Am J Transl Res 2022;14(7):5132-5138

www.ajtr.org /ISSN:1943-8141/AJTR0138633

Original Article
Enhanced rehabilitation intervention
improves postoperative recovery and quality of
life of patients after heart valve replacement surgery
Jinxia Hao

Department of Cardiothoracic, Cangzhou Central Hospital, Hebei Province, China

Received August 27, 2021; Accepted January 28, 2022; Epub July 15, 2022; Published July 30, 2022

Abstract: Objective: To explore the application value of enhanced recovery after surgery (ERAS) for heart valve
replacement surgery. Methods: A total of 86 patients with heart valve diseases admitted to our hospital from Jan.
2018 to Mar. 2020 were selected, and randomized into the control group (n=43) with regular nursing care and the
observation group (n=43) with ERAS. The postoperative recovery, rate of adverse events, quality of life, visual ana-
logue scale (VAS) score and nursing care satisfaction rate were compared between the two groups. Results: After
surgery, the time to first bowel movement and the first flatulence in the observation group were earlier than those
in the control group, and the hospital stay of patients in the observation group was shorter than that in the control
group. The rate of adverse events in the observation group was 4.65%, which was lower than that in the control
group (18.60%). In addition, the observation group obtained higher life quality scores but lower VAS, self-rating
anxiety scale (SAS) and self-rating depression scale (SDS) scores than the control group, and the observation group
showed lower serum levels of corticotropin and cortisol and exhibited a longer 6-minute walking distance than the
control group. Moreover, the nursing care satisfaction rate of the observation group was 95.35%, which was higher
than that (76.74%) of the control group (all P<0.05). Conclusions: ERAS can reduce adverse events and pain for
patients with heart valve replacement and improve their postoperative recovery, quality of life, and nursing care
satisfaction.

Keywords: Rapid rehabilitation for surgery, heart valve replacement surgery, postoperative recovery, quality of life

Introduction pation of patients and their families. At the cur-

rent stage, minimally invasive surgery is pre-
Heart valve replacement is usually performed ferred for the diagnosis and treatment of heart
to treat heart valve diseases in clinical practice, valve diseases and people have become in-
but it can induce complications such as nau- creasingly interested in ERAS. Implementing
sea, vomiting and hypoglycemia that compro- ERAS in patients with heart valve replacement
mise patients’ quality of life [1]. In recent years, surgery has obtained wide recognition [3]. How-
accelerated rehabilitation during the periopera- ever, there is insufficient research on the effect
tive period has gained considerable attention. of ERAS on the postoperative recovery and life
Enhanced recovery after surgery (ERAS) is a quality of patients undergoing heart valve
new nursing service mode that is designed to replacement surgery. Accordingly, this study
alleviate the post-operative stress response, was designed to provide references to improve
reduce postoperative complications and short- the prognosis of patients undergoing heart
en hospital stay by optimizing perioperative valve replacement surgery in clinical practice
management measures [2]. ERAS is an im- by evaluating the application value of ERAS.
portant component of perioperative nursing,
Materials and methods
including preoperative guidance, intraopera-
tive temperature monitoring, early identifica- General materials
tion and management of complications, post-
operative dietary guidance, analgesia and re- In this prospective study, patients admitted to
habilitation exercise, emphasizing the partici- our hospital due to heart valve diseases from
 Enhanced recovery after heart valve replacement surgery

Jan. 2018 to Mar. 2020 were selected as observed, the temperature and humidity in the
research subjects. The patients or their family operating room were adjusted to an appropri-
members signed an informed consent, and this ate range in advance to avoid hypothermia of
study was approved of by the Ethisc Committee the patient; lung protection was well carried
of Cangzhou Central Hospital (Approval No. LW out by timely cleaning of the patient’s respira-
2018/232). tory tract and oral secretions. The nursing st-
aff cooperated with the doctor to complete the
Inclusion criteria: (1) Patients who met the clini-
cal diagnostic criteria for heart valve diseases operation smoothly.
[4]; (2) Patients who were scheduled to have
④ Diet nursing: Before surgery, the patient
heart valve replacement surgery; (3) Patients
aged 53-57 years old. was instructed to carry out intestinal manage-
ment, and the patient was instructed to fast
Exclusion criteria: (1) Patients with a history of without water for 6 h before surgery, and a glu-
mental health issues; (2) Patients who had dif- cose solution was given orally when necessary
ficulties in communication; (3) Patients who to reduce the occurrence of postoperative
could not actively cooperate with this research. hypoglycemia. After surgery, patients were in-
structed to make a dietary list to ensure nutri-
Finally, 86 patients were enrolled in this re-
tional collocation by eating more vegetables,
search, and divided into the control group
fruits, protein and other foods, and avoiding
(n=43) and the observation group (n=43) by a
spicy and stimulating food, so as to promote a
random number table method. The general
data of patients were compared between the rapid recovery.
two groups, and the difference was not statisti-
⑤ Pain nursing: Postoperative multi-mode
cally significant, indicating the two groups were
comparable (P>0.05). analgesia program was applied, pain health
education and evaluation were carried out for
Methods patients, and an analgesia program was for-
mulated and adjusted according to patients’
Control group: The control group received regu- conditions.
lar nursing care intervention including basic
nursing, pipeline nursing, dietary guidance, ac- ⑥ Postoperative rehabilitation nursing: a) Early
tivity guidance, and medication guidance, etc. bedside activity: 24 h after surgery, the patients
were assisted to have bedside activity as soon
Observation group: The observation group
as possible, ranging from passive exercise to
received ERAS, covering the following aspects:
active exercise; and then according to the indi-
① Health education: Before surgery, health vidual differences, the patients were supported
education was conducted for patients and th- in bed exercise, and walking and exercise in the
eir families by distribution of relevant knowl- ward. b) Abdominal breathing training: after
edge in brochures and via oral instruction by surgery, the patients were assisted to take a
nursing staff, so that patients could have a cer- supine position and guided to relax the muscles
tain understanding of the basic knowledge, of the whole body and slowly breathe in through
treatment methods, treatment effects and the nose, so the abdomen was expanded, then
ERAS concepts of heart valve disease. holding of the breath, followed by and exhale
through the mouth, to relax the abdomen. The
② Psychological nursing: Before and after sur-
patients were supervised to exercise every day
gery, the adverse emotions of the patient were
with repetitions of 20-30 times/set and 2 sets
given attention, and active communication was
provided in this regard, and former patients per day.
with successful treatment were described, so
Outcome measures
as to improve the patient’s compliance with
treatment and enhance their confidence in
overcoming the disease. (1) The postoperative recovery of patients,
including the time to first bowel movement and
③ Operating room nursing: During the ope- flatulence, and length of hospital stay, were
ration, the patient’s condition was closely compared.

5133 Am J Transl Res 2022;14(7):5132-5138

 Enhanced recovery after heart valve replacement surgery

Table 1. Comparison of general data of patients between the Statistical analyses

two groups
_ SPSS23.0 was used to analyze
Groups N Male (n) Female (n) Average age ( x ±s, Y) the data. Qualitative data were
Observation group 43 23 20 53.46±6.71 expressed by cases and per-
Control group 43 22 21 53.86±6.24 centage and analyzed by χ2.
t/χ2 0.047 0.286 Quantitative
_ data were express-
P-value 0.829 0.775 ed as ( x ±s), and tested by the
pair-sample t test for intra-gr-
oup comparison and indepen-
Table 2. _Comparison of postoperative recovery between the two dent sample t test for inter-group
groups ( x ±s, d) comparison. P<0.05 indicated a
statistic significance.
The time to first The time to Hospital
Groups N
bowel movement first flatulence stay
Results
Observation group 43 1.73±0.51 0.86±0.25 13.36±4.77
Control group 43 2.72±0.63 1.45±0.47 18.53±5.98 Comparison of general data
t 8.009 7.268 4.432
P-value <0.001 <0.001 <0.001 There were 45 males and 41
females enrolled in this study,
and their average age was
(2) The rate of adverse events, including nau- 53.75±6.44 years old. No statistically signifi-
sea, vomiting, hypoglycemia, and bloating, we- cant difference was observed between the
re compared between the two groups. two groups. See Table 1.

(3) The quality of life of patients before surgery Comparison of postoperative recovery between
and 1 month after surgery was compared. It the two groups
was scored using the MOS 36-Item Short-
Form Health Survey (SF-36) from 4 dimensi- The time to first bowel movement, the time of
ons including psychological health, physical first flatulence, and hospital stay in the obser-
health, social function and material life, with vation group were all shorter than those in the
100 points for each dimension. A higher SF-36 control group (all P<0.0.5). See Table 2.
score indicated a better life quality.
Comparison of the incidence of adverse events
between the two groups
(4) Postoperative pain. Postoperative pain upon
waking and 1 d after surgery was evaluated by
The incidence of adverse events in the obser-
the visual analogue scale (VAS) with a full score vation group was lower than that in the control
of 10 points. The higher the score, the more group (6.98% vs. 20.93%, P<0.05). See Table
severe the pain. 3.
(5) Negative emotions of patients were evalu- Comparison of life quality between the two
ated using the self-rating anxiety scale (SAS) groups
score and self-rating depression scale (SDS).
Lower scores indicated better emotional states. The observation group experienced a higher
life quality than the control group at 1 month
(6) Stress factors of patients were also com- after surgery (P<0.05). See Table 4.
pared. Five mL fasting venous blood was col-
lected from each patient before and at 1 month Comparison of VAS scores between the two
after surgery, and the serum levels of cortico- groups
tropin and cortisol were detected by radioim-
munoassay. The VAS scores of the observation group upon
waking after surgery and 1 day after surgery
(7) The 6-minute walking distances of patients were all lower than that of the control group
were compared. (P<0.05). See Table 5.

5134 Am J Transl Res 2022;14(7):5132-5138

 Enhanced recovery after heart valve replacement surgery

Table 3. Comparison of the rate of adverse events Comparison of 6-minute walking distance
between the two groups (n) between the two groups
Total occurrence
Groups N LCOS PV VTE IE Before treatment, the 6-minute walking
(n, %)
Observation group 43 1 1 1 0 3 (6.98) distance was comparable between the
Control group 43 3 2 3 1 8 (20.93)
two groups (P>0.05); after treatment, the
distance of the two groups increased,
X2 3.486
and the distance of the observation group
P 0.031
was longer than that of the control group
Note: LCOS = Low cardiac output syndrome; PVL = perivalvular leak-
age; VTE = Venous thromboembolic events; IE = Infective endocar-
(P<0.05). See Figure 3.
ditis.
Discussion

Table 4. Comparison of quality-of-life scores Heart valve diseases are a common type of
_
between the two groups ( x ±s, points) heart disease [5] mainly triggered by infection
Before 1 month and rheumatic fever. They are common among
Groups N the elderly [6, 7], with their incidence increas-
surgery after surgery
Observation group 43 76.22±12.58 91.16±4.38 ing as the aging population grows in China [8].
Control group 43 78.15±14.06 85.37±11.55 Heart valve diseases mainly involve the aortic
t 0.671 3.074 valve, pulmonary valve, mitral valve and tricus-
P-value 0.504 0.003 pid valve, which can cause life-threatening
heart failure [9, 10]. Heart valve replacement
surgery is the clinical cure for heart valve dis-
Table 5. Comparison of postoperative
_
VAS eases. It mainly replaces stenotic or incom-
scores between the two groups ( x ±s, points) petence valves with artificial heart valves to
1 day after improve heart function [11]; however, it is not
Groups n Wake up
surgery beneficial to the short term prognosis of pa-
Observation group 43 1.59±0.52 2.16±0.65 tients due to the relatively poor postoperative
Control group 43 1.28±0.64 2.36±0.61 recovery [12, 13]. Therefore, perioperative nur-
t 2.465 3.678 sing care plays an important role in improv-
P-value 0.016 <0.001 ing the recovery of patients after heart valve
replacement surgery.

Comparison of negative emotions between the In this study, the time to first bowel movement,
two groups the time to first flatulence, and hospital stay in
the observation group were all shorter than
Before treatment, the two groups were not sig- those in the control group. The observation
nificantly different in the scores of SAS and group showed a lower rate of adverse events
SDS (both P>0.05); after treatment, SAS and than the control group and experienced a high-
SDS scores of both groups decreased, and the er quality of life than the control group. In ad-
scores of the observation were lower than dition, the VAS, SAS, and SDS scores of the
those of the control group (both P<0.05). See observation group were all lower than those of
Figure 1. the control group, and the observation group
showed lower serum levels of corticotropin and
Comparison of stress factors between the two cortisol than the control group, and experi-
groups enced a longer 6-minute walking distance than
the control group. In a vast majority of studies
Before treatment, the serum levels of cortico- on rapid recovery, readmission was adopted
tropin and cortisol were comparable between as a secondary outcome [14, 15]. A previous
the two groups (P>0.05); after treatment, the study similarly demonstrated a reduction in
levels in both groups increased, and the levels readmission rate by employing ERAS in pati-
in the observation group were lower than those ents undergoing laparoscopic colorectal sur-
in the control group (both P<0.05). See Figure gery [16]. This is likely related to standardiza-
2. tion in care and specific elements of ERAS such

5135 Am J Transl Res 2022;14(7):5132-5138

 Enhanced recovery after heart valve replacement surgery

urology, orthopedics, breast

surgery, and colorectal sur-
gery. Relevant experiments ha-
ve confirmed that the applica-
tion of ERAS nursing measures
can help improve the progno-
sis of patients undergoing car-
diac surgery [18, 19]. With the
core concept of accelerated
recovery, ERAS can boost
Figure 1. Comparison of negative emotions between the two groups. ***indi-
cates P<0.001 by independent sample t test between groups.
postoperative recovery [20].
Under this nursing mode, nurs-
es evaluate the perioperative
nursing risk factors for pa-
tients undergoing heart valve
replacement surgery, and im-
prove strategies to ensure the
recovery of patients [21]. The
concept of ERAS is widely ad-
opted in the perioperative peri-
od and has delivered good
clinical outcomes [22]. ERAS
takes the patient’s condition,
physiology, psychology and
Figure 2. Comparison of stress factors between the two groups. ***indicates
P<0.001 by independent sample t test between groups. other factors into account, and
collaborates across disciplin-
es. For example, mental heal-
th professionals provide psychological coun-
seling in the presence of anxiety, fear and other
psychological burdens that occur in patients,
to promote the appetite and improve sleep of
patients; the anesthesiologist provides effec-
tive pain relief; and nurses help patients get out
of bed early after surgery to improve self-care
ability. The application of systemic periopera-
tive nursing in patients can improve the cardiac
rehabilitation and recovery speed, thus improv-
ing the quality of life [23].

This study also has some limitations. First, the

limitation of the before-and-after study design
Figure 3. Comparison of 6-minute walking distance
between the two groups. ***indicates P<0.001 by in-
might introduce some selection bias, and there
dependent sample t test between groups. were no demographic differences between the
two groups of patients enrolled consecutively.
Therefore, ongoing efforts are needed to fur-
as the positive psychological and rapid nursing. ther improve the validity of the results.
ERAS, first proposed by Danish scholar Henrik
Kehle, aims to optimize the traditional periop- In summary, implementing ERAS in patients
erative diagnosis and treatment model by ad- after heart valve replacement surgery can re-
opting a series of effective measures based duce the incidence of adverse events and the
postoperative pain and improve the recovery
on evidence-based medicine, to reduce surgi-
process as well as life quality.
cal trauma, block the stress response caused
by surgery, and thus reduce complications and Disclosure of conflict of interest
speed up recovery [17]. ERAS is now being
implemented in a wide range of fields, including None.

5136 Am J Transl Res 2022;14(7):5132-5138

 Enhanced recovery after heart valve replacement surgery

Address correspondence to: Jinxia Hao, Depart- sion and reconstruction surgery - a scoping
ment of Cardiothoracic, Cangzhou Central Hospi- survey of UK foot and ankle surgeons and al-
tal, Hebei Province, China. Tel: +86-18531708022; lied health professionals. J Clin Orthop Trauma
E-mail: [email protected] 2020; 11: 471-473.
[12] Dams OC, van den Akker-Scheek I, Diercks RL,
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