COMPLETION OF A PHASE 2 OUTPATIENT CARDIAC REHABILITATION PROGRAM FOLLOWING TRANSCATHETER AORTIC VALVE IMPLANTATION OR SURGICAL AORTIC VALVE REPLACEMENT: A RETROSPECTIVE REVIEW

Abstract

BACKGROUND Referral to and enrolment in cardiac rehabilitation (CR) is considered a best practice recommendation following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (sAVR). TAVI patients are underrepresented in CR and few studies have investigated the effectiveness and completion of a structured outpatient (phase II) CR program comparing TAVI with sAVR patients. The objectives of this study were to: 1) compare the effectiveness of CR between TAVI and sAVR patients, and 2) compare program completion rate between cohorts, and 3) examine predictors of program completion. METHODS AND RESULTS A retrospective database review of 615 patients referred to a large, urban outpatient CR program following TAVI (n = 158; 26%) and sAVR (n = 457; 74%) was conducted between 2015-2019. The 6-month program included aerobic and resistance training, education, psychosocial and dietary counselling. Within-group (baseline versus discharge) and between-group comparisons of change (peak oxygen uptake (VO2peak), body mass index, Center for Epidemiologic Studies Depression score, and resting/peak heart rate and systolic blood pressure), and program completion rate were examined using t-test and chi-square analyses. Multivariable analyses were conducted to determine predictors of program completion in all patients. Overall, 66% of patients (n = 403) referred to CR enrolled in the program (TAVI: n = 92; 58% versus sAVR: n = 311; 68%; P = 0.03). Of the enrolled cohorts, TAVI patients had a 55% completion rate (47/86) compared to 61% in sAVR patients (179/295; P = 0.38). Peak oxygen uptake improved for TAVI (15.9 ± 3.7 to 18.1 ± 4.1 mL•kg-1•min-1; P < 0.0001) and sAVR (19.4 ± 6.0 to 22.7 ± 6.8 mL•kg-1•min-1; P < 0.0001) patients. No statistically significant differences were found in other outcomes of interest. In all patients, while adjusting for VO2peak and sex, age (80 to 70 years: OR 2.08, CI 1.32–3.30) and procedure type (TAVI to sAVR: OR 0.47, CI 0.24–0.91), only age and procedure type were independent predictors of program completion. CONCLUSION Cardiac rehabilitation enrolment was significantly higher in sAVR compared to TAVI patients; the rate of program completion did not differ significantly between the enrolled cohorts. Program completion led to significant improvements in cardiorespiratory fitness (VO2peak) for both groups, which can confer overall health and mortality benefits. Regression analysis revealed age and procedure type were predictors of program completion. Future prospective studies, targeting improved referral strategies and reducing enrolment barriers for TAVI patients are necessary to ensure optimal patient benefit. Referral to and enrolment in cardiac rehabilitation (CR) is considered a best practice recommendation following transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (sAVR). TAVI patients are underrepresented in CR and few studies have investigated the effectiveness and completion of a structured outpatient (phase II) CR program comparing TAVI with sAVR patients. The objectives of this study were to: 1) compare the effectiveness of CR between TAVI and sAVR patients, and 2) compare program completion rate between cohorts, and 3) examine predictors of program completion. A retrospective database review of 615 patients referred to a large, urban outpatient CR program following TAVI (n = 158; 26%) and sAVR (n = 457; 74%) was conducted between 2015-2019. The 6-month program included aerobic and resistance training, education, psychosocial and dietary counselling. Within-group (baseline versus discharge) and between-group comparisons of change (peak oxygen uptake (VO2peak), body mass index, Center for Epidemiologic Studies Depression score, and resting/peak heart rate and systolic blood pressure), and program completion rate were examined using t-test and chi-square analyses. Multivariable analyses were conducted to determine predictors of program completion in all patients. Overall, 66% of patients (n = 403) referred to CR enrolled in the program (TAVI: n = 92; 58% versus sAVR: n = 311; 68%; P = 0.03). Of the enrolled cohorts, TAVI patients had a 55% completion rate (47/86) compared to 61% in sAVR patients (179/295; P = 0.38). Peak oxygen uptake improved for TAVI (15.9 ± 3.7 to 18.1 ± 4.1 mL•kg-1•min-1; P < 0.0001) and sAVR (19.4 ± 6.0 to 22.7 ± 6.8 mL•kg-1•min-1; P < 0.0001) patients. No statistically significant differences were found in other outcomes of interest. In all patients, while adjusting for VO2peak and sex, age (80 to 70 years: OR 2.08, CI 1.32–3.30) and procedure type (TAVI to sAVR: OR 0.47, CI 0.24–0.91), only age and procedure type were independent predictors of program completion. Cardiac rehabilitation enrolment was significantly higher in sAVR compared to TAVI patients; the rate of program completion did not differ significantly between the enrolled cohorts. Program completion led to significant improvements in cardiorespiratory fitness (VO2peak) for both groups, which can confer overall health and mortality benefits. Regression analysis revealed age and procedure type were predictors of program completion. Future prospective studies, targeting improved referral strategies and reducing enrolment barriers for TAVI patients are necessary to ensure optimal patient benefit.