Effectiveness of Combined Preoperative and Postoperative Rehabilitation Versus Postoperative-Only Rehabilitation in Cardiac Surgery Patients: A Systematic Review

Prehabilitation, delivered before surgery in addition to standard postoperative rehabilitation, has been proposed as a strategy to improve outcomes in patients undergoing cardiac surgery. While postoperative rehabilitation is standard of care, the incremental benefit of adding a preoperative phase remains uncertain. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing combined preoperative and postoperative rehabilitation (Pre+Post) with postoperative rehabilitation alone (Post-only) in adults undergoing elective cardiac surgery. Comprehensive searches of PubMed, CINAHL, Cochrane, and MEDLINE were performed up to March 2025. Primary outcomes were postoperative pulmonary complications (PPCs), functional capacity, pulmonary function, and length of hospital stay (LOS). Secondary outcomes included ICU stay, duration of mechanical ventilation, quality of life (QoL), and psychological measures. The risk of bias was assessed using the RoB 2 tool for RCTs. Pooled analyses were conducted using random-effects models. Seventeen studies met the inclusion criteria, comprising 11 RCTs and six non-randomized studies, with over 3,200 participants. Meta-analysis of six RCTs (n = 1,729) showed that Pre+Post rehabilitation significantly reduced PPCs (RR 0.39, 95% CI 0.19-0.80, p = 0.01), corresponding to a 61% lower risk. Four RCTs (n = 315) demonstrated superior postoperative functional capacity in the Pre+Post group, with a pooled mean difference of +42 m in 6MWT (95% CI 32.39-51.68, p < 0.00001, I² = 0%). Pulmonary function was improved, with increases in FVC (+0.45 L, 95% CI 0.20-0.70) and FEV₁ (+0.36 L, 95% CI 0.14-0.58). Hospital LOS was reduced by almost three days (MD -2.92, 95% CI -4.52 to -1.31), though heterogeneity was high (I² = 87%). Effects on ICU stay and QoL were mixed. Adding a structured prehabilitation phase to standard postoperative rehabilitation significantly reduces PPCs, improves functional capacity, and enhances pulmonary function after cardiac surgery. While benefits on LOS and QoL are less consistent, the overall evidence supports the integration of prehabilitation into perioperative care pathways. Future large-scale RCTs with standardized protocols are warranted.