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Exercise-Based Cardiac Rehabilitation for Patients Following Open Surgical Aortic Valve Replacement and Transcatheter Aortic

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Exercise-Based Cardiac Rehabilitation for Patients Following Open Surgical Aortic Valve Replacement and Transcatheter Aortic Open access Valvular heart disease Open Heart: first published as 10.1136/openhrt-2018-000922 on 9 April 2019. Downloaded from Exercise-based cardiac rehabilitation for patients following open surgical aortic valve replacement and transcatheter aortic valve implant: a systematic review and meta-analysis Lizette Anayo, 1,2,3 Paula Rogers,4 Linda Long, 3 Miles Dalby,4 Rod Taylor3,5 ► Additional material is ABSTRACT Key questions published online only. To view Objectives Exercise-based cardiac rehabilitation (CR) please visit the journal online may be beneficial to patients following transcatheter aortic (http:// dx. doi. org/ 10. 1136/ What is already known about this subject? valve implantation (TAVI) and open surgical aortic valve openhrt- 2018- 000922). Aortic stenosis (AS) is the single most common pri- replacement (SAVR). We aimed to undertake a systematic ► mary valve lesion undergoing treatment in devel- review and meta-analysis to evaluate the efficacy, safety To cite: Anayo L, Rogers P, oped countries, and it is becoming a bigger health and costs of exercise-based CR post-TAVI and post-SAVR. Long L, et al. Exercise-based problem in an ageing population. There is often a cardiac rehabilitation for Methods We searched numerous databases, including period of deconditioning beforehand and slow or patients following open surgical Embase, CENTRAL and MEDLINE, up to October 2017. incomplete recovery following transcatheter aortic aortic valve replacement and We included randomised controlled trials (RCTs) and valve implantation (TAVI) or surgical aortic valve re- transcatheter aortic valve non-randomised controlled trials (non-RCTs) of exercise- placement (SAVR). Exercise-based cardiac rehabili- implant: a systematic review based CR compared with no exercise control in TAVI or tation (CR) may facilitate the recovery of post-TAVI and meta-analysis. Open Heart SAVR patients ≥18 years. Data extraction and risk of 2019;6:e000922. doi:10.1136/ and post-SAVR patients. bias assessments were performed independently by two openhrt-2018-000922 reviewers. Narrative synthesis and meta-analysis (where What does this study add? appropriate) were carried out for all relevant outcomes, ► Little is known about the impact of CR in patients http://openheart.bmj.com/ Received 17 August 2018 and a Grading of Recommendations Assessment, with AS following either TAVI or SAVR. This system- Revised 14 February 2019 Development and Evaluation (GRADE) analysis was also atic review and meta-analysis identified a small Accepted 16 February 2019 performed. comparative evidence base that suggests exer- Results Six studies, all at low risk of bias, were included: cise-based CR may improve exercise capacity of three RCTs and three non-RCTs (total of 27 TAVI, 99 post-TAVI and post-SAVR patients in the short term. SAVR and 129 mixed patients), with follow-up of 2–12 However, the effect of exercise-based CR on quali- months. There was an increase in pooled exercise capacity ty of life and clinical events, such as hospitalisation (standardised mean difference: 0.41, 95% CI 0.11 to 0.70; and mortality, remains uncertain. moderate certainty evidence as assessed by GRADE), with exercise-based rehabilitation compared with control. Data How might this impact on clinical practice? on September 24, 2021 by guest. Protected copyright. on other outcomes including quality of life and clinical ► Although suggesting likely benefit, the results of events were limited. this review indicate the need for more high-quality Conclusions Exercise-based CR probably improves multicentre trials in larger post-TAVI and post-SAVR exercise capacity of post-TAVI and post-SAVR patients in patient cohorts, with longer study periods to defin- the short term. Well conducted multicentre fully powered itively assess the effects of exercise-based CR in RCTs of ≥12 months follow-up are needed to fully assess these patients. the clinical and cost-effectiveness of exercise-based CR in © Author(s) (or their this patient population. employer(s)) 2019. Re-use PROSPERO Protocol Registration carry out daily physical activities and is also permitted under CC BY-NC. No Number CRD42017084716. significantly associated with an increased commercial re-use. See rights risk of mortality and morbidity.2 The most and permissions. Published by BMJ. effective treatment in patients with severe For numbered affiliations see aortic stenosis has traditionally been 3–5 end of article. INTRODUCTION surgical aortic valve replacement (SAVR). Heart valve disease accounts for up to a Open surgery however often leaves people Correspondence to third of heart diseases and is very common immobile during recovery and in particular Lizette Anayo,University of within the ageing population.1 When symp- 1 Exeter - Saint Lukes Campus, sternum healing, requiring a significant Exeter, UK; alizetteada@ yahoo. tomatic, valve disease can have a significant period of rehabilitation and is also associ- com negative effect on the patient’s ability to ated with higher risk of complications and Anayo L, et al. Open Heart 2019;6:e000922. doi:10.1136/openhrt-2018-000922 1 Open Heart Open Heart: first published as 10.1136/openhrt-2018-000922 on 9 April 2019. Downloaded from mortality in elderly patients.6 Transcatheter aortic Study selection valve implantation (TAVI), which is minimally inva- Studies for this review were considered eligible if they sive, is therefore usually preferred in elderly or frail included: (1) adults (≥18 years) who had undergone patients,6 7 but nevertheless is still associated with a either TAVI or SAVR, (2) who received exercise-based significant period of recovery. CR (as supervised/unsupervised, hospital based/home Cardiac rehabilitation (CR) is defined as ‘the coordi- based, inpatient/outpatient with or without education nated sum of activities necessary to provide patients with and psychological interventions), (3) compared a no the best physical, social and mental circumstances, as well exercise control group including usual medical care; as make an impact on the underlying cause of cardiovas- and (4) collected the outcomes of mortality, hospitali- cular disease.8 CR seeks to enable patients to maximise sations, health-related quality of life (HRQoL), exercise their function and halt or reverse disease progression capacity, functional capacity, return to work, adverse through positive changes in healthier lifestyle behaviour.8 events (safety) and cost. Studies were also included if a In addition to exercise training, comprehensive CR majority of participants (>50%) in a mixed valve replace- is recommended to include psychological and educa- ment population were adults and had received SAVR or tion-based interventions.9 The European Society of TAVI. Studies including patients who previously attended Cardiology10–12 and the American College of Cardiology/ defined exercise-based rehabilitation programmes were American Heart Association have given a Class I recom- excluded. mendation for using exercise-based CR as an interven- Study selection was independently carried out by tion in postmyocardial infarction and heart failure.13 14 two authors (LA and PR), and all disagreements were However, the impact of exercise-based CR in post-TAVI discussed before contacting a third author (LL or RT) if and post-SAVR populations remains less clear. Exer- no agreement was reached. Non-English language papers cise-based CR is recommended by the European Society were translated. of Cardiology Working Groups for selected patients after SAVR15 but not currently for the management of patients Data extraction and risk of bias assessment after TAVI.5 15 Previous systematic reviews of the use of Data on study characteristics (population, intervention, CR after valve surgery have limitations, as they either control and outcome) were extracted using a piloted data focused on patients with mitral valve surgery1 and failed collection form. Risk of bias was assessed using the revised to consider recent evidence.6 Cochrane Risk of Bias tool for randomised trials (ROB 18 This contemporary systematic review and meta-analysis 2.0), and the Risk of Bias In Non-randomised Studies – 19 aimed to assess the clinical effectiveness, safety and costs of Interventions tool. Assessment included: method of of exercise-based CR plus usual care for patients following randomisation, consideration of confounders, selection http://openheart.bmj.com/ SAVR or TAVI, compared with usual care only. Both of participants into the study, classification of interven- RCTs and non-RCTs were used, and several outcomes, tions, deviations from intended interventions, missing including exercise capacity, were considered. outcome data (ie, level of drop out), measurement of the outcome, selection of the reported result, baseline balance between both groups and comparable care received by both groups (excluding the intervention). Data extrac- METHODS tion and risk of bias assessment were independently This study was conducted according to the Cochrane carried out for the included studies by two authors (LA Handbook for Systematic Reviews of Interventions16 and and PR). All disagreements were resolved either through on September 24, 2021 by guest. Protected copyright. reported in line with the Preferred Reporting Items for discussion or by consulting a third reviewer RT. Grading Systematic Reviews and Meta-Analyses reporting guide- 17 of Recommendations Assessment, Development and lines. The protocol for this study was registered on Evaluation (GRADE) analysis using GRADEpro20
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