Effects of 12-Week Supervised Early Resistance Training (SEcReT) Versus Aerobic-Based Rehabilitation on Cognitive Recovery Following Cardiac Surgery via Median Sternotomy: A Pilot Randomised Controlled Trial.

AIMS: To investigate the effects of a 12-week early moderate-intensity resistance training program compared to aerobic-based rehabilitation on postoperative cognitive recovery following cardiac surgery via median sternotomy. METHODS: This was a multicentre, prospective, pragmatic, non-blinded, pilot randomised controlled trial (1:1 randomisation) of two parallel groups that compared a 12-week early moderate-intensity resistance training group to a control group, receiving aerobic-based rehabilitation. English-speaking adults (≥18 years) undergoing elective cardiac surgery via median sternotomy were randomised using sealed envelopes, with allocation revealed before surgery. The primary outcome was cognitive function, assessed using the Alzheimer's Disease Assessment Scale-cognitive subscale (ADAS-cog), at baseline, 14 weeks and 6 months postoperatively. RESULTS: The ADAS-cog score at 14 weeks was significantly better for the resistance training group (n=14, 7.2±1.4; 95% CI 4.3, 10.2, vs n=17, 9.2±1.3; 95% CI 6.6, 11.9, p=0.010). At 14 weeks postoperatively, 53% of the aerobic-based rehabilitation group (n=9/17) experienced cognitive decline by two points or more from baseline ADAS-cog score, compared to 0% of the resistance training group (n=0/14; p=0.001). CONCLUSION: Early resistance training appears to be safe and may improve cognitive recovery compared to standard, aerobic-based rehabilitation following cardiac surgery via median sternotomy, however as this was a pilot study, the sample size was small and further research is needed to determine a causal relationship.

Sternal Precautions and Prone Positioning of Infants Following Median Sternotomy: A Nationwide Survey.

PURPOSE: To describe current practice of pediatric sternal precautions (PSPs) and prone positioning restrictions (PPRs) in infants after median sternotomy. METHODS: A Web-based survey with 21 questions was developed on the basis of a review of current literature and expert consultation. Snowball sampling resulted in 68 participants well represented by profession throughout the United States. RESULTS: Approximately 80% of participants reported having institutional protocols for PSPs. Most common reported PSPs were no lifting at the axillae and no pulling of arms to achieve sitting. PSPs also included PPRs. The opinions of participants supported no PPRs or modified PPRs compared with strict PPRs. CONCLUSIONS: Types of PPRs varied across participants, with the majority of participants in favor of modified PPRs while PSPs were less varied. Research is needed to examine the effects of PSPs and PPRs in infants post-median sternotomy.

Effects of Supervised Early Resistance Training versus standard care on cognitive recovery following cardiac surgery via median sternotomy (the SEcReT study): protocol for a randomised controlled pilot study.

INTRODUCTION: Mild cognitive impairment is considered a precursor to dementia and significantly impacts upon quality of life. The prevalence of mild cognitive impairment is higher in the post-surgical cardiac population than in the general population, with older age and comorbidities further increasing the risk of cognitive decline. Exercise improves neurogenesis, synaptic plasticity and inflammatory and neurotrophic factor pathways, which may help to augment the effects of cognitive decline. However, the effects of resistance training on cognitive, functional and overall patient-reported recovery have not been investigated in the surgical cardiac population. This study aims to determine the effect of early moderate-intensity resistance training, compared to standard care, on cognitive recovery following cardiac surgery via a median sternotomy. The safety, feasibility and effect on functional recovery will also be examined. METHODS: This study will be a prospective, pragmatic, pilot randomised controlled trial comparing a standard care group (low-intensity aerobic exercise) and a moderate-intensity resistance training group. Participants aged 18 years and older with coronary artery and/or valve disease requiring surgical intervention will be recruited pre-operatively and randomised 1:1 to either the resistance training or standard care group post-operatively. The primary outcome, cognitive function, will be assessed using the Alzheimer's Disease Assessment Scale and cognitive subscale. Secondary measures include safety, feasibility, muscular strength, physical function, multiple-domain quality of recovery, dynamic balance and patient satisfaction. Assessments will be conducted at baseline (pre-operatively) and post-operatively at 2 weeks, 8 weeks, 14 weeks and 6 months. DISCUSSION: The results of this pilot study will be used to determine the feasibility of a future large-scale randomised controlled trial that promotes the integration of early resistance training into existing aerobic-based cardiac rehabilitation programs in Australia. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12617001430325p . Registered on 9 October 2017. Universal Trial Number (UTN): U1111-1203-2131.

The Impact of a Less Restrictive Poststernotomy Activity Protocol Compared With Standard Sternal Precautions in Patients Following Cardiac Surgery.

OBJECTIVE: Guidelines following median sternotomy typically include strict sternal precautions (SP). Recently, alternative approaches propose less functional restrictions while avoiding excessive stress to the sternum. The study aimed to determine the effect of a less restrictive (LR) approach versus a standard SP protocol after median sternotomy. METHODS: The study was a cross-sectional design (n = 364; SP: n = 172, 66.3 [SD = 11.2] years; LR: n = 196, 65.2 [SD = 11.2] years). This study ran in 2 consecutive phases and compared 2 groups after median sternotomy at a community-based hospital. The LR group received instructions on the Keep Your Move in the Tube approach. At 2 to 3 weeks after discharge, sternal instability was assessed using the Sternal Instability Scale, and patients completed a self-reported survey (perceived pain rating/frequency, sternal instability, and functional mobility). The 2 groups were compared using the Mann-Whitney U test and chi-square test (P < .05). RESULTS: There were no significant differences between the 2 groups for all the outcomes, Sternal Instability Scale, pain rating, pain frequency, perceived sternal instability, difficulty with functional mobility, length of stay, and discharge disposition. CONCLUSIONS: In our study, the implementation of the LR approach, Keep Your Move in the Tube, had no adverse effect on outcomes 2 to 3 weeks following median sternotomy. Although no statistically significant differences were noted for all outcomes, patients with the LR approach reported less difficulty with functional mobility. IMPACT STATEMENT: These data are useful in clinical decision-making regarding alternative approaches for mobility following sternotomy.

Resistance Training Following Median Sternotomy: A Systematic Review and Meta-Analysis.

OBJECTIVE: Despite no evidence to support weight limitations following median sternotomy, sternal precautions continue to be routinely prescribed. Moreover, international cardiac rehabilitation guidelines lack sufficient detail for the implementation of resistance training. This systematic review and meta-analysis aimed to determine what the literature defines as resistance training; how resistance training is applied, progressed and evaluated; and, whether resistance training improves physical and functional recovery postoperatively in the cardiac surgical population. DATA SOURCES: Five (5) electronic databases were searched from inception to 28 September 2018 for studies published in English that investigated the effects of a resistance training intervention on physical and functional recovery following median sternotomy. RESULTS: Eighteen (18) trials (n=3,462) met eligibility criteria and were included in the analysis. Seven (7) randomised controlled trials shared common outcome measures, allowing meta-analysis. The performance of resistance training appears to be safe and feasible, and resulted in similar improvements in both cardiopulmonary capacity and anthropometry, when compared to aerobic training alone. However, the definition and application of resistance training is frequently a lower intensity and volume than recommended by the American College of Sports Medicine. Furthermore, sternal precautions are not reflective of the kinematics and weights used when performing many activities of daily living. For this reason, resistance training needs to be task-specific, reflecting functional tasks to promote recovery. CONCLUSION: Resistance training, in isolation or when combined with aerobic training, may lead to greater improvements in physical and functional recovery following cardiac surgery via median sternotomy; however, further research is required to inform clinical guidelines.

Exercise Parameters and Outcome Measures Used in Cardiac Rehabilitation Programs Following Median Sternotomy in the Elderly: A Systematic Review and Meta-Analysis.

OBJECTIVE: The aim of this systematic review was to identify exercise parameters and outcome measures used in cardiac rehabilitation programs following median sternotomy, in the elderly cardiac population. DATA SOURCES: Five (5) electronic databases were searched for relevant studies published in English after 1997. STUDY SELECTION: The screening process was completed by two independent researchers, with a third independent reviewer for overall agreement. Studies were selected if they included only cardiac patients aged ≥65 years who had undergone valve surgery and/or coronary artery bypass grafting via median sternotomy, and who had undertaken a postoperative cardiac rehabilitation exercise intervention assessing physical function and/or cognitive recovery as outcomes. DATA EXTRACTION: Two researchers independently completed the data extraction and quality assessment. Quality was assessed using a modified Downs and Black tool. DATA SYNTHESIS: In total, 11 articles were included for appraisal with respect to the quality of the study. Only two randomised controlled trials were suitable for meta-analysis. A higher volume of exercise was shown to have a positive effect on functional recovery, assessed using the 6-minute walk test (6MWT) (mean difference=26.97m; 95% confidence interval [CI], 6.96-46.97; p=0.008; I2=0%). No significant improvement was shown between additional exercise compared to standard care in improving VO2peak, maximal power output or quality of life. No studies evaluated the effect of exercise on cognitive recovery. CONCLUSIONS: Exercise significantly improves functional recovery in the post-surgical elderly cardiac population, however uncertainty still exists with regard to which modes of exercise and their specific parameters are most effective in improving cognitive recovery.

Esternotomia parcial para tratamento de lesão iatrogênica do tronco braquiocefálico durante traqueostomia / Partial sternotomy for management of iatrogenic brachiocephalic trunk injury during tracheotomy

A toracotomia mediana é uma via de acesso que atravessa longitudinalmente o esterno e pode ser subdividida em vertical total, parcial superior e parcial inferior. Na prática cirúrgica, o uso da esternotomia mediana parcial é uma alternativa que proporciona menor agressão cirúrgica. O tronco braquiocefálico é um dos grandes vasos torácicos mais acometidos em traumas e sua abordagem classicamente é feita por esternotomia mediana. Neste trabalho, apresenta-se o uso da esternotomia parcial superior em "T" invertido como possibilidade de via de acesso em situação de lesão traumática iatrogênica do tronco braquiocefálico.

The median thoracotomy is an access incision made longitudinally through the sternum and variants can be subdivided into total vertical and partial upper or partial lower vertical incisions. In surgical practice, using a partial median sternotomy is an alternative option that causes less surgical aggression. The brachiocephalic artery is one of the thoracic vessels most often affected in traumas and it can be accessed via a median sternotomy. This report describes use of an upper partial sternotomy to provide access in a case of traumatic iatrogenic injury of the brachiocephalic trunk.

Early initiation of post-sternotomy cardiac rehabilitation exercise training (SCAR): study protocol for a randomised controlled trial and economic evaluation.

INTRODUCTION: Current guidelines recommend abstinence from supervised cardiac rehabilitation (CR) exercise training for 6 weeks post-sternotomy. This practice is not based on empirical evidence, thus imposing potentially unnecessary activity restrictions. Delayed participation in CR exercise training promotes muscle atrophy, reduces cardiovascular fitness and prolongs recovery. Limited data suggest no detrimental effect of beginning CR exercise training as early as 2 weeks post-surgery, but randomised controlled trials are yet to confirm this. The purpose of this trial is to compare CR exercise training commenced early (2 weeks post-surgery) with current usual care (6 weeks post-surgery) with a view to informing future CR guidelines for patients recovering from sternotomy. METHODS AND ANALYSIS: In this assessor-blind randomised controlled trial, 140 cardiac surgery patients, recovering from sternotomy, will be assigned to 8 weeks of twice-weekly supervised CR exercise training commencing at either 2 weeks (early CR) or 6 weeks (usual care CR) post-surgery. Usual care exercise training will adhere to current UK recommendations. Participants in the early CR group will undertake a highly individualised 2-3 week programme of functional mobility, strength and cardiovascular exercise before progressing to a usual care CR programme. Outcomes will be assessed at baseline (inpatient), pre-CR (2 or 6 weeks post-surgery), post-CR (10 or 14 weeks post-surgery) and 12 months. The primary outcome will be change in 6 min walk distance. Secondary outcomes will include measures of functional fitness, quality of life and cost-effectiveness. ETHICS AND DISSEMINATION: Recruitment commenced on July 2017 and will complete by December 2019. Results will be disseminated via national governing bodies, scientific meetings and peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT03223558; Pre-results.

Reliability of sternal instability scale (SIS) for transverse sternotomy in lung transplantation (LTX).

A surgical incision for bilateral sequential lung transplantation (BSLTX) is the "clam shell" (CSI) approach via bilateral anterior thoracotomies and a transverse sternotomy to allow for sequential replacement of the lungs. This can be associated with significant post-operative pain, bony overriding or sternal instability. The sternal instability scale (SIS) is a non-invasive manual assessment tool that can be used to detect early bony non-union or instability following CSI; however, its reliability is unknown. OBJECTIVE: This prospective blinded reliability study aimed to assess intra-rater and inter-rater reliability of the SIS following lung transplantation. METHOD: Participants post BSLTX aged older than 18 years underwent sternal assessment utilizing the SIS. Two assessors examined the sternum using a standardized protocol at two separate time points with a test-re-test time of 48 hours. The outcome measure was SIS tool using four categories from 0 (clinically stable) to 3 (separated sternum with overriding). RESULTS: In total, 20 participants (75% female) with a mean age of 48 years (SD 17) and mean pain score of 3 out of 10 were included, 60% having well healed wounds and 25% reporting symptoms of sternal clicking. The most painful self-reported painful activity was coughing. The SIS demonstrated excellent reliability with a kappa = 0.91 by different assessors on the same day, and kappa = 0.83 for assessments by the same assessor on different days. CONCLUSION: The SIS is a reliable manual assessment tool for evaluation of sternal instability after CSI following BSLTX and may facilitate the timely detection and management of sternal instability.

The protective role of sex hormones in females and exercise prehabilitation in males on sternotomy-induced cranial hypoperfusion in aortic banded mini-swine.

During cardiac surgery, specifically sternotomy, cranial hypoperfusion is linked to cerebral ischemia, increased risk of perioperative watershed stroke, and other neurocognitive complications. The purpose of this study was to retrospectively examine the effect of sex hormones in females and exercise prehabilitation in males on median sternotomy-induced changes in cranial perfusion in a large animal model of heart failure. Cranial blood flow (CBF) before and 10 and 60 min poststernotomy was analyzed in eight groups of Yucatan mini-swine: female control, aortic banded, ovariectomized, and ovariectomized + aortic banded; male control, aortic banded, aortic banded + continuous exercise trained, and aortic banded + interval exercise trained. A median sternotomy decreased cranial perfusion during surgery in all pigs (~24 ± 2% relative to baseline; P ≤ 0.05). CBF was 30 ± 7% lower across all time points in all females vs. all males (P ≤ 0.05) and sternotomy decreased cranial perfusion (P ≤ 0.05) independent of sex (females = 34 ± 3% and males = 14 ± 3%) and aortic banding (intact control = 31 ± 5% and intact aortic banded = 31 ± 4%). CBF recovery at 60 min tended to be better in females vs. males (relative to 10 min poststernotomy, females = 23 ± 13% vs. males = -1 ± 5%) and intact aortic banded vs. control pigs (relative to 10 min poststernotomy, aortic banded = 43 ± 20% vs. control = 6 ± 16%; P ≤ 0.05) at 60 min poststernotomy. Ovariectomy impaired CBF recovery during cranial reperfusion 60 min following sternotomy (relative to baseline, all intact females = -1 ± 9% vs. all ovariectomized females = -15 ± 4%; P ≤ 0.05). Chronic exercise training completely prevented significant sternotomy-induced cranial hypoperfusion independent of aortic banding (sternotomy-induced deficit, all sedentary males = -24 ± 6% vs. all exercise-trained males = -7 ± 3%; P ≤ 0.05). Female sex hormones protected against impaired CBF recovery during reperfusion, while chronic exercise training prevented sternotomy-induced cranial hypoperfusion despite cardiac pressure overload.NEW & NOTEWORTHY Our findings suggest a median sternotomy may predispose patients, possibly postmenopausal women and sedentary men, to perioperative cerebral ischemia, an increased risk of cardiac surgery-related stroke, and resulting neurocognitive impairments. Specifically, data from this common surgical procedure show: 1) median sternotomy independently decreases cranial perfusion; 2) female sex hormones improve cranial blood flow recovery following sternotomy; and 3) exercise prehabilitation prevents sternotomy-induced cranial hypoperfusion. Exercise prehabilitation before cardiac surgery may be advantageous for capable patients.

A retrospective multicenter study on long-term prevalence of chronic pain after cardiac surgery.

BACKGROUND: There are limited data on sternotomy as a cause of chronic postsurgical pain, mainly restricted to 1 year after surgery. AIMS: To assess the prevalence of chronic post-sternotomy pain and its interference on daily living. METHODS: In three groups of patients, a standardized telephone interview was obtained at 3 months (n = 313), 1 year (n = 313), and 3 years (n = 319) following the rehabilitation program after cardiac surgery, in 11 rehabilitation centers. Presence, site, and the severity and interference of pain on selected daily living items were assessed. RESULTS: The prevalence of pain after cardiac surgery was 35.3% in the 3-month group, 26.8% in the 1-year group, and 19.8% in the 3-year group (P < 0.0001). Pain in the 3-year group was rated as moderate to severe in one-third of the patients. In patients aged above 75 years, the prevalence of pain in the 3-month and the 3-year group was nonsignificantly different [34.2 and 29.3%, respectively (NS)]. In the 3-month group, pain was more frequent in the female (51.4%) than in the male patients (31.3%; P < 0.01); in the remaining groups, a comparable prevalence was documented. CONCLUSION: Results form this large, retrospective, multicenter survey indicated that one out of five patients still complain pain at 3 years after cardiac surgery; persistence of pain was more common in the older patients. The approach to management of chronic pain by cardiologists and cardiac surgeons should be improved.

Robot-Assisted Training Early After Cardiac Surgery.

BACKGROUND: To assess feasibility and safety of a robot-assisted gait therapy with the Lokomat® system in patients early after open heart surgery. METHODS: Within days after open heart surgery 10 patients were subjected to postoperative Lokomat® training (Intervention group, IG) whereas 20 patients served as controls undergoing standard postoperative physiotherapy (Control group, CG). All patients underwent six-minute walk test and evaluation of the muscular strength of the lower limbs by measuring quadriceps peak force. The primary safety end-point was freedom from any device-related wound healing disturbance. Patients underwent clinical follow-up after one month. RESULTS: Both training methods resulted in an improvement of walking distance (IG [median, interquartile range, p-value]: +119 m, 70-201 m, p = 0.005; CG: 105 m, 57-152.5m, p < 0.001) and quadriceps peak force (IG left: +5 N, 3.8 7 N, p = 0.005; IG right: +3.5 N, 1.5-8.8 N, p = 0.011; CG left: +5.5 N, 4-9 N, p < 0.001; CG right: +6 N, 4.3-9.8 N, p < 0.001) in all participants. Results with robot-assisted training were comparable to early postoperative standard in hospital training (median changes in walking distance in percent, p = 0.81; median changes in quadriceps peak force in percent, left: p = 0.97, right p = 0.61). No deep sternal wound infection or any adverse event occurred in the robot-assisted training group. CONCLUSIONS: Robot-assisted gait therapy with the Lokomat® system is feasible and safe in patients early after median sternotomy. Results with robot-assisted training were comparable to standard in hospital training. An adapted and combined aerobic and resistance training intervention with augmented feedback may result in benefits in walking distance and lower limb muscle strength (ClinicalTrials.gov number, NCT 02146196).

Selected methods of the chest wall reconstruction for sternal dehiscence after median sternotomy.

Dehiscence of a median sternotomy wound is a potentially devastating and life-threatening complication of cardiac procedures.Depending on the localization, extensiveness, and profoundness of the defect a variety of muscle flaps may be used to cover the frontal mediastinum, in particular: pectoralis major, rectus abdominisor latissimus dorsi. In spite of several options for restoration of sternal integrity we cannot avoid following serious local complications increasing patients morbidity. The aim of this paper is to report a method of sternal dehiscence management. Surgical technique and its results are presented on the example of two patients treated in Plastic, Reconstructive and Aesthetic Surgery Clinic, Medical University in Lódz because of sternal dehiscence after cardiovascular procedure with sternotomy. Our experience indicates that modified bilateral pectoralis major flap seems to be effective surgical method of sternal dehiscence treatment. Also it is worth to remember that surgical procedure in this complication should be performed as soon as possible to decrease patient's disability and to avoid following complications.

Ventilatory strategies in the six-minute walk test in older patients receiving a three-week rehabilitation programme after cardiac surgery through median sternotomy.

BACKGROUND: Although the six-minute walk test (6MWT) is widely used in cardiac rehabilitation, little is known about the ventilatory strategies adopted by older patients who have recently undergone median sternotomy, in order to meet the increased metabolic demand in the 6MWT. METHODS: Using a portable gas-analyser we assessed the breathing patterns in the 6MWT before and after a 3-week rehabilitation programme in 84 older patients, 58 men and 26 women, mean age 71 years (standard deviation (SD) 6 years), who had undergone median sternotomy. RESULTS: After rehabilitation, patients increased end-test ventilation (33.1 l (SD 9.8) vs. 30.9 l (SD 8.4), p < 0.001) by increasing tidal volume (1.158 l (SD 0.298) vs. 1.065 l (SD 0.255), p < 0.001), while breathing frequency remained unchanged (29.9 bpm (SD 5.4) vs. 30.2 bpm (SD 5.8), p = 0.621). As a consequence, the ventilatory equivalent for CO2, was significantly improved (39.9 (SD 5.3) vs. 43.5 (SD 7.4), p < 0.001). Furthermore, the improvement in ventilatory efficiency was significantly (p < 0.001) correlated with the improvement in the distance walked on the 6MWT. CONCLUSION: Older patients who have undergone median sternotomy meet the increased metabolic demand on the 6MWT after cardiac rehabilitation by increasing tidal volume. Accordingly, we should consider including as a routine specific exercises for inspiratory muscle training in current rehabilitation programmes to reduce inspiratory muscle effort and further improve ventilatory efficiency.