Prehabilitation in frail patients undergoing cardiac valve intervention

Management of valvular heart disease (VHD) has shifted from predominantly surgical approaches to widespread use of transcatheter interventions, including transcatheter aortic valve replacement (TAVR), mitral transcatheter edge-to-edge repair (M-TEER), transcatheter mitral valve replacement (TMVR), and emerging tricuspid transcatheter valve intervention (TTVI). Although ESC/EACTS and ACC/AHA guidelines recognize frailty as a major determinant of mortality, complications, and recovery, they offer limited guidance on how to modify frailty before intervention.

Frailty is highly prevalent in VHD, particularly among transcatheter candidates, and represents a dynamic, potentially reversible syndrome driven by sarcopenia, deconditioning, malnutrition, inflammation, and psychological vulnerability. It influences symptoms, procedural selection, and recovery, exerting prognostic effects beyond valve anatomy. Prehabilitation offers a strategy to convert the preprocedural interval from passive waiting into a therapeutic opportunity. Evidence from cardiac surgery and hemodynamic interventions shows that multimodal prehabilitation (including aerobic and resistance exercise, respiratory training, nutritional optimization and psychological support) can improve functional capacity, reduce pulmonary complications, and shorten hospitalization. In TAVR candidates, early data suggest that even short programs may enhance functional performance, mitigate frailty and reduce major adverse cardiovascular events. In contrast, dedicated trials for M-TEER, TMVR and TTVI remain limited, and current practice depends on evidence from other procedural settings. Ongoing studies are testing exercise-based, nutritional, and psychological interventions, including telemedicine-supported and home-based models, while incorporating objective measures of frailty reversal.

As procedural risk declines, patients' physiological reserve becomes the principal barrier to long-term benefit. Prehabilitation may provide a scalable strategy to bridge anatomical correction with meaningful functional recovery.