Exercise-based cardiac rehabilitation for adults after heart valve surgery.

Abstract

BACKGROUND\nThe impact of exercise-based cardiac rehabilitation (CR) following heart valve surgery is uncertain. We conducted an update of this systematic review and a meta-analysis to assess randomised controlled trial evidence for the use of exercise-based CR following heart valve surgery.\n\n\nOBJECTIVES\nTo assess the benefits and harms of exercise-based CR compared with no exercise training in adults following heart valve surgery or repair, including both percutaneous and surgical procedures. We considered CR programmes consisting of exercise training with or without another intervention (such as an intervention with a psycho-educational component).\n\n\nSEARCH METHODS\nWe searched the Cochrane Central Register of Clinical Trials (CENTRAL), in the Cochrane Library; MEDLINE (Ovid);\xa0Embase\xa0(Ovid); the Cumulative Index to Nursing and Allied Health Literature\xa0(CINAHL; EBSCO);\xa0PsycINFO (Ovid);\xa0Latin American Caribbean Health Sciences Literature\xa0(LILACS; Bireme);\xa0and Conference Proceedings Citation Index-Science (CPCI-S) on the Web of Science (Clarivate Analytics) on\xa010\xa0January 2020. We searched for ongoing trials from ClinicalTrials.gov, Clinical-trials.com, and the World Health Organization International Clinical Trials Registry Platform on 15 May 2020.\n\n\nSELECTION CRITERIA\nWe included randomised controlled trials that compared exercise-based CR interventions with no exercise training. Trial participants comprised adults aged 18 years or older who had undergone heart valve surgery for heart valve disease (from any cause) and had received heart valve replacement\xa0or heart valve repair. Both percutaneous and surgical procedures were included.\n\n\nDATA COLLECTION AND ANALYSIS\nTwo review authors independently extracted data. We assessed the risk of systematic errors ( bias ) by evaluating risk domains using the Risk of bias (RoB2) tool. We assessed clinical and statistical heterogeneity. We performed meta-analyses using both fixed-effect and random-effects models. We used the GRADE approach to assess the quality of evidence for primary outcomes (all-cause mortality, all-cause hospitalisation, and health-related quality of life).\n\n\nMAIN RESULTS\nWe included six trials with a total of 364 participants who have had open or percutaneous heart valve surgery. For this updated review, we identified four additional trials (216 participants). One trial had an overall low risk of bias, and we classified the remaining five trials as having some concerns. Follow-up ranged across included trials from 3 to 24 months. Based on data at longest follow-up, a total of nine participants died: 4 CR versus 5 control (relative risk (RR) 0.83, 95% confidence interval (CI)\xa00.26 to 2.68; 2 trials, 131 participants; GRADE quality of evidence\xa0very low). No trials reported on cardiovascular mortality. One trial reported\xa0one cardiac-related hospitalisation in the CR group and none in the control group (RR 2.72, 95% CI\xa00.11 to 65.56; 1 trial, 122 participants; GRADE quality of evidence\xa0very low). We are uncertain about\xa0health-related quality of life at completion of the intervention in CR compared to control (Short Form (SF)-12/36 mental component: mean difference (MD) 1.28, 95% CI\xa0-1.60 to 4.16; 2 trials, 150 participants;\xa0GRADE quality of evidence\xa0very low; and SF-12/36 physical component: MD 2.99, 95% CI\xa0-5.24 to 11.21; 2 trials, 150 participants; GRADE quality of evidence\xa0very low), or at longest follow-up (SF-12/36 mental component: MD -1.45, 95% CI\xa0-4.70 to 1.80; 2 trials, 139 participants; GRADE\xa0quality of evidence\xa0very low; and SF-12/36 physical component: MD -0.87, 95% CI\xa0-3.57 to 1.83; 2 trials, 139 participants; GRADE quality of evidence\xa0very low).\xa0 AUTHORS CONCLUSIONS: Due\xa0to lack of evidence and the very low quality of available evidence, this updated review is uncertain about\xa0the impact of exercise-CR in this population in terms of mortality, hospitalisation, and health-related quality of life. High-quality (low risk of bias) evidence on the impact of CR is needed to inform clinical guidelines and routine practice.