatory and strengthening of respiratory muscles, and aerobic exercise. Experimental group, in addition, will be treated with RT of peripheral muscles. Both hospital stay and ICU stay will be assessed as main variables. Other secondary variables such as exercise capacity, quality of life and respiratory values will also be assessed. Quantitative variables will be analysed with a T-Test or ANOVA, or Mann Witney if the distribution is non-parametric.

RESULTS AND CONCLUSION

This will be the first controlled clinical study focused on adding strength exercise as an additional treatment during prehabilitation. The results of this study will focus on helping to improve rehabilitation and prehabilitation protocols, considering that it is essential to maintain pulmonary training, as well as the inclusion of peripheral exercises that help people with heart disease to be in a better physical condition in order to increase their participation and sense of quality of life.

Safety and feasibility of early mobilization in patients submitted to cardiac surgery using subxiphoid drain

INTRODUCTION

Patients submitted to heart surgery are restricted to the bed of the Intensive Care Units (ICUs), due to this period of immobility the individual is likely to present clinical and functional alterations. These complications can be avoided by early mobilization; however, in some hospitals, this is not feasible due to the use of subxiphoid drain in the immediate postoperative period.

OBJECTIVE

To verify the safety and feasibility of mobilizing patients after cardiac surgery using subxiphoid drain.

METHODS

This was a prospective cohort study. On the first day the patient was positioned in sedestration in bed, then transferred from sitting to orthostasis, gait training and sedestration in an armchair. On the second postoperative day the same activities were performed, but with walking through the ICU with a progressive increase in distance. At all these moments, the patient was using the subxiphoid and intercostal drain. The patients were seen three times a day, but physical rehabilitation was performed twice. The adverse events considered were drain obstruction, accidental removal or displacement, total atrioventricular block, postoperative low output syndrome, cardiorespiratory arrest, pneumomediastinum, infection, and pericardial or myocardial damage.

RESULTS

176 patients were evaluated. Only 2 (0.4 %) of the patients had complications during or after mobilization, 1 (0.2 %) due to drain obstruction and 1 (0.2 %) due to accidental removal or displacement.

CONCLUSION

Based on the data observed in the results, we found that the application of early mobilization in patients using subxiphoid drain after cardiac surgery is a safe and feasible conduct.

Effects of 12-Week Supervised Early Resistance Training (SEcReT) Versus Aerobic-Based Rehabilitation on Cognitive Recovery Following Cardiac Surgery via Median Sternotomy: A Pilot Randomised Controlled Trial

AIMS

To investigate the effects of a 12-week early moderate-intensity resistance training program compared to aerobic-based rehabilitation on postoperative cognitive recovery following cardiac surgery via median sternotomy.

METHODS

This was a multicentre, prospective, pragmatic, non-blinded, pilot randomised controlled trial (1:1 randomisation) of two parallel groups that compared a 12-week early moderate-intensity resistance training group to a control group, receiving aerobic-based rehabilitation. English-speaking adults (≥18 years) undergoing elective cardiac surgery via median sternotomy were randomised using sealed envelopes, with allocation revealed before surgery. The primary outcome was cognitive function, assessed using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), at baseline, 14 weeks and 6 months postoperatively.

RESULTS

The ADAS-cog score at 14 weeks was significantly better for the resistance training group (n=14, 7.2±1.4; 95% CI 4.3, 10.2, vs n=17, 9.2±1.3; 95% CI 6.6, 11.9, p=0.010). At 14 weeks postoperatively, 53% of the aerobic-based rehabilitation group (n=9/17) experienced cognitive decline by two points or more from baseline ADAS-cog score, compared to 0% of the resistance training group (n=0/14; p=0.001).

CONCLUSION

Early resistance training appears to be safe and may improve cognitive recovery compared to standard, aerobic-based rehabilitation following cardiac surgery via median sternotomy, however as this was a pilot study, the sample size was small and further research is needed to determine a causal relationship.

Effect of postoperative high load long duration inspiratory muscle training on pulmonary function and functional capacity after mitral valve replacement surgery: A randomized controlled trial with follow-up

Objectives

Although, pre-operative inspiratory muscle training has been investigated and reported to be an effective strategy to reduce postoperative pulmonary complications, the efficacy of postoperative inspiratory muscle training as well as the proper load, frequency, and duration necessary to reduce the postoperative pulmonary complications has not been fully investigated. This study was designed to investigate the effect of postoperative high-load long-duration inspiratory muscle training on pulmonary function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries.

Design

Prospective randomized controlled trial.

Methods

A total of one hundred patients (mean age 38.3±3.29years) underwent mitral valve replacement surgery were randomized into experimental (n = 50) and control (n = 50) groups. The control group received conventional physiotherapy care, while experimental group received conventional care in addition to inspiratory muscle training, with 40% of the baseline maximal inspiratory pressure targeting a load of 80% by the end of the 8 weeks intervention protocol. Inspiratory muscle training started on the patient’s first day in the inpatient ward. Lung functions, inspiratory muscle strength, and functional capacity were evaluated using a computer-based spirometry system, maximal inspiratory pressure measurement and 6MWT respectively at 5 time points and a follow-up assessment was performed 6 months after surgery. Repeated measure ANOVA and post-hoc analyses were used (p <0.05).

Results

Group-time interactions were detected for all the studied variables (p<0.001). Between-group analysis revealed statistically significant postoperative improvements in all studied variables in the experimental group compared to the control group (p <0.001) with large effect size of η² ˃0.14. Within-group analysis indicated substantial improvements in lung function, inspiratory pressure and functional capacity in the experimental group (p <0.05) over time, and these improvements were maintained at follow-up.

Conclusion

High intensity, long-duration postoperative inspiratory muscle training is highly effective in improving lung function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries.

Haemodynamic determinants of improved aerobic capacity after tricuspid valve surgery in Ebstein anomaly

BACKGROUND

Although tricuspid valve surgery improves functional capacity in patients with Ebstein anomaly, it is not always associated with improvement in aerobic capacity. The purpose of this study was to identify the determinants of improved aerobic capacity after tricuspid valve surgery in adults with Ebstein anomaly with severe tricuspid regurgitation.

METHODS

Retrospective study of patients with severe tricuspid regurgitation due to Ebstein anomaly that had tricuspid valve surgery at Mayo Clinic Rochester (2000-2019) and had preoperative and postoperative cardiopulmonary exercise tests and echocardiograms. The patients were divided into aerobic capacity(+) and aerobic capacity(-) groups depending on whether they had postoperative improvement in %-predicted peak oxygen consumption (VO2).

RESULTS

Of 76 patients with severe tricuspid regurgitation due to Ebstein anomaly, 28 (37%) and 48 (63%) were in aerobic capacity(+) and aerobic capacity(-) groups, respectively. The average improvement in peak VO2 was 2.1±1.4 mL/kg/min and -0.9±0.4 mL/kg/min in the in aerobic capacity(+) and aerobic capacity(-) groups, respectively. Although both groups had similar severity of residual tricuspid regurgitation, the aerobic capacity(+) group had more postoperative improvement in right atrial (RA) function, left atrial (LA) function and left ventricular preload and stroke volume. Of the preoperative variables analysed, RA reservoir strain (relative risk 1.12; 95% CI 1.06 to 1.18); LA reservoir strain (relative risk 1.09; 95% CI 1.04 to 1.14) and LV stroke volume index (OR 1.04; 95% CI 1.01 to 1.07) were predictors of postoperative improvement in peak VO2.

CONCLUSIONS

One-third of patients with severe tricuspid regurgitation due to Ebstein anomaly had postoperative improvement in aerobic capacity, and atrial function indices were the best predictors of postoperative improvement in aerobic capacity. These data provide new insight into the haemodynamic determinants of exercise capacity and lay the foundation for further studies to determine whether postoperative improvement in aerobic capacity translates to improved long-term survival, and whether timing of tricuspid valve surgery based on these echocardiographic indices will improve long-term outcomes.

A systematic review and meta-analysis of the effects of early mobilization therapy in patients after cardiac surgery

BACKGROUND

Prolonged hospitalization and immobility of critical care patients elevate the risk of long-term physical and cognitive impairments. However, the therapeutic effects of early mobilization have been difficult to interpret due to variations in study populations, interventions, and outcome measures. We conducted a meta-analysis to assess the effects of early mobilization therapy on cardiac surgery patients in the intensive care unit (ICU).

METHODS

PubMed, Excerpta Medica database (EMBASE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Physiotherapy Evidence Database (PEDro), and the Cochrane Library were comprehensively searched from their inception to September 2018. Randomized controlled trials were included if patients were adults (≥18 years) admitted to any ICU for cardiac surgery due to cardiovascular disease and who were treated with experimental physiotherapy initiated in the ICU (pre, post, or peri-operative). Data were extracted by 2 reviewers independently using a pre-constructed data extraction form. Length of ICU and hospital stay was evaluated as the primary outcomes. Physical function and adverse events were assessed as the secondary outcomes. Review Manager 5.3 (RevMan 5.3) was used for statistical analysis. For all dichotomous variables, relative risks or odds ratios with 95% confidence intervals (CI) were presented. For all continuous variables, mean differences (MDs) or standard MDs with 95% CIs were calculated.

RESULTS

The 5 studies with a total of 652 patients were included in the data synthesis final meta-analysis. While a slight favorable effect was detected in 3 out of the 5 studies, the overall effects were not significant, even after adjusting for heterogeneity.

CONCLUSIONS

This population-specific evaluation of the efficacy of early mobilization to reduce hospitalization duration suggests that intervention may not universally justify the labor barriers and resource costs in patients undergoing non-emergency cardiac surgery.

PROSPERO RESEARCH REGISTRATION IDENTIFYING NUMBER

CRD42019135338.

Dynamic Pituitary-Adrenal Interactions in the Critically Ill after Cardiac Surgery

CONTEXT

Patients with critical illness are thought to be at risk of adrenal insufficiency. There are no models of dynamic hypothalamic-pituitary-adrenal (HPA) axis function in this group of patients and thus current methods of diagnosis are based on aggregated, static models.

OBJECTIVE

To characterize the secretory dynamics of the HPA axis in the critically ill (CI) after cardiac surgery.

DESIGN

Mathematical modeling of cohorts.

SETTING

Cardiac critical care unit.

PATIENTS

20 male patients CI at least 48 hours after cardiac surgery and 19 healthy (H) male volunteers.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Measures of hormone secretory dynamics were generated from serum adrenocorticotrophic hormone (ACTH) sampled every hour and total cortisol every 10 min for 24 h.

RESULTS

All CI patients had pulsatile ACTH and cortisol profiles. CI patients had similar ACTH secretion (1036.4 [737.6] pg/mL/24 h) compared to the H volunteers (1502.3 [1152.2] pg/mL/24 h; P = .20), but increased cortisol secretion (CI: 14 447.0 [5709.3] vs H: 5915.5 [1686.7)] nmol/L/24 h; P < .0001). This increase in cortisol was due to nonpulsatile (CI: 9253.4 [3348.8] vs H: 960 [589.0] nmol/L/24 h, P < .0001), rather than pulsatile cortisol secretion (CI: 5193.1 [3018.5] vs H: 4955.1 [1753.6] nmol/L/24 h; P = .43). Seven (35%) of the 20 CI patients had cortisol pulse nadirs below the current international guideline threshold for critical illness-related corticosteroid insufficiency, but an overall secretion that would not be considered deficient.

CONCLUSIONS

This study supports the premise that current tests of HPA axis function are unhelpful in the diagnosis of adrenal insufficiency in the CI. The reduced ACTH and increase in nonpulsatile cortisol secretion imply that the secretion of cortisol is driven by factors outside the HPA axis in critical illness.

Assessment of Patient Ambulation Profiles to Predict Hospital Readmission, Discharge Location, and Length of Stay in a Cardiac Surgery Progressive Care Unit

IMPORTANCE

Promoting patient mobility during hospitalization is associated with improved outcomes and reduced risk of hospitalization-associated functional decline. Therefore, accurate measurement of mobility with high-information content data may be key to improved risk prediction models, identification of at-risk patients, and the development of interventions to improve outcomes. Remote monitoring enables measurement of multiple ambulation metrics incorporating both distance and speed.

OBJECTIVE

To evaluate novel ambulation metrics in predicting 30-day readmission rates, discharge location, and length of stay using a real-time location system to continuously monitor the voluntary ambulations of postoperative cardiac surgery patients.

DESIGN, SETTING, AND PARTICIPANTS

This prognostic cohort study of the mobility of 100 patients after cardiac surgery in a progressive care unit at Johns Hopkins Hospital was performed using a real-time location system. Enrollment occurred between August 29, 2016, and April 4, 2018. Data analysis was performed from June 2018 to December 2019.

MAIN OUTCOMES AND MEASURES

Outcome measures included 30-day readmission, discharge location, and length of stay. Digital records of all voluntary ambulations were created where each ambulation consisted of multiple segments defined by distance and speed. Ambulation profiles consisted of 19 parameters derived from the digital ambulation records.

RESULTS

A total of 100 patients (81 men [81%]; mean [SD] age, 63.1 [11.6] years) were evaluated. Distance and speed were recorded for more than 14 000 segments in 840 voluntary ambulations, corresponding to a total of 127.8 km (79.4 miles) using a real-time location system. Patient ambulation profiles were predictive of 30-day readmission (sensitivity, 86.7%; specificity, 88.2%; C statistic, 0.925 [95% CI, 0.836-1.000]), discharge to acute rehabilitation (sensitivity, 84.6%; specificity, 86.4%; C statistic, 0.930 [95% CI, 0.855-1.000]), and length of stay (correlation coefficient, 0.927).

CONCLUSIONS AND RELEVANCE

Remote monitoring provides a high-information content description of mobility, incorporating elements of step count (ambulation distance and related parameters), gait speed (ambulation speed and related parameters), frequency of ambulation, and changes in parameters on successive ambulations. Ambulation profiles incorporating multiple aspects of mobility enables accurate prediction of clinically relevant outcomes.

A systematic review and meta-analysis of the effects of early mobilization therapy in patients after cardiac surgery: A protocol for systematic review

BACKGROUND

Prolonged hospitalization and immobility of critical care patients elevates the risk of long-term physical and cognitive impairments. However, the therapeutic effects of early mobilization have been difficult to interpret due to variations in study populations, interventions, and outcome measures. This systematic review and meta-analysis aims to assess the effects of early mobilization therapy for non-emergency cardiac surgery patients in the intensive care unit (ICU).

METHODS

The following databases will be used to search for relevant keywords: PubMed, Embase, CINAHL, PEDro, and the Cochrane Library from inception to September 2018 by 2 researchers independently. Randomized controlled trials (RCTs), will be included if patients are adults (≥18 years) admitted to any ICU for cardiac surgery due to cardiovascular disease and who are treated with experimental physiotherapy initiated in the ICU (pre, post, or perioperative). The Review Manager 5.3 will be used for meta-analysis and the evidence level will be assessed by using the method for Grading of Recommendations Assessment, Development, and Evaluation (GRADE). Continuous outcomes will be presented as the weighted mean difference (WMD) or standardized mean difference (SMD) with 95% confidence interval (CI), while dichotomous data will be expressed as relative risk (RR) with 95% CI. If the included studies have existing heterogeneity (P < 0.1), a random-effects model will be used. Otherwise, we will calculate using a fixed effects model.

RESULTS

This review will evaluate the effects of early mobilization on length of ICU and hospital stay, physical function and adverse events in patients with cardiac surgery patients in the ICU.

CONCLUSION

This systematic review will comprehensively provide conclusive evidence of the therapeutic effect of early mobilization on cardiac surgery patients in the ICU.PROSPERO Research registration identifying number: CRD42019135338.

Feasibility study of early outpatient review and early cardiac rehabilitation after cardiac surgery: mixed-methods research design-a study protocol

INTRODUCTION

Following cardiac surgery, patients currently attend an outpatient review 6 weeks after hospital discharge, where recovery is assessed and suitability to commence cardiac rehabilitation (CR) is determined. CR is then started from 8 weeks. Following a median sternotomy, cardiac surgery patients are required to refrain from upper body exercises, lifting of heavy objects and other strenuous activities for 12 weeks. A delay in starting CR can prolong the recovery process, increase dependence on family/carers and can cause frustration. However, current guidelines for activity and exercise after median sternotomy have been described as restrictive, anecdotal and increasingly at odds with modern clinical guidance for CR. This study aims to examine the feasibility of bringing forward outpatient review and starting CR earlier.

METHODS AND ANALYSES

This is a multicentre, randomised controlled, open feasibility trial comparing postoperative outpatient review 6 weeks after hospital discharge, followed by CR commencement from 8 weeks (control arm) versus, postoperative outpatient review 3 weeks after hospital discharge, followed by commencement of CR from 4 weeks (intervention arm). The study aims to recruit 100 eligible patients, aged 18-80 years who have undergone elective or urgent cardiac surgery involving a full median sternotomy, over a 7-month period across two centres. Feasibility will be measured by consent, recruitment, retention rates and attendance at appointments and CR sessions. Qualitative interviews with trial participants and staff will explore issues around study processes and acceptability of the intervention and the findings integrated with the feasibility trial outcomes to inform the design of a future full-scale randomised controlled trial.

ETHICS AND DISSEMINATION

Ethics approval was granted by East Midlands-Derby Research Ethics Committee on 10 January 2019. The findings will be presented at relevant conferences disseminated via peer-reviewed research publications, and to relevant stakeholders.

TRIAL REGISTRATION NUMBER

ISRCTN80441309.

PREhabilitation for improving QUality of recovery after ELective cardiac surgery (PREQUEL) study: protocol of a randomised controlled trial

INTRODUCTION

Frailty is a multidimensional syndrome in which multiple small physiological deficits accumulate gradually, resulting in a loss of physiological reserve and adaptability, putting a patient that is exposed to a stressor at a higher risk of adverse outcomes. Both pre-frailty and frailty are associated with poor patient outcomes and higher healthcare costs. The effect of a prehabilitation programme and standard care on the quality of recovery in pre-frail and frail patients undergoing elective cardiac surgery will be compared.

METHOD AND ANALYSIS

A single-centre, superiority, stratified randomised controlled trial with a blinded outcome assessment and intention-to-treat analysis. Pre-frail and frail patients awaiting elective coronary artery bypass graft, with or without valvular repair/replacement, will be recruited. 164 participants will be randomly assigned to either prehabilitation (intervention) or standard care (no intervention) groups. The prehabilitation group will attend two sessions/week of structured exercise (aerobic and resistance) training, supervised by a physiotherapist, for 6-10 weeks before surgery with early health promotion advice in addition to standard care. The standard care group will receive the usual routine care (no prehabilitation). Frailty will be assessed at baseline, hospital admission and at 1 and 3 months after surgery. The primary outcomes will be participants' perceived quality of recovery (15-item Quality of Recovery questionnaire) after surgery (day 3), days at home within 30 days of surgery and the changes in WHO Disability Assessment Schedule 2.0 score between baseline and at 1 and 3 months after surgery. Secondary outcomes will include major adverse cardiac and cerebrovascular events, psychological distress levels, health-related quality of life and healthcare costs.

ETHICS AND DISSEMINATION

The Joint CUHK-NTEC Clinical Research Ethics Committee approved the study protocol (CREC Ref. No. 2017.696 T). The findings will be presented at scientific meetings, in peer-reviewed journals and to study participants.

TRIAL REGISTRATION NUMBER

ChiCTR1800016098; Pre-results.

Quality of Life at Three Years after Cardiac Surgery: Relationship with Preoperative Status and Quality of Recovery

A reduction in symptoms, increased longevity, and improved quality of life (QoL), are goals of cardiac surgery. We measured QoL in 108 adult cardiac surgical patients at about three years after cardiac surgery, and assessed the predictive ability of a 40-item quality of recovery (QoR-40) score. Our follow-up rate was 86% (n=93). When compared with preoperative status, QoL was improved at three years after surgery (P<0.0005). The dimensions of QoL that were most affected were physical functioning, role limitations due to physical problems, vitality, social functioning, and role limitations due to emotional problems (all P<0.005). There was a mild correlation between the day 3 QoR-40 and the three year SF-36, r=0.23 (P=0.029). There was a strong correlation between the three year QoR-40 and the three year SF-36, r=0.73 (P<0.0005). The QoR-40 and SF-36 done at three years after cardiac surgery demonstrated good internal consistency, QoR-40 α=0.86 (P<0.0005), SF-36 α=0.91 (P<0.0005). A poor quality recovery in the days after surgery can predict a poor QoL at three years after surgery. The QoR-40 is a valid and reliable measure of quality of recovery after surgery and anaesthesia. The QoR-40 is a useful, patient-oriented method of assessing recovery from anaesthesia and surgery.

Relationship between Daytime Sleepiness and Health Utility in Patients after Cardiac Surgery: A Preliminary Study

Background Daytime sleepiness can be assessed by the Epworth Sleepiness Scale (ESS), which is widely used in the field of sleep medicine as a subjective measure of a patient's sleepiness. Also, health utility assessed by the mean Short-Form Six-Dimension (SF-6D) score, one of several preference-based utility measures, is an important measure in health care. We aimed to examine age-related differences in daytime sleepiness and health utility and their relationship in patients 5 months after cardiac surgery. Methods; This cross-sectional study assessed 51 consecutive cardiac surgery patients who were divided into a middle-aged (<65 years, n = 29) and older-age group (≥65 years, n = 22). The mean ESS and SF-6D utility scores were measured at 5 months after cardiac surgery and compared. In addition, the relationship between ESS and SF-6D utility scores were assessed. Results; There were no significant differences between the middle-aged and older-aged groups in either the mean ESS (5.14 ± 2.96 vs. 4.05 ± 3.23, p = 0.22) or SF-6D utility (0.72 ± 0.14 vs. 0.71 ± 0.10, p = 0.76) scores. However, there was a negative correlation between both values in all of the patients after cardiac surgery (r = -0.41, p = 0.003). Conclusions; Although there were no age-related differences in the ESS and SF-6D utility values between the two groups, there was a negative correlation between these values in all patients at 5 months after cardiac surgery. This suggested that sleepiness is associated with decreased utility scores in patients at 5 months after cardiac surgery.

Early Discharge From Intensive Care After Cardiac Surgery is Feasible With an Adequate Fast Track, Stepdown Unit: Waikato Experience

BACKGROUND

Enhanced recovery programs within cardiothoracic surgery are a well described benefit to patient postoperative outcomes. We describe our Australasian unit's experience of a day zero discharge enhanced recovery unit from the intensive care department.

METHODS

A retrospective study was conducted on a prospectively maintained database at Waikato Cardiothoracic Unit from September 2014 till October 2017 with 1,739 patients undergoing cardiac surgery. Twenty-two (22) patients were excluded as deaths either intraoperative or in the intensive care unit (ICU) and therefore never discharged. Total population of the study was 1,717 patients. The primary endpoint of this study was to determine if there is no survival disadvantage for the day zero discharge unit compared to standard treatment in ICU at follow-up. The secondary endpoint of the study was to highlight the association between pre and postoperative variables and the impact on discharge from the ICU.

RESULTS

One hundred sixty-eight (168) patients were discharged to the enhanced recovery unit (ERU) day zero. Mean number of hours spent in ICU for the day zero cohort was 7.18 (±1.59. Mean Age 62.5 (±11.22), M:F 4.25:1. Patients were more likely to be discharged day zero if they had a lower EuroSCORE II 1.57 (±1.67) and lower preoperative creatinine 89.4 (±27.5). Those admitted to the ERU on day zero postoperatively were more likely to be discharged with a lower creatinine level, a higher haemoglobin level and have less readmissions per 30days (p<0.05). Survival analysis demonstrated that the patients who were discharged early from ICU had significantly better follow-up survival compared to those who were discharged after 24hours (p<0.05).

CONCLUSIONS

A fast track unit increases the efficiency of an ICU and cardiac surgical department. With the advancements of cardiac surgery a higher number of patients will be suitable for a fast track method. Our unit has demonstrated that a day zero fast track unit in New Zealand can perform with adequate patient safety with no increased risk of mortality and with low rates of failure of the day zero discharge fast track therapy.

Validating the 6-minute walk test as an indicator of recovery in patients undergoing cardiac surgery: A prospective cohort study

The 6-minute walk test (6MWT) has been applied to assess postsurgical recovery in cardiac populations. This study mainly investigated whether the 6MWT could serve as an indicator for physical functioning in patients undergoing cardiac surgery.Participants completed the 6MWT and the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) at baseline, discharge, and 3 months postoperatively, in order to analyze the construct validity and responsiveness of the 6MWT. The participants in this study were 125 patients (92 males and 33 females) with an average age of 65.1 ± 11.1 years. The mean 6MWT was 308.9 ± 77.3 m in the preoperative phase, decreased to 277.3 ± 85.7 m at discharge, and returned to 378.1 ± 95.2 m at 3-month follow-up. The results showed that the 6-minute walk distances at baseline and at 3-month follow-up were moderately to highly correlated with the physical functioning subscale of the SF-36 (rs = .44 and .54, respectively) and had weak correlation with the nonphysical functioning subscales. The recovery level of physical functioning is meaningfully associated with the 6MWT change from baseline to discharge and from baseline to 3-month follow-up. Patients with higher New York Heart Association (NYHA) Functional Classification levels had lower 6MWT. Additionally, the 6MWT was sensitive to change during the perioperative period (effect sizes from -0.51 to 1.72).The supporting evidence includes the construct validity and responsiveness of the 6MWT. This study supports the feasibility of the 6MWT as an evaluation tool of physical functioning for assessment of postcardiac surgical recovery.

Systematic review of preoperative physical activity and its impact on postcardiac surgical outcomes

OBJECTIVES

The objective of this systematic review was to study the impact of preoperative physical activity levels on adult cardiac surgical patients' postoperative: (1) major adverse cardiac and cerebrovascular events (MACCEs), (2) adverse events within 30 days, (3) hospital length of stay (HLOS), (4) intensive care unit length of stay (ICU LOS), (5) activities of daily living (ADLs), (6) quality of life, (7) cardiac rehabilitation attendance and (8) physical activity behaviour.

METHODS

A systematic search of MEDLINE, Embase, AgeLine and Cochrane library for cohort studies was conducted.

RESULTS

Eleven studies (n=5733 patients) met the inclusion criteria. Only self-reported physical activity tools were used. Few studies used multivariate analyses to compare active versus inactive patients prior to surgery. When comparing patients who were active versus inactive preoperatively, there were mixed findings for MACCE, 30 day adverse events, HLOS and ICU LOS. Of the studies that adjusted for confounding variables, five studies found a protective, independent association between physical activity and MACCE (n=1), 30-day postoperative events (n=2), HLOS (n=1) and ICU LOS (n=1), but two studies found no protective association for 30-day postoperative events (n=1) and postoperative ADLs (n=1). No studies investigated if activity status before surgery impacted quality of life or cardiac rehabilitation attendance postoperatively. Three studies found that active patients prior to surgery were more likely to be inactive postoperatively.

CONCLUSION

Due to the mixed findings, the literature does not presently support that self-reported preoperative physical activity behaviour is associated with postoperative cardiac surgical outcomes. Future studies should objectively measure physical activity, clearly define outcomes and adjust for clinically relevant variables.

REGISTRATION

Trial registration number NCT02219815. PROSPERO number CRD42015023606.

Noninvasive Ventilation During Immediate Postoperative Period in Cardiac Surgery Patients: Systematic Review and Meta-Analysis

OBJECTIVE

To verify the effectiveness of noninvasive ventilation compared to conventional physiotherapy or oxygen therapy in the mortality rate and prevention of pulmonary complications in patients during the immediate postoperative period of cardiac surgery.

METHODS

Systematic review and meta-analysis recorded in the International Prospective Register of Ongoing Systematic Reviews (number CRD42016036441). The research included the following databases: MEDLINE, Cochrane Central, PEDro, LILACS and manual search of the references of studies published until March 2016. The review included randomized controlled trials with patients during the immediate postoperative period of cardiac surgery, which compared the use of noninvasive ventilation, BiLevel modes, continuous positive airway pressure, intermittent positive pressure breathing and positive pressure ventilation with conventional physiotherapy or oxygen therapy, and assessed the mortality rate, occurrence of pulmonary complications (atelectasis, pneumonia, acute respiratory failure, hypoxemia), reintubation rate, ventilation time, time spent in the intensive care unit (ICU), length of hospital stay and partial pressure of oxygen.

RESULTS

Among the 479 selected articles, ten were included in the systematic review (n=1050 patients) and six in the meta-analysis. The use of noninvasive ventilation did not significantly reduce the risk for atelectasis (RR: 0.60; CI95% 0.28-1.28); pneumonia (RR: 0.20; CI95% 0.04-1.16), reintubation rate (RR: 0.51; CI95%: 0.15-1.66), and time spent in the ICU (-0.04 days; CI95%: -0.13; 0.05).

CONCLUSION

Prophylactic noninvasive ventilation did not significantly reduce the occurrence of pulmonary complications such as atelectasis, pneumonia, reintubation rate and time spent in the ICU. The use is still unproven and new randomized controlled trials should be carried out.

Poor preoperative nutritional status is an important predictor of the retardation of rehabilitation after cardiac surgery in elderly cardiac patients

BACKGROUND

Preoperative nutritional status and physical function are important predictors of mortality and morbidity after cardiac surgery. However, the influence of nutritional status before cardiac surgery on physical function and the progress of postoperative rehabilitation requires clarification.

AIMS

To determine the effect of preoperative nutritional status on preoperative physical function and progress of rehabilitation after elective cardiac surgery.

METHODS

We enrolled 131 elderly patients with mean age of 73.7 ± 5.8 years undergoing cardiac surgery. We divided them into two groups by nutritional status as measured by the Geriatric Nutritional Risk Index (GNRI): high GNRI group (GNRI ≥ 92, n = 106) and low GNRI group (GNRI < 92, n = 25). Physical function was estimated by handgrip strength, knee extensor muscle strength (KEMS), the Short Physical Performance Battery (SPPB), and 6-minute walk test (6MWT). Progress of postoperative rehabilitation was evaluated by the number of days to independent walking after surgery, length of stay in the ICU, and length of hospital stay.

RESULTS

After adjusting for potential confounding factors, preoperative handgrip strength (P = 0.034), KEMS (P = 0.009), SPPB (P < 0.0001), and 6MWT (P = 0.012) were all significantly better in the high GNRI group. Multiple regression analysis revealed that a low GNRI was an independent predictor of the retardation of postoperative rehabilitation.

CONCLUSIONS

Preoperative nutritional status as assessed by the GNRI could reflect perioperative physical function. Preoperative poor nutritional status may be an independent predictor of the retardation of postoperative rehabilitation in patients undergoing elective cardiac surgery.

[Experience of the military sanatorium "Arkhangelsk" on medical rehabilitation of patients after surgery]

Experience of the military sanatorium <<Arkhangelsk>> on medical rehabilitation of patients after surgery in the treatment of coronary heart disease. Showing features of the organization of medical rehabilitation of patients with coronary artery disease after surgical treatment at a sanatorium stage. The technology of application of restorative treatment, physical and psychological recovery, natural and premature medicinal factors are given. Based on the dynamics of the functional status of patients given control of complex clinical and instrumental studies in comparison with analogous-tech at discharge, to translate them into functional class, characterized with greater functionality is installed, the high efficiency of rehabilitation.

Greater functional improvement in patients with diabetes after rehabilitation following cardiac surgery

BACKGROUND

Diabetes increases the risk of in-hospital complications in medical or surgical patients. Few data are available in the rehabilitation phase after cardiac surgery.

AIM

To assess the influence of diabetes on outcome and complication rate in the rehabilitation phase after cardiac surgery.

METHODS

Data prospectively recorded in the Hospital Information System from 5261 patients consecutively admitted between 1 January 2008 and 31 May 2013 for a comprehensive cardiac rehabilitation programme directly after cardiac surgery were analysed retrospectively.

RESULTS

The study cohort included 1285 (24%) patients with diabetes and 3976 (76%) without. Coronary artery bypass graft (CABG) was more frequent in patients with diabetes (58% vs. 37%, P < 0.01), and valvular surgery was more frequent in patients without diabetes (37% vs. 22%, P < 0.01). Patients with diabetes were more disabled after surgery, with severe disability (Barthel Index < 60) observed in 22% (vs. 17% in patients without diabetes, P < 0.001). During rehabilitation, complications were more frequent in patients with diabetes than those without (28% vs. 21%, P < 0.01); in particular, patients with diabetes had more infections, heart failure and more difficult surgical wound healing. However, the improvement in the Barthel Index was greater in patients with diabetes (+16 ± 15) than without (+13 ± 15, P < 0.001).

CONCLUSIONS

In a large cohort of patients directly admitted to an early inpatient rehabilitation programme after cardiac surgery, those with diabetes were more disabled. Nonetheless, and despite the higher rate of complications, patients with diabetes had the greatest benefit in terms of functional improvement.

[DIAGNOSTIC AND THERAPEUTIC BRONCHOSCOPY IN PATIENTS UNDERGOING CARDIAC SURGERY IN INTRA- AND POSTOPERATIVE PERIODS]

The article presents research conducted to evaluate the use of diagnostic and therapeutic fiberoptic bronchoscopy in the treatment of ventilator-associated pneumonia (VAP) and tracheobronchitis in patients in cardiac ICU. The paper presents the results of the study and comparison of invasive techniques for sampling from the respiratory tract for bacteriological analysis. We studied the bacterial profile of ICU, original content of the respiratory tract of cardiac patients in the intraoperative period and possible ways for prevention of VAP and tracheobronchitis in the postoperative period using bronchoscopy. In addition data on the effect of bronchoscopy on the respiratory and cardiovascular systems in cardiac surgical patients undergoing mechanical ventilation presented.

Pain and cardiorespiratory responses of children during physiotherapy after heart surgery

OBJECTIVE

The aim of the present study was to determine the occurrence of pain and changes in blood pressure, heart rate, respiratory rate, and arterial oxygen saturation associated with physiotherapy in children undergoing cardiac surgery.

METHODS

Eighteen extubated children were assessed for the presence of pain using the face, legs, activity, cry, consolability scale, and blood pressure, heart rate, respiratory rate and arterial oxygen saturation were simultaneously recorded. The physiological parameters were measured at the following time periods: immediately before physiotherapy, five and 10 minutes after the beginning of physiotherapy, and five minutes after its end. Pain was assessed immediately before physiotherapy, ten minutes after the beginning of physiotherapy and five minutes after its end. Pain and physiological changes were assessed by the Friedman test and the correlation between the physiological parameters and the pain scores was assessed by the Spearman test.

RESULTS

Pain increased during physiotherapy and decreased significantly after it compared to pre-physiotherapy scores. Systolic blood pressure and heart rate increased significantly after 10 minutes of the beginning of physiotherapy. Arterial oxygen saturation tended to decrease during physiotherapy and to increase after it, although without significance. The correlation between pain scores and the physiological variables was significant only for systolic blood pressure and heart rate ten minutes after the beginning of physiotherapy.

CONCLUSION

Manipulation after the beginning of physiotherapy seems to be accompanied by significant pain and by important associated cardiovascular changes. Apparent analgesia and improved respiratory function were observed after respiratory physiotherapy.

Evaluation of peripheral muscle strength of patients undergoing elective cardiac surgery: a longitudinal study

INTRODUCTION

Peripheral muscle strength has been little explored in the literature in the context of cardiac rehabilitation.

OBJECTIVE

To evaluate the peripheral muscle strength of patients undergoing elective cardiac surgery.

METHODS

This was a longitudinal observational study. The peripheral muscle strength was measured using isometric dynamometry lower limb (knee extensors and flexors) at three different times: preoperatively (M1), the day of discharge (M2) and hospital discharge (M3). Participants received physiotherapy pre and postoperatively during the days of hospitalization during the morning and afternoon.

RESULTS

Twenty-two patients were evaluated. The values of peripheral muscle strength of knee extensors preoperative found were about 50% lower than those predicted for the healthy population. When comparing muscle strength prior (M1), with the remaining evaluation, found himself in a fall of 29% for the movement of knee extension and 25% for knee flexion in M2 and a decrease of 10% movement for knee extension and 13% for knee flexion in M3 when comparing with M1.

CONCLUSION

The values of peripheral muscle strength prior of the study patients were lower than predicted for the healthy population of the same age. After the surgical event this reduction is even more remarkable, being reestablished until the time of discharge, to values close to baseline.

Cardiovascular risk of high- versus moderate-intensity aerobic exercise in coronary heart disease patients

BACKGROUND

Exercise performed at higher relative intensities has been found to elicit a greater increase in aerobic capacity and greater cardioprotective effects than exercise at moderate intensities. An inverse association has also been detected between the relative intensity of physical activity and the risk of developing coronary heart disease, independent of the total volume of physical activity. Despite that higher levels of physical activity are effective in reducing cardiovascular events, it is also advocated that vigorous exercise could acutely and transiently increase the risk of sudden cardiac death and myocardial infarction in susceptible persons. This issue may affect cardiac rehabilitation.

METHODS AND RESULTS

We examined the risk of cardiovascular events during organized high-intensity interval exercise training and moderate-intensity training among 4846 patients with coronary heart disease in 3 Norwegian cardiac rehabilitation centers. In a total of 175 820 exercise training hours during which all patients performed both types of training, we found 1 fatal cardiac arrest during moderate-intensity exercise (129 456 exercise hours) and 2 nonfatal cardiac arrests during high-intensity interval exercise (46 364 exercise hours). There were no myocardial infarctions in the data material. Because the number of high-intensity training hours was 36% of the number of moderate-intensity hours, the rates of complications to the number of patient-exercise hours were 1 per 129 456 hours of moderate-intensity exercise and 1 per 23 182 hours of high-intensity exercise.

CONCLUSIONS

The results of the current study indicate that the risk of a cardiovascular event is low after both high-intensity exercise and moderate-intensity exercise in a cardiovascular rehabilitation setting. Considering the significant cardiovascular adaptations associated with high-intensity exercise, such exercise should be considered among patients with coronary heart disease.

[Initial clinical experience of early cardiac rehabilitation for very elderly patients over 85 years old following open heart surgery]

In this study, we evaluated the initial clinical experience of early cardiac rehabilitation( CR) for very elderly patients over 85 years old after open heart surgery. From September 2007 to January 2011, 7 consecutive patients (85~90 years, mean 85.9 years, male:female=4:3) who underwent cardiac surgery in our institute were selected. Preoperative activity of daily living (ADL) scores were similar in all cases, and 1 patient used a cane for walking. Preoperative New York Heart Association (NYHA) classification was class III :3, class IV:4. Three patients were admitted for acute congestive heart failure approximately 1 month prior to surgery. Standard open heart surgery using bioprosthesis was performed: 3 patients underwent mitral valve replacement( MVR), 3 had aortic valve replacement( AVR), and 1 had tricuspid valve replacement (TVR). Postoperative clinical course was uneventful, and the mean time of ventilator support was 12.1 hours. Thereafter, early CR was introduced at the intensive care unit( ICU) in all patients, and the mean time of introduction of early rehabilitation was 1.7 days. In the last 4 cases, early CR was done the 1st day following surgery. CR was effectively performed in all cases without any problems or cardiac events, and all patients improved enough to leave their beds at 3~7 days, a mean of 4.4 days after surgery. The mean hospital stay after surgery was 30.9 days( 23 ~ 42 days), almost all patients were able to walk independently, and ADL scores at discharge were improved. Only 2 patients required a cane for walking. Postoperative NYHA classification was improved to class I :5, class II :2. From these results, early CR for very elderly patients over 85 years old could be a safe and effective tool to improve and maintain the ADL and quality of life following surgical intervention.

The improvement of walking speed after cardiac rehabilitation is associated with the reduction in the metabolic cost of walking in older persons

BACKGROUND

To walk a given distance older persons consume more metabolic energy than younger adults across all speeds. As physical activity interventions improve a variety of physical performance measures in older persons, including walking speed, in this study we hypothesized that the improvement of walking speed might be associated with the reduction of the metabolic cost of walking and we tested our hypothesis in a selected sample of older patients receiving cardiac rehabilitation.

METHODS

In 120 patients (88 men and 32 women, mean age 74.1 years±SD 5.0) we assessed energy expenditure during the 6-min Walk Test (6mWT) before and after the rehabilitation using a portable system for direct calorimetry.

RESULTS

On the 6mWT performed after the rehabilitation patients significantly increased total energy expenditure (28.0 kcal±SD 8.3 vs. 25.7 kcal±SD 7.6, p<0.001), the distance walked (398 m±SD 93 vs. 343 m±SD 95, p<0.001) and, consequently, walking speed (1.11 m/s±SD 0.26 vs. 0.95m/s±SD 0.26, p<0.001) while the metabolic cost of walking, i.e. the amount of energy used to move a body mass of 1 kg for a distance of 1m, was significantly reduced (1.00 cal/kg/m±SD 0.19 vs. 1.11 cal/kg/m±SD 0.32, p<0.001).

CONCLUSIONS

In older patients receiving cardiac rehabilitation the improvement of walking speed is associated with the improvement of walking economy. This might be a contributory factor to the favourable effects of physical activity interventions on physical performance measures.

The process of family management when a baby is diagnosed with a lethal congenital condition

The Family Management Style Framework (FMSF) was used as a conceptual basis for secondary data analysis of 55 previously conducted interviews with mothers and fathers of children with a lethal congenital condition from two surgical treatment eras. The directed content analysis was guided by a coding structure developed from family management dimensions identified in prior research of family response to childhood chronic conditions. Results indicated that application of the FMSF was helpful in differentiating families and their processes of family management at the onset of their infant's illness through to surviving the first surgery and going home. The dimensions of Illness View and Child Identity were central to the parents' capacity to manage their baby's illness demands within their family context. Applying a robust family framework to a complex neonatal condition at illness onset provides compelling direction for clinical interventions and their rigorous evaluation.

Creating a postoperative wellness model to optimize and enhance rapid surgical recovery

Rapid surgical recovery (RSR) is a bundle of multimodal, preventive, best and promising practices based on available evidence that simplify care and treatment processes. When performed together, the synergy has real potential for improving patient safety, quality care, and access. RSR is an aggressive, goal-directed, and outcome-driven approach that seeks to rapidly return patients to their functional baseline. This is achieved through humanizing, normalizing, preventive and restorative strategies designed to make patients feel remarkably well soon after surgery. Reimer-Kent's postoperative wellness model is a conceptual framework that provides strong support for attaining RSR. The results from program evaluations have demonstrated the positive impact of RSR on both the patient and the health care system. An overview of the model and the importance of RSR are provided in this article.

A pilot randomized trial of a smoking cessation nursing intervention in cardiac patients after hospital discharge

BACKGROUND

One fifth of Canadians are smokers despite the availability of community-based smoking cessation programs. It was hypothesized that offering a post-discharge smoking cessation program to cardiac patients would decrease smoking rates at six months.

METHOD

This pilot randomized study explored the feasibility, acceptability and preliminary efficacy of a smoking cessation intervention delivered by a smoking cessation nurse specialist (SCNS) to cardiac patients after hospital discharge.

SAMPLE

Participants (N=40) were randomized to either a postdischarge telephone intervention delivered weekly for the first month and then monthly until the third month (experimental group [EG]), or referral to usual community care (control group [CG]).

FINDINGS

The researchers confirmed the feasibility of recruitment and acceptability of the intervention, but dfficulty with follow-up. The intention-to-treat analysis showed similar smoking cessation rates in both groups at six months (25% EG versus 30% CG; p = 0.72).

CONCLUSION

An intensifed follow-up protocol, or a more intensive, comprehensive and multidisciplinary intervention might be required, given the characteristics of the smokers.

Critical illness hyperglycemia in pediatric cardiac surgery

Critical illness hyperglycemia (CIH) is common in pediatric and adult intensive care units (ICUs). Children undergoing surgical repair or palliation of congenital cardiac defects are particularly at risk for CIH and its occurrence has been associated with increased morbidity and mortality in this population. Strict glycemic control through the use of intensive insulin therapy (IIT) has been shown to improve outcomes in some adult and pediatric studies, yet these findings have sparked controversy. The practice of strict glycemic control has been slow in extending to pediatric ICUs because of the documented increase in the incidence of hypoglycemia in patients treated with IIT. Protocol driven approaches with more liberal glycemic targets have been successfully validated in general and cardiac critical care pediatric patients with low rates of hypoglycemia. It is unknown whether a therapeutic benefit is obtained by keeping patients in this more liberal glycemic control target. Definitive randomized controlled trials of IIT utilizing these targets in critically ill children are ongoing.

Adolescents with d-transposition of the great arteries corrected with the arterial switch procedure: neuropsychological assessment and structural brain imaging

BACKGROUND

We report neuropsychological and structural brain imaging assessments in children 16 years of age with d-transposition of the great arteries who underwent the arterial switch operation as infants. Children were randomly assigned to a vital organ support method, deep hypothermia with either total circulatory arrest or continuous low-flow cardiopulmonary bypass.

METHODS AND RESULTS

Of 159 eligible adolescents, 139 (87%) participated. Academic achievement, memory, executive functions, visual-spatial skills, attention, and social cognition were assessed. Few significant treatment group differences were found. The occurrence of seizures in the postoperative period was the medical variable most consistently related to worse outcomes. The scores of both treatment groups tended to be lower than those of the test normative populations, with substantial proportions scoring ≥1 SDs below the expected mean. Although the test scores of most adolescents in this trial cohort are in the average range, a substantial proportion have received remedial academic or behavioral services (65%). Magnetic resonance imaging abnormalities were more frequent in the d-transposition of the great arteries group (33%) than in a referent group (4%).

CONCLUSIONS

Adolescents with d-transposition of the great arteries who have undergone the arterial switch operation are at increased neurodevelopmental risk. These data suggest that children with congenital heart disease may benefit from ongoing surveillance to identify emerging difficulties.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000470.

Effect of the combination of music and nature sounds on pain and anxiety in cardiac surgical patients: a randomized study

BACKGROUND

Postoperative pain and anxiety are common in cardiac surgery patients. Studies have suggested that music can decrease anxiety in hospitalized patients. Primary Study Objective This study focused on the efficacy and feasibility of special music, which included nature sounds, for pain and anxiety.

METHODS/DESIGN

In this randomized controlled trial, postoperative cardiovascular surgery patients were randomly assigned to a music group to receive 20 minutes of standard postoperative care and music twice daily on postoperative days 2 through 4 or to a control group to receive 20 minutes of standard care with a quiet resting period twice daily on postoperative days 2 through 4.

SETTING

Cardiovascular surgical unit of Saint Marys Hospital, Rochester, Minnesota.

PARTICIPANTS

One hundred patients completed the study (music group, n = 49; control group, n = 51). Intervention The music was delivered through CD players in the patients' rooms.

PRIMARY OUTCOME MEASURES

Pain, anxiety, satisfaction, and relaxation were evaluated from visual analog scales.

RESULTS

Data showed a significant decrease in mean (SD) pain scores after the second session of day 2 for the music group (change, ?1.4 [1.4]) compared with the control group (change, ?0.4 [1.4]) (P = .001). Mean relaxation scores improved more at the first session of day 2 for the music group (change, 1.9 [2.7]) compared with the control group (change, 0.3 [2.9]) (P = .03). The music group also showed lower anxiety and increased satisfaction overall, but these differences were not statistically significant. No major barriers to using the therapy were identified.

CONCLUSION

Recorded music and nature sounds can be integrated into the postoperative care of cardiovascular surgery patients. The recordings may provide an additional means for addressing common symptoms of pain and anxiety while providing a means of relaxation for these patients.

Exercise capacity and the quality of life late after surgical correction of congenital heart defects

BACKGROUND

The long-term impact of surgical correction of congenital heart defects (CHD) on exercise capacity and quality of life (QoL) has not been well established.

AIM

To evaluate exercise capacity, QoL, physical activity and depression in young adult patients with a history of congenital heart defect surgery (GUCH) for simple left-to-right shunts, and to compare these parameters with those obtained in healthy volunteers.

METHODS

The study group consisted of 30 young adults with congenital heart defects (14 males, 16 females), aged 18-36 (mean 24.6) years who underwent corrective cardiac surgery at least 10 years earlier. The control group comprised 30 healthy students (15 males, 15 females), aged 21-28 (mean 24.4) years. We performed cardiopulmonary exercise testing on bicycle ergometer, QoL and physical activity tests, and depression inventory.

RESULTS

In young adult GUCH patients the exercise parameters were lower when compared to healthy peers. The Stanford questionnaire showed that physical activity was diminished as well as QoL in EuroQoL5 test. The Beck inventory showed more expressed depression in GUCH group.

CONCLUSIONS

The exercise capacity, physical activity and QoL of young adults with a history of surgical treatment of CHD are worse than observed in healthy peers, and the health status does not fulfil the definition of complete recovery.

Physical activity, sports participation and aerobic fitness in children who have undergone surgery for congenital heart defects

AIM

To investigate physical activity, sports participation and aerobic fitness in children who have undergone surgery for congenital heart defects.

SUBJECTS AND METHODS

Children who had undergone surgery for congenital heart defects and healthy controls in the Gothenburg area were invited to participate in the study. All participants were aged 9-11 or 14-16 years. The activity monitor ActiReg was used to assess physical activity. Participants were interviewed about their participation in sports and performed a maximal exercise test on a bicycle with measured oxygen uptake.

RESULTS

A total of 32 and 25 patients, and 61 and 45 controls, in the two age-groups were included, respectively. The patients had a wide range of severity of congenital heart defects. The physical activity level was similar in the patients and the controls. The rate of sports participation was high for both patients and controls; 80-94% of all participants took part in sports at least once a week. The majority of the patients were considered to have at least a moderate level of aerobic fitness.

CONCLUSIONS

Although children who have undergone surgery for congenital heart defects have a similar level of physical activity compared with that of healthy children, some of them may require support to participate in exercise and vigorous physical activity.

Long term results and functional outcomes following cardiac surgery in octogenarians

OBJECTIVE

Cardiac surgery for patients >80 years has seen a dramatic increase in the last decade. The aim was to assess the long term survival and quality of life in this patient population.

METHOD

Patients who underwent cardiac surgery between 1995 and 2007 were identified and case notes reviewed. Follow-up was undertaken by personal interview with the patient or the nearest kin to complete a pre-planned questionnaire.

RESULTS

Sixty six (M:F; 45:21) octogenarians had Coronary artery bypass grafting (CABG) only (55%), Aortic valve replacement (AVR) only (12%), Mitral valve replacement (MVR) only (3%), Valve and CABG (25%) and complex procedures (5%). Fifty-eight percent were elective procedures. Operative mortality was 8% (n = 5). Multivariate analysis identified complex procedures, prolonged bypass time and re-do/emergency surgery as predictors of death (p < 0.05). Median Intensive care unit (ICU) stay was 206 h (range 43-1176 h), with >70% leaving ICU in 72 h. Late mortality involved five patients (8%) who died at 10 yr; 7 yr; 3 yr; 1 yr; and 8 months; and 2 yr and 7 months, respectively. Survival by Kaplan-Meir was 8.8 yr (Standard Error (SE) = 0.66, Confidence interval (CI) 7.6-10.1), median survival was 10 yr and mean Barthel's index 17.7 (min 0, max 20).

CONCLUSIONS

Cardiac surgery can be accomplished in octogenarians with good long-term survival and quality of life. However, complex procedures, prolonged bypass and re-do/emergency surgery contribute significantly to mortality.

Relationship between exercise capacity, endothelial progenitor cells and cytochemokines in patients undergoing cardiac rehabilitation

No data are available about the possible role of endothelial progenitor cells (EPCs), cytochemokines and N-terminal pro-brain natriuretic peptide (NT-proBNP) in determining a different response to short period of cardiologic rehabilitation (CR), as measured by the improvement of exercise capacity. In a population of 86 cardiac surgery patients, we evaluated the numbers of EPCs, pro- and anti-inflammatory cytokines (IL-6, IL-8, IL-10, IL-1ra), hs-C-reactive protein (CRP), vascular endothelial growth factor (VEGF) and NT-proBNP before (T1), and after 15 days of CR (T2). EPCs were measured by flow cytometry, and the exercise capacity was measured at T1 and T2 by using the six-minute walk test (6MWT). At T2, a significant increase of 6MWT (p<0.0001) was detected. No significant increase of EPCs was observed, while a significant (at least p<0.05) decrease in cytochemokines, CRP and NT-ProBNP levels was evidenced. By analyzing the median improvement of 6MWT, only patients with a median improvement > or = 23% showed a significant (p<0.05) increase of EPCs at T2, with significant correlations between EPCs, VEGF and IL-10. On the contrary, in patients with a median improvement <23% a negative correlation between CRP and EPCs was observed. Finally, CD34+/KDR+ EPCs showed significant correlation with IL-8 at T1. In conclusion, a short period of CR intervention determines a different pattern of modifications for EPCs in relation to the improvement of exercise capacity.

Subjective usability of the CARDSS guideline-based decision support system

Clinical decision support systems (CDSSs) differ from other health information systems in their aim to directly influence the decision-making behaviour of healthcare professionals. As a result, CDSSs face additional challenges with respect to user acceptance. The objective of this study was to investigate subjective usability of a guideline-based CDSS for outpatient cardiac rehabilitation. The system, named CARDSS, was previously found to be effective in improving guideline adherence of rehabilitation professionals in a cluster randomized trial. To assess CARDSS' usability, a modified version of the IBM Computer System Usability Questionnaire was sent to all 68 professionals from the 28 outpatient clinics that participated in the trial. The questionnaire was returned by 63 respondents (93%) from 27 clinics. Factors that influenced CARDSS' usability were identified using linear regression analysis. Analysis showed that professionals who managed to smoothly integrate the system with their daily routine were more satisfied with ease of system use. Furthermore, a positive attitude of respondents towards CDSSs in general and a better agreement with the content of the national guidelines were positively correlated to satisfaction with CARDSS' overall usability and each of its sub-domains.

The 6-min walking test early after cardiac surgery. Reference values and the effects of rehabilitation programme

BACKGROUND

The 6-min walking test (6MWT) is a simple test, which does not require expensive equipment or advanced training. It has been used in heart failure patients to assess exercise tolerance, the effects of therapy and prognosis. Accordingly, post-surgical cardiac rehabilitation may be a potential field of application of this test.

MATERIALS AND METHOD

One thousand three hundred seventy patients (70% males, mean age 64+/-10 years), consecutively admitted for intensive cardiac rehabilitation, underwent 6MWT within 15 days after different types of cardiac surgery (67% coronary artery bypass graft (CABG), 25% valve replacement, 4% both, 4% other). The 6MWT was repeated in a subgroup of 348 patients after 15+/-3 days of an in-hospital cardiac rehabilitation programme.

RESULTS

6MWT (expressed as absolute value in metres and as a percentage of the predicted value) was well tolerated in all patients. The mean distance walked in 1370 patients was 304+/-89 m (corresponding to 58+/-15% of the predicted value). Distances walked were significantly shorter in older patients than younger (p<0.05) and in women compared to men (251+/-78 m, 53+/-15%, vs 328+/-34 m, 60+/-14%, p<0.001). Furthermore, the absolute distance walked in 6 min was significantly shorter in diabetics compared to non-diabetics (283+/-85 m vs 302+/-87 m, p=0.001) and in no CABG compared to CABG patients (285+/-91 m vs 303+/-84 m, p<0.001); no relation was found between distance walked and left ventricular ejection fraction (p=0.5). Gender, age, comorbidities and type of surgery were independently associated with 6MWT in the multivariate model. In the subgroup of patients repeating the 6MWT after the rehabilitation programme, the distance walked significantly increased (from 281+/-90 m, 51+/-76%, to 411+/-107 m, 77+/-81%, p<0.001). The extent of improvement observed was similar according to sex, age, presence/absence of diabetes and type of surgery.

CONCLUSIONS

Our data suggest that 6MWT is feasible and well tolerated in adult and older patients shortly after uncomplicated cardiac surgery and provides reference values for distance walked after cardiac surgery in this population.

Early and Late Rehabilitation and Physical Training in Elderly Patients After Cardiac Surgery

OBJECTIVE

Few randomized trials have enrolled patients who have undergone cardiac surgery, and even fewer have included patients aged 75 yrs or more. Furthermore, the optimal timing of cardiac rehabilitation for postsurgical patients has not yet been codified. The aim of this study was to verify whether rehabilitation outcomes are also favorable in postsurgical patients aged 75 yrs or more and whether an early rehabilitation program is as effective and safe as a late one.

DESIGN

Three hundred patients who underwent cardiac surgery, 27.7% of whom were at least 75 yrs old, were randomly assigned to a rehabilitation program starting within the second week after operation or within the fourth week. All events occurring during the rehabilitation program or in the following year were recorded.

RESULTS

During the rehabilitation program, new-onset atrial fibrillation was significantly more frequent in the early rehabilitation group, independent of age class, and anemia was significantly more frequent in older patients, independent of rehabilitation timing. At the end of the rehabilitation program, more than 90% of patients showed significant increases in walking distance, and during the follow-up, no significant difference was found with regard to mortality, nonfatal events, functional ability, or control of cardiovascular risk factors, independent of rehabilitation timing and age class.

CONCLUSIONS

This study provides evidence that in selected patients who have undergone cardiac surgery, rehabilitation outcomes are also favorable in patients aged 75 yrs or more, and an early rehabilitation program is as effective and safe as a traditionally late one.

The telephone interview is an effective method of data collection in clinical nursing research: A discussion paper

There are varying points of view regarding the advisability and utility of using the telephone to conduct research interviews. When undertaking the Women's Recovery from Sternotomy Study, we found the telephone was an effective mechanism for data collection. Our aim is to identify the advantages and challenges of using the telephone as a mechanism for data collection in clinical nursing research. The potential benefits associated with using telephone interviews as a mechanism of data collection include (a) using economic and human resources efficiently, (b) minimizing disadvantages associated with in-person interviewing, (c) developing positive relationships between researchers and participants, and (d) improving quality of data collection. The potential challenges to telephone interviewing include (a) maintaining participant involvement, (b) maintaining clear communication, (c) communicating with participants who offer extraneous information, (d) encountering participants with health concerns, and (e) communicating with a third party. Telephone interviewing can be an effective method of data collection when interviewers understand the potential benefits as well as challenges. We offer solutions to the identified challenges and make pragmatic recommendations to enhance researcher success based on the current literature and our research practice. Supportive training for interviewers, effective communication between interviewers and with research participants, and standardized telephone follow-up procedures are needed to ensure successful telephone data collection. We have found our 'Manual of Operations' to be an effective tool that assists research assistants to meet the requirements for successful telephone interviewing.