Impact of the Preoperative Risk and the Type of Surgery on Exercise Capacity and Training After Valvular Surgery

doi:10.1016/j.amjcard.2014.01.413

The American Journal of Cardiology

Volume 113, Issue 8, 15 April 2014, Pages 1383-1389

https://doi.org/10.1016/j.amjcard.2014.01.413 Get rights and content

Information on exercise capacity and training in patients who underwent valvular surgery is scarce. The aim of this study is to evaluate postoperative exercise capacity and functional improvement after exercise training according to the preoperative risk and type of surgery. In this prospective study, 145 patients who underwent aortic valve surgery (AVS) or mitral valve surgery (MVS) and who were referred for cardiac rehabilitation were stratified according to the preoperative risk (European System for Cardiac Operative Risk Evaluation [EuroSCORE]) and type of surgery (sternotomy vs ministernotomy or port access). Exercise capacity was evaluated at the start and end of cardiac rehabilitation. Postoperative exercise capacity and the benefit from exercise training were compared between the groups. Patients with a higher preoperative risk had a worse postoperative exercise capacity, with a lower load, peak VO₂, anaerobic threshold and 6-minute walking distance (all p <0.001), and a higher VE/VCO₂ slope (p = 0.01). In MVS, port access patients performed significantly better at baseline (all p <0.05), but in AVS, ministernotomy patients performed better than sternotomy patients with a concomitant coronary artery bypass graft (p <0.05). Training resulted in an improvement in exercise capacity in each risk group and each type of surgery (all p <0.05). This gain in exercise capacity was comparable for the EuroSCORE risk groups and for the types of surgery, for patients after AVS or MVS. In conclusion, exercise capacity after cardiac surgery is related to the preoperative risk and the type of surgery. Despite these differences in postoperative exercise capacity, a similar benefit from exercise training is obtained, regardless of their preoperative risk or type of surgery.

Section snippets

Methods

One hundred and forty-five patients who underwent AVS (n = 72) or MVS (n = 73) for valvular regurgitation or stenosis and who were referred for cardiac rehabilitation between October 2007 and March 2012 were prospectively included. Patients with multivalvular disease were not eligible for inclusion, and neither were patients with transcatheter aortic valve implantation or mitraclip because of the fewer number of these procedures. Only patients with classic sternotomy, ministernotomy, or port

Results

Clinical characteristics of the 145 study patients are listed in Table 1. Age, gender, and body mass index were comparable between AVS and MVS. MVS patients had a slightly lower preoperative left ventricular function as compared with AVS patients (60% vs 67%, p <0.01). MVS was mainly performed for mitral regurgitation (97%), whereas AVS patients were mainly referred for aortic stenosis (75%). Mitral valve repair was performed in 85% of those who were referred for MVS. The large majority of

Discussion

The main novel finding of this study is that exercise capacity after valvular surgery is related to the preoperative risk and to the type of surgery. However, a similar benefit from exercise training can be obtained, independent of the preoperative risk class or the type of surgery. Therefore, exercise training should be offered to all patients after valvular surgery, regardless of their EuroSCORE risk (low or high risk) or type of surgery (classic sternotomy or minimal invasive surgery).

Our

Acknowledgment

We thank the cardiac rehabilitation team of AZ Maria Middelares Ghent and Onze-Lieve-Vrouw Hospital Aalst for their contribution to data collection.

References (14)

T. Le Tourneau et al.
Effect of mitral valve surgery on exercise capacity, ventricular ejection fraction and neurohormonal activation in patients with severe mitral regurgitation
J Am Coll Cardiol
(2000)
R. Belardinelli et al.
Exercise training intervention after coronary angioplasty: the ETICA trial
J Am Coll Cardiol
(2001)
P. Meurin et al.
Working Group of Cardiac Rehabilitation of the French Society of Cardiology. Early exercise training after mitral valve repair: a multicentric prospective French study
Chest
(2005)
E. Tamas et al.
Measurement of physical work capacity in patients with chronic aortic regurgitation: a potential improvement in patient management
Clin Physiol Funct Imaging
(2009)
K. Hedman et al.
Decreased aerobic capacity 4 years after aortic valve replacement in male patients operated upon for chronic aortic regurgitation
Clin Physiol Funct Imaging
(2012)
F. Roques et al.
Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients
Eur J Cardiothorac Surg
(1999)
S.A. Nashef et al.
European system for cardiac operative risk evaluation (EuroSCORE)
Eur J Cardiothorac Surg
(1999)

There are more references available in the full text version of this article.

Cited by (20)

Contrasting effects of three breathing techniques on pulmonary function, functional capacity and daily life functional tasks in patients following valve replacement surgery- A pilot randomized clinical trial
2021, Heliyon
Citation Excerpt :
When administered, a flow-oriented device leads to labored breathing and increases the thoracic muscle activity whereas a volume-oriented spirometer imposes reduced breathing efforts and also improves the movement of the diaphragm [18, 19]. Cardiac surgeries also affect the functional capacity, thoracic mobility and pulmonary function which taking together could influence the quality of life of these patients [22, 23]. The evaluation of the effectiveness of physiotherapeutic methods in the postoperative period of valve surgery can assist in the choice and recommendation, considering lung function, functional capacity and its impact on the quality of life of these patients.
Valve replacement surgeries affect the physiological mechanisms of patients leading to various postoperative pulmonary complications. Lung expansion therapy consisting of numerous techniques is routinely used for the prevention and treatment of these complications.
Our study aimed to compare the effects of diaphragmatic breathing (DB), flow (FS) and volume-oriented incentive spirometer (VS) in patients following valve replacement surgery.
29 patients posted valve replacement surgeries were randomly assigned to VS, FS and DB groups. Patients underwent preoperative training and seven-day rehabilitation post-surgery. Pulmonary function tests were performed before surgery and for seven days afterward. On the seventh postoperative day, patients performed a six-minute walk test and completed a functional difficulties questionnaire (FDQ).
Pulmonary function test values reduced in all three groups postoperatively when compared to the preoperative values but improved by the seventh postoperative day (p < 0.05). On comparing the seventh postoperative day values to the preoperative values, the VS group had no significant difference (p = 1.00) (Forced Vital Capacity- % change: DB-37.76, VS-1.59, FS-27.98), indicating that the value had nearly returned to the baseline. As compared to the DB and FS groups, FVC showed a greater improvement in the VS group (p = 0.01 and p = 0.06 respectively). No significant differences were observed between groups for distance walked (p > 0.05), however, FDQ scores demonstrated positive changes in favor of VS when contrasted with FS or DB (p < 0.05).
Diaphragmatic breathing, flow or volume-oriented spirometer could improve pulmonary function in the postoperative period. The volume-oriented spirometer, however, was found to be the most beneficial among the three techniques in improving patients’ pulmonary function and daily life functional tasks. Further research is warranted to confirm these findings.
Implementing resistance training in the rehabilitation of coronary heart disease: A systematic review and meta-analysis
2017, International Journal of Cardiology
Resistance training has demonstrated efficacy in cardiac rehabilitation programs, but the optimal prescription of resistance training is unknown. This systematic review with meta-analysis compared the effectiveness of cardiac rehabilitation consisting of resistance training either alone (RT) or in combination with aerobic training (CT) with aerobic training only (AT) on outcomes of physical function. Further, resistance training intensity and intervention duration were examined to identify if these factors moderate efficacy.
Six electronic databases were searched to identify studies investigating RT, coronary heart disease and physical function. The overall quality of evidence was assessed using the GRADE approach. Meta-analyses were performed when possible and qualitative analysis was performed for the remaining data.
Improvements in peak oxygen uptake (WMD: 0.61, 95% CI: 0.20–1.10), peak work capacity (SMD: 0.38, 95% CI: 0.11–0.64) and muscular strength (SMD: 0.65, 95% CI: 0.43–0.87) significantly favoured CT over AT with moderate quality evidence. There was no evidence of a difference in effect when comparing RT and AT. Shorter duration CT was superior to shorter duration AT for improving peak oxygen uptake and muscular strength (low quality evidence) while longer duration CT was only superior to longer duration AT in improving muscular strength (moderate quality evidence).
CT is more beneficial than AT alone for improving physical function. Although preliminary findings are promising, more high-quality evidence is required to determine the efficacy of high intensity resistance training. Shorter duration interventions that include resistance training might allow patients to return to their normal activities of daily living earlier.
High readmission rate after heart valve surgery: A nationwide cohort study
2015, International Journal of Cardiology
Citation Excerpt :
Mortality and short-term follow-up after heart valve surgery are thoroughly described [5], yet possibly leaving out important details regarding longer term patient status [6]. Comparing pre- and post-surgery, quality of life and physical capacity usually improve [7,8]. Despite these benefits decreased physical function, anxiety, and depression might remain [9], being well-known independent predictors of long-term morbidity and mortality [10].
After heart valve surgery, knowledge on long-term self-reported health status and readmission is lacking. Thus, the optimal strategy for out-patient management after surgery remains unclear.
Using a nationwide survey with linkage to Danish registers with one year follow-up, we included all adults 6–12 months after heart valve surgery irrespective of valve procedure, during Jan–June 2011 (n = 867). Participants completed a questionnaire regarding health-status (n = 742), and answers were compared with age- and sex-matched healthy controls. Readmission rates and mortality were investigated.
After valve surgery, the self-reported health was lower (Short Form-36 (SF-36) Physical Component Scale (PCS): 44.5 vs. 50.6 and Mental Component Scale (MCS): 51.9 vs. 55.0, p < 0.0001) and more were physically sedentary compared with healthy controls (11.1% vs. 15.2%). Clinical signs of anxiety and depression were present in 13.6% and 13.8%, respectively (Hospital Anxiety and Depression Scale score ≥ 8). Twelve months following discharge, 483 persons (56%) were readmitted. Readmission was associated with lower self-reported health (SF-36 PCS: 46.5 vs. 43.9, and MCS 52.2 vs. 50.7). Higher age (hazard ratio (95% CI): 1.3 (1.0–1.6)), male sex (1.2 (1.0–1.5)), mitral valve surgery (1.3 (1.0–1.6)), and infective endocarditis after surgery (1.8 (1.1–3.0), p: 0.01) predicted readmission, whereas higher age (2.3 (1.0–5.4)), higher comorbidity score (3.2 (1.8–6.0)), and infective endocarditis after surgery (3.2 (1.2–8.9)) predicted mortality.
6–12 months after heart valve surgery the readmission rate is high and the self-reported health status is low. Readmission is associated with low self-reported health. Therefore, targeted follow-up strategies post-surgery are needed.
Inspiratory Muscle and Functional Performance of Patients Entering Cardiac Rehabilitation after Cardiac Valve Replacement
2023, Journal of Cardiovascular Development and Disease
Effectiveness of early cardiac rehabilitation in patients with heart valve surgery: a randomized, controlled trial
2022, Journal of International Medical Research
Fit, Female or Fifty–Is Cardiac Rehabilitation “Fit” for Purpose for All? A Systematic Review and Meta-Analysis With Meta-Regression
2022, Frontiers in Cardiovascular Medicine

View all citing articles on Scopus

: This project was supported by a grant of the Research Foundation Flanders (FWO Vlaanderen), project number G.0628.10 N.

: See page 1388 for disclosure information.

View full text

Valvular Heart DiseaseImpact of the Preoperative Risk and the Type of Surgery on Exercise Capacity and Training After Valvular Surgery

Section snippets

Methods

Results

Discussion

Acknowledgment

J Am Coll Cardiol

J Am Coll Cardiol

Chest

Measurement of physical work capacity in patients with chronic aortic regurgitation: a potential improvement in patient management

Clin Physiol Funct Imaging

Decreased aerobic capacity 4 years after aortic valve replacement in male patients operated upon for chronic aortic regurgitation

Clin Physiol Funct Imaging

Risk factors and outcome in European cardiac surgery: analysis of the EuroSCORE multinational database of 19030 patients

Eur J Cardiothorac Surg

European system for cardiac operative risk evaluation (EuroSCORE)

Eur J Cardiothorac Surg

Valvular Heart Disease
Impact of the Preoperative Risk and the Type of Surgery on Exercise Capacity and Training After Valvular Surgery