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.

Experiencia en un programa de rehabilitación cardíaca extrahospitalario usando cardiotacómetros: seguridad y eficacia / Experience in an outpatient cardiac rehabilitation program using cardiotachometers: safety and effectiveness / Experiência em programa de reabilitação cardíaca extra-hospitalar com uso de cardiotacômetros: segurança e eficácia

Introducción: El ejercicio físico, integrando la rehabilitación cardíaca (RC), tiene un efecto positivo demostrado en el pronóstico de los pacientes con enfermedad cardiovascular, optimizando el rendimiento cardíaco en términos de capacidad funcional. Mediante los programas de RC se pretende obtener los máximos beneficios clínicos del ejercicio físico con un mínimo riesgo para el paciente. Objetivos: Evaluar la seguridad y eficacia de un programa de RC extrahospitalario en pacientes de todos los niveles de riesgo, monitorizando con cardiotacómetros (instrumento de pulsera que detecta frecuencia cardíaca y permite programar alarmas) a pacientes de moderado y alto riesgo, con base en la ausencia de complicaciones cardíacas graves y la mejoría funcional de los participantes. Material y métodos: Estudio de cohorte retrospectiva, sometida a un plan de RC durante 12 semanas en el período comprendido entre enero de 2014 y marzo de 2020. Se evaluaron parámetros clínicos y funcionales al inicio y al final del plan de rehabilitación, controlando la tolerancia al esfuerzo, la presión arterial y la frecuencia cardíaca mediante el uso de cardiotacómetros. Resultados: Se incluyeron 181 pacientes, con edad promedio de 58,7 ± 9,7 años, 87,8% del sexo masculino, mayoritariamente portadores de cardiopatía isquémica (90,1%). Según la clasificación de la Asociación Americana de Rehabilitación Cardiovascular y Pulmonar, 54 pacientes (29,8%) eran de alto riesgo, 29 (16,0%) de moderado riesgo y 98 (54,1%) de bajo riesgo. En más de 10.000 horas de actividad física realizadas, un paciente requirió el implante de un marcapaso definitivo por bloqueo auriculoventricular completo, sin observarse otras complicaciones graves. Se obtuvo una mejoría significativa (p = 0,001) de la capacidad funcional, que aumentó de 7,34 ± 2,68 a 10,20 ± 2,35 METs (incremento relativo individual promedio 28,1%). Conclusiones: La RC es un tratamiento seguro y efectivo en los pacientes cardiópatas, aún en aquellos de moderado y alto riesgo. El uso de cardiotacómetros permite una adecuada monitorización del ejercicio y una oportuna detección de complicaciones.

Introduction: physical exercise, integrating cardiac rehabilitation (CR), has a proven positive effect on the prognosis of patients with cardiovascular disease, optimizing cardiac performance in terms of functional capacity. CR programs aim to obtain maximum clinical benefits with minimal risks to the patient. Objectives: assess the safety and efficacy of a cardiotachometer-monitored out-of-hospital CR program in high- and moderate-risk patients, based on the absence of major cardiac complications and improvement in participant's functional capacity. Materials and methods: retrospective cohort study, submitted to a CR plan for 12 weeks in the period between January 2014 and March 2020. Clinical and functional parameters were evaluated at the beginning and at the end of the rehabilitation plan, controlling effort tolerance, blood pressure and heart rate using cardiotachometers. Results: 181 patients were included, aged 58.7 ± 9.7 years and 87.8% female, of whom 90% were carriers of ischemic heart disease. According to the classification of the American Association of Cardiovascular and Pulmonary Rehabilitation, the patients were distributed as follows: 54 (29.8%) at high risk, 29 (16.0%) at intermediate risk, and 98 (54.1%) low risk. In more than ten thousand hours of physical activity performed, one patient required implantation of a permanent pacemaker due to complete atrioventricular block. A significant improvement (p = 0.001) of the functional capacity, from 7.34 ± 2.68 to 10.2 ± 2.35 (mean relative improvement: 28.1%.) was obtained. Conclusions: the CR is a safe and effective procedure for cardiac patients, even in moderate or high-risk subjects. The use of cardiotachometers allows adequate exercise monitoring and timely detection of complications.

Introdução: o exercício físico, integrando a reabilitação cardíaca (RC), tem comprovado efeito positivo no prognóstico de pacientes com doença cardiovascular, otimizando o desempenho cardíaco em termos de capacidade funcional. Os programas de RC visam obter o máximo de benefícios clínicos com riscos mínimos para o paciente. Objetivos: avaliar a segurança e eficácia de um programa de RC fora do hospital monitorado por cardiotacômetro em pacientes de alto e moderado risco, com base na ausência de complicações cardíacas maiores e na melhora da capacidade funcional dos participantes. Materiais e métodos: trata-se de um estudo descritivo, de um plano de RC de 12 semanas, em um período entre janeiro de 2014 a março de 2020. Os parâmetros clínicos e funcionais foram avaliados no início e no final do plano de reabilitação, a tolerância ao esforço, pressão arterial e frequência cardíaca utilizando cardiotacômetros. Resultados: foram incluídos 181 pacientes, com média de idade de 58,7 ± 9,7 anos e 87,8% do sexo masculino, dos quais 90% eram portadores de cardiopatia isquêmica. De acordo com a classificação da Associação Americana de Reabilitação Cardiovascular e Pulmonar, os pacientes foram distribuídos da seguinte forma: 54 (29,8%) de alto risco, 29 (16,0%) de risco intermediário e 98 (54,1%) de baixo risco. Em mais de dez mil horas de atividade física realizada, um paciente necessitou de implante de marcapasso definitivo por bloqueio atrioventricular total. A avaliação final mostrou melhora significativa (p = 0,001) na capacidade funcional medida em METs; este passou de 7,34 ± 2,68 para 10,2 ± 2,35 (melhora relativa média: 28,1%). Conclusões: este trabalho demonstra que a RC é um tratamento seguro e eficaz para pacientes com doenças cardíacas, mesmo em indivíduos de risco moderado e alto. O uso de cardiotacômetros permite o monitoramento adequado do exercício e a detecção oportuna de complicações.

Tele-rehabilitation and hospital-based cardiac rehabilitation are comparable in increasing patient activation and health literacy: A pilot study.

BACKGROUND: Cardiac tele-rehabilitation is defined as using information and communication technology to support rehabilitation services. However, it requires a high level of patient activation and health literacy; this has not yet been explored. AIMS: The purpose of this study was to evaluate patient activation and health literacy in tele-rehabilitation compared to hospital-based cardiac rehabilitation. METHODS: We conducted a pilot study in patients with ischaemic or heart valve disease. In a non-randomised design, 24 patients attended a 12-week tele-rehabilitation programme, and 53 matched controls a 12-week hospital-based cardiac rehabilitation programme. The primary outcome was patient activation, which was assessed using the Patient Activation Measure before the intervention, at the end of the intervention and at follow-up six months after the intervention. The secondary outcome was health literacy, assessed using three dimensions from the Health Literacy Questionnaire before rehabilitation and at six-month follow-up: actively manage my health (HLQ3), ability to engage with healthcare providers (HLQ6) and understanding health information (HLQ9). RESULTS: Patient activation improved similarly in tele-rehabilitation and hospital-based cardiac rehabilitation at all time points. Six months after the intervention, patients in tele-rehabilitation significantly improved on the dimension HLQ6 compared to patients in hospital-based cardiac rehabilitation. No significant between-group differences were found in HLQ3 or HLQ9. CONCLUSION: Tele-rehabilitation and hospital-based cardiac rehabilitation seemed to be equally successful in improving patient activation and health literacy. Tele-rehabilitation should be further tested in a randomised controlled trial, with a focus on whether patient levels of education and self-management at the initiation of rehabilitation are decisive factors for tele-rehabilitation participation.

[Rehabilitation of valvular patient]. / La réadaptation du patient valvulaire.

Valvular disease is the second indication of cardiac rehabilitation (CR) after coronary artery disease. Patients suffering valvular disease are addressed to CR after valvular repair, and are usually old. Valvular replacement are the most frequent, and more and more patients being treated by TAVI are addressed to CR. CR takes place on two phases: From the seventh (day 7) to the fifteenth (day 15) day: management of complications, respiratory physio, and help to autonomy if necessary. From the fifteenth day (day 15): rehabilitation to exercise after an exercise stress test with or without MVO2 measurement. Because the patients are taking anticoagulants and are at risk of endocarditis, therapeutic education takes an important place during the stage. CR of patients suffering valvular disease has demonstrated its usefulness with: An increase of exercise capacity in all kind of valvular disease; A reduction of left ventricular hypertrophy in patients with aortic valve stenosis. No serious complication was observed in all studies regarding CR in patients with valvular disease.

Exercise recommendations in patients with valvular heart disease.

Valvular heart disease affects 1%-2% of young individuals, many of whom aspire to partake in competitive sport or high intensity recreational exercise. There are limited reports on the impact of intensive physical activity on the progression of valvular heart disease; therefore, current recommendations are based on consensus opinion. The management of exercising individuals with valvular heart disease requires a structured approach that incorporates several key factors including symptomatic status, functional capacity, type and nature of the valvular lesion, impact on ventricular structure and function and effect on pulmonary artery pressure. Asymptomatic individuals with minor valvular abnormalities may engage in all forms of competitive sport, whereas those with lesions of moderate severity may exercise intensively if an exercise stress test tailored to the relevant physical activity reveals good functional capacity without myocardial ischaemia, haemodynamic disturbances or arrhythmia. Symptomatic athletes and those with severe valvular heart disease, impaired ventricular function, pulmonary hypertension and arrhythmias should refrain from most competitive sports. Athletes with a bicuspid aortic valve and aortic root diameter >40 mm should avoid sport with a strong isometric component even with minimal valvular dysfunction. There is an association between mitral valve prolapse and sudden cardiac death in the general population; however, there is limited evidence of increased risk with competitive sport. Athletes undergoing corrective surgery may return to exercise after 3 months if ventricular function and exercise capacity are preserved. Individuals anticoagulated for mechanical bioprosthetic valves should avoid contact or collision sport to minimise the risk of bleeding.

Prognostic Value of the 6-Min Walk Test After Open-Heart Valve Surgery: EXPERIENCE OF A CARDIOVASCULAR REHABILITATION PROGRAM.

PURPOSE: This single-center retrospective analysis aimed to evaluate the prognostic relevance of 6-min walk test (6MWT) in patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery. METHODS: One hundred one patients able to perform a 6MWT within the first week of admission (time after surgery: 16 ± 8 d) were included (age 68 ± 11 y; 55% female; median left ventricular ejection fraction 55% [interquartile range: 50-60]; 51% after aortic valve surgery). Study endpoints were cardiovascular death and the combined outcome of cardiovascular death/cardiac hospitalization. Univariate and multivariate analyses were performed to analyze predictive value of the 6MWT. RESULTS: After a median follow-up of 27 mo, cardiovascular mortality was 9.9% while combined endpoint occurrence was 33%. Patients experiencing study endpoints had lower left ventricular ejection fraction, higher N-terminal prohormone of brain natriuretic peptide serum levels, and longer in-hospital stay (all P < .05). The 6MWT distance was a significant predictor of cardiovascular death (hazard ratio [HR] = 0.89, 95% CI: 0.81-0.97, P = .007) and cardiac hospitalizations (HR = 0.95, 95% CI: 0.90-0.99, P = .02). Even after adjusting for the relevant confounding variables of cardiovascular death and cardiac hospitalization, the adjusted HR = 0.88, 95% CI: 0.75-0.98, P = .028 and adjusted HR = 0.95, 95% CI: 0.90-0.99, P = .05, respectively. CONCLUSIONS: In patients admitted to an in-hospital cardiovascular rehabilitation program after open-heart valve surgery, 6MWT proved to be an independent prognostic tool, potentially allowing identification of high-risk patients for whom a more intensive and tailored in-hospital cardiovascular rehabilitation program should be designed and implemented in order to avoid unfavorable cardiovascular events.

Patient perceptions of experience with cardiac rehabilitation after isolated heart valve surgery.

BACKGROUND: Little evidence exists on whether cardiac rehabilitation is effective for patients after heart valve surgery. Yet, accepted recommendations for patients with ischaemic heart disease continue to support it. To date, no studies have determined what heart valve surgery patients prefer in a cardiac rehabilitation programme, and none have analysed their experiences with it. AIMS: The purpose of this qualitative analysis was to gain insight into patients' experiences in cardiac rehabilitation, the CopenHeartVR trial. This trial specifically assesses patients undergoing isolated heart valve surgery. METHODS: Semi-structured interviews were conducted with nine patients recruited from the intervention arm of the trial. The intervention consisted of a physical training programme and a psycho-educational intervention. Participants were interviewed three times: 2-3 weeks, 3-4 months and 8-9 months after surgery between April 2013 and October 2014. Data were analysed using qualitative thematic analysis. RESULTS: Participants had diverse needs and preferences. Two overall themes emerged: cardiac rehabilitation played an important role in (i) reducing insecurity and (ii) helping participants to take active personal responsibility for their health. Despite these benefits, participants experienced existential and psychological challenges and musculoskeletal problems. Participants also sought additional advice from healthcare professionals both inside and outside the healthcare system. CONCLUSIONS: Even though the cardiac rehabilitation programme reduced insecurity and helped participants take active personal responsibility for their health, they experienced existential, psychological and physical challenges during recovery. The cardiac rehabilitation programme had several limitations, having implications for designing future programmes.

Characteristics of structured physical training currently provided in cardiac patients: insights from the Exercise Training in Cardiac Rehabilitation (ETCR) Italian survey.

BACKGROUND: Uncertainty exists about current delivery levels of exercise training (ET) during Cardiac Rehabilitation (CR) programmes. AIM OF THE STUDY: To evaluate ET modalities in the real world of CR facilities in Italy. METHODS: This was an observational survey of aggregate data, collected from CR facilities on a voluntary basis. Snapshots of a single working day at a local site were made, in terms of characteristics of patients and ET programmes delivered. RESULTS. Overall, 612 patients from 26 CR units were included, with an in-patient vs. out-patient ratio of 3:1. Coronary artery disease (57.6%), heart failure (20.3%), and valve disease/surgery (22.1%) were the most represented target groups. The prevalence of endurance continuous training, interval training, and resistance/strength training was 66.7%, 11.1%, and 9.0%; other non-aerobic endurance and non-resistance training modalities such as respiratory muscle training and calisthenics were reported in 39.9% and 42.9% of cases respectively. Workloads for endurance exercise training were determined by cardiopulmonary test, conventional 12-leads ECG exercise testing, 6min-walking test, theoretical determination of heart rate, and rating of perceived exertion in 9%, 8%, 27%, 9%, and 40% of cases respectively. The average duration of the programmes (on an intention to treat basis) was 25 sessions of 42±11  minutes, with a frequency of >4 sessions/week in 67% of patients. CONCLUSIONS: Despite advances in CR interventions, there is a significant need for improvement of functional evaluation and exercise training prescription, and consideration of a wider range of training modalities in Italy. .

Patients' preference for exercise setting and its influence on the health benefits gained from exercise-based cardiac rehabilitation.

OBJECTIVE: To assess patient preference for exercise setting and examine if choice of setting influences the long-term health benefit of exercise-based cardiac rehabilitation. METHODS: Patients participating in a randomised controlled trial following either heart valve surgery, or radiofrequency ablation for atrial fibrillation were given the choice to perform a 12-week exercise programme in either a supervised centre-based, or a self-management home-based setting. Exercise capacity and physical and mental health outcomes were assessed for up to 24months after hospital discharge. Outcomes between settings were compared using a time×setting interaction using a mixed effects regression model. RESULTS: Across the 158 included patients, an equivalent proportion preferred to undertake exercise rehabilitation in a centre-based setting (55%, 95% CI: 45% to 63%) compared to a home-based setting (45%, 95% CI: 37% to 53%, p=0.233). At baseline, those who preferred a home-based setting reported better physical health (mean difference in physical component score: 5.0, 95% CI 2.3 to 7.4; p=0.001) and higher exercise capacity (mean between group difference 15.9watts, 95% CI 3.7 to 28.1; p=0.011). With the exception of the depression score in the Hospital Anxiety and Depression Score (F(3.65), p=0.004), there was no evidence of a significant difference in outcomes between settings. CONCLUSION: The preference of patients to participate in home-based and centre-based exercise programmes appears to be equivalent and provides similar health benefits. Whilst these findings support that patients should be given the choice between exercise-settings when initiating cardiac rehabilitation, further confirmatory evidence is needed.

Cost-utility analysis of cardiac rehabilitation after conventional heart valve surgery versus usual care.

Background While cardiac rehabilitation in patients with ischaemic heart disease and heart failure is considered cost-effective, this evidence may not be transferable to heart valve surgery patients. The aim of this study was to investigate the cost-effectiveness of cardiac rehabilitation following heart valve surgery. Design We conducted a cost-utility analysis based on a randomised controlled trial of 147 patients who had undergone heart valve surgery and were followed for 6 months. Methods Patients were randomised to cardiac rehabilitation consisting of 12 weeks of physical exercise training and monthly psycho-educational consultations or to usual care. Costs were measured from a societal perspective and quality-adjusted life years were based on the EuroQol five-dimensional questionnaire (EQ-5D). Estimates were presented as means and 95% confidence intervals (CIs) based on bootstrapping. Costs and effect differences were presented in a cost-effectiveness plane and were transformed into net benefit and presented in cost-effectiveness acceptability curves. Results No statistically significant differences were found in total societal costs (-1609 Euros; 95% CI: -6162 to 2942 Euros) or in quality-adjusted life years (-0.000; 95% CI -0.021 to 0.020) between groups. However, approximately 70% of the cost and effect differences were located below the x-axis in the cost-effectiveness plane, and the cost-effectiveness acceptability curves showed that the probability for cost- effectiveness of cardiac rehabilitation compared to usual care is at minimum 75%, driven by a tendency towards costs savings. Conclusions Cardiac rehabilitation after heart valve surgery may not have improved health-related quality of life in this study, but is likely to be cost-effective for society, outweighing the extra costs of cardiac rehabilitation.

Inspiratory Muscle Training and Functional Capacity in Patients Undergoing Cardiac Surgery.

INTRODUCTION: Cardiac surgery is a highly complex procedure which generates worsening of lung function and decreased inspiratory muscle strength. The inspiratory muscle training becomes effective for muscle strengthening and can improve functional capacity. OBJECTIVE: To investigate the effect of inspiratory muscle training on functional capacity submaximal and inspiratory muscle strength in patients undergoing cardiac surgery. METHODS: This is a clinical randomized controlled trial with patients undergoing cardiac surgery at Instituto Nobre de Cardiologia. Patients were divided into two groups: control group and training. Preoperatively, were assessed the maximum inspiratory pressure and the distance covered in a 6-minute walk test. From the third postoperative day, the control group was managed according to the routine of the unit while the training group underwent daily protocol of respiratory muscle training until the day of discharge. RESULTS: 50 patients, 27 (54%) males were included, with a mean age of 56.7±13.9 years. After the analysis, the training group had significant increase in maximum inspiratory pressure (69.5±14.9 vs. 83.1±19.1 cmH2O, P=0.0073) and 6-minute walk test (422.4±102.8 vs. 502.4±112.8 m, P=0.0031). CONCLUSION: We conclude that inspiratory muscle training was effective in improving functional capacity submaximal and inspiratory muscle strength in this sample of patients undergoing cardiac surgery.

Survey Reported Participation in Cardiac Rehabilitation and Survival After Mitral or Aortic Valve Surgery.

We sought to measure the impact of cardiac rehabilitation (CR) on mortality in patients with mitral or aortic heart valve surgery (HVS) and nonobstructive coronary artery disease. We surveyed all patients (or a close family member if the patient was deceased) who had HVS without coronary artery bypass in 2006 through 2010 at the Mayo Clinic to assess if they attended CR after their HVS. We performed a propensity-adjusted landmark analysis to test the association between CR attendance and long-term all-cause mortality conditional on surviving the first year after HVS. Survey response rate was 40% (573/1,420), with responders more likely to be older, have longer hospitalizations, and have more aortic valve disease. A total of 547 patients (59% aortic surgery, ejection fraction 64%) with valid survey responses and 1-year follow-up were included in the propensity analysis, of whom 296 (54%) attended CR. There were 100 deaths during a median follow-up of 5.8 years. For all patients, the propensity-adjusted model suggested no impact of CR on mortality (hazard ratio [HR] 1.03, 95% CI 0.66 to 1.62). When stratified by procedure, results suggested a potentially favorable, but nonsignificant, effect in patients with mitral valve surgery (HR 0.49, 95% CI 0.15 to 1.56), but not in patients with aortic valve surgery (HR 1.00, 95% CI 0.61 to 1.64.) In conclusion, we found no survival advantage for patients with normal preoperative ejection fraction who attended CR after surgical "correction" of their severe aortic or mitral valve disease.

Inspiratory muscle training and functional capacity in patients undergoing cardiac surgery

Abstract Introduction: Cardiac surgery is a highly complex procedure which generates worsening of lung function and decreased inspiratory muscle strength. The inspiratory muscle training becomes effective for muscle strengthening and can improve functional capacity. Objective: To investigate the effect of inspiratory muscle training on functional capacity submaximal and inspiratory muscle strength in patients undergoing cardiac surgery. Methods: This is a clinical randomized controlled trial with patients undergoing cardiac surgery at Instituto Nobre de Cardiologia. Patients were divided into two groups: control group and training. Preoperatively, were assessed the maximum inspiratory pressure and the distance covered in a 6-minute walk test. From the third postoperative day, the control group was managed according to the routine of the unit while the training group underwent daily protocol of respiratory muscle training until the day of discharge. Results: 50 patients, 27 (54%) males were included, with a mean age of 56.7±13.9 years. After the analysis, the training group had significant increase in maximum inspiratory pressure (69.5±14.9 vs. 83.1±19.1 cmH2O, P=0.0073) and 6-minute walk test (422.4±102.8 vs. 502.4±112.8 m, P=0.0031). Conclusion: We conclude that inspiratory muscle training was effective in improving functional capacity submaximal and inspiratory muscle strength in this sample of patients undergoing cardiac surgery.

[Return to work in patients with heart disease after cardiac rehabilitation]. / Reincorporación laboral en trabajadores cardiópatas posterior a rehabilitación cardiaca.

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.

Introducción: en un estudio observacional, retrospectivo evaluamos la frecuencia, presentación clínica y tratamiento de linfocele en pacientes pediátricos con trasplante renal. Métodos: de enero de 2004 a enero de 2009 se realizaron 242 trasplantes renales, 197 de donantes vivos y 45 trasplantes de donantes cadavéricos. La técnica quirúrgica utilizada fue la habitual y la de los implantes uretrales fue la técnica Ricard modificada. El tratamiento fue por punción cutánea y drenajes internos mediante una ventana peritoneal laparoscópica. Resultados: se diagnosticaron siete pacientes con linfoceles (2.9 % con un IC 95 % 0.6-5.2 %). Una paciente del sexo femenino y seis del sexo masculino, todos fueron sometidos a drenajes por punción cutánea, seis pacientes fueron recidivados y tratados exitosamente por drenaje interno mediante una ventana peritoneal laparoscópica. Conclusiones: nuestra frecuencia es igual a la reportada en otros estudios (0.6-18 %). El drenaje interno mediante la ventana peritoneal laparoscópica parece ser lo más apropiado en pacientes pediátricos.

Connections between nutritional status and proton pump inhibitor therapy in patients scheduled for cardiovascular rehabilitation after treatment for ischaemic and valvular heart disease.

BACKGROUND: Multiple and yet uncertain connections exist between cardiovascular diseases and the nutritional status of patients, particularly in relation to cardiovascular treatments. Proton pump inhibitors (PPI) are among the most commonly used group of drugs. AIM: To analyse utilisation of PPI in association with nutritional risk of patients scheduled for rehabilitation after treatment for ischaemic and valvular heart disease. METHODS: Retrospective analyses on a consecutive sample of patients, which included drug utilisation of PPI and nutritional risk screening, using a standardised NRS-2002 tool. The patients (n = 536) were divided into groups based on previous cardiovascular treatments and use of PPI. RESULTS: Nearly half of the patients (244, 46.1%) had PPI in their chronic therapy despite the clinically negligible prevalence of conditions that are their fundamental indications. The odds for using PPI in patients with increased nutritional risk, estimated by logistic regression, were 3.34 (95% confidence intervals [CI] 2.26-4.94), p < 0.001. Receiver operating curve analyses also revealed significant differences of PPI utilisation in connection with NRS-2002 > 3: positive likelihood-ratio (LR) 2.35 (95% CI 2.10-2.60); negative LR 0.46 (95% CI 0.4-0.6); area under the curve (AUC) 0.720; p < 0.001; as well as the percentage weigh loss history > 6.36% (positive LR 2.22 [95% CI 2.00-2.50]; negative LR 0.41 [95% CI 0.30-0.50]; AUC 0.707; p < 0.001). CONCLUSIONS: Utilisation of PPI was found to be of relatively high prevalence and significantly associated with parameters of nutritional risk screening. Furthermore, it was in correlation with the age of patients and the existence of chronic kidney disease, which are well-established predispositions for poor nutritional status. Nutritional risk seems to be additionally negatively challenged by utilisation of PPI due to gastric malabsorption and anaemia.

Routine initial exercise stress testing for treatment stratification in comprehensive cardiac rehabilitation.

There is evidence of substantial benefit of cardiac rehabilitation (CR) for patients with low exercise capacity at admission. Nevertheless, some patients are not able to perform an initial exercise stress test (EST). We aimed to describe this group using data of 1094 consecutive patients after a cardiac event (71±7 years, 78% men) enrolled in nine centres for inpatient CR. We analysed sociodemographic and clinical variables (e.g. cardiovascular risk factors, comorbidities, complications at admission), amount of therapy (e.g. exercise training, nursing care) and the results of the initial and the final 6-min walking test (6MWT) with respect to the application of an EST. Fifteen per cent of patients did not undergo an EST (non-EST group). In multivariable analysis, the probability of obtaining an EST was higher for men [odds ratio (OR) 1.89, P=0.01], a 6MWT (per 10 m, OR 1.07, P<0.01) and lower for patients with diabetes mellitus (OR 0.48, P<0.01), NYHA-class III/IV (OR 0.27, P<0.01), osteoarthritis (OR 0.39, P<0.01) and a longer hospital stay (per 5 days, OR 0.87, P=0.02). The non-EST group received fewer therapy units of exercise training, but more units of nursing care and physiotherapy than the EST group. However, there were no significant differences between both groups in the increase of the 6MWT during CR (123 vs. 108 m, P=0.122). The present study confirms the feasibility of an EST at the start of CR as an indicator of disease severity. Nevertheless, patients without EST benefit from CR even if exercising less. Thus, there is a justified need for individualized, comprehensive and interdisciplinary CR.

A propose of pulmonary dysfunction stratification after valve surgery by physiotherapeutic assistance level.

OBJECTIVE: a) to propose and implement an evaluation system; b) to classify the pulmonary involvement and determine levels of physical therapy; c) to check the progress postoperatively. METHODS: Patients underwent physiotherapy assessment preoperatively, postoperatively and after 5 days of intervention. They were classified into three levels of care: level 1 - low risk of complication; Level 2 - medium risk; Level 3 - high risk. We used analysis of variance and Kruskal-Wallis and analysis of variance for repeated measures or Friedman. Chi-square test or Fisher for proportions. We considered statistical significance level P<0.05. RESULTS: We studied 199 patients, 156 classified within level 1, 32 at level 2 and 11 at level 3. Thoracoabdominal motion and auscultation changed significantly postoperatively, persisting at levels 2 and 3 (P<0.05). Oxygenation and respiratory rate changed at levels 2 and 3 postoperatively (P<0.05) with recovery at the end. Significant decrease in lung volumes occurred in three levels (P<0.05) with partial recovery at level 1, lung collapse occurred at all levels, with recovery by 56% at level 1, 47% at level 2, 27% at level 3. CONCLUSION: The proposed assessment identified valve surgery patients who require differentiated physical therapy. Level 1 patients had rapid recovery, while the level 2 showed significant changes with functional gains at the end. Level 3 patients, more committed and prolonged recovery, should receive greater assistance.

Update to the study protocol, including statistical analysis plan for a randomized clinical trial comparing comprehensive cardiac rehabilitation after heart valve surgery with control: the CopenHeartVR trial.

BACKGROUND: Heart valve diseases are common with an estimated prevalence of 2.5% in the Western world. The number is rising because of an ageing population. Once symptomatic, heart valve diseases are potentially lethal, and heavily influence daily living and quality of life. Surgical treatment, either valve replacement or repair, remains the treatment of choice. However, post-surgery, the transition to daily living may become a physical, mental and social challenge. We hypothesize that a comprehensive cardiac rehabilitation program can improve physical capacity and self-assessed mental health and reduce hospitalization and healthcare costs after heart valve surgery. METHODS: This randomized clinical trial, CopenHeartVR, aims to investigate whether cardiac rehabilitation in addition to usual care is superior to treatment as usual after heart valve surgery. The trial will randomly allocate 210 patients 1:1 to an intervention or a control group, using central randomization, and blinded outcome assessment and statistical analyses. The intervention consists of 12 weeks of physical exercise and a psycho-educational intervention comprising five consultations. The primary outcome is peak oxygen uptake (VO2 peak) measured by cardiopulmonary exercise testing with ventilatory gas analysis. The secondary outcome is self-assessed mental health measured by the standardized questionnaire Short Form-36. Long-term healthcare utilization and mortality as well as biochemistry, echocardiography and cost-benefit will be assessed. A mixed-method design will be used to evaluate qualitative and quantitative findings, encompassing a survey-based study before the trial and a qualitative pre- and post-intervention study. CONCLUSION: This randomized clinical trial will contribute with evidence of whether cardiac rehabilitation should be provided after heart valve surgery. The study is approved by the local regional Research Ethics Committee (H-1-2011-157), and the Danish Data Protection Agency (j.nr. 2007-58-0015). TRIAL REGISTRATION: Trial registered 16 March 2012; ClinicalTrials.gov ( NCT01558765 ).

A propose of pulmonary dysfunction stratification after valve surgery by physiotherapeutic assistance level / Proposta de estratificação da disfunção pulmonar após cirurgia valvar segundo níveis de assistência fisioterapêutica

Abstract Objective: a) to propose and implement an evaluation system; b) to classify the pulmonary involvement and determine levels of physical therapy; c) to check the progress postoperatively. Methods: Patients underwent physiotherapy assessment preoperatively, postoperatively and after 5 days of intervention. They were classified into three levels of care: level 1 - low risk of complication; Level 2 - medium risk; Level 3 - high risk. We used analysis of variance and Kruskal-Wallis and analysis of variance for repeated measures or Friedman. Chi-square test or Fisher for proportions. We considered statistical significance level P<0.05. Results: We studied 199 patients, 156 classified within level 1, 32 at level 2 and 11 at level 3. Thoracoabdominal motion and auscultation changed significantly postoperatively, persisting at levels 2 and 3 (P<0.05). Oxygenation and respiratory rate changed at levels 2 and 3 postoperatively (P<0.05) with recovery at the end. Significant decrease in lung volumes occurred in three levels (P<0.05) with partial recovery at level 1, lung collapse occurred at all levels, with recovery by 56% at level 1, 47% at level 2, 27% at level 3. Conclusion: The proposed assessment identified valve surgery patients who require differentiated physical therapy. Level 1 patients had rapid recovery, while the level 2 showed significant changes with functional gains at the end. Level 3 patients, more committed and prolonged recovery, should receive greater assistance. .

Resumo Objetivo: a) propor e aplicar um sistema de avaliação; b) classificar o comprometimento pulmonar e determinar os níveis de assistência fisioterapêutica; c) verificar a evolução no pós-operatório de cirurgia valvar. Métodos: Pacientes realizaram avaliação fisioterapêutica no pré-operatório, pós-operatório e após 5 dias de intervenção. Foram classificados em três níveis de atenção: nível 1 - baixo risco de complicação; nível 2 - médio risco; nível 3 - alto risco. Utilizou-se Análise de Variância e Kruskal-Wallis e Análise de Variância para medidas repetidas ou Friedmann. Teste qui-quadrado ou Fisher para as proporções. Considerou-se nível de significância estatística P<0,05. Resultados: Foram estudados 199 pacientes, 156 classificados no nível 1, 32 nível 2 e 11 nível 3. Movimento toracoabdominal e ausculta pulmonar alteraram significantemente no pós-operatório, persistindo nos níveis 2 e 3 (P<0,05). Oxigenação e frequência respiratória se modificaram nos níveis 2 e 3 no pós-operatório (P<0,05), com recuperação no final. Diminuição significante dos volumes pulmonares ocorreu nos três níveis (P<0,05), com recuperação parcial no nível 1. Colapso pulmonar ocorreu em todos os níveis, com recuperação em 56% no nível 1, 47% no nível 2, 27% no nível 3. Conclusão: A avaliação proposta identificou pacientes de cirurgia valvar que necessitam de assistência fisioterapêutica diferenciada. Pacientes do nível 1 tiveram rápida recuperação, enquanto os do nível 2 mostraram alterações significativas, com ganhos funcionais no final. Pacientes do nível 3, mais comprometidos e com recuperação prolongada, devem receber maior assistência. .