Predictors of Functional Decline in Activities of Daily Living at Discharge in Patients After Cardiovascular Surgery

Characteristics of cardiac rehabilitation progress during hospitalization and in-hospital outcomes after mitral transcatheter edge-to-edge repair

Mitral regurgitation is a prevalent cardiac valvular disease, and its incidence is increasing with the aging population. While surgical intervention has traditionally been the standard treatment for this disease, in Japan, mitral transcatheter edge-to-edge repair (M-TEER) has emerged as a less invasive alternative since 2018. M-TEER demonstrates promising outcomes in reducing postoperative complications and shortening hospital stays. However, scarce data on cardiac rehabilitation (CR) following M-TEER is available. Therefore, in this study, we aimed to investigate the characteristics of CR progress during hospitalization and in-hospital outcomes following M-TEER. This single-center, retrospective cohort study involved 244 patients who underwent M-TEER at the Sakakibara Heart Institute between April 2018 and March 2023. Data on progress in CR and in-hospital outcomes, including hospitalization-associated disability (HAD), rate of return to home, and hospitalization that extended beyond 30 days after M-TEER, were collected. After excluding patients who met the exclusion criteria-including conversion to surgical mitral valve replacement or the absence of CR during hospitalization-233 patients were included in the analysis. The patients' median age was 81 years, with 48.5% being female. In 43% of cases, the hospitalizations were unplanned. Ambulation was initiated at a median of 1 day after M-TEER, with 88.4% of patients being able to commence ambulation as early as 2 days after M-TEER. However, only 19.3% engaged in aerobic exercise using equipment in the CR room. The median length of stay following M-TEER was 6 days, with 4.7% of hospitalizations resulting in a stay of 30 days or more. Ultimately, 90.6% of patients were discharged home, with an incidence of HAD of 9.9%. Compared to the planned hospitalization group, the unplanned hospitalization group had a significantly lower rate of early postoperative ambulation (planned hospitalization group: 97.7% vs. unplanned hospitalization group: 76.2%, p < 0.01), a higher proportion of patients with hospital stays exceeding 30 days (0% vs. 10.9%, p < 0.01), a lower rate of home discharge (98.5% vs. 80.2%, p < 0.01), and an increased incidence of HAD (0.8% vs. 22.2%, p < 0.01). M-TEER provides a minimally invasive treatment option for mitral regurgitation with favorable early rehabilitation and in-hospital outcomes, particularly in planned hospitalization. However, for unplanned hospitalizations, inpatient outcomes were poor.

Predictors of frailty after cardiovascular surgery and the relationship between frailty and postoperative recovery: A cross-sectional study

AIM

To investigate the factors affecting postoperative frailty and the relationship between frailty and postoperative recovery in patients undergoing cardiovascular surgery.

DESIGN

The study was descriptive, cross-sectional, and predictive.

METHODS

Data were collected by researchers in a university research and application hospital cardiovascular surgery inpatient clinic between March 2022 and March 2023. Sociodemographic-Clinical Characteristics Form, Comorbidity Index, Edmonton Frail Scale, Postoperative Recovery, and Nutritional Risk Screening were used to collect the data.

RESULTS

Of the 145 patients included in the study, 65.51% (n = 95) were male and the mean age was 62.02 ± 10.16 years. While frailty was not found to be significant by age group, it was found that women had more comorbidities and were more frail than men. It was found that 17.2% (n = 25) of patients had a history of falls before surgery, 26.2% (n = 38) had a fear of falling after surgery and 17.24% (n = 25) had rehospitalisations. While postoperative recovery index predicted fraility by 34% in patients undergoing cardiovascular surgery; general symptoms and psychological symptoms, which are the sub-dimensions of the postoperative recovery index and comorbidity and, fear of falling after surgery predicted frailty by 61%. The order of importance of variables on fraility: general symptoms (β = 0.297), fear of falling (β = 0.222), psychological symptoms (β = 0.218), Charlson Comorbidity Index (β = 0.183).

PATIENT OR PUBLIC CONTRIBUTION

This study clarifies the role of frailty as an important factor influencing the recovery process in patients undergoing cardiovascular surgery. The findings show that frailty has a determining effect on postoperative recovery in these patients. Among the factors affecting frailty status, comorbidities, fear of postoperative falls, and postoperative general and psychological symptoms were found to contribute. These findings emphasise that these factors should be taken into account when assessing and managing the postoperative recovery process. Understanding these factors that influence postoperative frailty is crucial for patient care. Recognising the multifaceted nature of frailty, personalised interventions are needed to improve patient care and postoperative outcomes. Personalised interventions are particularly important for older women with multiple comorbidities, as they are more likely to be frail.

Exploring frailty: muscle strength, functional capacity, activities of daily living and cognition in adult congenital heart disease

PURPOSE

The study aimed to assess frailty in adults with congenital heart disease (ACHD) and to compare muscle strength, functional capacity, activities of daily living (ADL), and cognition between frail and non-frail ACHD patients.

MATERIALS AND METHODS

A cross-sectional study design was used. Sixty people with ACHD aged between 18 and 45 years were included. Frailty was determined according to the Fried criteria. Peripheral muscle strength was assessed with a digital dynamometer, functional capacity with the 6-min walk test (6MWT), ADL with the Glittre ADL test, and cognition with the Montreal Cognitive Assessment (MoCA) test.

RESULTS

Frailty was seen in 38.33% (frail = 23 and non-frail = 37) of the participants. In the frail patients, dominant knee extensor strength (p = 0.002), shoulder abductor strength (p = 0.005), 6MWT distance (p = 0.021), and MoCA score (p = 0.005) were significantly lower than those in the non-frail patients. Glittre ADL test (p = 0.002) was significantly higher in the frail patients.

CONCLUSIONS

Muscle strength, functional capacity, ADL, functional mobility, and cognition were lower in the frail participants with ACHD. Early assessment of frailty in ACHD and planning individualized exercise training programs for frail individuals may be a strategy to reduce the impact of frailty on adverse clinical outcomes.

Examination of factors related to the performance index of patients with cardiovascular disease in a convalescent rehabilitation hospital

Fujii D, Morisawa T, Yamamoto S, Matsuo T, Nyuba K, Maehata M, Iwaki H, Iwata K, Saitoh M, Endo M, Takahashi T. Examination of factors related to the performance index of patients with cardiovascular disease in a convalescent rehabilitation hospital. Jpn J Compr Rehabil Sci 2024; 15: 63-70.

Objective

The purpose of this study was to identify the characteristics of patients with cardiovascular disease who received cardiac rehabilitation (CR) at a convalescent rehabilitation hospital (rehabilitation hospital) after treatment at an acute-care hospital and whose performance index was 40 or higher.

Methods

A total of 43 patients with cardiovascular disease were admitted to two rehabilitation hospitals. Based on the performance index, which is an indicator of the effectiveness of rehabilitation in rehabilitation hospitals, patients were classified into two groups: a "high-performance index group" (performance index of 40 or higher) and a "low-performance index group" (performance index of less than 40). We then compared the patient characteristics of the two groups.

Results

The high-performance group accounted for 62.8% of the total. Compared to patients in the low-performance group, high-performers were significantly younger at the time of admission to the rehabilitation hospital and had significantly higher physical function and exercise tolerance. The results of the effect size measurement showed that the effect size was 0.98 and 0.93 on the Short Physical Performance Battery (SPPB) at admission to the rehabilitation hospital and on the pre-illness Kihon checklist, respectively, which were related to the achievement of the performance index.

Conclusions

This study suggests that the SPPB at admission to a rehabilitation hospital and the pre-illness Kihon checklist are associated with obtaining a performance index of 40 or higher in patients with cardiovascular disease.

Characteristics of longitudinal changes in quality of life and associated factors in patients post cardiac and thoracic aortic surgery: insights from a prospective cohort study

BACKGROUND

Although quality of life (QOL) is an outcome of postoperative cardiac rehabilitation (CR), its course and related factors from postoperative hospitalization to the post-discharge period have not been adequately investigated. Additionally, the EuroQol-5Dimension-5Level (EQ-5D-5L) index score has not been characterized over the same period. We aimed to characterize QOL changes assessed by the EQ-5D-5L, over the period from hospitalization to 1 year post-discharge, in patients post-cardiac and thoracic aortic surgery, and investigate the factors associated with these temporal changes.

METHODOLOGY

This prospective, single-center study included 117 patients who underwent open cardiovascular surgery (median age, 72 years; men, 69%). Patients were assessed for QOL status when transferred to the general ward; at discharge; and at 6 and 12 months after discharge, using the EQ-5D-5L index score and a generalized linear mixed model with random intercepts. Patients were classified into two groups based on score changes post-discharge. Logistic regression analysis evaluated factors associated with QOL decrease post-discharge.

RESULTS

The EQ-5D-5L index score significantly increased over time, except between 6 and 12 months post-discharge; "Common activities" was the most common dimension showing score improvement. In 25 patients (21%), the EQ-5D-5L index scores were lower after discharge compared to their scores at discharge. In the logistic regression analysis, Barthel Index pre-admission, preoperative hemoglobin level, and Mini-Mental State Examination-Japanese scores pre-discharge were significantly associated with QOL decline after adjusting for the European System for Cardiac Operative Risk Evaluation II score.

CONCLUSIONS

Most patients post-cardiac or thoracic aortic surgery experienced improved QOL from postoperative hospital stay to 1 year post-discharge. However, in patients with pre-operative basic activities of daily living, hemoglobin and post-operative cognitive decline may require ongoing comprehensive CR because of reduced QOL. Given the potential selection bias introduced by the relatively small sample size in this study, future research involving larger populations is necessary.

Predictors of postoperative physical functional decline at hospital discharge in elderly patients with prolonged intensive care unit stay after cardiac surgery

BACKGROUND

A prolonged stay in the intensive care (ICU) is associated with physical function decline following cardiac surgery. To predict physical function decline after cardiac surgery, it may be important to evaluate physical function in the ICU.

OBJECTIVES

This study aimed to determine that physical function examination at ICU discharge was independently associated with physical functional decline at hospital discharge in elderly patients who had undergone cardiac surgery and prolonged the ICU stay.

METHODS

We assessed physical function before and after cardiac surgery in elderly patients who had spent ≥72 h in the ICU in this retrospective cohort study using the short physical performance battery (SPPB). At hospital discharge, a decrease of at least 1 point on the SPPB was considered a postoperative physical functional decline. Postoperative physical functional decline at hospital discharge was predicted using multiple logistic regression.

RESULTS

We revealed postoperative physical functional deterioration in 28.0% of patients who spent ≥72 h in the ICU following cardiac surgery. The Medical Research Council sum score (MRC-SS) (OR: 0.96, 95% CI: 0.82-0.99) and mechanical ventilation days (OR: 1.27, 95% CI: 1.01-1.64) were independently associated with physical functional decline at hospital discharge.

CONCLUSIONS

Physical function at ICU discharge and mechanical ventilation days were predictors of postoperative physical functional decline at hospital discharge in patients. MRC-SS was more accurate in predicting postoperative physical functional decline at hospital discharge when performed at the time of ICU discharge.

Association between Hospital-acquired Disability and Clinical Outcomes in Older Patients Who Underwent Cardiac Surgical

OBJECTIVE

This study aimed to clarify the association between hospital-acquired disability (HAD) and prognosis in older patients who underwent cardiac surgery.

METHODS

This single-center, retrospective, observational study included 141 patients aged ≥65 years who underwent cardiac surgery at our hospital from November 2016 to August 2021. The primary endpoint of this study was the occurrence of major adverse cardiac and cerebrovascular events (MACCEs) within 2 years of hospital discharge. HAD was defined as a score of ≤5 on any one of the functional independence measure (FIM) subitems at discharge compared to preoperatively.

RESULTS

MACCE was observed in 16.3%, and the incidence of MACCE was significantly higher in the HAD group than that in the non-HAD group (12.1 vs. 34.5%, log-rank, p = 0.003). HAD was also significantly associated with the MACCE (hazard ratio [HD]: 2.575, 95% confidence interval [CI]: 1.001-9.655, p = 0.046). The incidence rate of HAD was 20.6%, with age (odds ratio [OR]: 1.260, 95% CI: 1.080-1.470, p = 0.004), preoperative short physical performance battery (SPPB) score (OR: 0.462, 95% CI: 0.301-0.708, p <0.001), and postoperative delirium (OR: 6.660, 95% CI: 1.480-30.000, p = 0.014) identified as significant factors.

CONCLUSION

HAD is an independent predictor of MACCE in older patients who underwent cardiac surgery.

Exploring the Frailty Components Related to Hospitalization-Associated Disability in Older Patients After Cardiac Surgery Using a Comprehensive Frailty Assessment

BACKGROUND

We investigated the components of frailty associated with hospitalization-associated disability (HAD) after cardiac surgery.

METHODS AND RESULTS

This retrospective, observational study evaluated 1,446 older patients after elective cardiac surgery at the Sakakibara Heart Institute. We examined the association between HAD and 7 domains of frailty assessed by the Kihon Checklist. HAD was defined as a decline in the ability to perform activities of daily living (ADL) between admission and discharge, as assessed by the Barthel Index. Logistic regression and decision tree analysis were used to identify associations between the number and type of frailty components and HAD. Of the 1,446 patients, 190 were excluded, and 90 (7%) developed HAD. An increase in the number of frailty components was a risk factor for HAD (odds ratio: 1.88, 95% confidence interval: 1.62-2.17). Decision tree analysis identified physical functional decline, depression, and cognitive dysfunction as factors associated with HAD. The incidence of HAD was highest in cases of physical functional decline (21%) and lowest for cases in which the 3 aforementioned factors were absent (2.8%).

CONCLUSIONS

An increased number of frailty factors increased the risk of HAD and the findings also reaffirmed the importance of a comprehensive assessment to evaluate the risk of HAD, including evaluation of physical function, cognitive function, and depression.

Utility of Cardiac Rehabilitation for Long-Term Outcomes in Patients with Hospital-Acquired Functional Decline after Cardiac Surgery: A Retrospective Study

Hospital-acquired functional decline is an important outcome that affects the long-term prognosis of patients after cardiac surgery. Phase II cardiac rehabilitation (CR) for outpatients is expected to improve prognosis; however, this is not clear in patients with hospital-acquired functional decline after cardiac surgery. Therefore, this study evaluated whether phase II CR improved the long-term prognosis of patients with hospital-acquired functional decline after cardiac surgery. This single-center, retrospective observational study included 2371 patients who required cardiac surgery. Hospital-acquired functional decline occurred in 377 patients (15.9%) after cardiac surgery. The mean follow-up period was 1219 ± 682 days in all patients, and there were 221 (9.3%) cases with major adverse cardiovascular events (MACE) after discharge during the follow-up period. The Kaplan-Meier survival curves indicated that hospital-acquired functional decline and non-phase II CR was associated with a higher incidence of MACE than other groups (log-rank, p < 0.001), additionally exhibiting prognosticating MACE in multivariate Cox regression analysis (HR, 1.59; 95% CI, 1.01-2.50; p = 0.047). Hospital-acquired functional decline after cardiac surgery and non-phase II CR were risk factors for MACE. The participation in phase II CR in patients with hospital-acquired functional decline after cardiac surgery could reduce the risk of MACE.

Factors Determining the Functional State of Cardiac Surgery Patients with Complicated Postoperative Period

The purpose of this work was to study the factors determining the functional state of cardiac surgery patients with a complicated postoperative period upon discharge from the hospital. This observational study included 60 patients who underwent cardiac surgery with a complicated postoperative course and with a prolonged intensive care unit stay of more than 72 h. We assessed handgrip and lower-extremity muscle strength and the six-minute walk test (6MWT) distance 3 days after the surgery and at discharge from the hospital. Some patients (53%) additionally underwent a course of neuromuscular electrostimulation (NMES). Two groups of patients were formed: first (6MWT distance at discharge of more than 300 m) and second groups (6MWT distance of 300 m or less). The patients of the second group had less lower-extremity muscle strength and handgrip strength on the third postoperative day, a longer aortic clamping time and a longer stay in the intensive care unit. Independent predictors of decreased exercise tolerance at discharge were body mass index, foot extensor strength and baseline 6MWT distance in the general group, duration of cardiopulmonary bypass in the NMES group and in the general group, and age in the NMES group. Thus, the muscle status on the third postoperative day was one of the independent factors associated with the 6MWT distance at discharge in the general group, but not in patients who received NMES. It is advisable to use these results in patients with complications after cardiac surgery with the use of NMES rehabilitation.