• CLINICAL VIGNETTE

Horse riding as an atypical type of rehabilitation to improve physical capacity in a patient after cardiac surgeries and before liver transplantation

Aleksandra Bodys-Pełka1, 2, Joanna Raszeja-Wyszomirska3, Tomasz Jakimowicz4, Renata Główczyńska1

11st Department of Cardiology, Medical University of Warsaw, Warszawa, Poland

2Doctoral School, Medical University of Warsaw, Warszawa, Poland

3Liver and Internal Medicine Unit, Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warszawa, Poland

42nd Chair and Department of General, Vascular and Transplant Surgery, Medical University of Warsaw, Warszawa, Poland

End-stage liver failure, regardless of etiology, is a progressive and fatal disease characterized by the loss of liver function which affects other organs [1]. Cardiopulmonary Exercise Testing attracts great interest as a functional test used for assessing the risk before liver transplantation (LTx). It may be helpful to predict mortality, morbidity and length of hospitalization after a non-cardiac procedure [2]. Horse riding is a non-standard physical activity in patients before LTx and after cardiac surge­ries. It aims to improve motor functions, body posture, and stamina [3].

A 58-year-old male patient with a history of liver cirrhosis and other co-morbidities was admitted for surgery for a brachycephalic trunk aneurysm. A graft was used to create an anastomosis between the ascending aorta and the right common carotid artery (CCA), and an anastomosis with the distal segment of the brachycephalic trunk was performed. Postoperative complications occurred: respiratory and renal failure, paroxysmal atrial fibrillation, and a worsening of the hepatic function.

Over time, the patient was admitted to the hospital due to moderately severe condition with symptoms of hepatic encephalopathy, jaundice, and ascites. LTx was considered due to end-stage liver disease. Computed tomography angiography showed an aneurysm-like bulge, adjacent to the origin of the left CCA (Figure 1A).

It could have been a false aneurysm or the stump of the aneurysm resected earlier. A hybrid procedure based on the implantation of a stent graft into the aortic arch covering the brachycephalic trunk and the left CCA and a right to left carotid-carotid bypass graft (Figure 1B). Qualification for LTx was postponed. Four months later spirometry revealed pulmonary obturation. Cardiopulmonary Exercise Testing demonstrated exercise oscillation of ventilation and ventilatory obstruction (Figure 1C and 1E), reduced exercise capacity with peak oxygen uptake (VO2peak) 18.9 ml/kg/min and oxygen uptake at anaerobic threshold (AT) 11.2 ml/kg/min (Figure 1G). The 6-minute walk test was aborted at 5.5 METS due to the patient’s fatigue. Additionally, complex exertion-induced ventricular arrhythmia was diagnosed. Qualification for LTx was delayed for further 4 months, and pharmacological treatment was initiated: beta-adrenolytics and bronchodilators. At the next qualification attempt, persistent pulmonary obturation and decreased physical capacity were noted, and LTx was postponed for further 2 months. After that time, without any new pharmacotherapy, the patient demonstrated an improved physical capacity compared with previous exams: better profile of ventilation (Figure 1D and 1F), improved VO2peak of 21.9 ml/kg/min, AT of 14.2 ml/kg/min (Figure 1H), and the 6-minute walk test with 6.3 METS. No significant heart rhythm disturbances were observed. It turned out that the patient had taken up horse riding as his new hobby and rehabilitation, which improved his physical performance and allowed for his qualification for LTx, which was performed without complications.

Physical capacity is an important parameter determining the success of an operation [4]. Unfortunately, there is a lack of data on the beneficial effects of horse riding as rehabilitation in patients suffering from heart and liver diseases. It was analyzed as a therapy for many diseases, but never as a form of rehabilitation after surgery [5]. More research is needed to evaluate the benefits of horse riding on the circulatory system and before LTx.

Article information

Conflict of interest: None declared.

Funding: None.

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REFERENCES

1. Violi F, Nocella C, Bartimoccia S, et al. Gut dysbiosis-derived low-grade endotoxemia: A common soil for liver and cardiovascular disease. Kardiol Pol. 2023; 81(6): 563–571, doi: 10.33963/KP.a2023.0115, indexed in Pubmed: 37191190.
2. Kristensen SD, Knuuti J, Saraste A, et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J. 2014; 35(35): 2383–2431, doi: 10.1093/eurheartj/ehu282, indexed in Pubmed: 25086026.
3. Sehgal L, Srivastava P, Pandey C, et al. Preoperative cardiovascular investigations in liver transplant candidate: An update. Indian J Anaesth. 2016; 60(1): 12–18, doi: 10.4103/0019-5049.174870, indexed in Pub­med: 26962249.
4. Moran J, Wilson F, Guinan E, et al. Role of cardiopulmonary exercise testing as a risk-assessment method in patients undergoing intra-abdominal surgery: a systematic review. Br J Anaesth. 2016; 116(2): 177–191, doi: 10.1093/bja/aev454, indexed in Pubmed: 26787788.
5. Koca TT, Ataseven H. What is hippotherapy? The indications and effectiveness of hippotherapy. North Clin Istanb. 2015; 2(3): 247–252, doi: 10.14744/nci.2016.71601, indexed in Pubmed: 28058377.