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A pilot prehabilitation program worked well for one center and its frail patients undergoing coronary artery bypass grafting (CABG) surgery.

The 100 surgical candidates who underwent multimodal prehabilitation from September 2020 to July 2021 -- a program comprising lifestyle counseling, exercise training, and other activities -- tended to have better perioperative outcomes than a historical matched cohort undergoing CABG from June 2019 to September 2020, said Serdar Gunaydin, MD, PhD, of the University of Health Sciences and Ankara City Hospital in Turkey.

Prehabilitation was associated with earlier extubation after surgery, fewer reoperations and reintubations, and fewer readmissions at 6 months. Moreover, prehabilitated CABG patients had shorter ICU stays (average 35 vs 58 hours) and hospital stays (7.2 vs 9.2 days), for a 35.2% reduction in total treatment costs, Gunaydin reported at the Society of Thoracic Surgeons (STS) virtual meeting.

"We believe multimodal prehabilitation combined with ERAS [Enhanced Recovery After Surgery], as a value-based approach, can consistently result in earlier recovery, cost reductions, and increased patient and staff satisfaction in cardiac surgery," he said.

ERAS pathways offer a multidisciplinary approach to improving patient recovery and reducing surgical complications. The currently give prehabilitation a class IIa recommendation based on limited evidence. That may change in this year's anticipated guideline update, Gunaydin suggested.

At his hospital, prehabilitation comprises regular supervised endurance and exercise training sessions, promotion of physical activity and lifestyle, respiratory physiotherapy, nutrition counseling, and mindfulness sessions, with the aim of improving patients' frailty scores. Gunaydin highlighted the surprising benefit of nutritional support in particular, which has recently become the modality of focus.

The Turkish center has now performed cardiac surgeries under the prehabilitation protocol in over 800 patients to date. The success rate of implementing the pathway was around 75% to 80% at the beginning of this study. "Now we are over 90%," Gunaydin said.

"Your practice setting may be a little different than what we experience in North America, [where] the referring cardiologists may not take too kindly to delaying their patients' CABG surgery, or family members may not be happy about waiting a few weeks to get their operation," said STS session co-moderator Linda Martin, MD, MPH, of the University of Virginia in Charlottesville.

This was also a problem in Turkey, said Gunaydin, who noted that his group found that standard education of the patients helped, as did having a vast network of referring cardiologists and cardiac surgeons trained in the strict prehabilitation pathway.

"You know it's the right thing to do but the cardiologist is chomping at the bit to get them in the OR [operating room]," Martin noted of expectations in the U.S.

"In America, it's instant coffee, instant surgery. They're not going to wait for anything," agreed co-moderator J. Michael DiMaio, MD, of Baylor Scott & White Health and the Heart Hospital in Plano, Texas.

The study included 100 consecutive frail patients matched to 100 patients before the era of prehabilitation at Gunaydin's hospital. Mean ages of the two groups were 79 and 76 years, and their STS scores were 13 and 14, respectively.

Eight people in the prehabilitation group were ultimately excluded from the analysis because of insufficient follow-up data.

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