Outpatient cardiovascular rehabilitation after aortic valve surgery: Croatian experience

    Authors

    Abstract

    **Introduction:** While the benefits of the cardiovascular rehabilitation (CVR) after the myocardial surgical coronary revascularization are well documented, only a few studies have indicated the benefits of CVR in patients after the aortic valve surgery. (1, 2) The aim of the paper is to show the experience of the only Croatian center of the outpatient CVR in patients after the aortic valve surgery. **Patients and Methods:** We retrospectively analyzed the data from the medical charts of all patients with operated aortic valve involved in the outpatient CVR program in the Institute for Cardiovascular Diseases Prevention and Rehabilitation in Zagreb from 10th January 2012, and who ceased to participate in the program by 6th October 2016. The performance of the CVR program in the Insitute has already been described. (3) In addition to the data on a type of intervention and risk factors, we have also analyzed the frequency of the optimally performed anticoagulant therapy (4) and changes to the functional capacity at the end of the CVR. The results were presented by groups according to gender by using the descriptive statistics methods. **Results:** Out of 53 patients involved, 18 (34%) were women and 35 (66%) men. The average duration of CVR was 2.6 months. The main disease is aortic stenosis, which was present in 80% of men and 89% of women. The analysis of the frequency of the interventions performed, risk factors and the success of anticoagulant therapy is shown in **Table 1**. The mean functional capacity value at the beginning and end of the CVR was 5.9±1.39 and 6.8±1.17 for men and 5.6±0.85 and 6.4±1,12 METs for women. ### Table 1: The frequency of performed cardiac surgeries, risk factors and success of anticoagulant therapy in patients undergoing outpatient cardiovascular rehabilitation following aortic valve surgery. | | | **Men** **n = 35** | **Women** **n = 18** | **All** **N = 53** | | --- | --- | --- | --- | --- | | **Aortic stenosis** | | 80.0% (28/35) | 88.9% (16/18) | 83.0% (44/53) | | **Aortic Valve Replacement Surgery** | | | | | | **Bioprosthetic aortic valve replacement** | | 54.3% (19/35) | 66.7% (12/18) | 58.5% (31/53) | | – bioprosthesis + coronary artery bypass grafting | | 26.3% (5/19) | 25.0% (3/12) | 25.8% (8/31) | | – bioprosthesis + surgery of ascending aorta | | 0% (0/19) | 8.3% (1/12) | 3.2% (1/31) | | **Mechanical aortic valve replacement** | | 45.7% (16/35) | 27.8% (5/18) | 39.6% (21/53) | | – mechanical prostheses + surgery of ascending aorta | | 37.5% (6/16) | 20.0% (1/5) | 33.3% (7/21) | | **Transcatheter aortic valve implantation** | | 0% (0/35) | 5.6% (1/18) | 1.9% (1/53) | | **Risk factors** | | | | | | Average age ± standard deviation (years) | | 64 ± 12.4 | 70 ± 8.9 | 66.1 ± 11.6 | | Age range (minimum-maximum; years) | | 28-81 | 41-80 | 28-81 | | Hypertension | | 85.7% (30/35) | 77.8% (14/18) | 83.0% (44/53) | | Dyslipidemia | | 80.0% (28/35) | 66.7% (12/18) | 75.5% (40/53) | | Diabetes | | 25.7% (9/35) | 11.1% (2/18) | 20.8% (11/53) | | Active smoking | | 17.1% (6/35) | 27.8% (5/18) | 20.8% (11/53) | | Coronary artery disease | | 31.4% (11/35) | 38.9% (7/18) | 34.0% (18/53) | | Mean body mass indeks (kg/m2) | | 28 | 27.9 | 28.2 | | Overweight | | 71.4% (25/35) | 50.0% (9/18) | 64.2% (34/53) | | Obesity | | 17.1% (6/35) | 22.2% (4/18) | 18.9% (10/53) | | Optimaly anticoagulated patients with indications (time in target range of PV/INR) | | 55.0% (15/27) | 55.0% (5/9) | 55.0% (20/36) | **Conclusions:** Men are more often involved in the outpatient CVR program following the aortic valve surgery. Aortic stenosis is a dominant disease, where out of risk factors there is hypertension, dyslipidemia and increased body mass index to be emphasized. Patients with implanted bioprosthetic valve were involved more frequently. Anticoagulant therapy was optimal in a half of the subjects. The CVR program after the aortic valve replacement surgery improves the functional capacity. Further studies on a greater number of patients as well as additional education about the importance of anticoagulant therapy are needed.

    Keywords

    aortic valve surgery, outpatient cardiovascular rehabilitation, Croatia

    DOI

    https://doi.org/10.15836/ccar2016.628

    Literature

    1. Butchart EG, Gohlke-Bärwolf C, Antunes MJ, Tornos P, De Caterina R, Cormier B, et al. Working Groups on Valvular Heart Disease, Thrombosis, and Cardiac Rehabilitation and Exercise Physiology, European Society of Cardiology. Recommendations for the management of patients after heart valve surgery. Eur Heart J. 2005;26(22):2463–71. https://doi.org/10.1093/eurheartj/ehi426
    2. Piepoli MF, Corrŕ U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, et al. Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010;17(1):1–17. https://doi.org/10.1097/HJR.0b013e3283313592
    3. Ivanuša M, Narančić Skorić K, Glavaš Vražić S, Kruhek Leontić D, Heinrich M, Mažuran Brkljačić L, et al. Outpatient Cardiovascular Rehabilitation in Croatia. Cardiol Croat. 2015;10(1-2):28–42. https://doi.org/10.15836/ccar.2015.28
    4. National Quality Measures Clearinghouse (NQMC). Measure summary: Percent time in therapeutic INR range (TTR): mean TTR achieved among patients who received prescriptions for warfarin and had sufficient INR values to calculate TTR. In: National Quality Measures Clearinghouse (NQMC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2011 Jan 01. [cited 2016 Nov 2]. Available:. https://www.qualitymeasures.ahrq.gov
    Cardiologia Croatica
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    Outpatient cardiovascular rehabilitation after aortic valve surgery: Croatian experience

    Extended Abstract
    Issue12
    Published
    Pages628-629
    PDF via DOIhttps://doi.org/10.15836/ccar2016.628
    aortic valve surgery
    outpatient cardiovascular rehabilitation
    Croatia

    Authors

    Kristina Narančić SkorićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Mario Ivanuša*ORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Jadranka Dražić-BalovORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia
    Žaklina MuminovićORCIDInstitute for Cardiovascular Prevention and Rehabilitation, Zagreb, Croatia

    *Correspondence email: mivanusa@gmail.com

    Abstract

    **Introduction:** While the benefits of the cardiovascular rehabilitation (CVR) after the myocardial surgical coronary revascularization are well documented, only a few studies have indicated the benefits of CVR in patients after the aortic valve surgery. (1, 2) The aim of the paper is to show the experience of the only Croatian center of the outpatient CVR in patients after the aortic valve surgery. **Patients and Methods:** We retrospectively analyzed the data from the medical charts of all patients with operated aortic valve involved in the outpatient CVR program in the Institute for Cardiovascular Diseases Prevention and Rehabilitation in Zagreb from 10th January 2012, and who ceased to participate in the program by 6th October 2016. The performance of the CVR program in the Insitute has already been described. (3) In addition to the data on a type of intervention and risk factors, we have also analyzed the frequency of the optimally performed anticoagulant therapy (4) and changes to the functional capacity at the end of the CVR. The results were presented by groups according to gender by using the descriptive statistics methods. **Results:** Out of 53 patients involved, 18 (34%) were women and 35 (66%) men. The average duration of CVR was 2.6 months. The main disease is aortic stenosis, which was present in 80% of men and 89% of women. The analysis of the frequency of the interventions performed, risk factors and the success of anticoagulant therapy is shown in **Table 1**. The mean functional capacity value at the beginning and end of the CVR was 5.9±1.39 and 6.8±1.17 for men and 5.6±0.85 and 6.4±1,12 METs for women. ### Table 1: The frequency of performed cardiac surgeries, risk factors and success of anticoagulant therapy in patients undergoing outpatient cardiovascular rehabilitation following aortic valve surgery. | | | **Men** **n = 35** | **Women** **n = 18** | **All** **N = 53** | | --- | --- | --- | --- | --- | | **Aortic stenosis** | | 80.0% (28/35) | 88.9% (16/18) | 83.0% (44/53) | | **Aortic Valve Replacement Surgery** | | | | | | **Bioprosthetic aortic valve replacement** | | 54.3% (19/35) | 66.7% (12/18) | 58.5% (31/53) | | – bioprosthesis + coronary artery bypass grafting | | 26.3% (5/19) | 25.0% (3/12) | 25.8% (8/31) | | – bioprosthesis + surgery of ascending aorta | | 0% (0/19) | 8.3% (1/12) | 3.2% (1/31) | | **Mechanical aortic valve replacement** | | 45.7% (16/35) | 27.8% (5/18) | 39.6% (21/53) | | – mechanical prostheses + surgery of ascending aorta | | 37.5% (6/16) | 20.0% (1/5) | 33.3% (7/21) | | **Transcatheter aortic valve implantation** | | 0% (0/35) | 5.6% (1/18) | 1.9% (1/53) | | **Risk factors** | | | | | | Average age ± standard deviation (years) | | 64 ± 12.4 | 70 ± 8.9 | 66.1 ± 11.6 | | Age range (minimum-maximum; years) | | 28-81 | 41-80 | 28-81 | | Hypertension | | 85.7% (30/35) | 77.8% (14/18) | 83.0% (44/53) | | Dyslipidemia | | 80.0% (28/35) | 66.7% (12/18) | 75.5% (40/53) | | Diabetes | | 25.7% (9/35) | 11.1% (2/18) | 20.8% (11/53) | | Active smoking | | 17.1% (6/35) | 27.8% (5/18) | 20.8% (11/53) | | Coronary artery disease | | 31.4% (11/35) | 38.9% (7/18) | 34.0% (18/53) | | Mean body mass indeks (kg/m2) | | 28 | 27.9 | 28.2 | | Overweight | | 71.4% (25/35) | 50.0% (9/18) | 64.2% (34/53) | | Obesity | | 17.1% (6/35) | 22.2% (4/18) | 18.9% (10/53) | | Optimaly anticoagulated patients with indications (time in target range of PV/INR) | | 55.0% (15/27) | 55.0% (5/9) | 55.0% (20/36) | **Conclusions:** Men are more often involved in the outpatient CVR program following the aortic valve surgery. Aortic stenosis is a dominant disease, where out of risk factors there is hypertension, dyslipidemia and increased body mass index to be emphasized. Patients with implanted bioprosthetic valve were involved more frequently. Anticoagulant therapy was optimal in a half of the subjects. The CVR program after the aortic valve replacement surgery improves the functional capacity. Further studies on a greater number of patients as well as additional education about the importance of anticoagulant therapy are needed.

    Literature

    1. 1.
      Butchart EG, Gohlke-Bärwolf C, Antunes MJ, Tornos P, De Caterina R, Cormier B, et al. Working Groups on Valvular Heart Disease, Thrombosis, and Cardiac Rehabilitation and Exercise Physiology, European Society of Cardiology. Recommendations for the management of patients after heart valve surgery. Eur Heart J. 2005;26(22):2463–71.DOI
    2. 2.
      Piepoli MF, Corrŕ U, Benzer W, Bjarnason-Wehrens B, Dendale P, Gaita D, et al. Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Secondary prevention through cardiac rehabilitation: from knowledge to implementation. A position paper from the Cardiac Rehabilitation Section of the European Association of Cardiovascular Prevention and Rehabilitation. Eur J Cardiovasc Prev Rehabil. 2010;17(1):1–17.DOI
    3. 3.
      Ivanuša M, Narančić Skorić K, Glavaš Vražić S, Kruhek Leontić D, Heinrich M, Mažuran Brkljačić L, et al. Outpatient Cardiovascular Rehabilitation in Croatia. Cardiol Croat. 2015;10(1-2):28–42.DOI
    4. 4.
      National Quality Measures Clearinghouse (NQMC). Measure summary: Percent time in therapeutic INR range (TTR): mean TTR achieved among patients who received prescriptions for warfarin and had sufficient INR values to calculate TTR. In: National Quality Measures Clearinghouse (NQMC) [Web site]. Rockville (MD): Agency for Healthcare Research and Quality (AHRQ); 2011 Jan 01. [cited 2016 Nov 2]. Available:.Link