The Benefit of Acute Early Cardiac Rehabilitation after Transcatheter Aortic Valve Implantation (TAVI)

Research Article

Phys Med Rehabil Int. 2022; 9(1): 1198.

The Benefit of Acute Early Cardiac Rehabilitation after Transcatheter Aortic Valve Implantation (TAVI)

Hartmann N¹*, Don M², Holzhause A², Pinnau R², HasenfuΒ G¹ and Puls M¹

¹Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Germany

²Clinic and Rehabilitation Center Lippoldsberg, Germany

*Corresponding author: Hartmann N, Clinic of Cardiology and Pneumology, University Medical Center Göttingen, Robert-Koch-StraΒe 40, 37075 Göttingen, Germany

Received: April 25, 2022; Accepted: May 24, 2022; Published: May 31, 2022

Abstract

Background: Cardiac Rehabilitation (CR) has been shown to increase physical and cognitive performance and to improve quality of life. However, evidence concerning CR in frail patients after transcatheter aortic valve implantation (TAVI) is still limited. Thus, the aim of the present study was to investigate the effect of inpatient acute early cardiac rehabilitation in frail patients dependent on nursing care immediately after TAVI.

Methods: In this retrospective observational single-center cohort study, we included 12 consecutive TAVI patients referred for Acute Early Cardiac Rehabilitation (AECR) to the cardiac rehabilitation hospital Lippoldsberg between August 31st and December 31st 2021. The impact of AECR on 6-minute walking test distance (6-MWD), Body Mass Index (BMI), and performance in Activities of Daily Living (ADL) as measured by Katz Index and Barthel Index was evaluated.

Results: On admission, patients were characterized by advanced age (mean, 84.3±1.3 years), a high burden of comorbidities, severe impairment in ADLs (Katz Index 2.1±0.4, Barthel Index 40.2±5.5 points), but preserved cognitive function (mini-mental state examination 24.5±1.27 points). At time of AECR discharge, a significant improvement of 6-MWD (mean gain + 73±12m) and autonomy in ADLs (Katz Index: mean gain + 0.3±0.4 points; P=0.0001; Barthel Index: mean gain + 33±3 points, P<0.0001) could be observed. Importantly, five individuals (42%) were independent from nursing care after AECR, whereas none had been before.

Conclusions: Acute early cardiac rehabilitation in frail octogenarians after TAVI is safe and significantly improves exercise capacity as well as functional autonomy in activities of daily living, also in individuals with initial severe disability.

Keywords: 6-minute Walking Test Distance; Acute Early Cardiac Rehabilitation; Exercise Capacity; Transcatheter Aortic Valve Implantation

Abbreviations

AS: Aortic Stenosis; SAVR: Surgical Aortic Valve Replacement; TAVI: Transcatheter Aortic Valve implantation; CR: Cardiac Rehabilitation; 6-MWD: Six-Minute Walking Test Distance; AECR: Acute Early Cardiac Rehabilitation; BMI: Body Mass Index; ADL: Activities of Daily Living; VARC: Valve Academic Research Consortium; MMSE: Mini-Mental State Examination; SaO2: Oxygen Saturation; CAD: Coronary Artery Disease; CKD: Chronic Kidney Disease; COPD: Chronic Obstructive Pulmonary Disease; RBC: Red Blood Cell Count; RCT: RECOVER-TAVI; EF: Ejection Fraction; MI: Myocard Infarction; CABG: Coronary Artery Bypass Grafting

Introduction

Severe Aortic Stenosis (AS) is one of the most common clinically relevant primary valve lesions and is associated with increased morbidity and mortality [1]. Due to the aging population, the prevalence is rapidly increasing. Surgical Aortic Valve Replacement (SAVR) or transcatheter treatment are the first-line therapies for the treatment of severe symptomatic AS. Transcatheter Aortic Valve Implantation (TAVI) has been developed as an alternative to surgical valve replacement, especially for elderly, frail patients with multiple comorbidities and a high perioperative mortality [2,3]. Previous reports have already provided evidence that these vulnerable patients may benefit from Cardiac Rehabilitation programs (CR) after surgical [4-8] or percutaneous valve interventions [7,9-14]. CR is already recommended for cardiac conditions such as heart failure or myocardial infarction to maintain independence or facilitate reintegration into daily life [14-17]. CR has been shown to increase physical and cognitive performance, thereby improving quality of life and reducing mortality and hospital re-admissions [6-8,14,18-20]. Despite these promising data, cardiac rehabilitation after TAVI has not yet received a guideline recommendation. However, emerging scientific evidence suggests that CR in TAVI patients are safe [7,10] and improves exercise tolerance [9, 11-13] as well as quality of life [7,9,14]. To assess the aforementioned effects, established parameters such as six-minute walking test distance (6-MWD), Barthel index, body mass index, or various neurological follow-up parameters have been studied.

Nevertheless, there are still only few studies focusing on Acute Early Cardiac Rehabilitation (AECR) immediately after TAVI. Due to the minimally invasive nature of the procedure, TAVI patients are frequently characterized by advanced age, multiple comorbidities, and frailty. In such patient cohorts, the maintenance or recovery of independence in functional tasks of daily living is of utmost importance - for the individual person itself as well as for healthcare in common. Thus, the aim of the present study was to investigate the effect of inpatient acute early cardiac rehabilitation in frail patients dependent on nursing care immediately after TAVI. Therefore, the impact of AECR on 6-MWD, Body Mass Index (BMI), and performance in Activities of Daily Living (ADL) as measured by Katz Index and Barthel Index was evaluated.

Materials and Methods

Patient population and study design

In this retrospective observational single-center cohort study, we included 12 consecutive TAVI patients who were dependent on nursing care and referred for AECR to the cardiac rehabilitation hospital Lippoldsberg between August 31st and December 31st 2021. Study participants had been treated with transfemoral TAVI at the University Medical Center Goettingen immediately before AECR. Goettingen represents a high-volume TAVI-center, with at least 400 procedures per year. Patients’ baseline characteristics were recorded before the intervention. Transfemoral TAVI was performed as previously described using standard techniques. Peri-procedural complications were evaluated according to the Valve Academic Research Consortium (VARC2)-recommendations [21].

Ethics Approval and Consent to Participate

In accordance with the local ethics committee, all patients gave written informed consent for the TAVI procedure itself as well as for the use of their anonymized data for research purposes. The study was performed in accordance with the ethical standards defined in the Declaration of Helsinki.

Acute Early Cardiac Rehabilitation Program

After transferal to the rehabilitation clinic, all patients attended a standardized three-week multicomponent inpatient AECR program including an educational interview on admission, physical therapy, neurophysiological co-assessment, nutritional counseling, and planning of post-discharge care. During the first physiotherapeutic session, the patients’ training condition and resilience was evaluated by experienced physiotherapists. A six-minute walking test including documentation of the perceived exertion scale was performed in a long indoor corridor under repeat recordings of blood pressure, heart rate, breathing rate and SaO2. Cognitive function was assessed by the Mini- Mental State Examination (MMSE) test, a 30-point questionnaire including simple questions in a number of areas like orientation, registration, attention, calculation, recall, and language. Afterwards, patients participated in daily individual physiotherapeutic training units of 30 minutes duration including a combination of endurance and coordination training. Supplementary, they performed daily physical training on the seat bike (Motomed) with individually adapted duration and intensity to improve the individual aerobic capacity. During the second week of AECR, the supervised exercise program was expanded by other training methods like swimming, bicycle ergometer and treadmill training, strength and muscle building. Each patient received at least 90 minutes of physical therapy per day. Individual therapeutic goals were defined and evaluated in weekly meetings with all therapists, nursing staff and physicians. Before discharge, the six-minute walking test was repeated.

At the beginning and the end of the AECR, patients’ performance in activities of daily living was documented by evaluation of Katz Index and Barthel Index. The Katz Index assigns one point for complete independence in each of the six areas feeding, bathing, dressing, transferring, toileting, and urinary continence. Thus, a patient with a score of six points is independent from nursing care. The more precise Barthel Index measures the performance in 10 items on an ordinal scale with a given number of points assigned to each level of ranking. The maximum score of 100 points indicates complete independence.

Statistical analysis

All data are presented as mean±SEM (software: GraphPad Prism Version 9.0). For pairwise comparisons, paired student’s t-tests were used. Results with P<0.05 were considered as statistically significant.

Results

Patient characteristics

The 12 patients (4 men, 8 women) who underwent AECR after elective TAVI were characterized by advanced age (mean, 84.3±1.3 years) and a high burden of comorbidities like coronary artery disease (CAD, 41.7%), chronic kidney disease (CKD, 41.7%), hypertension (91.7%), chronic obstructive pulmonary disease (COPD, 16.7%), reduced ejection fraction <50% (41.7%), and prior stroke (25%). The calculated surgical risk as estimated by logistic EuroScore 1 (mean, 20.5±7.7%) indicated a high-risk cohort. At time of admission in the rehabilitation clinic, the majority of patients was severely impaired in activities of daily living, as documented by a mean Katz Index of 2.1±0.4 points and a mean Barthel Index of 40.2±5.5 points. None of the participants was independent from nursing care at the beginning of AECR. Cognitive function as estimated by MMSE was normal in most patients (mean, 24.5±1.27 points), except for two individuals with mild (MMSE 21 points) and moderate (MMSE 15 points) cognitive impairment. Mean six-minute walking test distance before AECR was 109±26 m (range, 0-250 m). Baseline characteristics of the cohort are displayed in table 1.

Citation: Hartmann N, Don M, Holzhause A, Pinnau R, HasenfuΒ G and Puls M. The Benefit of Acute Early Cardiac Rehabilitation after Transcatheter Aortic Valve Implantation (TAVI). Phys Med Rehabil Int. 2022; 9(1): 1198.