Cardiac rehabilitation outcome after transcatheter aortic valve implantation

Cardiac Rehabilitation in TAVI Patients: Safety and Benefits: A Narrative Review

Transcatheter aortic valve implantation (TAVI) has redefined the management of severe aortic stenosis, particularly in surgical high-risk patients. As the number of TAVI procedures increases, there is a growing need for effective post-procedural care. Cardiac rehabilitation (CR) has emerged as a critical component of treatment in these patients. The most recent update of the European recommendations highlights the importance of including post-TAVI patients in CR programs. However, the benefits of CR in this particular patient group still need to be fully understood. The objective of this narrative review is to summarize the safety and benefits of post-TAVI CR by evaluating its impact on functional capacity, frailty, muscular strength, mental health, quality of life, and long-term survival. While emerging evidence supports its safety and effectiveness in the aforementioned outcomes, gaps remain regarding the optimal rehabilitation protocols, including the timing, duration, and intensity of CR as well as its long-term cardiovascular benefits. Further research is needed to develop personalized approaches for different patient groups. This article highlights the current knowledge, identifies critical gaps, and underlines the need for tailored rehabilitation strategies to improve post-TAVI recovery and patient outcomes.

Impact of in-hospital cardiac rehabilitation on hospital-associated disability after transcatheter aortic valve implantation

BACKGROUND

Hospital-associated disability (HAD), a decline in the ability to perform activities of daily living (ADL) during hospitalization, is a modifiable target in integrated care for older adults. The aim of this study was to determine the impact of inpatient cardiac rehabilitation (CR) on the development of HAD in older patients with aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).

METHODS

Older patients undergoing TAVI were extracted from the Japanese nationwide database (JROAD-DPC) from April 2014 to March 2021 and were divided into patients receiving inpatient CR (CR group) and a non-CR group. HAD was defined as a decrease in the Barthel Index (BI) score ≥5 points at discharge compared with the score at admission.

RESULTS

Of 19,789 eligible patients, 17,066 (86%) underwent inpatient CR. The overall prevalence of HAD was 9.6%, with a lower incidence in the CR group than in the non-CR group (8.8% vs. 14.2%, p < 0.001). Random forest analysis revealed key features associated with HAD risk including BI score at admission, inpatient CR participation, age, body mass index (BMI), and chronic kidney disease. The results of multivariate logistic regression analysis showed that participation in inpatient CR was associated with a lower odds ratio (OR) of HAD (OR, 0.62; 95% confidence interval, 0.54-0.70), with similar results in inverse probability of treatment weighting-adjusted logistic regression analyses (OR, 0.82; 95% confidence interval, 0.77-0.88). Analyses in subgroups of interest showed heterogeneity in the effects of inpatient CR with possible loss in patients with a BMI of <18.5 kg/m2 or a BI score of less than 60 points at admission.

CONCLUSIONS

The data suggest a beneficial effect of inpatient CR participation on the prevention of HAD in older patients undergoing TAVI, but the effect may be limited in lean patients with disability for ADL before TAVI.

Comprehensive geriatric assessment, and related interventions, to improve outcomes for older patients undergoing transcatheter aortic valve implantation (TAVI): a systematic review

INTRODUCTION

Transcatheter aortic valve implantation (TAVI) is a treatment for people with severe symptomatic aortic stenosis, particularly those living with frailty. Increasing frailty is associated with poorer outcomes post-TAVI. Comprehensive Geriatric Assessment (CGA) has been shown in other settings to improve outcomes in those with frailty, including perioperatively. This systematic review aims to determine whether CGA, or interventions targeting its components, improves outcomes for older people undergoing TAVI.

METHODS

EMBASE, MEDLINE, CINAHL and Cochrane CENTRAL were searched on 09/01/23 and then the search was rerun on the 16/04/24. The review was registered on PROSPERO (CRD42022299955). Included studies had to evaluate either CGA, or a single- or multi-domain intervention targeting components of CGA, in those aged ≥ 65.

RESULTS

From 4091 papers, 24 met the inclusion criteria. Two studies assessed CGA pre-TAVI and reported mixed improvements in functional independence but no change in length of stay or post-operative delirium, although both studies had a serious risk of bias. Fifteen papers described an exercise-based intervention, and 1 paper detailed a Cognitive Behavioural Therapy-based intervention. Seven studies evaluated a multi-component intervention. There were conflicting results reported for the multi-component and single-component interventions. All studies had at least a moderate risk of bias.

CONCLUSION(S)

There is a lack of evidence to determine whether CGA, or related interventions, improve outcomes for older adults undergoing-TAVI. The evidence for perioperative CGA, and the results of this review, support the need for well-designed trials evaluating whether CGA improves outcomes post-TAVI for older adults living with frailty.

Impact of cardiac rehabilitation on pre- and post-operative transcatheter aortic valve replacement prognoses

Transcatheter aortic valve replacement (TAVR) is a relatively new treatment method for aortic stenosis (AS) and has been demonstrated to be suitable for patients with varying risk levels. Indeed, among high-risk patients, TAVR outcomes are comparable to, or even better, than that of the traditional surgical aortic valve replacement (SAVR) method. TAVR outcomes, with respect to post-surgical functional capacity and quality of life, have also been found to be improved, especially when combined with cardiac rehabilitation (CR). CR is a multidisciplinary system, which integrates cardiology with other medical disciplines, such as sports, nutritional, mind-body, and behavioral medicine. It entails the development of appropriate medication, exercise, and diet prescriptions, along with providing psychological support, ensuring the cessation of smoking, and developing risk factor management strategies for cardiovascular disease patients. However, even with CR being able to improve TAVR outcomes and reduce post-surgical mortality rates, it still has largely been underutilized in clinical settings. This article reviews the usage of CR during both pre-and postoperative periods for valvular diseases, and the factors involved in influencing subsequent patient prognoses, thereby providing a direction for subsequent research and clinical applications.

Exercise-Based Real-time Telerehabilitation for Older Adult Patients Recently Discharged After Transcatheter Aortic Valve Implantation: Mixed Methods Feasibility Study

BACKGROUND

The use of telehealth technology to improve functional recovery following transcatheter aortic valve implantation (TAVI) has not been investigated.

OBJECTIVE

In this study, we aimed to examine the feasibility of exercise-based cardiac telerehabilitation after TAVI.

METHODS

This was a single-center, prospective, nonrandomized study using a mixed methods approach. Data collection included testing, researchers' observations, logbooks, and individual patient interviews, which were analyzed using a content analysis approach. The intervention lasted 3 weeks and consisted of home-based web-based exercise training, an activity tracker, a TAVI information website, and 1 web-based session with a nurse.

RESULTS

Of the initially included 13 patients, 5 (40%) completed the study and were interviewed; the median age was 82 (range 74-84) years, and the sample comprised 3 men and 2 women. Easy access to supervised exercise training at home with real-time feedback and use of the activity tracker to count daily steps were emphasized by the patients who completed the intervention. Reasons for patients not completing the program included poor data coverage, participants' limited information technology skills, and a lack of functionality in the systems used. No adverse events were reported.

CONCLUSIONS

Exercise-based telerehabilitation for older people after TAVI, in the population as included in this study, and delivered as a web-based intervention, does not seem feasible, as 60% (8/13) of patients did not complete the study. Those completing the intervention highly appreciated the real-time feedback during the web-based training sessions. Future studies should address aspects that support retention rates and enhance patients' information technology skills.