Prehabilitation is hypothesised to play an important role in optimising postoperative outcomes. However, achieving high adherence can be challenging. Our objectives were to synthesise current approaches to adherence measurement and reporting, estimate prehabilitation adherence across trials, identify procedural-, programme-, or patient-level factors associated with adherence, and report barriers and facilitators to adherence. Ovid MEDLINE, Embase, the CINAHL, PsycINFO, Web of Science, and the Cochrane CENTRAL Register of Controlled Trials were searched from inception until April 10, 2024. We included randomised trials of adults undergoing major elective surgery allocated to a prehabilitation programme, with at least one binary or continuous measure of adherence to prehabilitation, to an individual component, or both. Random-effects meta-analysis pooled overall adherence rates; meta-regression evaluated predictors of adherence. Qualitative synthesis of reported barriers and facilitators was informed by the Theoretical Domains Framework. We screened 11 652 titles and abstracts, followed by 1232 full texts, and included 105 trials (n=4941). Pooled adherence was 79% (95% confidence interval [CI] 70-88; I²=95.4%). Substantial qualitative and statistical heterogeneity existed in defining prehabilitation adherence. Only patient age was significantly associated with adherence (per year older: odds ratio 0.95 [95% CI 0.91-0.99]). Based on qualitative synthesis, common barriers were logistical issues and health conditions; facilitators included supervision by specialists and personalisation. Prehabilitation adherence metrics are variable across trials and standardisation is required to improve reporting and interpretation of prehabilitation evidence. Little credible evidence identifies factors associated with adherence; however, qualitative barriers and facilitators could inform programme design and implementation. PROSPERO (CRD42024518851).

Background: Acute myocardial infarction-related cardiogenic shock (AMI-CS) remains associated with high mortality despite advances in revascularization, critical care, and temporary mechanical circulatory support (MCS). Recent randomized trials have challenged the concept of routine device-based therapy and highlighted the importance of matching MCS strategy to shock phenotype, timing, and patient risk profile. Methods: We reviewed contemporary randomized clinical trials and prespecified or post hoc analyses evaluating temporary MCS strategies in adult patients with AMI-CS. PubMed was searched for English-language studies published from January 2021 through June 2026, focusing on intra-aortic balloon pump (IABP), microaxial flow pumps, and venoarterial extracorporeal membrane oxygenation (VA-ECMO/ECLS). Outcomes of interest included mortality, hemodynamic recovery, end-organ outcomes, and device-related complications. Results: Recent randomized evidence demonstrates that no temporary MCS device provides universal benefit across the heterogeneous AMI-CS population. Routine IABP use has not been associated with improved survival and is now reserved for selected patients requiring modest circulatory support, bridge-to-decision strategies, or specific mechanical complications. The DanGer Shock trial provided the strongest contemporary randomized evidence supporting temporary MCS, demonstrating reduced 180-day mortality with routine Impella CP support in carefully selected patients with STEMI-related cardiogenic shock. However, this benefit was accompanied by increased major bleeding, limb ischemia, acute kidney injury, and renal replacement therapy. Prespecified secondary and exploratory post hoc analyses have generated hypotheses that treatment response may vary according to age, baseline hemodynamics, timing of support, and shock phenotype; however, these findings require prospective validation and should not be interpreted as established treatment-selection criteria. In contrast, ECLS-SHOCK, ECMO-CS, EURO SHOCK, and randomized meta-analytic data did not demonstrate a survival benefit for routine early VA-ECMO in broad AMI-CS populations and consistently identified higher rates of bleeding and vascular complications. Strategies for routine early left ventricular unloading during VA-ECMO have improved physiologic parameters but have not demonstrated a mortality benefit. Conclusions: Contemporary randomized trials have shifted the role of temporary MCS in AMI-CS from routine device deployment toward individualized, phenotype-guided therapy. Impella CP, as evaluated in the DanGer Shock trial, currently provides the strongest randomized survival signal but should be applied selectively in patients with predominantly left ventricular failure treated within experienced shock systems. VA-ECMO remains an important rescue option in carefully selected patients with refractory circulatory collapse, severe hypoxemia, cardiac arrest, or biventricular failure, although routine early use is not supported. Future research should focus on earlier shock phenotyping, physiology-guided device selection, complication reduction, and strategies that integrate mechanical support with recovery-focused care.

Exercise is the most common approach to prehabilitation; the optimal exercise interventions to improve postoperative outcomes are unknown. This was a systematic review with network meta-analysis that followed a prespecified protocol (CRD420251034396). Peer-reviewed search strategies were applied from inception to 4 April 2025, to Ovid MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Central Register of Controlled Trials (CENTRAL), without language restrictions. We included all RCTs of prehabilitation that included at least one exercise intervention (aerobic, strength, pulmonary, or functional exercises) and that reported at least one critical outcome (postoperative complications, length of stay, health-related quality of life, or physical recovery). P-scores were used to rank interventions by their probability of being most beneficial. Best practices, including duplicate review, were followed. Confidence in network meta-analysis informed certainty ratings. We screened 7660 citations, reviewed 1480 full-text articles, and included 96 unique RCTs (N=7396). Combined aerobic, pulmonary, and functional exercise were most likely to reduce complications (P-score 0.94, odds ratio 0.16, 95% CI 0.05-0.60; very low certainty) and length of stay (P-score 0.97, mean difference -3.4 days, 95% CI -5.7 to -1.0; moderate certainty). Combined aerobic and strength exercise was most likely to improve health-related quality of life (P-score 0.93, standardised mean difference 0.67, 95% CI 0.07-1.27; low certainty). No exercise interventions significantly improved physical recovery. The efficacy of exercise prehabilitation interventions may be outcome-specific. Implementation of aerobic and pulmonary exercise prehabilitation may be warranted. Low-risk-of-bias trials are required to confirm or refute available data, which are mostly low certainty.