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.

[Return to work in patients with heart disease after cardiac rehabilitation]

BACKGROUND

Cardiac rehabilitation is a secondary prevention strategy which it includes a set of activities that would assure cardiac patients a place as normal as it could be into the society, being also essential for going back to work, by improving their quality of life and reducing costs for institutions.

METHODS

A non-randomized clinical study was conducted at the "Siglo XXI" Cardiology Hospital; We included patients with the diagnosis of ischemic heart disease and/or valve disease, the response variables were: percentage of patients going back to work and disability time upon return to duty. Cardiac rehabilitation program was applied for 1 month and followed up at 2 months and 1 year.

RESULTS

Two groups were formed, the ones who received cardiac rehabilitation, N = 40 (experimental group) against a control group, N = 25. The percentage of patients going back to work with a cardiac rehabilitation was 75 % versus 60 % of the group did not receive cardiac rehabilitation, p = 0.2, with a mean of 68 days of disability in the experimental group against 128 in the control group, p = 0.001.

CONCLUSIONS

The experimental group showed a higher percentage of patients who returned to work, working time reentry (in days) was lower compared to the control group.

[SURGICAL TREATMENT OF ELDERLY AND SENILE PATIENTS FOR AFFECTION OF CARDIAC VALVES]

Operations on the open heart, of them in 62 (32.9%)--the valves prosthesis, were conducted on the base of Clinical Treatment-Diagnosis Centre "Simedgroup" of Ivano-Frankivskiy National Medical University in 2012 - 2015 yrs in 188 patients. Hemodynamically significant failures of a mitral valve and/or the aortal valve were considered as indications for the operative treatment conduction. Combined surgical treatment--the valve prosthesis and coronary shunting--were conducted in coincident ischemic heart disease. More durable rehabilitation is needed for elderly and senile patients.

Protocol for the PREHAB study-Pre-operative Rehabilitation for reduction of Hospitalization After coronary Bypass and valvular surgery: a randomised controlled trial

INTRODUCTION

Frailty is a geriatric syndrome characterised by reductions in muscle mass, strength, endurance and activity level. The frailty syndrome, prevalent in 25-50% of patients undergoing cardiac surgery, is associated with increased rates of mortality and major morbidity as well as function decline postoperatively. This trial will compare a preoperative, interdisciplinary exercise and health promotion intervention to current standard of care (StanC) for elective coronary artery bypass and valvular surgery patients for the purpose of determining if the intervention improves 3-month and 12-month clinical outcomes among a population of frail patients waiting for elective cardiac surgery.

METHODS AND ANALYSIS

This is a multicentre, randomised, open end point, controlled trial using assessor blinding and intent-to-treat analysis. Two-hundred and forty-four elective cardiac surgical patients will be recruited and randomised to receive either StanC or StanC plus an 8-week exercise and education intervention at a certified medical fitness facility. Patients will attend two weekly sessions and aerobic exercise will be prescribed at 40-60% of heart rate reserve. Data collection will occur at baseline, 1-2 weeks preoperatively, and at 3 and 12 months postoperatively. The primary outcome of the trial will be the proportion of patients requiring a hospital length of stay greater than 7 days.

POTENTIAL IMPACT OF STUDY

The healthcare team is faced with an increasingly complex older adult patient population. As such, this trial aims to provide novel evidence supporting a health intervention to ensure that frail, older adult patients thrive after undergoing cardiac surgery.

ETHICS AND DISSEMINATION

Trial results will be published in peer-reviewed journals, and presented at national and international scientific meetings. The University of Manitoba Health Research Ethics Board has approved the study protocol V.1.3, dated 11 August 2014 (H2014:208).

TRIAL REGISTRATION NUMBER

The trial has been registered on ClinicalTrials.gov, a registry and results database of privately and publicly funded clinical studies (NCT02219815).

Obesity dilemma in the global burden of cardiovascular diseases

AIM

Obesity is a well-known risk factor in the cardiovascular disease continuum. However, its clinical effects are multimodal, perplexed and non-unanimously understood. Our aim was to assess the prevalence and effects of obesity on the cardiometabolic risk factors and systolic function of left ventricle ejection fraction (LVEF) in patients scheduled for cardiovascular rehabilitation.

METHODS

A cohort of 302 consecutive patients recently treated for ischaemic or valvular heart disease was matched according to the existence of obesity, defined with body mass index (BMI ≥ 30 kg/m(2) ; n = 90 vs. 212), and the advanced grade of obesity (BMI ≥ 35 kg/m(2) ; n = 19 vs. 283). Nutritional risk screening was performed using the standardised NRS-2002 tool.

RESULTS

The mean age of patients was 62.4 ± 11.2 (range 23-86) years; there were more men than women 244 (80.8%) : 58 (19.2%). Group of obese conveyed higher prevalence of ischaemic heart disease than non-obese (OR = 2.69; 95% CI: 1.01-7.20; p = 0.048); while the difference was insignificant for the advanced grade of obesity (n = 17; 89.5%) vs. controls (n = 233; 82.3%; p > 0.05). There was no significant difference in prevalence of other comorbidities (diabetes, glucose intolerance, hypercholesterolaemia, chronic renal and chronic obstructive pulmonary disease) between studied groups (p > 0.05). Utilisation of lipid-lowering drugs was of similar range between the studied groups (p > 0.05), respectively. LVEF (%) was 50.5 ± 8.2 vs. 50.7 ± 7.7 (p > 0.05) and 50.6 ± 7.8 vs. 49.6 ± 10.9 (p > 0.05; Rho = 0.001; p > 0.05), respectively.

CONCLUSION

In studied set of patients, BMI positively correlated with left ventricle dimension and thickness. No significant connection of obesity was found with the prevalence of chronic comorbidities, increased nutritional risk, laboratory diagnostics or systolic function of left ventricle. Existence of obesity paradox in clinical practice was in part reaffirmed with our study.

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.

[Efficacy of the education program in the improvement of treatment compliance in patients with artificial heart valves]

The study included 94 patients with artificial heart valves aged 55.5 +/- 68 years including 47 (50%) with rheumatic heart diseases, 26 (27.7%) with infectious endocarditis, 21 (22.3%) with connective tissue dysplasia. Compliance with the treatment was estimated by the method of S.V. Davydov before and after education. The leading causes of poor compliance was insufficient socio-medical knowledge and dissatisfaction with the prescribed therapeutic regimen. The education program permitted to achieve a 3-fold decrease in the incidence of negative factors affecting compliance and 1.5-fold increase in the frequency of positive factors; socio-medical awareness and satisfaction with the prescribed treatment increased by 45.8% and 37.1% respectively (p < 0.05). The integral index of compliance before education +4.39 +/- 0.09 characterized it as a moderately positive one. It increased to +8.11 +/- 1.23 after education (p < 0.01). It is concluded that the education program based on the principle of continuity of in- and out-patient treatment improved compliance and socio-medical awareness of the patients, promoted their medico-social adaptation, increased satisfaction with the prescribed treatment and its outcome.

[Major epidemiological changes and clinical variables in patients undergoing a program of heart rehabilitation after cardiac surgery - MEPHISTOPHELES]

BACKGROUND

Recent observational studies show an increase of more complex and critically ill patients referred to Italian cardiac rehabilitation (CR) departments; the exact mechanisms underlying this phenomenon, however, have not been clearly identified. The aim of our study was to evaluate the epidemiological and clinical changes that occurred over the last decade in patients hospitalized in CR departments with high admittance rates.

METHODS

We have retrospectively evaluated all patients admitted between 2002 and 2009 to our division of CR (n = 3340, 1155 female, mean age 66.4 ± 11 years) after recent cardiac surgery. The study population was divided into two homogeneous groups: the four-year period 2002-2005, group A (n = 1614, 540 female, mean age 66.1 ± 10 years) and the four-year period 2006-2009, group B (n = 1726, 615 female, mean age 67.4 ± 11 years). Data were compared using specific indicators of clinical complexity.

RESULTS

Patients aged >75 years were more in group B compared to A (26.3 vs 19.8%, p<0.0001), as well as patients with recent complex surgical interventions, such as combined coronary artery bypass grafting and heart valve surgery (16.4 vs 10.2%, p<0.0001). An increased incidence of cardiovascular death (1.4 vs 0.6%, p=0.02), acute coronary syndrome (1.5 vs 0.7%, p=0.02) and persistent atrial fibrillation/flutter (13.5 vs 7.1%, p<0.0001) was observed in group B, as well as an increased prevalence of systolic heart failure (18.3 vs 9.0%, p<0.0001). Similarly, the incidence of acute respiratory failure episodes (1.0 vs 0.4%, p=0.05), the prevalence of patients admitted with a tracheostomy tube (2.6 vs 0.2%, p<0.0001) and the incidence of acute renal failure (1.1 vs 0.5%, p=0.05) were significantly increased in group B. Postoperative infections and surgical wound complications were 4-fold higher in group B (13.9 vs 3.1%, p<0.0001, and 12.8 vs 2.3%, p<0.0001, respectively). Compared to group A, patients of group B showed a significantly lower physical performance, as expressed by the Rivermead motility index (3.8 ± 1.1 vs 5.2 ± 0.8, p<0.001); moreover, the number of subjects able to perform an incremental training program was significantly lower in group B than group A (14.8 vs 60.6%, p<0.0001). Mean hospital stay was longer in group B than group A (25.4 ± 13 vs 22.1 ± 9 days, p<0.001).

CONCLUSIONS

Our study, by collecting data from a CR division in northern Italy with high admittance rates, demonstrates a dramatic increase in clinical complexity over the last few years. This points to the need for new expertise and major resources to be allocated to CR departments.

[The programme of managed ambulatory rehabilitation for patients after heart valve defect surgery]

THE AIM of our research was to evaluate the impact of 8-week comprehensive rehabilitation programme on circulatory parameters, left ventricular (LV) function and functional capacity of patients after aortal (ao) and mitral (mi) heart defect surgery.

PATIENT SAMPLE AND METHODOLOGY

The rehabilitation programme was completed by 54 patients (exercising, RHB+) following valve defect surgery (13 women/41 men), aged 27-83 (56 +/- 16) years. The majority were patients with aortal (ao) stenosis (39), the remainder had a combined ao defect (7), ao regurgitation (3) or mitral (mi) regurgitation (5). Myocardial revascularisation was concomitantly performed in 18 patients. There were 18 patients in the control group (non-exercising, RHB-). Patients from both groups were assessed before and after the rehabilitation with exercise echocardiography and spiroergometry to the individual maximum. The intervention group underwent the managed rehabilitation programme. The control group exercised individually.

RESULTS

Reduction of the heart rate (HR) values at rest and on exercise and of the systolic and diastolic blood pressure (sBP, dBP) was observed in the exercising group. However, these changes were not statistically significant. The systolic, diastolic and global LV function parameters showed improvement although, once again, not statistically significant. Highly significant improvement in exercise tolerance (1.41 W/kg before and 1.67 W/kg after, p < 0.01) and peak oxygen consumption (20.0 ml/min/kg before and 23.6 ml/min/kg after, p < 0.01) were observed in the exercising patients. Improvement in functional and aerobic capacity in the control group was not statistically significant. The resting and exercise parameters (SF, sBP, dBP) have not changed either.

CONCLUSION

The ambulatory rehabilitation programme was associated with improvement in circulatory response to exercise together with reduction in resting and exercise SF, sBP a dBP values. Tendency towards improvement in systolic, diastolic and global LV function parameters was observed even though not statistically significant in our sample. Unlike control group, the exercising group showed significant increase in exercise tolerance and aerobic capacity (p < 0.01). Managed rehabilitation programme enabled evaluation of the outcomes of the surgery, better education of the patients and optimal adjustment ofpharmacotherapy, the anticoagulation treatment in particular. We did not observe any adverse reactions or other complications associated with the exercise.

Association of Age and Quality of Life Following Phase II Cardiac Rehabilitation

The benefits of cardiac rehabilitation following a major cardiac event are without question. Less well known, however, is the association of age with improved quality of life following rehabilitation. Subjects (n = 300) completed a 3-month phase II cardiac rehabilitation program following either a coronary artery bypass graft or a valve procedure. There were similar gains in health-related quality of life across all age groups; our results suggest that there needs to be a greater focus on emotional needs among our younger patients.

Benefit of outpatient cardiac rehabilitation in under-represented patient subgroups

OBJECTIVE

To assess the effect of outpatient cardiac rehabilitation in important patient subgroups.

DESIGN

Prospective cohort study.

SUBJECTS

Consecutive patients from March 1999 until July 2003.

METHODS

This study assessed the results of symptom-limited bicycle stress testing and health-related quality of life (Profil der Lebensqualität Chronisch Kranker) at baseline and after a 3-month rehabilitation program, and complications and drop-outs during outpatient cardiac rehabilitation.

RESULTS

Of 1061 patients, 155 (15%) women, 87 (8%) men aged >or= 75 years, 162 (15%) had diabetes mellitus and 88 (8%) did not speak the local language. Reasons for outpatient cardiac rehabilitation included acute coronary artery disease (87%), valvular heart disease (9%) and congestive heart failure (1%). Mean age was 62 years (standard deviation 11). Patients increased both their age- and body-weight-adjusted workload (p < 0.0001) and quality of life (p < 0.0001) during the program. Although the initial workload achieved was lower than for normal patients (p < 0.0001), it increased in all subgroups during outpatient cardiac rehabilitation (p < 0.0001). Baseline quality of life was lower in women, but increased in most dimensions for all subgroups assessed.

CONCLUSION

Important subgroups, such as women, elderly men, diabetic patients and ethnic minorities, are under-represented in outpatient cardiac rehabilitation, although they benefit similarly to other patients. Due to lower baseline quality of life, women may need special medical attention prior to outpatient cardiac rehabilitation.

Cardiac rehabilitation in Austria: short term quality of life improvements in patients with heart disease

BACKGROUND

The goal of cardiac rehabilitation programs is not only to prolong life, but also to improve physical functioning, symptoms, wellbeing and health-related quality of life (HRQL). The aim of the study was to document short-term outcomes of cardiac rehabilitation programs in Austria.

METHODS

Consecutive patients (N = 487, 64.7% male, age 60.9 +/- 12.5 SD years) after myocardial infarction (MI), with or without percutaneous interventions (PCI), coronary artery bypass grafting (CABG) or heart valve surgery (HVS), referred to the six inpatient rehabilitation centers of the Austrian PVA insurance company, were included in the study. Exercise capacity, risk factors and HRQL (MacNew Heart Disease Quality of Life Instrument [MacNew] and EuroQoL-5D [EQ-5D]) were measured at the beginning and end of the 4-week inpatient cardiac rehabilitation program.

RESULTS

Global HRQL (MacNew) improved significantly over time in all patients combined (+0.75 +/- 0.88 SD, T = -16.99, df = 394, p < .001) and exceeded the minimal important difference. Patients with CABG, HVS or MI without PCI showed the greatest improvements in global HRQL after cardiac rehabilitation (p < .02). Blood pressure, cholesterol, triglyceride, body mass index, waist circumference improved significantly (all p < .001).

CONCLUSION

These findings provide evidence that the improvements in HRQL and risk factors following cardiac rehabilitation in Austria are clinically important. HRQL should become a standard outcome parameter in cardiac rehabilitation.

Recommendations for the management of patients after heart valve surgery

Approximately 50,000 valve replacement operations take place in Europe annually and almost as many valve repair procedures. Previous European guidelines on management of patients after valve surgery were last published in 1995 and were limited to recommendations about antithrombotic prophylaxis. American guidelines covering the broader topic of the investigation and treatment of patients with valve disease were published in 1998 but devoted relatively little space to post-surgical management. This document represents the consensus view of a committee drawn from three European Society of Cardiology (ESC) Working Groups (WG): the WG on Valvular Heart Disease, the WG on Thrombosis, and the WG on Rehabilitation and Exercise Physiology. In almost all areas of patient management after valve surgery, randomized trials and meta-analyses do not exist. Such randomized trials as do exist are very few in number, are narrowly focused with small numbers, have limited general applicability, and do not lend themselves to meta-analysis because of widely divergent methodologies and different patient characteristics. Recommendations are therefore almost entirely based on non-randomized studies and relevant basic science.

Long-term outcomes of valve replacement with modern prostheses in young adults

OBJECTIVES

To examine the multiple impacts of valve replacement on the lives of young adults.

METHODS

Patients (N=500) between age 18 and 50 who had aortic valve replacement (AVR) and/or mitral valve replacement (MVR) with contemporary prostheses were followed annually. Events, functional status, and quality of life were examined with regression models.

RESULTS

Median follow-up was 7.1+/-5.3 years (maximum 26.7 years). Five, 10, and 15-year survival was 92.7+/-1.7, 88.3+/-2.4 and 80.1+/-4.7% after AVR, and 93.1+/-2.3, 79.5+/-4.3 and 71.5+/-5.4% after MVR, respectively. Survival decreased with concomitant coronary disease (hazard ratio (HR): 4.5) and preoperative LV grade (HR: 2.0/grade increase) in AVR patients, and with atrial fibrillation (HR: 5.5), coronary disease (HR: 5.7), preoperative left atrial diameter (HR: 3.0/cm increase) and NYHA class (HR: 2.1/class increase) in MVR patients. Despite reoperation, late survival was equivalent between bioprostheses and mechanical valves in both implant positions. The ten-year cumulative incidence of embolic stroke was 6.3+/-2.4% for mechanical AVR patients, 6.4+/-2.9% for bioprosthetic AVR patients, 12.7+/-3.9% for mechanical MVR patients, and 3.1+/-3.1% for bioprosthetic MVR patients. Atrial fibrillation (HR: 2.8) and smoking (HR: 4.0) were risk factors for stroke in MVR patients. In AVR patients, SF-12 physical scores, freedom from recurrent heart failure, and freedom from disability were significantly higher in bioprosthetic than mechanical valve patients. Career or income limitations were more often subjectively linked to a mechanical prosthesis in both implant positions.

CONCLUSIONS

Late outcomes of modern prosthetic valves in young adults remain suboptimal. Bioprostheses deserve consideration in the aortic position, as mechanical valves are associated with lower physical capacity, a higher prevalence of disability, and poorer disease perception. Early surgical referral and atrial fibrillation surgery may improve survival after MVR.

[Is there any difference in quality of life after 12 months surgical treatment of acquired heart valve disease in comparison to results after three months?]

The quality of life in eighty patients three and twelve months after surgical treatment of acquired heart valve disease was assessed. The significant extension of distance in 6 minute walk test and clinical improvement measured in change of NYHA functional classes after three and twelve months was noticed. However twelve months after valve replacement in comparison to results after three months no further improvement of quality of life in the matter of physical, psychical and social factors was seen.

[Clinical and laboratory support for multiple-modality treatment of rheumatic patients with mitral valve disease]

In 158 rheumatic patients with mitral valvular disease (MVD), clinical-and-laboratory indices were studied together with a possibility for correction of the detected disorders in a multiple-modality staged treatment involving basic drug therapy, EHF-therapy, and sanatorium-health resort stage of rehabilitation. It has been found out that EHF-therapy and sanatorium-health resort treatment have a positive effect on the clinical course of the trouble and on the laboratory indices for the inflammatory process contributing to optimization of medicamentous treatment of rheumatic patients with MVD.

Carers' opinions and emotional responses following cardiac surgery: cardiac rehabilitation implications for critical care nurses

The recent joint position statement made by the RCN Critical Care and Rehabilitation Nursing Forums highlights the need for rehabilitation to commence early. This paper reports the findings of a descriptive survey of 59 carers of cardiac surgery patients and presents implications for cardiac rehabilitation. Data were obtained by postal questionnaire during early recovery (one week following discharge) and six weeks later. The questionnaire explored carers' perceptions about the timing of discharge from hospital; opinions of the information provided by hospital staff; and anxiety and depression measured on the Hospital Anxiety and Depression Scale. The results indicated that carers assumed a heavy burden once the patient had left the specialist cardiac centre. Carers responding at one week were less satisfied with the timing of discharge than those questioned at six weeks. Information provided by nurses was rated more highly than that provided by doctors or physiotherapists. However, there was scope for increasing input. The findings suggest that cardiac rehabilitation needs to be aimed at carers as well as patients. Investment in targeted carer support could facilitate patient recovery and rehabilitation. Strategies aimed at the carer need to begin early and commence during the acute stage of the patients' recovery.

The postpericardiotomy syndrome as a cause of pleurisy in rehabilitation patients

Pleuritic chest pain in patients on a rehabilitation unit may be caused by several conditions. We report 2 cases of postpericardiotomy syndrome (PPS) as a cause of pleuritic pain. PPS occurs in 10% to 40% of patients who have coronary bypass or valve replacement surgery. The syndrome is characterized by fever, chest pain, and a pericardial or pleural friction rub. Its etiology is believed to be viral or immunologic. The syndrome can be a diagnostic challenge, and an increase in length of hospitalization because of it has been documented. Identified risk factors for PPS include age, use of prednisone, and a history of pericarditis. A higher incidence has been reported from May through July. Many patients undergo a battery of expensive procedures before PPS is diagnosed. The pain is sharp, associated with deep inspiration, and changes with position. Pleural effusions may be present and tend to occur bilaterally. Pericardial effusions are a documented complication. A pericardial or pleural rub may be present and is often transient. Serial auscultation is important. Laboratory work provides clues with a mild leukocytosis and an elevated erythrocyte sedimentation rate. However, this does not provide the definitive diagnosis. Cardiac enzymes are not reliably related to the syndrome. An electrocardiogram will show changes similar to those associated with pericarditis. The patient may have a fever, but it is rarely higher than 102.5 degrees F. Complications include pericardial effusions, arrhythmias, premature bypass graft closure, and cardiac tamponade. Treatment consists of a 10-day course of nonsteroidal anti-inflammatory drugs.

[Early recovery after valvular heart surgery]

There have been published not a few reports concerning the early recovery from heart surgery. But most of them were restricted in CABG cases. We report our efforts and its results about the early recovery from valvular heart surgery. To make a contribution to the early recovery we have made some efforts since 1995, including normothermic perfusion, low-dose fentanyl and introduction of terminal warm blood cardioplegia. As the results, the tracheal intubation period was shortened from 12.6 +/- 5.3 (hour) to 6.7 +/- 4.1. The number of the cases who had tracheal extubation in the operative day increased from 27% to 84%. The postoperative cardiac function was satisfactory and there were no abdominal or neurologic disturbances among the patients those who were entered into the early recovery protocol. We obtained satisfied early recovery in safe after valvular heart surgery.

[Evaluation of the effectiveness of an ambulatory after-care rehabilitation program]

Effects of an outpatient cardiological rehabilitation programme that is offered to patients following their inpatient treatment in a rehab clinic are measured and compared with the data collected from an untreated group. The study group consists of 155 cardiological patients (after heart attack, bypass operation and heart-valve prosthesis) in the treatment group as well as 136 in the non-treatment group. The outpatient programme takes place twice a week in a cardiological rehab clinic, with patients participating for a maximum period of twelve weeks. Data are collected at the beginning, the end and three months after the end of the programme from the treatment group resp. twice with a six months interval from the non-treatment group. The used outcome measures are a number of medical variables (e.g. stress ECG, BMI, blood pressure), variables concerning vocational reintegration, plus a questionnaire. This questionnaire consists of a Functional Limitation Scale, a Mood Check List, a "Health Locus of Control"-Scale as well as a number of items regarding health-related behaviour and heart complaint symptoms. The project duration was 36 months, starting in June 1993. The funding source is the "Landesversicherungsanstalt Westfalen", a regional division of the German Statutory Old Age Insurance. As data concerning vocational reintegration indicate, the programme can be a meaningful complement to a larger amount of reintegrated patients (66.9%) compared to the non-treatment group (50.2%). To estimate the long-term effects of the programme, a 24-month-follow-up was started in January 1996.

[Possibilities for greater flexibility in a cardiologic rehabilitation clinic by supplementary ambulatory/partial inpatient therapeutic services]

This study shows that additional outpatient/partially inpatient treatment provided in a cardiological rehabilitation hospital effectively complements inpatient rehabilitation treatment but does not replace it. Our flexible system which comprises a shorter stay in hospital and subsequent partially inpatient treatment allows more intensive treatment of the patient in the early phase of rehabilitation. It supports patients when they have returned home and have to test out how they manage with their restricted physical and mental performance in their social environment. It appears possible to develop criteria to select the individually appropriate form of treatment. The introduction of outpatient/partially inpatient therapy in a cardiological rehabilitation hospital does not appear to entail disadvantages for the patients. It contributes to more flexible, and in particular to more individualized, treatment. The ongoing pilot projects will show whether in the final analysis this will also entail a saving of costs. Not only in view of their specialist competence are the cardiological rehabilitation hospitals suitable and able to participate in measures to increase the flexibility of cardiological rehabilitation. They should therefore either completely integrate outpatient/partially inpatient methods in their concept of therapy or after a shortened inpatient treatment. They should then evaluate these methods so as to be able to contribute to an informed discussion on this topic. This also would mean that available resources would be better utilized, which would in addition be of particular importance at present, in a situation dominated by discussions of costs.

The effect of moderate exercise training on oxygen uptake post-aortic/mitral valve surgery

BACKGROUND

This study determined the response of aortic and/or mitral valve replacement/reconstruction (AVR/MVR) surgery patients to a 3-month exercise rehabilitation program (ERP) of moderate intensity, frequency, and duration that commenced approximately 9 weeks post-operatively.

METHODS

Based on geographic proximity and availability of transportation to attend ERP classes, 29 experimental subjects were enrolled in the ERP and 20 control subjects received standard care that did not include the ERP, but did not prohibit activity/exercise. Exercise tolerance was determined from estimated oxygen uptake (VO2) during exercise tolerance testing (GXT) before and after standard care or the ERP.

RESULTS

VO2 at the maximum stage of the GXT increased significantly (P < or = 05) for the experimental (4.89 +/- 5.07 mL/kg/min) and control (5.11 +/- 4.48 mL/kg/min) groups. No significant between-group differences were noted in VO2 at the maximum stage of the exercise testing or at the target heart rate (HR). Furthermore, reported exercise levels of subjects in both groups were comparable and sufficient for training effects to occur.

CONCLUSION

Alternate strategies to improve exercise tolerance such as home-based rehabilitation programs should be investigated for relatively healthy aortic and/or mitral valve surgical patients.

Quantifying and predicting recovery after heart surgery

The validity of the biopsychosocial approach to the study of health and illness is reaffirmed by the prospective findings of the Recovery Study. This is a multidisciplinary examination, conducted in four teaching hospitals, of the predictors of symptoms of cardiac illness in 463 patients 6 months after coronary artery bypass or cardiac valve surgery. We found that the following preoperative measures predict freedom from cardiac symptoms 6 months after surgery: low levels of all of the following: angina pain, shortness of breath, fatigue and sleep problems, lifetime cigarette usage, and preoperative hospitalization for cardiac treatment; low levels of anxiety, depression, and hostility, and few life change events; high levels of all of the following: self-esteem, well-being, vigor; prevalence of activities and hobbies, social participation, and social support. The six variables in bold print contributed independently in a multiple regression equation that accounted for 21% of the variance of the symptoms score and was associated with an estimated 45% difference in success of recovery. The statistical strength and general nature of many of the predictors indicate that the predictors may also be important in recovery from other health crises. Psychosocial and biomedical factors correlate across time (predictively), as well as cross-sectionally, indicating that psychological, social, and biological mechanisms may be parts of a single general multifaceted process influencing recovery of health. A clinical trial could determine if psychological, social, or behavioral interventions will hasten and improve recovery from physical illness or trauma.

Exercise testing in special situations

This article discusses exercise testing in valvular heart disease, hypertension, and the evaluation of patients for surgery. It also provides information on the effects of drugs on the exercise test and the clinical significance of block patterns and arrhythmias encountered during exercise.

Exercise tolerance and working capacity after valve replacement

Between 1978 and 1987, 1270 patients who survived single aortic or mitral valve replacement at the Rehabilitation Center in Bad Krozingen, Germany, underwent a comprehensive rehabilitation program. The preoperative diagnosis was isolated aortic stenosis in 425, isolated aortic regurgitation in 159, mixed aortic lesion in 211, isolated mitral stenosis in 208, isolated mitral insufficiency in 137 and mixed mitral lesion in 130 cases. Follow up examinations were carried out one and six months after surgery, and at yearly intervals thereafter. Exercise testing was performed with an electrically braked bicycle ergometer in the supine position, and the load was increased by 25 or 50 watts every two minutes until fatigue, severe angina, more than 0.3 mV ST-segment depression, or 80% of the age predicted maximum heart rate was achieved. Patients after aortic valve replacement had a better exercise performance one month after operation than did those after mitral valve replacement. Those with mitral stenosis showed more severe impairment of exercise tolerance than did the mitral insufficiency group. There was a steady increase in exercise tolerance between one and six months postoperatively, both in patients with aortic and those with mitral valve replacement, but the difference in performance between the two groups was still present (72% versus 57% of normal). The results of univariate and multivariate analyses showed that the preoperative employment status was the most important factor for postoperative return to work, followed by gender (male > female), exercise tolerance and valualar lesion (aortic > mitral).(ABSTRACT TRUNCATED AT 250 WORDS)

[The physiotherapeutic correction of secondary immunodeficiency in the preoperative period in patients with rheumatic heart defects]

Directed correction of immunity by physiotherapeutic methods was used at the period of preoperative preparing 45 patients who needed the operation for rheumatic valvular disease of the heart. The number of purulent complications during the postoperative period in the group of patients subjected to direct correction of the immune status was found to be less than in the control group.

[Return to work of professional drivers after cardiac rehabilitation]

This study analysed the possibilities of returning to work of professional drivers after a cardiac event and rehabilitation. The population comprised 94 consecutive patients, all men, average age 48.8 years (range 30 to 63 years) referred after coronary bypass surgery (N = 39), myocardial infarction (N = 38), angina (N = 4) or valve replacement surgery (N = 13). Advice on professional reinsertion was given after the rehabilitation program, authorization to drive being given in the absence of cardiac symptoms, residual myocardial ischaemia, severe left ventricular dysfunction and serious ventricular arrhythmias. After 35 months, 4 patients were lost to follow-up; of the 90 remaining patients, the frequency of return to work (maximal at the 9th month) was 65.6% with 84.7% obtaining a renewal of their driving licence. In this series, 81% of patients were asymptomatic, 2 died, 16.7% had further cardiovascular complications. The morbidity and mortality were significantly greater in the group who had to stop driving (N = 40) (32.5% vs 8%, p < 0.001). Non complications occurred during work in those who resumed driving. This study confirms the safety of allowing low risk professional drivers, identified during cardiac rehabilitation by simple, reliable clinical and paraclinical criteria, to return to work.

[The internal picture of the disease in subjects with a history of a heart valve prosthetic operation under artificial circulation]

Sensitive, emotional, intellectual, motivation, preoperative and postoperative aspects of the disease pattern were studied in 93 patients who had acquired valvular defects and underwent replacement of the valves in conditions of artificial circulation. The findings provided evidence in support of psychic correction for preoperative preparation of the patients and postoperative restoration of their personality and social status.

[Prognosis of long-term results of aortic and mitral valve prosthesis by the data of treadmill test]

The treadmill test was conducted in 328 patients who underwent prosthetics of the aortic or mitral valve for rheumatic heart disease. The object of the test was evaluation of the heart pumping function according to the dynamics of the oxygen debt, pulmonary hypertension according to the pseudoanaerobic threshold, and decompensation of metabolic acidosis according to the appearance of the hypocapnic reaction. The findings were compared with the results of preoperative examination. The results of the preoperative treadmill test were found to be in accord with the probability of a positive effect of prosthetics. Depending on an increase of the critical loads level this probability rose from 2 to 87% in mitral and from 25 to 100% in aortic prosthetics. It is shown that development of lactoacidosis decompensation in addition to the heart pumping function defect significantly aggravates the late-term results of the operation.

Emotional profiles of families with a heart-operated patient: a pilot study

Family interaction is a basic factor in determining the quality of life of patients undergoing heart surgery. The present study investigates the emotional attitudes in the relatives of 10 heart-operated patients. The results indicate that a high amount of relatives' emotional overinvolvement and warmth tends toward a correlation with lower anxiety and depression scores, and with a better 12-month outcome of the illness.

Physical training in patients with valvular heart disease after surgery

The necessity, the methodology and clinical benefit of physical training were evaluated in 85 patients with valvular heart surgery. In 21 patients who had undergone the exercise stress test before surgery, corrective valvular surgery increased maximal oxygen uptake (max.VO2) from 15.4 before to 18.9 ml/min/kg, while 11 (52%) of them failed to increase exercise capacity over 5 METs. Of the total 85 patients, 41 (58%) again showed reduced exercise capacity in the initial postoperative stress test, suggesting that a return to work might be difficult without rehabilitation in these patients. We then compared two training programs: program A of short duration and frequent exercise and program B of longer duration and less frequent exercise, both using a bicycle exercise set at an intensity of 70% of the max.VO2. Both programs similarly increased max.VO2, while patients preferred program A, suggesting that exercise of longer duration could not be tolerated because of deconditioning. Program A was then prescribed to 62 patients, and it increased max.VO2 from 18.2 to 20.7 ml/min/kg after 4 weeks training without any complication. In 9 patients who served as controls undergoing no physical training, no spontaneous improvement in exercise capacity was observed. Of the 76 patients who received either program A or B, 28 patients failed to increase the max.VO2 by 10% or more. These patients presented atrial fibrillation, a cardiothoracic ratio greater than or equal to 60% or exercise-induced ST depression more frequently, suggesting that residual cardiac dysfunction might inhibit the training effects.(ABSTRACT TRUNCATED AT 250 WORDS)

[Effect of physical training on children after reconstructive heart surgery]

The authors composed a programme of physical training for children with congenital valvular defect. The training programme was applied before and after the heart operation. Two years after a successful reconstructive heart operation the fitness condition of 40 children was examined. The average age of the children was 8.0 +/- 3.6 years. Twenty of the children participated and 20 did not participate in the programme. The physical condition of the children who took part in the training was found to be significantly better than that of the others without training.

Physical training and occupational rehabilitation after aortic valve replacement

Forty-four patients were tested 2, 6 and 12 months after an isolated aortic valve implantation in order to evaluate the influence of training and vocational assistance on physical work capacity and the rate of reemployment. They were randomly allocated to a training group (A) or a control group (B). Training was carried out from the eighth to the twelfth week after operation and the socio-occupational status was evaluated. Training increased physical work capacity, expressed as cumulated work (CW), by 58 per cent (P less than 0.001), decreased the rate-pressure product (RPP) by 13 per cent (P less than 0.001) and the rate of perceived exertion (RPE) by 13 per cent (P less than 0.001) at the highest comparable work load. The CW was 38 per cent higher in the training than the control group after 6 (P less than 0.02) and 37 per cent after 12 months (P less than 0.025). After one year 81 per cent in group A and 65 per cent in group B were working (NS). Reemployment correlated significantly with the CW and inversely with the duration of sick leave prior to operation. Thus, physical training shortly after aortic valve operation rapidly and persistently improves physical work capacity while return to work is less influenced by training and socio vocational assistance.

A long-term follow-up study of valve replacements

We have studied the long-term results of valve replacement operations in 591 patients, one year or more after surgery, and also analyzed rates of social return in 523 patients (response rate, 86.1 per cent) by questionnaire. Of the 591 patients, 81 patients suffered early death (mortality rate, 13.7 per cent) and 41 patients late death (mortality rate, 6.9 per cent). The causes of the latter were left atrial thrombus (18 cases), heart failure (10 cases), artificial valve failure (five cases), renal failure (two cases) and hepatic insufficiency, infection and accident (one case each). Second replacement was performed in 18 patients (3.0 per cent), 49 months on average from the first operation. The survival rate at the 12th postoperative year was 68.7 per cent. The overall rate of social return after valve replacement was 64.8 per cent, including 74.8 per cent for mitral valve replacement, 54.3 per cent for aortic and 51.5 for multivalvular. The rate of social return has been improved to 76.4 per cent in the last five years.

Are maximal inspiratory breathing exercises or incentive spirometry better than early mobilization after cardiopulmonary bypass?

Forty-nine adults who had undergone cardiopulmonary bypass surgery were randomly assigned to one of three exercise programs to determine if either maximal inspiratory breathing exercises or incentive spirometry offered a therapeutic advantage over early mobilization alone. After extubation, the patients started their assigned exercise programs. A physical examination and pulmonary function tests were performed preoperatively, at the start of the exercise program, and 24 and 48 hours after the start of the program. The results showed a significant decrease (approximately 50%) in lung volumes but no airflow obstruction in patients who had coronary artery bypass graft. In those patients who had valve replacement, lung volumes fell, and in addition, mild airflow obstruction occurred. A majority of patients had postoperative pulmonary complications. There were no significant differences among the exercise programs in improving lung volumes and airflow or in preventing postoperative complications. We conclude that maximal inspiratory breathing exercises or incentive spirometry, when used in addition to early mobilization, offers no therapeutic advantage over early mobilization alone after cardiopulmonary bypass surgery.

Exercise capacity before and after cardiac valve surgery

Exercise stress testing and right-heart catheterization were carried out in 131 patients before and 6 months after cardiac valve surgery. The exercise capacity increased only a little in patients with mitral or double-valve surgery. In contrast, most patients with an aortic valve replacement had good exercise performance after surgery. Corresponding to the reduced exercise capacity most of the patients also had disturbed hemodynamics after surgery, with an elevated mean pulmonary artery pressure at rest, that raised inappropriately during exercise, and a diminished cardiac output at rest, that failed to increase during exercise, in relation to oxygen uptake.