Peri‐operative rehabilitation in elective cardiac valve surgery

We read with interest the study by Liu et al. [1], which reported a large, single-centre randomised controlled trial evaluating a four-component peri-operative rehabilitation programme in patients undergoing elective cardiac valve surgery. We commend the authors for conducting this comprehensive trial and for showing a significant reduction in postoperative pulmonary complications, particularly pneumonia, within 7 days of surgery. Despite the reduction in postoperative pulmonary complications, the composite outcome of mortality, prolonged hospitalisation and postoperative pulmonary complications did not differ between groups. This suggests that the weight assigned to each component obscured clinically meaningful benefits in respiratory recovery. A stratified or hierarchical approach to composite outcomes might provide clearer insight into which domains of recovery are sensitive to rehabilitation interventions [2]. The study population was relatively low risk, comprising predominantly younger patients with preserved left ventricular function and normal pulmonary reserve. In this context, the absolute event rate for mortality and prolonged hospitalisation was low. Given previous evidence that inspiratory muscle training and early mobilisation confer the greatest benefit in patients who are frail or high risk [3], replication of this multimodal programme in cohorts with advanced age, sarcopenia or impaired spirometry could help define the true therapeutic window of peri-operative rehabilitation. While the safety and feasibility of the intervention were shown, implementation success was modest, with a median of only six inspiratory training sessions pre-operatively. Adherence tracking and continuation following discharge were not reported. Incorporating remote models might sustain engagement and extend functional recovery beyond hospital discharge [4]. Finally, the authors highlight that standard respiratory exercises were included in usual care, which potentially dilutes between-group effects. We suggest that multicentre designs where baseline physiotherapy practices are stratified could help delineate the incremental benefit attributable to structured rehabilitation bundles. To further broaden the applicability and long-term impact of peri-operative rehabilitation in cardiac valve surgery, we encourage research focused on developing tiered, risk-stratified rehabilitation strategies. Future studies should also explore the integration of multimodal prehabilitation for high-risk patients, which may improve physiological reserve before surgery and amplify the benefits of postoperative rehabilitation. Such strategies could yield better pulmonary outcomes, longer term functional capacity, quality of life and overall survival for a broader spectrum of patients undergoing cardiac valve surgery.