Multimodal prehabilitation as a strategy to reduce postoperative complications in cardiac surgery

BACKGROUND: Prehabilitation has shown efficacy in improving postoperative outcomes in abdominal surgery. Data on cardiac surgery are controversial. OBJECTIVE: To determine if a multimodal prehabilitation programme reduces the rate of postoperative complications after elective cardiac surgery. DESIGN: Randomised controlled trial. SETTING: Single-centre study in a tertiary hospital with inclusion period spanned from March 2018 to June 2021. PATIENTS: One hundred and fifty-one patients, with an expected waiting time before surgery of 6 weeks or more, completed the study. Excluded were those with functional, anatomical or cognitive impairment; cardiac instability; dynamic left ventricle outflow tract obstruction or proven exercise-induced arrhythmias. INTERVENTION: Four to six weeks of a multimodal prehabilitation programme, including exercise training, psychological and nutritional support. MAIN OUTCOME: Incidence of postoperative complications. RESULTS: No differences were found in the rate of postoperative complications (80% in both groups, P = 0.968), most of which were mild, with a Comprehensive Complication Index of 21 and more than 70% with Clavien-Dindo grade I or II. Prehabilitated patients showed a significant improvement in endurance time assessed by a constant-work rate cycling exercise test: preintervention vs . postintervention (301 ± 109 vs . 578 ± 257 s, P = 0.001), and in 6-min walk test (6MWT) (487 ± 77 vs . 504 ± 74 min, P = 0.001). No patients experienced adverse events attributable to the intervention. A sub-analysis restricted to prehabilitated patients who showed a meaningful response to exercise assessed by the 6MWT (increase ≥ 30 m) showed a reduction in the number and severity of postoperative complications, compared to nonresponders (1.1 ± 0.9 vs . 2 ± 2 complications per patient, P = 0.038); and the Comprehensive Complication Index (16 ± 15 vs . 25 ± 19, P = 0.044). CONCLUSION: A multimodal prehabilitation programme before elective cardiac surgery did not reduce the incidence of postoperative complications. Nevertheless, when analysis was restricted to meaningful responders to intervention, a significant reduction in postoperative complications and their severity was observed. TRIAL REGISTRATION: ClinicalTrials.gov (NCT03466606).