Prehabilitation in Patients Undergoing Cardiac Surgery: An Umbrella Review of Systematic Reviews and Meta-Analysis

Background/Objective: Prehabilitation aims to improve physiological reserve before surgery to enhance postoperative outcomes. Multiple systematic reviews have evaluated preoperative interventions in adult cardiac surgery; however, variability in scope, methodological quality, and overlap of primary trials complicates interpretation. The aim of this study is to synthesise and critically appraise evidence from systematic reviews and meta-analyses evaluating prehabilitation interventions in adults undergoing cardiac surgery. No funding was received for this study. Methods: We conducted an umbrella systematic review following a prospectively registered protocol (PROSPERO: CRD420261292354) and PRISMA 2020 guidance. PubMed, Web of Science, and Scopus were searched from inception to 31 December 2025. Eligible reviews included adults (≥18 years) undergoing cardiac surgery, evaluated and compared preoperative inspiratory muscle training (IMT), respiratory muscle training, and exercise-based, educational, or multimodal prehabilitation with usual care or sham intervention. Reviews focused solely on postoperative interventions or non-cardiac surgery were excluded. Methodological quality was assessed using AMSTAR-2. Certainty of evidence was evaluated using GRADE. Overlap of primary studies was quantified using the Corrected Covered Area (CCA). A structured narrative synthesis with a direction-of-effect framework was applied. Results: Eighteen systematic reviews (published 2012–2025) were included, comprising 46 unique primary studies and more than 6674 participants (exact totals unavailable due to incomplete reporting in at least one review). Overall overlap was high (CCA 12.5%). Respiratory-focused prehabilitation, particularly IMT, demonstrated consistent reductions in postoperative pulmonary complications (PPCs) (risk ratios approximately 0.42–0.53), pneumonia (RR ~0.44–0.45), and atelectasis (RR ~0.49–0.59), favouring prehabilitation over usual care. Hospital length of stay was reduced by approximately 1.5–3 days across multiple reviews. Inspiratory muscle strength improved consistently (mean difference ~+12 to +17 cmH2O). Effects on ICU length of stay and mechanical ventilation duration were inconsistent or non-significant. Exercise-based programmes improved functional capacity (6 min walk distance increase ~50–75 m) and showed modest reductions in hospital stay, but heterogeneity was substantial. No intervention demonstrated a consistent reduction in postoperative mortality. Evidence was limited by clinical heterogeneity, performance bias in primary trials, inconsistent outcome definitions, and high overlap of key IMT trials across reviews. Mortality outcomes were underpowered. Conclusions: Preoperative IMT provides evidence for reducing pulmonary complications and shortening hospital stays in adult cardiac surgery. Exercise-based prehabilitation improves functional capacity but requires further high-quality, standardised trials. Integration of respiratory prehabilitation into cardiac surgical pathways appears supported by the current evidence.

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