Postoperative care of cardiac surgery

patients: A protocolized approach

towards enhanced recovery versus the
conventional approach
Moustafa Ibrahim Abd EL-Aal Halwag, Mahar Ahmed Doghiem, Moustafa Abdelaziz
Moustafa & Hossam Ossama Ahmed Sorour
Background
Enhanced Recovery after Surgery (ERAS) is a multimodal, trans-disciplinary care initiative to promote the recovery of
surgical patients throughout their perioperative journey [1]. The main aims of such program are to reduce
complications, shorten the period of hospital stay, reduce costs and eventually speed up the patient return to his
preoperative daily routine [2,3]. Cardiac surgery patients experience a great deal of challenges when it comes to the
postoperative period unrelated to their cardiac performance such as respiratory, gastrointestinal and renal problems,
which can be exaggerated by prolonged opioid intake, ineffective pain control and late mobilization, which will add to
the problem of their advanced age and comorbid conditions, all of which will eventually increase the overall
morbidity, mortality and eventually hospital stay [4]. Traditionally, conventional oxygenation methods were used to
correct hypoxemia but they were always experienced by the limitation of patient’s intolerance to the application
system and the limitation of oxygen flow to 15 l/min, which may fail to cover the minute ventilation of patients in
respiratory failure and eventually inhaled flow is mixed with air from the atmosphere dropping the fraction of inspired
oxygen [5]. In addition, oxygen is not always delivered under optimal conditions regarding temperature and humidity
[5]. High flow nasal oxygen therapy carries the benefit of reducing the dilution of the administered oxygen [6,7], dead
space washout [7–9], the generation of continuous positive airway pressure (CPAP) [10–13] and improving mucociliary
transport courtesy of the active humidification and heating of the administered gas [14,15]. Utilization of regional
blocks in cardiac surgery have been shown to provide improved post-operative pain control and decreased opiate
requirements with less possible complications [16–18]. The aim of the present study was to compare two protocols of
postoperative care: An enhanced recovery program consisted of high flow nasal oxygen therapy together with
pectointercostal block versus conventional
Background
The ARIS hypothesis
‘Exercise and functional intolerance in patients with HF are
associated not only with reduced muscle endurance but also
with both reduced muscle strength and decreased inspiratory
muscle function, contributing to weakness, dyspnoea, fatigue,
and low aerobic capacity, and that the ARIS training programme
may result in maximal exercise pathophysiological and
functional benefits in HF patients
Aim
The multicentre ARISTOS-HF (Aerobic, Resistance, InSpiratory
Training OutcomeS in Heart Failure) randomized trial was
initiated to test this hypothesis and to compare ARIS to
AT/RT, AT/IMT and AT, maintaining an equal exercise time
among supervised programmes and evaluating both
functional and cardiac indices in order to provide the
evidence for the ‘optimum’ exercise programme for HF
patients.
 Methods
Study design
• Study type : Interventional (clinical trial)
• Allocation : randomized
• Intervention model : parallel
• Masking : Double (participant, investigator)
• Centers : Onassis Cardiac Surgery Center Greek, National Institute
of Cardiology Poland, Asklepieion General Hospital Greece.
• Time : January 2017 and May 2020.
• The trial complies with the Declaration of Helsinki and approved by
the Hospital Ethics Committee.
• Blind statistical analyses.
 Methods
Patients
• Exclusion criteria
• Uncontrolled arrhythmia
• Pulmonary oedema, or pulmonary congestion in the last 30 days
• Cognitive, neurological, or orthopaedic limitations
• Respiratory infection during 30 days before the start of the study
• Pulmonary limitations (e.g. chronic obstructive pulmonary disease).
• Inclusion criteria
• Age 18–80 years
• Symptomatic New York Heart Association (NYHA) class II–III
• Chronic HF under optimum medical treatment
• Left ventricular ejection fraction (LVEF) <_35%
• Randomization : block randomization to 4 arms
 Methods
Interventions
Arms Periode F T T I

ARIS 12
weeks
3 times/week
60’/day
Aerobic 30’ 60-80% max HR (or peakVO2)

Resistance 10’ 50% of 1 Repetition Maximum

(1RM)

Inspiration 20’ 60% of PImax/SPImax

AT/RT Aerobic 30’ 60-80% max HR (or peakVO2)

Resistance 30’ 50% of 1 Repetition Maximum

(1RM)

AT/IMT Aerobic 30’ 60-80% max HR (or peakVO2)

Inspiration 30’ 60% of PImax/SPImax

AT Aerobic 60’ 60-80% max HR (or peakVO2)

 Method
Study endpoints
Primary endpoints

Change in peak oxygen consumption (peakVO2) Cardiopulmonary exercise testing

Change in left ventricular dimension (mm) Resting 2-dimensional echocardiography

Secondary endpoints

Change in walking distance 6-minute walking test (6MWT)

Change in quality of Life Minnesota Living with Heart Failure

questionnaire

Preference Program Survey Standardised 5-point Likert scale

 Method
Statistical Analysis
Target sample size 22 patients for each arm

Power 84% (10% pVO2)

93% (2 mm difference of LVEDD-LVESD)

Continuous variables Mean, 95% CI

Baseline comparisons Analysis of variance and the x2 test

Training induced changes The paired t-test

Normality P–P plots

Endpoint analysis Linear model (12-week values (outcome) and baseline

(covariates))

Between-group analysis Estimated marginal mean contrasts, 95% CI

PPS comparison Pairwise Wilcoxon

Results
Results

13 pts withdrew or
loss to follow up
Results
Results
Primary endpoints - peakVO2
Results
Primary endpoints - peakVO2
Results
Primary endpoints - LVEDD, LVESD, LVEF
Results
Secondary outcome

Secondary endpoints. (A) Significant benefit shown for 6MWT distance in the ARIS group
compared to AT and AT/IMT groups. (B) Significant benefit shown for MLwHFQ score in the
ARIS group compared to AT and AT/RT groups. (C) Significant benefit shown for the
programme preference survey score in the ARIS group compared to AT group.
Results
Other Endpoints
Limitations
• Blinding of the research personnel was not always possible.
• Patient enrolment was slow and the patient number remains
small.
• Patients at different centres underwent CPX using different
protocols.
• Unintended small proportion of female pts (7%).
Conclusion
• Exercise training for 180 min/week is recommended for HF
patients.
• The ARIS training programme was superior to other exercise
programmes in improving the aerobic response to training, left
ventricular dimensions towards reverse remodelling and
secondary functional outcomes, supporting the prescription of
the triple training regime for patients with chronic systolic HF
 Critical Appraisal
P : Age 18–80 years, NYHA FC II–III on optimum medical treatment, LVEF ≤35%
I : ARIS (aerobic, resistance, inspiration training)
C : AT/RT (aerobic, resistance training), AT/IRT (aerobic, inspiration training), AT
O : peak oxygen consumption (peakVO2), LV dimension
Critical Appraisal

✔
Critical Appraisal

✔
 No significant differences (P = ns) were found
between baseline characteristics in study groups
Critical Appraisal

✔
Critical Appraisal

✔
Critical Appraisal

✔
Critical Appraisal
Critical Appraisal