Telemedicine in cardiovascular surgery during COVID-19 pandemic: A systematic review and our experience.

OBJECTIVE: The SAR-COV-2 pandemic has had an unprecedented effect on the UK's healthcare systems. To reduce spread of the virus, elective treatments and surgeries have been postponed or canceled. There has been a rise in the use of telemedicine (TM) as an alternative way to carry outpatient consultations. This systematic review aims to evaluate the extent to which TM may be able to support cardiac and vascular surgery patients in the COVID-19 era. METHODS: We looked into how TM can support the management of patients via triaging, preoperative, and postoperative care. Evaluations targeted the clinical effectiveness of common TM methods and the feasibility of applying those methods in the UK during this pandemic. RESULTS: Several studies have published their evidence on the benefit of TM and its benefit during COVID-19, the data related to cardiovascular surgery and how this will impact future practice of this speciality is emerging and yet larger studies with appropriate timing of outcomes to be published. CONCLUSION: Overall, the use of virtual consultations and remote monitoring is feasible and best placed to support these patients via triaging and postoperative monitoring. However, TM can be limited by the need of sophisticated technological requirement and patients' educational and know-how computer literacy level.

Preoperative frailty is associated with progression of postoperative cardiac rehabilitation in patients undergoing cardiovascular surgery.

OBJECTIVE: Preoperative frailty affects the progression of cardiac rehabilitation (CR) after cardiovascular surgery. Different frailty assessment measures are available. However, it remains unclear which tool most likely predicts the progress of CR. Our aim was to evaluate preoperative frailty using different methods and to identify the predictors in the progress of postoperative CR. METHODS: Eighty-nine patients underwent elective cardiovascular surgery at our institution between May 2016 and April 2018. Mortality cases and patients without evaluation of preoperative frailty were excluded. This study included the remaining 78 patients. We divided the patients into two groups: 47 patients who achieved 100 m walking within 7 days after surgery (successful CR group) and 31 patients who achieved 100 m walking later than 8 days after surgery (delayed CR group). Preoperative frailty was assessed using the Kaigo-Yobo Check-List, Cardiovascular Health Study, Short Physical Performance Battery, and Clinical Frailty Scale. RESULTS: The prevalence of frailty defined by these four measures was higher in the delayed CR group. The delayed CR group had lower nutritional status, serum hemoglobin level, serum albumin level, and psoas muscle index. Multivariable analysis demonstrated the Kaigo-Yobo Check-List score as an independent predictor for delayed CR (odds ratio 1.53, 95% confidence interval 1.18-1.98, p = 0.001) and Clinical Frailty Scale as an independent predictor for discharge to a health care facility (odds ratio 3.70, 95% confidence interval 1.30-10.51, p = 0.014). CONCLUSIONS: Among the various tools for assessing frailty, the Kaigo-Yobo Check-List was most likely to predict the progress of postoperative CR after elective cardiovascular surgery.

Cardiac Rehabilitation in a Rural Setting: OPTIMIZATION OF REFERRAL AND PARTICIPATION RATES.

PURPOSE: The cardiac rehabilitation (CR) program at Dartmouth-Hitchcock Medical Center (DHMC) devotes a nurse to the inpatient units in an attempt to optimize the referral process. This report defines the rates of referral and participation at DHMC and explores potential factors that affect participation. METHODS: Seven hundred ten consecutive patients who underwent percutaneous coronary intervention, coronary artery bypass grafting, or valve surgery from January 1, 2015 to June 30, 2015 were reviewed to determine whether the patient was referred for CR. Participation rates and the effect of time delay and patient-specific factors on participation were examined. RESULTS: Six hundred ninety-eight (98%) of the 710 post-procedural patients were evaluated by the inpatient rehabilitation nurse. One hundred sixty-seven patients were ineligible for outpatient therapy on the basis of established criteria; the remaining 543 patients were referred to DHMC or regional rehabilitation programs. Of those referred to the on-site program at DHMC, 84% participated. Of those referred to regional programs, 60% participated. There was an inverse correlation (r = -0.82; P = .003) between wait times and participation rates for the various programs. CONCLUSIONS: Despite its rural location with a large geographic catchment area, DHMC achieves high rates of CR referral and participation. The approach used at DHMC, which includes a CR nurse working with the inpatient cardiac services, a strong level of integration with the physician community, and well-developed relationships with regional rehabilitation programs, may be helpful for those programs wishing to improve referral and participation rates. Shorter wait times between hospital discharge and initiation of rehabilitation may improve participation rates.

Preoperative nutritional status is associated with progression of postoperative cardiac rehabilitation in patients undergoing cardiovascular surgery.

OBJECTIVE: Progression of cardiac rehabilitation after cardiovascular surgery can be affected by frailty. The nutritional status of the patient has been proposed as an indicator of frailty. In this study, we aimed to evaluate the influence of preoperative nutritional status on the progress of postoperative cardiac rehabilitation. METHODS: This study included 146 patients (82 males, 64 females, average age 71.9 ± 12.0 years) who underwent elective cardiovascular surgery. In-hospital mortality cases were excluded to focus on postoperative cardiac rehabilitation. We classified patients with a Geriatric Nutritional Risk Index of 92 or higher as the good nutrition group and those with a Geriatric Nutritional Risk Index less than 92 as the malnutrition group. Preoperative patient characteristics and postoperative cardiac rehabilitation progress were compared between the good nutrition (n = 93) and malnutrition (n = 53) groups. RESULTS: The patients in the good nutrition group had an earlier progression to walking after postoperative rehabilitation (p = 0.002), a shorter postoperative hospital stay (p = 0.004), and a higher rate of discharge home (p = 0.028) than those in the malnutrition group. Multivariable analysis demonstrated preoperative malnutrition to be an independent predictor for the day to 100 m walking (p = 0.010). CONCLUSIONS: Preoperative nutritional status was associated with progression of postoperative cardiac rehabilitation.

The Impact of Roller Pump vs. Centrifugal Pump on Homologous Blood Transfusion in Pediatric Cardiac Surgery.

Centrifugal pumps are considered to be less destructive to blood elements (1) when compared to roller pumps. However, their large prime volumes render them unsuitable as arterial pumps in heart lung machine (HLM) circuitry for children. In November of 2014, the circuit at Arnold Palmer Hospital, a Biomedicus BP-50 with kinetic assist venous drainage (KAVD) and 1/4″ tubing was converted to a roller pump in the arterial position with gravity drainage. Vacuum-assisted venous drainage (VAVD) was mounted on the HLM as a backup, but not used. Tubing was changed to 3/16″ in the arterial line in patients <13 kg. A retrospective study with a total of 140 patients compared patients placed on cardiopulmonary bypass (CPB) with Biomedicus centrifugal pumps and KAVD (Centrifugal Group, n = 40) to those placed on CPB with roller pumps and gravity drainage (Roller Group, n = 100). Patients requiring extra-corporeal membrane oxygenation (ECMO)/cardio-pulmonary support (CPS) or undergoing a hybrid procedure were excluded. Re-operation or circulatory arrest patients were not excluded. Prime volumes decreased by 57% from 456 ± 34 mL in the Centrifugal Group to 197 ± 34 mL in the Roller Group (p < .001). There was a corresponding increase in hematocrit (HCT) of blood primes and also on CPB. Intraoperative homologous blood transfusions also decreased 55% from 422 mL in the Centrifugal Group to 231 mL in the Roller Group (p < .001). The Society of Thoracic Surgeons--European Association for Cardio-Thoracic Surgery (STAT) categorized intubation times and hospital length of stay (LOS) for all infants showed a trend toward reduction, but was not statistically significant. Overall mortality was 5% utilizing the centrifugal configuration and 0% in the roller pump cohort. We demonstrated that the transition to roller pumps in the arterial position of the HLM considerably reduced our priming volume and formed a basis for a comprehensive blood conservation program. By maintaining higher HCTs on CPB, we were able to reduce intraoperative homologous blood transfusions.

Neuromuscular electrical stimulation may attenuate muscle proteolysis after cardiovascular surgery: A preliminary study.

OBJECTIVE: To explore the efficacy of postoperative neuromuscular electrical stimulation (NMES) on muscle protein degradation and muscle weakness in patients after cardiovascular surgery. METHODS: Sixty-one patients underwent NMES daily from postoperative days (PODs) 1 to 5 in addition to postoperative mobilization program (NMES group), and 41 patients underwent postoperative mobilization program only (non-NMES group). The primary outcome was the concentration of 3-methylhistidine (3-MH) in 24-hour urine corrected for urinary creatinine content (3-MH/Cre) from PODs 1 to 5. The secondary outcomes were knee extensor isometric strength (KEIS) and handgrip strength at POD 7. RESULTS: Baseline characteristics such as age, sex, preoperative body mass index, hemoglobin, handgrip strength, KEIS, surgery type, cardiopulmonary bypass time, and immediate postoperative interleukin-6 were not different between the groups. Urinary 3-MH/Cre was increased significantly in both groups; however, urinary 3-MH/Cre in the NMES group peaked earlier compared with that in the non-NMES group. KEIS at POD 7 was significantly greater in the NMES group (median [interquartile range], 0.40 kg/weight [0.33-0.45] in the NMES group vs 0.23 kg/weight [0.15-0.36] in the non-NMES group; P < .01). Handgrip strength at POD 7 was also significantly greater in the NMES group (median [interquartile range], 32 kg [24.5-35.3] in the NMES group vs 24 kg [16.0-30.0] in the non-NMES group; P < .01). CONCLUSIONS: This study demonstrated that NMES might attenuate skeletal muscle protein degradation and muscle weakness after cardiovascular surgery. A cause-effect relationship between NMES and functional preservation would be a future challenging issue.

Effects of eHealth physical activity encouragement in adolescents with complex congenital heart disease: The PReVaiL randomized clinical trial.

OBJECTIVE: To assess benefit and harms of adding an eHealth intervention to health education and individual counseling in adolescents with congenital heart disease. DESIGN: Randomized clinical trial. SETTING: Denmark. PATIENTS: A total of 158 adolescents aged 13-16years with no physical activity restrictions after repaired complex congenital heart disease. INTERVENTIONS: PReVaiL consisted of individually tailored eHealth encouragement physical activity for 52weeks. All patients received 45min of group-based health education and 15min of individual counseling involving patients' parents. OUTCOMES: The primary outcome was maximal oxygen uptake (VO2 peak) at 52weeks after randomization. The secondary outcome was physical activity. Exploratory outcomes were generic and disease-specific questionnaires. RESULTS: In the intervention group, 58 patients (72%) completed the final test, but of those, only 46 (57%) fulfilled the compliance criteria of using the eHealth application for at least 2 consecutive weeks. In the control group, 61 patients (79%) completed both exercise tests. Adjusted for baseline values, the difference between the intervention group and the control group in mean VO2 peak at 1year was -0.65ml·kg(-1)·min(-1) (95% CI -2.66 to 1.36). Between-group differences at 1year in physical activity, generic health-related quality of life, and disease-specific quality of life were not statistically significant. CONCLUSIONS: Adding a tailored eHealth intervention to health education and individual counseling did not affect outcomes among adolescents with congenital heart disease. Our results do not support the use of this eHealth intervention in adolescents with complex congenital heart disease. TRIAL REGISTRATION: Clinical trials.gov identifier: NCT01189981.

Multimedia Exercise Training Program Improves Distance Walked, Heart Rate Recovery, and Self-efficacy in Cardiac Surgery Patients.

BACKGROUND: Patient education has been shown to be more effective when delivered using multimedia than written materials. However, the effects of using multimedia to assist patients in cardiac rehabilitation have not been investigated. OBJECTIVE: The purpose of this study is to examine the effect of an inpatient multimedia exercise training program on distance walked in the 6-minute walking test (6MWT), heart rate recovery, and walking self-efficacy of patients who had undergone heart surgery. METHODS: For this longitudinal quasi-experimental study, 60 consecutive patients were assigned to an experimental (n = 20; inpatient multimedia exercise training program) or control (n = 40; routine care) group. Data were collected at 3 times (before surgery, 1 to 2 days before hospital discharge, and 1 month after hospital discharge) and analyzed with the generalized estimating equation approach. RESULTS: Most subjects were men (66.7%), had a mean age of 61.32 ± 13.4 years and left ventricular ejection fraction of 56.96% ± 13.28%, and underwent coronary artery bypass graft surgery (n = 34, 56.7%). Subjects receiving the exercise training program showed significantly greater improvement than those in the control group in the 6MWT walking distance (P < .001), heart rate recovery (P = .04), and self-efficacy (P = .002) at hospital discharge. Furthermore, the intervention effects on 6MWT distance (P < .001) and self-efficacy (P < .001) were sustained at 1 month after hospital discharge. CONCLUSION: Our inpatient multimedia exercise training program safely improved distance walked in the 6MWT, heart rate recovery, and self-efficacy at hospital discharge in patients after heart surgery and maintained their improvement in 6MWT and self-efficacy 1 month later.

El significado de la experiencia de cuidar en casa a una persona con cirugía cardiovascular: la mirada del cuidador informal / The meaning of home care experience for a person with cardiovascular surgery: the look of the informal caregiver

El objetivo de este trabajo fue comprender el significado que le otorga el cuidador informal a la experiencia de cuidar en casa a un paciente con cirugía cardiovascular dado de alta desde las unidades de cuidado intensivo. Es un estudio cualitativo con enfoque fenomenológico interpretativo, en el cual participaron 8 cuidadores y se utilizo como técnica de recolección la entrevista en profundidad. Los resultados permiten comprender la experiencia del cuidador, quien asume la dependencia de la persona cuidada como propia, para lo cual requiere de conocimientos y habilidades que permitan realizar las actividades de cuidado en el hogar tal como se hacían en el hospital. Este nuevo rol es interpretado por el cuidador como una situación difícil que genera emociones y cansancio.

Recovery of deambulation after cardiothoracic surgery: a single center experience.

BACKGROUND: Surgical procedure and postoperative bed rest lead to musculoskeletal system alterations with a possibility of new walking dependence of patients who undergo cardiothoracic surgery, which is sometimes associated with prolonged hospitalization and increased health expenditure. AIM: The aim of this study was to assess the postoperative motor disability in inpatients admitted to the cardiothoracic surgical ward, and the results of customized rehabilitation in terms of recovery of postural changes and walking capacity with respect to the preoperative condition and destination after discharge. DESIGN: A prospective observational study was conducted. SETTING AND POPULATION: Four hundred seventeen inpatients, who had undergone cardiothoracic surgery, were enrolled between March 2011 and January 2012 in a Hospital Unit of Cardiothoracic Surgery. METHODS: A computerized system was used to collect data about ambulation at home, type and number of rehabilitation sessions proposed, ambulation at discharge, destination after discharge from ward of origin. All patients, who give their consent, undergone rehabilitative treatment on the ward of origin with an expert physiotherapist. RESULTS: Three hundred seventy-five inpatients were examined in Cardiac Surgery. One patient (0.26%) refused rehabilitative treatment. Two patients (0.53%) died. At the time of discharge 236 (74.45%) patients had recovered the ability to walk independently. After discharge 87.64% of patients was transferred to a specialist ward for intensive rehabilitation. Forty-two inpatients were enrolled in thoracic surgery. Two patients died whilst in hospital. At the time of discharge, 36 patients (94.73%) were able to walk independently. After discharge 80% of patients returned home. CONCLUSION: In our study, the application of an early and simple rehabilitation program on the ward of origin after surgery has made possible the recovery of ambulation of most inpatients who referred independence at home in a few days, limiting hospitalization and health expenditure. CLINICAL REHABILITATION IMPACT: Data about recovery of ambulation with respect to the preoperative condition and destination after discharge resume the importance of identifying motor impairment after surgery, in order to apply an adequate, early and feasible rehabilitation protocol to inpatients, limiting hospitalization and health expenditure.

Feasibility of neuromuscular electrical stimulation immediately after cardiovascular surgery.

OBJECTIVE: To determine the safety and feasibility of neuromuscular electrical stimulation (NMES) from postoperative days (PODs) 1 to 5 after cardiovascular surgery. DESIGN: Pre-post interventional study. SETTING: Surgical intensive care unit and thoracic surgical ward of a university hospital. PARTICIPANTS: Consecutive patients (N=144) who underwent cardiovascular surgery were included. Patients with peripheral arterial disease, psychiatric disease, neuromuscular disease, and dementia were excluded. Patients with severe chronic renal failure and those who required prolonged mechanical ventilation after surgery were also excluded because of the possibility of affecting the outcome of a future controlled study. INTERVENTIONS: NMES to the lower extremities was implemented from PODs 1 to 5. MAIN OUTCOME MEASURES: Feasibility outcomes included compliance, the number of the patients who had changes in systolic blood pressure (BP) >20 mmHg or an increase in heart rate >20 beats/min during NMES, and the incidence of temporary pacemaker malfunction or postoperative cardiac arrhythmias. RESULTS: Sixty-eight of 105 eligible patients participated in this study. Sixty-one (89.7%) of them completed NMES sessions. We found no patients who had excessive changes in systolic blood pressure, increased heart rate, or pacemaker malfunction during NMES. Incidence of atrial fibrillation during the study period was 26.9% (7/26) for coronary artery bypass surgery, 18.2% (4/22) for valvular surgery, and 20.0% (4/20) for combined or aortic surgery. No sustained ventricular arrhythmia or ventricular fibrillation was observed. CONCLUSIONS: The results of this study demonstrate that NMES can be safely implemented even in patients immediately after cardiovascular surgery.

[Main ways of improvements of the systems of medical rehabilitation of military servicemen after cardiovascular surgery].

For better improvement of medical rehabilitation referred to effective restoration of functional status of servicemen after cardiovascular surgery it is necessary to introduce standards of medical rehabilitation at all stages of rehabilitation, syndrome-pathologic principle of grouping patients, multidisciplinary organisation of medical activity: cardiologist-physician, specialist of functional diagnostics, specialist of physical therapy, psychotherapist, physical therapeutic, surgeon and specialist of professional rehabilitation. Basic ways of improvement of the system of rehabilitation were organisational technologies of interaction during early and late stages of rehabilitation and persistent control of quality and effectiveness of rehabilitation. Optimization of organisation of late stage of hospitalisation allowed to reduce the average time of rehabilitation to 33,3% and at the same time to improve effectiveness of rehabilitation.

[Development and importance of outpatient cardiac rehabilitation in German-speaking countries]. / Entwicklung und Stellenwert der ambulanten kardiologischen Rehabilitation im deutschsprachigen Raum.

Cardiac rehabilitation is a coordinated treatment approach. The interdisciplinary team aims to provide the best possible physical and psychological outcomes for patients with cardiac diseases. Patients should be enable to independently resume work and and social life. Furthermore cardiac rehabilitation wants to limit or reverse the progress of cardiac disease through sustained health-related life habits. Cardiac rehabilitation significantly contributes to long-term success based on comprehensive care of cardiac patients. Outpatient cardiac rehabilitation has shown to be effective after myocardial infarction, coronary artery bypass grafting and chronic heart failure. However randomized controlled trials were performed only in Anglo-American countries. In these trials effects were observed mainly for exercise-based cardiac rehabilitation programs. Because the results have been derived from different program settings they cannot simply be translated to German-speaking countries. However, several cohort studies predominantly performed in Germany also revealed effects of inpatient and outpatient cardiac rehabilitation programs for German-speaking countries. The most recent results demonstrated a significant reduction of recurrent events in patients after inpatient cardiac rehabilitation. Following the current evidence concerning the effect of inpatient and outpatient cardiac rehabilitation programs particularly after myocardial infarction international guidelines provide Class I (USA) and IIa (Europe) recommendation for this treatment intervention.In contrast to Anglo-American countries cardiac rehabilitation in Austria, Germany and Switzerland was established at its beginning exclusively for inpatient programs. In addition more and more outpatient programs were introduced in the last decades. Nevertheless inpatient cardiac rehabilitation is still the most common program in German-speaking countries.Future challenges of cardiac rehabilitation should not address the competition between inpatient and outpatient programs but provide answers to the question "which patient needs which program?" Future cardiac rehabilitation will offer patient-tailored programs. In German-speaking countries inpatient cardiac rehabilitation has long been well established whereas treatment potential of outpatient programs have increased. Outpatient cardiac rehabilitation is more flexible, close to home and it can be done part-time. Furhtermore, outpatient cardiac rehabilitation programs can take on important tasks in long-term cardiac care and thus provide relief to inpatient programs. The initiation of such programs is a challenge and can add to better future development of comprehensive cardiac rehabilitation.

Respiratory muscle training in patients recovering recent open cardiothoracic surgery: a randomized-controlled trial.

OBJECTIVES: To evaluate the clinical efficacy and feasibility of an expiratory muscle training (EMT) device (Respilift) applied to patients recovering from recent open cardiothoracic surgery (CTS). DESIGN: Prospective, double-blind, 14-day randomised-controlled trial. PARTICIPANTS AND SETTING: A total of 60 inpatients recovering from recent CTS and early admitted to a pulmonary rehabilitation program. Interventions. Chest physiotherapy plus EMT with a resistive load of 30 cm H2O for active group and chest physiotherapy plus EMT with a sham load for control group. MEASURES: Changes in maximal expiratory pressure (MEP) were considered as primary outcome, while maximal inspiratory pressures (MIP), dynamic and static lung volumes, oxygenation, perceived symptoms of dyspnoea, thoracic pain, and well being (evaluated by visual analogic scale-VAS) and general health status were considered secondary outcomes. RESULTS: All outcomes recorded showed significant improvements in both groups; however, the change of MEP (+34.2 mmHg, P < 0.001 and +26.1%, P < 0.001 for absolute and % of predicted, resp.) was significantly higher in active group. Also VAS dyspnoea improved faster and more significantly (P < 0.05) at day 12, and 14 in active group when compared with control. The drop-out rate was 6%, without differences between groups. Conclusions. In patients recovering from recent CTS, specific EMT by Respilift is feasible and effective. This trial is registered with ClinicalTrials.gov NCT01510275.

Surgical treatment of Dunbar syndrome / Tratamento cirúrgico da síndrome de Dunbar

Dunbar syndrome or celiac artery compression syndrome is an infrequently described clinical condition with poorly defined diagnostic criteria and an obscure pathophysiology. It is usually associated with an extrinsic compression upon the celiac axis near its takeoff from the aorta by fibrous diaphragmatic bands or sympathetic neural fibers. The authors report the case of a 70-year-old male patient presenting with nausea, epigastric pain, and weight loss. An aortography showed a compression of the celiac trunk. A preliminary attempt at percutaneous transluminal angioplasty and stenting proved unsuccessful. The patient became asymptomatic and his clinical condition improved after surgical release of the celiac trunk by partial section of the arcuate ligament of the diaphragm and with resection of the neural, fibrotic, and lymphatic tissues surrounding the aortic and visceral vessels. The purpose of this report is to discuss the indications and the therapeutic options of this syndrome.

A síndrome de Dunbar ou compressão do tronco celíaco é uma condição clínica infrequente, com poucos critérios para diagnóstico e com patofisiologia obscura. Está usualmente associada à compressão extrínseca do tronco celíaco por banda fibrosas do diafragma e fibras neurais simpáticas, próximo a sua emergência da aorta. Os autores relatam um caso de um paciente de 70 anos de idade com quadro de náuseas, dor epigástrica e perda de peso. Uma arteriografia mostrou compressão do tronco celíaco. Uma primeira tentativa de angioplastia com stent foi realizada em outro serviço, mas sem sucesso. Após o tratamento cirúrgico que consistiu de secção parcial do ligamento arqueado do diafragma com ressecção dos tecidos fibróticos, neurais e linfáticos que circundavam a aorta e as artérias viscerais, o paciente obteve melhora clínica e tornou-se assintomático. O objetivo deste estudo é discutir as indicações e opções terapêuticas desta síndrome.

[Selection criteria for referral to cardiac rehabilitation centers]. / Criteri per la selezione dei pazienti da inviare ai centri di cardiologia riabilitativa.

Current guidelines state that cardiac rehabilitation is indicated after the acute phase of major cardiovascular diseases and interventions; on the other hand implementation of these indications is difficult because of several barriers, i.e. the number of patients per year with an indication exceeds by far the accommodation offer of cardiac rehabilitation centers; the demand for access to cardiac rehabilitation from acute cardiac care hospitals is low because the attention is focused on the acute phase of cardiac diseases. The present Consensus Document describes the changes in clinical epidemiology of the main cardiovascular diseases, showing that complications are increasingly more frequent in the postacute phase, especially in the setting of myocardial infarction. The Joint ANMCO/IACPR-GICR Committee defines priority criteria based on clinical risk for admission to cardiac rehabilitation centers as inpatients. This Consensus Document represents, therefore, an important step forward in the search for continuity of care in high-risk patients during the post-acute phase.

[Selection criteria for patient admission to cardiac rehabilitation centers]. / Criteri per la selezione dei pazienti da inviare ai centri di cardiologia riabilitativa.

Current guidelines state that cardiac rehabilitation is indicated after the acute phase of major cardiovascular diseases and interventions; on the other hand implementation of these indications is difficult because of several barriers, i.e. the number of patients per year with an indication exceeds by far the accommodation offer of cardiac rehabilitation centers; the demand for access to cardiac rehabilitation from acute cardiac care hospitals is low because the attention is focused on the acute phase of cardiac diseases. The present Consensus Document describes the changes in clinical epidemiology of the main cardiovascular diseases, showing that complications are increasingly more frequent in the post-acute phase, especially in the setting of myocardial infarction. The Joint ANMCO/IACPR-GICR Committee defines priority criteria based on clinical risk for admission to cardiac rehabilitation centers as inpatients. This Consensus Document represents, therefore, an important step forward in the search for continuity of care in high-risk patients during the post-acute phase.

Avaliação do desempenho funcional em pacientes submetidos à cirurgia cardiaca / Evaluation of functional performance in patients undergoing cardiac surgery

Fundamentos: A cirurgia cardíaca é uma forma de tratamento que, apesar de trazer melhora para o paciente, acarreta alterações no organismo. Objetivo: Avaliar a influência da dor, na primeira cirurgia e na reoperação com uso de circulação extracorpórea (CEC), na medida de independência funcional (MIF). Métodos: Foram estudados 22 pacientes cardiopatas, internados na Fundação de Beneficência Hospital de Cirurgia, submetidos à cirurgia cardíaca eletiva por toracotomia médio-esternal (TME) com uso de circulação extracorpórea (CEC) no período de março a abril 2010. Utilizou-se o questionário da medida de independência funcional (MIF) e a escala de dor pela escala visual analógica (EVA) no pré-operatório, 2º/3º dias pós-operatórios (DPO) e 5º/6º DPO. Resultado: Houve uma redução da dor do 2º/3º DPO para o 5º/6º DPO; uma perda de desempenho funcional do pré-operatório para o 2º/3ºDPO e um ganho deste do 2º/3º DPO para 5º/6º DPO com p<0,001. Não se obteve uma correlação significante entre a dor e o quantitativo cirúrgico com o desempenho funcional, apenas deste com o tempo de CEC, que se mostrou inversamente proporcional. Conclusão: A dor, na primeira cirurgia e na reoperação, não influenciou a medida de independência funcional, sendo apenas influenciada pelo tempo de CEC.

Background: Cardiac surgery is a form of treatment that causes changes in the body, although offering improvement for the patient. Objective: To evaluate the influence of pain during the initial surgery and reoperation with the use ofcardiopulmonary bypass (CPB) on the functional independence measure (FIM).Methods: This study focused on 22 cardiac patients in the Fundação de Beneficência Hospital de Cirurgia(FBHC) hospitalized for elective heart surgery through mid-sternal thoracotomy (MST) with cardiopulmonary bypass (CPB) between March and April 2010, using thefunctional independence measure (FIM) questionnaire and the Visual Analog Scale (VAS) for pain in the preoperative, 2/3 and 5/6 PODs. Results: Pain reduction was noted between 2/3 and 5/6 PODs; a loss of functional performance between the preoperativeperiod and the 2/3 PODs; and a gain between the 2/3 and 5/6 PODs with p<0.001. No statistically significant correlation was found between pain and the amount of surgery with functional performance, but only between the latter and the duration of the CPB, whichwas inversely proportional. Conclusion: Pain caused by the first surgery andreoperation did not affect the functional independence measure, which was influenced only by the CPB.

Oxygen uptake kinetics in older patients receiving postacute cardiac rehabilitation: effects of low-intensity aerobic training.

OBJECTIVE: Older patients who receive postacute cardiac rehabilitation improve their physical performance in terms of distance walked at the 6-min walk test. However, the slower and more complicated recovery, along with age-related chronic comorbidities, remarkably limits the intensity of aerobic training, which actually represents the core of cardiac rehabilitation. The aim of this study was to verify whether postacute cardiac rehabilitation also improves the cardiovascular adjustment to exercise, despite low-intensity aerobic training. DESIGN: Using a portable gas analyzer, we assessed the O(2) uptake kinetics during the 6-min walk test at the beginning and at the end of the rehabilitation in 84 patients aged 65 yrs and above. RESULTS: All patients significantly improved the distance walked at the 6-min walk test. The comparison of the time constants of O(2) uptake kinetics showed that 40% of patients also significantly improved the hemodynamic response to exercise. This improvement was independently associated with the report of sedentary lifestyle or low-intensity physical activity in the year before surgery and with longer time constants before physical training. CONCLUSIONS: Low-intensity aerobic training improves the cardiovascular adjustment to exercise selectively in patients with physical deconditioning. This confirms the notion that elderly frail patients are those who benefit most from cardiac rehabilitation.