Cardiac rehabilitation and acute aortic dissection: understanding and addressing the evidence GAP a systematic review.

Despite guideline recommendations, strategies for implementing cardiac rehabilitation (CR) in patients with acute aortic dissection (AAD) are not well established with little evidence to risk stratify prudent and effective guidelines for the many required variables. We conducted a systematic review of studies (2004-2023) reporting CR following type A (TA) and type B (TB) AAD. Our review is limited to open surgical repair for TA and medical treatment for TB. A total of 5 studies were included (4 TA-AAD and 1 TB-AAD) in the qualitative analysis. In general, observational data included 311 patients who had an overall favorable effect of CR in AAD consisting of a modestly improved exercise capacity and work load during cycle cardiopulmonary exercise test (TB-AAD), and improved quality of life (QoL). No adverse events were reported during symptom limited pre-CR treadmill or cycle exercise VO2 max or CR. Given the overall potential in this high risk population without adequate evidence for important variables such as safe time from post-op to CR, intensity of training, duration and frequency of sessions and followup it is time for a moderate sized well designed safe trial for patients' post-op surgery for TA-AAD and medically treated TB-AAD who are treated with standardized evidence based medical therapy and physical therapy from discharge randomized to CR versus usual care. PROSPERO registry ID: CRD42023392896.

Exercise parameters for the chronic type B aortic dissection patient: a literature review and case report.

INTRODUCTION: The conservative management of a Stanford type B aortic dissection (TBD) is optimal blood pressure management, cardiac rehabilitation, and progressive return to activities of daily living (ADL) while preventing advancing dissection and aortic dilation. Recent case reports indicate higher levels of activity may be safe; however, the exercise parameters for chronic TBD conditions span a broad range and the research is limited. CASE PRESENTATION: The clinical presentation and outpatient cardiac and physical rehabilitation program for a 61-year-old male with a chronic TBD from his subclavian artery to common iliac arteries is presented. The exercise protocol was developed and based on the available literature for the management of chronic aortic diseases. Eighteen months after the patient's acute TBD event, he began an exercise protocol designed to address the sport specific functional deficits related to his recreational activities. The program incorporated a variety of exercises from resistance training to cardiovascular exercise and high interval training. The therapeutic goals included restoration of cardiac fitness and improvement of core stability and appendicular strength, ultimately aiming toward a potential to return to recreational sport involving short duration, high intensity activity. CONCLUSION: In conjunction with the appropriate anti-hypertensive medication treatment, understanding the concepts of aortic hemodynamics as they relate to exercise can serve as a guideline for clinicians in developing an individualized exercise program for their TBD patients. Moreover, these physical training programs may include particular exercise guidelines beyond general recommendations of light to moderate cardiovascular activities.

Long-term outcome and quality of life following emergency surgery for acute aortic dissection type A: a comparison between young and elderly adults.

Objectives: Innovations in surgical techniques and perioperative management have continuously improved survival rates for acute aortic dissection type A (AADA). The aim of our study was to evaluate long-term outcome and quality of life (QoL) after surgery for AADA in elderly patients compared with younger patients. Methods: We retrospectively evaluated 242 consecutive patients, who underwent surgery for AADA between January 2004 and April 2014. Patients were divided into two groups: those aged 70 years and older (elderly group; n = 78, mean age, 76 ± 4 years) and those younger than 70 years (younger group; n = 164, mean age, 56 ± 10 years). QoL was assessed with the Short Form Health Survey Questionnaire (SF-36) 1 year after surgery. Results: The questionnaire return rate was 91.0%. There were already significant differences noted between the two groups with regard to preoperative risk factors on admission. The clinical presentation with a cardiac tamponade was higher in the elderly group (62.8% vs 47.6%; P = 0.03). Intraoperatively, complex procedures were more common in the younger group (21.3% vs 5.2%; P = 0.001). Accordingly, cardiopulmonary bypass and cross-clamping times were significantly longer in the younger group. The operative mortality was similar in both groups (3.8% vs 1.2%; P = 0.33). In the elderly population, 30-day mortality was higher (21.8% vs 7.9%; P = 0.003). One-year (72% vs 85%), 3-year (68% vs 84%) and 5-year (63% vs 79%) survival rates were satisfactory for the elderly group, but significantly lower compared with the younger group ( P = 0.008). The physical component summary score also was similar between the groups (39.14 ± 11.12 vs 39.12 ± 12.02; P = 0.99). However, the mental component summary score might be slightly higher in the elderly group but not statistically significant (51.61 ± 10.73 vs 48.63 ± 11.25; P = 0.12). Conclusions: Satisfactory long-term outcome and the general perception of well-being encourage surgery in selected elderly patients with AADA.

Post aortic dissection: Gap between activity recommendation and real life patients aerobic capacities.

BACK GROUND: Regular exercise at a safe level, i.e. 3-5 metabolic equivalents, is recommended to improve blood pressure control and quality of life even after aortic dissection, although aerobic exercise capacities in these patients are unexplored yet. METHODS: We prospectively collected data from 105 patients with a history of post aortic dissection referred for a cardiopulmonary exercise testing (CPX) aiming to guide exercise rehabilitation. RESULTS: The population was composed of 76% of male, with a mean age of 57.9±12.4years. There were an equal distribution between the two type of dissection (47% of type A and 53% of type B aortic dissection). No cardiac event occurred during or after CPX. One third of patients have normal aerobic exercise capacity defined as peak oxygen uptake upper than 85% of their predicted capacity. Mean oxygen uptake peak was quite low 19.2±5.2ml/kg/min (5.5±1.5 metabolic equivalents). Aerobic capacity was limited by cardiac chronotropic incompetence in 42% or peripheral deconditioning in 45%. Blood pressure remained in an acceptable range during the exercise. Systolic and diastolic blood pressures were respectively 151±20 and 77±13mmHg at first ventilatory threshold. CONCLUSIONS: CPX is a safe exploration in patients with post aortic dissection syndrome. Given the fact that most of these patients are faced with significant alteration of aerobic capacities, the recommended daily practice of moderate exercise at 3-5 METS should be adapted and personalized to each patient thanks to CPX.

Pregnancy after a previous gestation complicated by an acute aortic dissection.

Acute aortic dissection is a rare life-threatening event. No further pregnancies in women who had a previous acute aortic dissection have been reported. We present the case of a chronic hypertensive woman, who in her previous gestation was submitted to an acute aortic dissection repair at 28 weeks of gestation with cesarean delivery at the same operative procedure. The index pregnancy was uneventful. An elective cesarean was performed at 33 weeks' gestation. Aneurysm expansion, rupture or redissections are potential complications of operated aortic dissection. Normal blood pressure values and close cardiologic and obstetrical follow-up are essential to obtain a favourable outcome.

French registry of cases of type I acute aortic dissection admitted to a cardiac rehabilitation center after surgery.

BACKGROUND: After surgery for type I acute aortic dissection, the aorta remains partly dissected. This new population of patients is now referred to cardiac rehabilitation centers (CRCs). The feasibility of subsequent physical exercise is unknown. METHODS: Thirty-three consecutive patients (aged 55.1+/-9.3 years) were included in a prospective registry with clinical and radiological follow-up for 1 year after admission to a CRC. Twenty-six patients had undergone standard training sessions with exercise on a bicycle ergometer. Physical training programs included calisthenics, respiratory physiotherapy, walking, and cycling. Seven patients did not perform standard exercise training sessions but only walking and respiratory physiotherapy. RESULTS: For trained patients, the sessions (18+/-10) were carried out at 11.3+/-1.5 on the Borg scale ('light'), with blood pressure monitoring on exercise (<160 mmHg in 75% of patients). Maximum workload during exercise test (bicycle ergometer, 10 watts/min) increased from 62.7+/-11.8 to 91.6+/-16.5 watts (P=0.002). We identified three complications in two patients requiring further thoracic aorta surgery during follow-up. There was also one case of aortic valve replacement after 5 months and three cases of peripheral ischemia. No deaths, cerebral vascular accidents, or myocardial infarctions were recorded. Ten of the 19 patients of working age were able to return to work. CONCLUSION: Physical training of moderate intensity seems feasible and beneficial in postsurgical type I aortic dissection patients.

Optimal clinical pathway for the patient with type B acute aortic dissection.

BACKGROUND: The traditional medical treatment for type B acute aortic dissection (AAD) is widely accepted, but the optimal clinical pathway has not been confirmed. Methods and Results From admissions over the past 12 years, 210 patients with uncomplicated type B AAD were divided into 2 groups: Conventional therapy group (CG) of 90 who were treated by 7 days of bed rest and intravenous antihypertensive agents and the Clinical pathway group (CPG) of 120 who were treated by early rehabilitation. In the CPG, patients were administered oral medication from the first day after onset and took a short walk from the third day after onset. The incidence of respiratory complications, and of delirium, was significantly decreased in the CPG. Early mortality was similar: 3.3% and 2.5%, respectively. The diameter of the aorta had not enlarged in either group 1 month later. Conclusions The clinical pathway of treatment for uncomplicated type B AAD was safer and better for preventing early complications and cost benefit.

Validation of the Cardiac Depression Scale in a cardiac rehabilitation population.

OBJECTIVE: The current study was undertaken to provide further evidence supporting the reliability and validity of the Cardiac Depression Scale (CDS) in a population of cardiovascular patients. METHODS: The CDS was administered to 627 consecutive ambulatory adult cardiac patients attending an outpatient Cardiac Rehabilitation program, and a subgroup also completed the Geriatric Depression Scale--Short Form (GDS-SF). RESULTS: Factor analysis revealed six subscales accounting for 62% of scale variance. The CDS demonstrated high internal consistency (Cronbach's alpha=.92) and correlation coefficient with the GDS-SF of .77. Receiver operating characteristic curves suggested a CDS cutoff score of 100 to detect more severe depression, and 90 to detect mild to moderate depression. CONCLUSION: These findings encourage the continued use and evaluation of the CDS for measuring symptoms of depressive affect in cardiac patients.

Survival and quality of life after repair of acute type A aortic dissection in patients aged 75 years and older justify intervention.

OBJECTIVE: Controversy still exists about averting expenditure of health care resources on the growing elderly population. This study evaluates clinical outcome of patients aged 75 years and older operated upon for acute type A aortic dissection. METHODS: Between January 1990 and April 2004, of 247 patients undergoing emergency operation for acute type A aortic dissection at our Institution, 40 patients (16%) were aged 75 years and older (mean 78+/-3 years, range 75-88 years) and represent the study population. On admission, 9 (22.5%) had cardiogenic shock/hypotension, 20 (50%) cardiac tamponade, 14 (35%) kidney failure, 11 (27.5%) limb ischemia, 3 (7.5%) neurologic deficit, and 1 (2.5%) myocardial ischemia. Surgical procedures included isolated replacement of the ascending aorta in 34 patients (85%), associated with total root replacement in 5 (12.5%), and with aortic valve replacement in 1 (2.5%). Eleven patients (27.5%) underwent aortic arch replacement (hemiarch: n=8, 20%; total arch: n=3, 7.5%). RESULTS: In-hospital mortality was 30% (12 patients). Mortality tended to be higher (8/21, 38% vs 4/19, 21%; p=NS) for patients presenting with any one of the following complications: tamponade, shock, brain and/or myocardial, renal, limb malperfusion. Actuarial survival at 1, 5, and 7 years was 93+/-5%, 80+/-8%, and 80+/-8%, respectively, and freedom from reoperation 97+/-2%, 97+/-2%, and 97+/-2%, respectively. Actuarial event-free rates were 94+/-3%, 90+/-5%, and 90+/-5%. Seventy-four percent of survivors are in NYHA FC I, and quality of life test (RAND SF-36) revealed a generalized perception of independency and well-being, comparable to an age-matched population. CONCLUSIONS: Overall results for emergency repair of acute type A aortic dissection in the elderly justify intervention, particularly in uncomplicated cases. Expeditious referral and intervention by lowering pre-operative dissection-related complications and comorbidities might help to improve results. Survivors show functional status and quality of life similar to contemporary individuals.

[Usefulness and safety of the early rehabilitation program for patients with acute aortic dissection].

The usefulness and safety of the early rehabilitation program (2- and 3-week courses) were validated for patients with acute aortic dissection. This program undergone by 42 consecutive patients between 1996 and 1997 was compared to the conventional program undergone by 66 patients between 1993 and 1995, using the prognosis and complications for elderly patients. Mortality rate and morbidity rate were not significantly different between the early and conventional programs. The incidence of intensive care unit (ICU) syndrome in elderly patients was 16% (3 of 19 cases) vs 50% (15 of 30 cases), respectively (p < 0.05). The duration of hospital stays was 26 +/- 7 vs 37 +/- 13 days, respectively (p < 0.05). The early rehabilitation program for patients with acute aortic dissection was safe and useful to prevent complications in elderly patients, and was cost effective.

[Return to work after reconstructive arterial surgery (author's transl)]. / Etude de la reprise de l'activité professionnelle des sujets ayant subi une restauration artérielle.

The authors studied the conditions of the return to work of 65 patients, with a maximum age of 55 years, after reconstructive arterial surgery. Of the 51 patients who were working at the time of the operation, 46 (90.2%) had started working after an average period of 97 days, but only one of the patients who were no longer working started work after the operation. If the nature and more especially the site of the operation is analyzed, the highest level of return to work was after aorto-iliac surgery (96,4%), with a lower level (81%) after femorotibial operations. In a small group of 6 patients operated upon for aneurysms (of which 5 were aneuryms of the abdominal aorta), 4 had started work again, but after a longer period of 4 months on average. These results are compared with those obtained by a British team in Newcastle (Waters, Proud, and Chamberlain) who conducted a similar study in 1977. These overall results prove that reconstructive arterial surgery is favourable from the social and occupational point of view, as very large proportion of the operated patients continue working, and some of them start work again after having stopped their occupation before the operation.