Changes in health-related quality of life following coronary artery bypass graft surgery

Identifying coronary artery bypass grafting patients at high risk for adverse long-term prognosis using serial health-related quality of life assessments

BACKGROUND

Patients who undergo coronary artery bypass grafting (CABG) are known to be at a significant risk of experiencing long-term adverse events, emphasizing the importance of regular assessments. Evaluating health-related quality of life (HRQoL) serves as a direct method to gauge prognosis. Our objective is to ascertain the prognostic significance of consecutive HRQoL assessments using the Physical Component Summary (PCS) and Mental Component Summary (MCS) derived from the Short-Form 36 (SF-36) health survey in CABG patients.

METHODS

The study population consisted of 433 patients who underwent isolated elective CABG at Fuwai Hospital between 2012 and 2013. SF-36 assessments were conducted during both the hospitalization period and follow-up. The primary endpoint of the study was all-cause mortality, while the secondary outcome was a composite measure including death, myocardial infarction, stroke, and repeat revascularization. We assessed the relationships between the PCS and MCS at baseline, as well as their changes during the first 6 months after the surgery (referred to as ΔPCS and ΔMCS, respectively), and the observed outcomes.

RESULTS

The patients were followed for an average of 6.28 years, during which 35 individuals (35/433, 8.1%) died. After adjusting for clinical variables, it was observed that baseline MCS scores (hazard ratio [HR] for a 1-standard deviation [SD] decrease, 1.57; 95% confidence interval [CI], 1.07-2.30) and ΔMCS (HR for a 1-SD decrease, 1.67; 95% CI, 1.09-2.56) were associated with all-cause mortality. However, baseline PCS scores and ΔPCS did not exhibit a significant relationship with all-cause mortality. Notably, there was a dose-response relationship observed between ΔMCS and the likelihood of all-cause mortality (HRs for the 2nd, 3rd and 4th quartiles compared to the 1st quartile, 0.33, 0.45 and 0.11, respectively).

CONCLUSIONS

Baseline MCS and changes in MCS were independent predictors for long-term mortality of CABG. Better mental health status and recovery indicated better prognosis.

Association of chronic poststernotomy pain and health-related quality of life: a prospective cohort study

PURPOSE

Chronic poststernotomy pain (CPSP) after cardiac surgery is multifactorial and impacts patient recovery. We aimed to evaluate the association between CPSP severity and health-related quality of life at six months after cardiac surgery.

METHODS

This was a single-centre prospective cohort study of patients who underwent cardiac surgery with median sternotomy between September 2020 and March 2021. Telephone interviews were conducted at six and 12 months postoperatively using the Short Form McGill Pain Questionnaire and the EQ-5D-5L. Strength of correlation was described using Spearman's correlation coefficient. Multivariable regression analysis was used to account for confounding variables.

RESULTS

A total of 252 patients responded to the six-month interview (response rate, 65%). The mean (standard deviation) age of respondents was 65 (13) yr. Twenty-nine percent of respondents (72/252) reported CPSP at six months, and 14% (41/252) reported more than mild pain (score ≥ 2/5). At 12 months, of the 89% (64/72) patients who responded, 47% (30/64) still reported pain. The strength of the correlation between pain scores and EQ-5D-5L was weak (Spearman's correlation coefficient, -0.3). Risk factors for CPSP at six months included higher pain score on postoperative day 1, history of chronic pain prior to surgery, and history of depression. Intraoperative infusion of dexmedetomidine or ketamine was associated with a reduced risk of CPSP at six months.

CONCLUSION

Chronic poststernotomy pain still affects patient recovery at six and 12 months after cardiac surgery. The severity of that pain is poorly correlated with patients' quality of life.

STUDY REGISTRATION

www.osf.io ( https://osf.io/52rsw ); registered 14 May 2022.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Demystifying the Value of Minimal Clinically Important Difference in the Cardiothoracic Surgery Context

The aim of this review is to describe the different statistical methods used in estimating the minimal clinically important difference (MCID) for the assessment of quality of life (QOL)-related and clinical improvement interventions, along with their implementation in cardiothoracic surgery. A thorough literature search was performed in three databases (PubMed/Medline, Scopus, Google Scholar) for relevant articles from 1980 to 2022. We included articles that implemented and assessed statistical methods used to estimate the concept of MCID in cardiothoracic surgery. MCID has been successfully implemented in several medical specialties. Anchor-based and distribution-based methods are the most common approaches when evaluating the MCID. Nonetheless, we found only five studies investigating the MCID in the context of cardiothoracic surgery. Four of them used anchor-based approaches, and one used both anchor-based and distribution-based methods. MCID values were very variable depending on the methods applied, as was the clinical context of the study. The variables of interest were certain QOL measuring questionnaires, used as anchors. Multiple anchors and methods were applied, leading to different estimations of MCID. Since cardiothoracic surgery is related to important perioperative morbidity, MCID might represent an important and efficient adjunct tool to interpret clinical outcomes. The need for MCID methodology implementation is even higher in patients with heart failure undergoing cardiac surgery. More studies are needed to validate different MCID methods in this context.

Pre-surgery optimization of patients' expectations to improve outcome in heart surgery: Study protocol of the randomized controlled multi-center PSY-HEART-II trial

The PSY-HEART-I trial indicated that a brief expectation-focused intervention prior to heart surgery improves disability and quality of life 6 months after coronary artery bypass graft surgery (CABG). However, to investigate the clinical utility of such an intervention, a large multi-center trial is needed to generalize the results and their implications for the health care system. The PSY-HEART-II study aims to examine whether a preoperative psychological intervention targeting patients' expectations (EXPECT) can improve outcomes 6 months after CABG (with or without heart valve replacement). EXPECT will be compared to Standard of Care (SOC) and an intervention providing emotional support without targeting expectations (SUPPORT). In a 3-arm multi-center randomized, controlled, prospective trial (RCT), N = 567 patients scheduled for CABG surgery will be randomized to either SOC alone or SOC and EXPECT or SOC and SUPPORT. Patients will be randomized with a fixed unbalanced ratio of 3:3:1 (EXPECT: SUPPORT: SOC) to compare EXPECT to SOC and EXPECT to SUPPORT. Both psychological interventions consist of 2 in-person sessions (à 50 minute), 2 phone consultations (à 20 minute) during the week prior to surgery, and 1 booster phone consultation post-surgery 6 weeks later. Assessment will occur at baseline approx. 3-10 days before surgery, preoperatively the day before surgery, 4-6 days later, and 6 months after surgery. The study's primary end point will be patients' illness-related disability 6 months after surgery. Secondary outcomes will be patients' expectations, subjective illness beliefs, quality of life, length of hospital stay and blood sample parameters (eg, inflammatory parameters such as IL-6, IL-8, CRP). This large multi-center trial has the potential to corroborate and generalize the promising results of the PSY-HEART-I trial for routine care of cardiac surgery patients, and to stimulate revisions of treatment guidelines in heart surgery.

Improvement in Health-Related Quality of Life After Total Ankle Arthroplasty Compares Well With Other Successful Orthopaedic and Nonorthopaedic Procedures

Background. Ankle arthritis is a major cause of disability. Orthopaedic literature suggests improvement in health-related quality of life (HRQOL) after total ankle arthroplasty (TAA). This has not been compared with improvements observed in successful orthopaedic and nonorthopaedic procedures, including anterior cervical discectomy/fusion (ACDF), total knee arthroplasty (TKA), coronary artery bypass grafting (CABG), and orthotopic liver transplant (OLT). We hypothesize that the effects after TAA are comparable to several successful surgical procedures. Methods. 500 consecutive TAA patients were included and grouped with 2 other large series. Short Form-36 (SF36) were collected at standardized intervals. A systematic literature review identified studies comparing preoperative and postoperative SF36 physical (PCS) and mental component summary (MCS) scores. Using meta-analyses, we pooled the data for each procedure to compare with the TAA group. Results. Patients in all cohorts had preoperative SF36 MCS and PCS scores that were significantly lower than that in the general population. Improvements in HRQOL after TAA were not statistically different from improvements reported in PCS and MCS after ACDF, TKA, and OLT. However, improvement in PCS after TAA was better than that observed after CABG. Conclusions. Disability with ankle arthritis is severe. Disability associated with cervical disc disease, knee arthrosis, coronary artery disease, and liver failure is also severe, with surgical intervention providing major improvements in HRQOL postoperatively. The improvement in HRQOL after TAA did not differ statistically from ACDF, TKA, CABG, and OLT. Our investigation suggests that the HRQOL benefits of TAA meet benchmarks set by some of modern medicine's best.Levels of Evidence: Level III: Systematic review.

Health-related quality of life in men and women who experienced cardiovascular diseases: Tehran Lipid and Glucose Study

Background

Cardiovascular diseases (CVDs) are among the most common causes of death worldwide, including in Iran. Considering the adverse effects of CVDs on physical and psychosocial health; this study aims to investigate the association between experience of CVDs and health-related quality of life (HRQoL) in adult participants of the Tehran Lipid and Glucose Study (TLGS).

Methods

The participants of this cross-sectional study were 7009 adults (≥ 20 years) who participated in the TLGS during 2014–2017. Demographic information and HRQoL data was collected through validated questionnaires by trained interviewers. HRQoL was assessed by the Iranian version of the SF-12 questionnaire. Data was analyzed using the SPSS software.

Results

The mean age of participants was 46.8 ± 14.6 years and 46.1% of them were men. A total of 9.0% of men and 4.4% of women had CVDs. In men, the mean physical HRQoL summary score was significantly lower in those with CVDs compared to those without CVDs (46.6 ± 0.8 vs. 48.5 ± 0.7, p > 0.001). In women, the mean mental HRQoL summary scores was significantly lower in those with CVDs compared to those without CVDs (42.8 ± 1.0 vs. 45.2 ± 0.5, p = 0.009). In adjusted models, men with CVDs were more likely to report poor physical HRQoL compared to men without CVDs (OR(95%CI): 1.93(1.32–2.84), p = 0.001); whereas for women, the chance of reporting poor mental HRQoL was 68% higher in those with CVDs than those without CVDs (OR(95%CI): 1.68(1.11–2.54), p = 0.015).

Conclusion

The findings of the current study indicate poorer HRQoL in those who experienced CVDs compared to their healthy counterparts with a sex specific pattern. While for men, CVDs were associated with more significant impairment in the physical dimension of HRQoL, women experienced a similar impairment in the mental dimension of HRQoL.

The effect of postoperative complications on health-related quality of life and survival 12 years after coronary artery bypass grafting - a prospective cohort study

BACKGROUND

Despite the steady improvements in survival and operative safety, postoperative complications still remain a significant cause of morbidity and mortality after coronary artery bypass grafting (CABG). However, less is known on the impact of postoperative complications on health-related quality of life (QoL). The main objective of our study was to investigate the impact of postoperative complications on long-term QoL and survival after CABG surgery.

METHODS

Data of 508 patients, who underwent isolated CABG was prospectively collected. The RAND-36 Health Survey (RAND-36) was used to evaluate patients' QoL status preoperatively, 1 year and 12 years after the surgery. Predefined postoperative complications were reported during primary and secondary hospital stay. QoL and survival analysis were performed primarily on three patient groups: patients with and without complications and patients with major adverse cardiac and cerebrovascular events (MACCE).

RESULTS

In total 205(40%) of 508 patients had at least one postoperative complication and 73 (14%) experienced MACCE. Patients' thirty-day, 1-year and 10-year survival rates were, 99, 98, 84% without complications, 97, 95, 72% with complications, and 90, 89, 64% with MACCE, respectively (log-rank p < 0.001). Patients without complications showed significant(p < 0.05) improvements in seven and patients with complications in five out of eight RAND-36 QoL dimensions. All patient groups showed significant improvements in RAND-36 summary scores compared with preoperative values. Patients with complications and especially with MACCE had more profound decline in their RAND-36 summary scores while patients without complications maintained their health status best.

CONCLUSIONS

Despite the constant deterioration, both patients with and without complications showed improvements even 12 years after CABG compared with preoperative state. Postoperative complications and especially MACCE were associated with impaired long-term QoL.

Effect of Cardiac Surgery on One-Year Patient-Reported Outcomes: A Prospective Cohort Study

BACKGROUND

Current cardiac surgery risk algorithms and quality measures focus on perioperative outcomes. However, delivering high-value, patient-centered cardiac care will require a better understanding of long-term patient-reported quality of life after surgery. Our objective was to prospectively assess the effect of cardiac surgery on long-term patient-reported outcomes.

METHODS

Patients undergoing cardiac surgery at an academic medical center (2016 to 2017) were eligible for enrollment. Patient-reported outcomes were measured using the National Institutes of Health Patient-Reported Outcomes Measurement Information System preoperatively and 1 year postoperatively across five domains: mental health, physical health, physical functioning, social satisfaction, and applied cognition. Baseline data and perioperative outcomes were obtained from The Society of Thoracic Surgeons Database. The effect of cardiac surgery on long-term patient-reported quality of life was assessed.

RESULTS

Ninety-eight patients were enrolled and underwent cardiac surgery, with 92.9% (91 of 98) successful follow-up. The most common operation was coronary artery bypass graft surgery at 63.3% (62 of 98), with 60.2% (59 of 98) undergoing an elective operation. One-year all-cause mortality was 5.1% (5 of 98). Rate of major morbidity was 11.2% (11 of 98). Cardiac surgery significantly improved patient-reported outcomes at 1 year across four domains: mental health (preoperative 47.3 ± 7.7 vs postoperative 51.1 ± 8.9, P < .001), physical health (41.2 ± 8.2 vs 46.3 ± 9.3, P < .001), physical functioning (39.8 ± 8.6 vs 44.8 ± 8.5, P < .001), and social satisfaction (46.8 ± 10.9 vs 50.7 ± 10.8, P = .023). Hospital discharge to a facility did not affect 1-year patient-reported outcomes.

CONCLUSIONS

Cardiac surgery improves long-term patient-reported quality of life. Mental, physical, and social well-being scores were significantly higher 1 year postoperatively. Data collection with the National Institutes of Health Patient-Reported Outcomes Measurement Information System provides meaningful, quantifiable results that may improve delivery of patient-centered care.

Quality of life in patients after coronary artery bypass grafting with bilateral internal thoracic artery versus single internal thoracic artery

Introduction

The left internal thoracic artery to the left anterior descending artery graft is recognized as the gold standard for coronary revascularization. We compared quality of life (QoL) in patients who received bilateral internal thoracic arteries (BITA) and those with a single internal thoracic artery (SITA) graft.

Aim

To assess QoL during a 10-year follow-up in patients who underwent coronary artery bypass grafting (CABG) with BITA vs. SITA.

Material and methods

We recruited 300 patients with multivessel coronary artery disease who underwent CABG from January 2005 to October 2010. Mean duration (standard deviation – SD) of follow-up was 3568 ±409 days. QoL was measured subjectively using a Likert scale and objectively by the WHOQOL-BREF questionnaire. Patients were interviewed by telephone.

Results

BITA patients reported marked improvement and improvement more often than SITA patients (58% vs. 43.3%, p = 0.02). Marked deterioration was noted by 2% of BITA patients and 3.3% of SITA patients (p = 0.03). Summarized results of the WHOQOL-BREF questionnaire showed significantly better QoL in the BITA group (median: 15.0) vs. SITA group (median: 14.75) (p = 0.02). There were more angina-free patients in the BITA group (84%) compared to SITA patients (72.7%) (p = 0.006). QoL did not correlate with patients’ body mass index (p = 0.10) or residence status (p = 0.51), but there was a weak negative correlation between QoL and patients’ age (r = –0.14, p = 0.01).

Conclusions

Surgical coronary revascularization using BITA improves QoL, particularly when measured by a Likert scale.

Comparison of postoperative cognitive decline in patients undergoing conventional vs miniaturized cardiopulmonary bypass: A randomized, controlled trial

Background:

Neurocognitive dysfunction is a common complication of coronary artery bypass grafting (CABG) with incidence of 19–38%. The miniaturized cardiopulmonary bypass (MCPB) system was developed to reduce hemodilution and inflammation and provides better cerebral protection than conventional cardiopulmonary bypass (CCPB). In a meta-analysis, MCPB was associated with a 10-fold reduction in the incidence of strokes. However, its effect on postoperative cognitive decline (POCD) is unknown. We assessed if MCPB decreases POCD after CABG and compared the risk factors.

Methods:

A total of 71 Asian patients presenting for elective CABG at a tertiary center were enrolled. They were randomly assigned to MCPB (n = 36) or CCPB group (n = 35) and followed up in a single-blinded, prospective, randomized controlled trial. The primary outcome was POCD as measured by the repeatable battery of neuropsychological status (RBANS). Inflammatory markers (tumor necrosis factor-alpha and interleukin-6), hematocrit levels, and neutron-specific enolase (NSE) levels were studied.

Results:

Overall, the incidence of POCD at 3 months was 50%, and this was not significantly different between both groups (51.4 vs 50.0%, P = 0.90). Having <6 years of formal education [risk ratio (RR) = 3.014, 95% confidence interval (CI) = 1.054–8.618, P = 0.040] was significantly associated with POCD in the CCPB group, while the lowest hematocrit during cardiopulmonary bypass was independently associated with POCD in the MCPB group (RR = 0.931, 95% CI = 0.868–0.998, P = 0.044). The postoperative inflammatory markers and NSE levels were similar between the two groups.

Conclusions:

This study shows that the MCPB was not superior to CCPB with cell salvage and biocompatible tubing with regard to the neurocognitive outcomes measured by the RBANS.

Anaesthesia geriatric evaluation to guide patient selection for preoperative multidisciplinary team care in cardiac surgery

BACKGROUND

A multidisciplinary approach to improve postoperative outcomes in frail elderly patients is gaining interest. Multidisciplinary team care should be targeted at complex patients at high risk for adverse postoperative outcome to limit the strain on available resources and to prevent an unnecessary increase in patient burden. This study aimed to improve patient selection for multidisciplinary care by identifying risk factors for disability after cardiac surgery in elderly patients.

METHODS

This was a two-centre prospective cohort study of 537 patients aged ≥70 yr undergoing elective cardiac surgery. Before surgery, 11 frailty characteristics were investigated. Outcome was disability at 3 months defined as World Health Organization Disability Assessment Schedule 2.0 ≥25%. Multivariable modelling using logistic regression, concordance statistic (c-statistic), and net reclassification index was used to identify factors contributing to patient selection.

RESULTS

Disability occurred in 91 (17%) patients. Ten out of 11 frailty characteristics were associated with disability. A multivariable model, including the European System for Cardiac Operative Risk Evaluation II and preoperative haemoglobin, yielded a c-statistic of 0.71 (95% confidence interval [CI]: 0.66-0.77). After adding pre-specified frailty characteristics (polypharmacy, gait speed, physical disability, preoperative health-related quality of life, and living alone) to this model, the c-statistic improved to 0.78 (95% CI: 0.73-0.83). The net reclassification index was 0.32 (P<0.001), showing improved discrimination for patients at risk for disability at 3 months.

CONCLUSIONS

The addition of preoperative frailty characteristics to a multivariable model improved discrimination between elderly patients with and without disability at 3 months after cardiac surgery, and can be used to guide patient selection for preoperative multidisciplinary team care.

CLINICAL TRIAL REGISTRATION

NCT02535728.

Health-related quality of life after heart surgery - Identification of high-risk patients: A cohort study

BACKGROUND

This cohort study evaluated factors, which have been shown to be relevant for Health-Related Quality of Live (HRQL) after cardiac surgery and investigated the combinatory impact on HRQL. Additionally, the aim was to introduce a first attempt to developing a risk estimation model which could identify patients at risk for impaired HRQL.

METHODS

For this single-centre cohort study, 6099 cardiac surgical patients (60% isolated coronary bypass surgery) filled in the Nottingham Health Profile (NHP) for the evaluation of HRQL six months after surgery and provided information regarding their medical and socio-demographic status. For the NHP scores the deviation to the matched normative data of a healthy sample was calculated. A robust linear regression examined factors that influence HRQL. As a next step, based on the regression model, a risk estimation model was developed which is a first attempt to classify patients into risk categories.

RESULTS

Male gender, age below 60 or between 60 and 74 years, living alone, no occupation, bypass surgery, NYHA status II, III or IV and chest pain were identified as risk factors to determine impaired HRQL. The model explains 29.13% of the variance. Based on the risk estimation model 27.4% were classified as medium or high risk.

CONCLUSIONS

For the first time a multilevel method was applied to evaluate HRQL after heart surgery showing that socio-demographic variables are important co-factors to dyspnea and chest pain. We take a first attempt in developing a new approach that should encourage further research in this field to frame a screening tool that may help identifying patients at risk in the future.

Impact of Preoperative Functional Status on Quality of Life after Cardiac Surgery

BACKGROUND

 With increasing importance, health-related quality of life (HRQoL) has become a crucial outcome measure of cardiac surgery. The aim of this study was to assess the dynamics of HRQoL change within 12 months after surgery and to identify predictors of deterioration in physical and mental health.

METHODS

 The cohort of this prospective study included 164 consecutive patients who underwent elective surgery. HRQoL was assessed on the basis of the Short-Form 36 questionnaire at three different times: upon admission and at 3 and 12 months after surgery. The minimal clinically important difference (MCID) was used to determine whether the surgery resulted in deterioration of HRQoL.

RESULTS

 In general, physical and mental health status improved within the first year after cardiac surgery. However, after 12 months, 7.9 and 21.2% of patients had clinically significant poorer physical (PCS) and mental component summary (MCS) scores, based on the MCID approach. The results of multivariate analysis identified preoperative health status, age < 70 years, coronary artery bypass grafting, and a previous neurological event as predictors of deterioration in postoperative HRQoL. The greatest risks for deterioration were higher preoperative PCS and MCS scores.

CONCLUSION

 Although we were able to demonstrate a general improvement in the HRQoL following cardiac surgery, in one-fifth of patients, there was no recovery of mental health status even after 1 year. As this effect is mainly determined by preoperative functional status, HRQoL should be an integral part of medical consultation, especially in younger patients with a positive perception of quality of life.

Quality of Life at Three Years after Cardiac Surgery: Relationship with Preoperative Status and Quality of Recovery

A reduction in symptoms, increased longevity, and improved quality of life (QoL), are goals of cardiac surgery. We measured QoL in 108 adult cardiac surgical patients at about three years after cardiac surgery, and assessed the predictive ability of a 40-item quality of recovery (QoR-40) score. Our follow-up rate was 86% (n=93). When compared with preoperative status, QoL was improved at three years after surgery (P<0.0005). The dimensions of QoL that were most affected were physical functioning, role limitations due to physical problems, vitality, social functioning, and role limitations due to emotional problems (all P<0.005). There was a mild correlation between the day 3 QoR-40 and the three year SF-36, r=0.23 (P=0.029). There was a strong correlation between the three year QoR-40 and the three year SF-36, r=0.73 (P<0.0005). The QoR-40 and SF-36 done at three years after cardiac surgery demonstrated good internal consistency, QoR-40 α=0.86 (P<0.0005), SF-36 α=0.91 (P<0.0005). A poor quality recovery in the days after surgery can predict a poor QoL at three years after surgery. The QoR-40 is a valid and reliable measure of quality of recovery after surgery and anaesthesia. The QoR-40 is a useful, patient-oriented method of assessing recovery from anaesthesia and surgery.

Diabetics have Inferior Long-Term Survival and Quality of Life after CABG

A prevalence of diabetes is increasing among the patients undergoing coronary artery bypass grafting (CABG). Data on whether health-related quality of life improves similarly after CABG in diabetics and nondiabetics are limited. We assessed long-term mortality and changes in quality of life (RAND-36 Health Survey) after CABG. Seventy-four of the 508 patients (14.6%) operated on in a single institution had a history of diabetes and were compared with nondiabetics. The RAND-36 Health Survey was used as an indicator of quality of life. Assessments were made preoperatively and repeated 1 and 12 years later. Thirty-day mortality was 2.7 versus 1.6 ( p  = 0.511) in the diabetics and nondiabetics. One- and 10-year survival rates in the diabetics and nondiabetics were 94.6% versus 97.0% ( p  = 0.287) and 63.5% versus 81.6% ( p  < 0.001), respectively. After 1 year, diabetics improved significantly ( p  < 0.005) in seven, and nondiabetics ( p  < 0.001) in all eight RAND-36 dimensions. Despite an ongoing decline in quality of life over the 12-year follow-up, an improvement was maintained in four out of eight dimensions among diabetics and in seven dimensions among nondiabetics. Physical and mental component summary scores on the RAND-36 improved significantly ( p  < 0.001) in both groups after 1 year, and at least slight improvement was maintained during the 12-year follow-up time. Diabetics have inferior long-term survival after CABG as compared with nondiabetics. They gain similar improvement of quality of life in 1 year after surgery, but they have a stronger decline tendency over the years.

Preoperative determinants of quality of life a year after coronary artery bypass grafting: a historical cohort study

Background

Health related quality of life (HRQL) is an important patient related outcome measure after cardiac surgery. Preoperative determinants for postoperative HRQL have not yet been identified, but could aid in preoperative decision making. The aim of this article is to identify associations between preoperative determinants and change in HRQL 1 year after coronary artery bypass grafting (CABG).

Methods

Single centre retrospective cohort study in 658 patients. Change in HRQL was defined as a decrease or increase of ≥5 points on the physical or mental domain of the Short Form 12 (SF-12) questionnaire. Patients were stratified in three groups according to worse, unchanged, or better HRQL. Multinomial logistic regression analysis was used to investigate the association between preoperative risk factors and postoperative change in HRQL.

Results

Physical HRQL improved in 22.8% of patients, did not change in 61.2% of patients and worsened in 16.0% of patients. Comorbidities associated with change in physical HRQL were a history of stroke, atrial fibrillation, vascular disease or pulmonary disease. Most important risk factor for change in physical HRQL was preoperative HRQL. Higher preoperative SF-12 score decreased the odds for worse physical HRQL and increased the odds for better physical HRQL. Mental HRQL improved in 49.8% of patients, remained unchanged in 34.5% of patients and worsened in 15.7% of patients. Preoperative HRQL was an important risk factor for a change in mental HRQL. Higher preoperative physical HRQL increased the odds for improved mental HRQL. Lower preoperative mental HRQL increased the odds for better mental HRQL.

Conclusions

One year after CABG the majority of patients experiences equal or improved HRQL compared to before surgery. Most important preoperative risk factor for change in HRQL is preoperative HRQL.

Electronic supplementary material

The online version of this article (10.1186/s13019-018-0798-2) contains supplementary material, which is available to authorized users.

Quality of Life After Cardiac Operations Based on the Minimal Clinically Important Difference Concept

BACKGROUND

Health-related quality of life (HRQOL) is an increasingly important issue in assessing the consequences of any surgical or medical intervention. Our study aimed to evaluate change in HRQOL 6 months after elective cardiac operations and to identify specific predictors of poor HRQOL.

METHODS

In this prospective, single-center study, HRQOL was evaluated before and 6 months after the operation using the Medical Outcome Study 36-Item Short Form Health Survey questionnaire and its two components: the Physical Component Summary and the Mental Component Summary. We distinguished patients with worsening of HRQOL according to the minimal clinically important difference. All consecutive adult patients undergoing cardiac operations were included.

RESULTS

The preoperative and postoperative 36-Item Short Form Health Survey questionnaires were completed by 326 patients, and 24 patients died before completing follow-up questionnaires. On the basis of the definition used, clinically significant deterioration of HRQOL was observed in 93 patients (26.6%) for the Physical Component Summary and in 99 patients (28.2%) for the Mental Component Summary. Renal replacement for acute renal failure and mechanical ventilation for longer than 48 hours were independent risk factors for Physical Component Summary and Mental Component Summary worsening or death.

CONCLUSIONS

Although our study showed overall improvement of quality of life after cardiac operations, more than one-quarter of the patients manifested deterioration of HRQOL at 6 months postoperatively. The findings from this study should help clinicians to inform patients about their likely postoperative functional status and quality of life.

Neurological outcome after minimal invasive coronary artery surgery (NOMICS): protocol for an observational prospective cohort study

INTRODUCTION

Adverse neurocognitive outcomes are still an important cause of morbidity and mortality after cardiac surgery. The most common neurocognitive disorders after conventional cardiac surgery are postoperative cognitive dysfunction (POCD), stroke and delirium. Minimal invasive cardiac procedures have recently been introduced into practice. Endoscopic coronary artery bypass grafting (Endo-CABG) is a minimal invasive cardiac procedure based on the conventional CABG procedure. Neurocognitive outcome after minimal invasive cardiac surgery, including Endo-CABG, has never been studied. Therefore, the main objective of this study is to examine neurocognitive outcome after Endo-CABG.

METHODS AND ANALYSIS

We will perform a prospective observational cohort study including 150 patients. Patients are categorised into three groups: (1) patients undergoing Endo-CABG, (2) patients undergoing a percutaneous coronary intervention and (3) a healthy volunteer group. All patients in the Endo-CABG group will be treated following a uniform, standardised protocol. To assess neurocognitive outcome after surgery, a battery of six neurocognitive tests will be administered at baseline and at 3-month follow-up. In the Endo-CABG group, a neurological examination will be performed at baseline and postoperatively and delirium will be scored at the intensive care unit. Quality of life (QOL), anxiety and depression will be assessed at baseline and at 3-month follow-up. Satisfaction with Endo-CABG will be assessed at 3-month follow-up. Primary endpoints are the incidence of POCD, stroke and delirium after Endo-CABG. Secondary endpoints are QOL after Endo-CABG, patient satisfaction with Endo-CABG and the incidence of anxiety and depression after Endo-CABG.

ETHICS AND DISSEMINATION

The neurological outcome after minimal invasive coronary artery surgery study has received approval of the Jessa Hospital ethics board. It is estimated that the trial will be executed from December 2016 to January 2018, including enrolment and follow-up. Analysis of data, followed by publication of the results, is expected in 2018.

TRIAL REGISTRATION NUMBER

NCT02979782.

Comorbidities and characteristics of coronary heart disease patients: their impact on health-related quality of life

BACKGROUND

Patients with coronary heart disease (CHD) commonly present with more than one comorbid condition, contributing to poorer health-related quality of life (HRQoL). The aim of our study was to identify the associations between HRQoL and patient characteristics, vascular comorbidities and anxiety/depression disorders.

METHODS

This observational study was conducted in 36 family medicine practices selected by random stratified sampling from all regions of Slovenia. HRQoL was assessed using the European Quality of Life - 5 Dimensions (EQ-5D) questionnaire and EQ Visual Analogue Scale (EQ-VAS). The associations between HRQoL and patient characteristics stratified by demographics, vascular comorbidities, health services used, their assessment of chronic illness care, and anxiety/depression disorders were identified by ordinal logistic regression and linear regression models.

RESULTS

The final sample included 423 CHD patients with a mean age of 68.0 ± SD 10.8 years; 35.2% were female. Mean EQ-VAS score was 58.6 ± SD 19.9 (median: 60 with interquartile range of 45-75), and mean EQ-5D index was 0.60 ± SD 0.19 (median: 0.56 with interquartile range of 0.41-0.76). The statistically significant predictors of a lower EQ-VAS score were higher family physician visit frequency, heart failure (HF) and anxiety/depression disorders (R² 0.240; F = 17.368; p < 0.001). The statistically significant predictor of better HRQoL, according to EQ-5D was higher patient education, whereas higher family physician visit frequency, HF and peripheral artery disease (PAD) were predictors of poorer HRQoL (Nagelkerke R 2 = 0.298; χ 2 = 148.151; p < 0.001).

CONCLUSIONS

Results of our study reveal that comorbid conditions (HF and PAD), family physician visit frequency and years in education are significant predictors of HRQoL in Slovenian CHD patients.

Enhancing Postoperative Recovery of Cardiac Surgery Patients

The purpose of this trial was to determine the effectiveness of advanced practice nursing support on cardiac surgery patients’ during the first 5 weeks following hospital discharge. Patients ( N = 200) were randomly allocated to two groups: (a) an intervention group who received telephone calls from an advanced practice nurse (APN) familiar with their clinical condition and care needs, twice during the first week following discharge then weekly thereafter for 4 weeks, and (b) a usual care group. Measures of health-related quality of life (HRQL), symptom distress, satisfaction with recovery care, and unexpected health care contacts were obtained at 5 weeks following discharge. There were no significant group differences in HRQL, unexpected contacts with the health care system, or symptom distress. The provision of APN support via telephone followup after cardiac surgery is feasible. However, further randomized trials of single and multicomponent APN interventions are needed to prove effectiveness.

Hypothermia-induced platelet aggregation and cognitive decline in coronary artery bypass surgery: a pilot study

Hypothermia-induced platelet aggregation (HIPA) was previously reported in whole blood exposed to synthetic surfaces at 24°-32°C in one-third of normal subjects tested. Cardiopulmonary bypass, conducted with hypothermia, may lead to such aggregation, resulting in microvascular occlusion contributing to cognitive impairment. This pilot study was conducted to explore the relationship between HIPA and cognitive outcome at hospital discharge in patients undergoing coronary artery bypass graft (CABG) surgery as a first step toward a longer-term study.

Patients (n=45) undergoing mild to moderate hypothermia (32°-28°8C) during CABG surgery underwent cognitive testing preoperatively and prior to hospital discharge. Tests included: visual and verbal memory, mental processing speed, executive function, language, and intellectual function. HIPA was identified using an in vitro assay in which blood flowing in polyvinychloride tubing was subjected to hypothermia, and platelet aggregates were detected using microscopy and passing the exiting blood through a 20-μm pore filter.

Forty-four percent of patients exhibited HIPA. The entire cohort exhibited significant postoperative cognitive decline in verbal memory, mental processing speed and executive function. There was greater cognitive decline in the group with HIPA compared with the group not exhibiting this phenomenon. The patients with HIPA showed significant decline in four of five cognitive measures whereas patients not exhibiting this phenomenon declined in only two of five cognitive measures.

HIPA appears to be associated with an added risk of cognitive decline immediately following CABG surgery employing mild to moderate hypothermia. The findings of our study suggest the long-term cognitive effects of hypothermia-induced platelet aggregation need to be explored.

Patient Experiences Following Cardiothoracic Surgery: An Interview Study

Background: Numerous studies have investigated patient outcomes of cardiac surgery, including some examining health-related quality of life. While these studies have provided some insight into patients' physical function, social abilities and perceived quality of life, studies examining the experiences of individuals recovering from cardiac surgery have received only limited investigation.

Aims: This paper presents a thematic analysis of interviews conducted with patients recovering from cardiothoracic surgery, about their memories and experiences of hospital and recovery post-hospital discharge.

Methods: Using an exploratory qualitative approach, eight participants were interviewed 6 months following their surgery. Transcripts of interviews were examined using a content analysis approach, with open coding of text and categorising of similar concepts into themes.

Findings: Participants reported varying degrees of pain and physical dysfunction during their recovery from surgery and some had still not returned to optimal function. Seven themes emerged from the data: impressions of ICU; comfort/discomfort; being sick/getting better; companionship/isolation; hope/hopelessness; acceptance/apprehension; and life changes. A number of the themes were constructed as a continuum, with participants often demonstrating a range of views or experiences. Many had little or no memory of their stay in the intensive care unit, although others had vivid recollections. Their impressions of hospital were mostly positive, although many experienced fear, apprehension, and mood disturbances at some time during their recovery. Most participants recalled being sick, reaching a turning point, and then getting better. Many participants reported a change in life view since their recovery from surgery.

Conclusions: Attention to specific areas of patient orientation, education and support was identified to facilitate realistic expectations of recovery. In addition, some form of systematic follow-up that focuses on patient recovery in terms of both physical and psychological function is important.

Preoperative biomedical risk and depressive symptoms are differently associated with reduced health-related quality of life in patients 1year after cardiac surgery

OBJECTIVE

To examine whether preoperative biomedical risk and depressive symptoms were associated with physical and mental components of health-related quality of life (HRQoL) in patients 1year after cardiac surgery.

METHOD

Seventy-five patients completed a psychological evaluation, including the Center for Epidemiological Study of Depression scale, the 12-item Short-Form Physical Component Scale (SF-12-PCS) and Mental Component Scale (SF-12-MCS), the Instrumental Activities of Daily Living questionnaire for depressive symptoms and HRQoL, respectively, before surgery and at 1-year follow-up.

RESULTS

Preoperative depressive symptoms predicted the SF-12-PCS (beta=-.22, P<.05) and SF-12-MCS (beta=-.30, P<.04) scores in patients 1year after cardiac surgery, whereas the European System for Cardiac Operative Risk Evaluation was associated with SF-12-PCS (beta=-.28, P<.02), but not SF-12-MCS (beta=.01, P=.97) scores postoperatively.

CONCLUSIONS

The current findings showed that preoperative depressive symptoms are associated with poor physical and mental components of HRQoL, whereas high biomedical risk predicts reduced physical, but not mental, functioning in patients postoperatively. This study suggests that a preoperative assessment of depressive symptoms in addition to the evaluation of common biomedical risk factors is essential to anticipate which patients are likely to show poor HRQoL after cardiac surgery.

Age and gender differences and factors related to change in health-related quality of life from before to 6 months after left ventricular assist device implantation: Findings from Interagency Registry for Mechanically Assisted Circulatory Support

BACKGROUND

Gaps in the literature exist regarding health-related quality of life (HRQOL) early after left ventricular assist device (LVAD) surgery. The purposes of our study were to describe HRQOL over time, by age and gender, and identify risk factors for poor HRQOL early after LVAD implant.

METHODS

Patients (n = 7,353) from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database received a continuous-flow LVAD as a primary implant at 133 United States hospitals. Of these, 5,640 patients had pre-LVAD HRQOL data, 3,353 patients had 6-month post-LVAD HRQOL data, and 2,748 patients had data at both times. HRQOL was measured using the EQ-5D-3L (Euro-Qol) instrument. Data were collected pre-implant and 3 and 6 months post-operatively. Statistical analyses included chi-square test, t-test, Pearson correlation coefficients, and multiple regression analysis.

RESULTS

Overall HRQOL and dimensions of HRQOL improved from before to 6 months after device implant when examined by age and gender. However, younger patients and women reported significantly more problems regarding all dimensions before implant and significantly more problems regarding pain/discomfort and anxiety/depression at 3 and 6 months after implant. An increase in overall HRQOL from before to 6 months after implant was related to pre-implant INTERMACS Level 1. Factors related to a decrease in HRQOL from before to 6 months after implant were listed for heart transplant before surgery, comorbidities, better preoperative HRQOL, adverse events within 6 months after implant, bridge to transplant moderately likely and unlikely, and New York Heart Association Functional Classification IV at 6 months after LVAD (R(2) = 41%).

CONCLUSIONS

Overall HRQOL and dimensions of HRQOL improve in sub-groups of patients from before to 6 months after surgery, although differences in improvement exist. Adverse events are risk factors for decreased HRQOL across time and support the ongoing need to improve device technology with the aim of reducing adverse events.

Course of functional status in elderly patients after coronary artery bypass surgery: 6-month follow up

AIM

To determine longitudinal changes in functional status using three functional assessment scales in elderly patients undergoing coronary artery bypass grafting.

METHODS

This was a prospective observational cohort study of 73 patients aged ≥60 years undergoing elective coronary artery bypass grafting. Patients were assessed for functional status before admission, at hospital discharge, and at 1 and 6 months after discharge using the Functional Independence Measure, Katz Activities of Daily Living scale, and Lawton Instrumental Activities of Daily Living scale. Data were stratified by age (≥70 years and <70 years) and complications (with and without) for analysis.

RESULTS

In patients aged ≥70 years (n = 38), Functional Independence Measure scores ranged from 121.30 ± 6.42 (pre-admission) to 112.10 ± 17.10 (1 month) and 117.80 ± 13.50 (6 months), Katz scores from 5.88 ± 0.32 (pre-admission) to 5.45 ± 1.04 (1 month) and 5.83 ± 0.65 (6 months), and Lawton scores from 25.40 ± 3.30 (pre-admission) to 20.05 ± 4.93 (1 month) and 24.50 ± 4.10 (6 months; P < 0.001 for all). No significant changes were found in scale scores over time between groups with (n = 34) and without (n = 39) complications. When groups aged ≥70 years (n = 38) and <70 (n = 35) were compared, Functional Independence Measure scores showed a difference toward recovery over time in older patients (discharge - pre-admission, P = 0.010; 1 month - pre-admission, P = 0.0004; and 6 months - pre-admission, P = 0.079).

CONCLUSIONS

The Functional Independence Measure was able to detect significant functional loss over a 6-month period in elderly patients undergoing coronary artery bypass grafting, suggesting that this scale is a promising tool for the assessment of functional recovery over time after cardiac surgery, especially in patients aged older than 70 years. Geriatr Gerontol Int 2015; ●●: ●●-●●.

Evaluation of Quality Of Life after Cardiac Surgery in High-Risk Patients

<p><b>Background:</b> Conventionally, there is controversy over subjecting high-risk patients to cardiac operations, due to major postoperative complications. Higher survival rates and less morbidity as well as better quality of life can be good predictors of the outcome of surgery. This study evaluates the quality of life before and 12 months after cardiac operations on high-risk patients.</p><p><b>Methods:</b> In this study, the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was used to separate high-risk patients from others. The quality of life was assessed using the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) before surgery and one year afterward. Based on SF-36, the score for each of the eight different dimensions of the quality of life was quantified; and, their differences between pre-surgery and post-follow up period were analyzed.</p><p><b>Results:</b> 126 high-risk patients were included in this study. The mean age of the patients was 64.29 � 12.35 years. The median of EuroSCORE II score in these cases was 6.83 (6.04-25.98). The results reveal that the majority of the quality of life dimensions, except mental health, improved significantly after the follow-up period.</p><p><b>Conclusion:</b> Cardiac surgery on high-risk patients can noticeably promote the different aspects of their quality of life; although, such improvements should be considered against surgical complications.</p>

Is quality of life post cardiac surgery overestimated?

Background

Quality of Life (QoL) studies concerns the difference in QoL between the baseline and the post-surgical assessment. Many such studies, however, suffer from incomplete QoL-data with regard to patients with a proven survival - the drop-outs. Our hypothesis is that patients with a low preoperative QoL, high operative risk and older age are at higher risk for drop-out, which may result in a biased conclusion.

Methods

This study includes 1675 patients, all of whom were operated between July 1, 2009 and July 1,2012 and have a proven one-year survival, as well as a complete preoperative EuroQoL registration (EQ-5D and EQ-VAS). Based on the calculated 30 and 70 percentiles of age, EuroSCORE risk, and EQ-5D and EQ-VAS values, the group was split into three different subgroups. We studied whether (1) there was a correlation between age, risk, preoperative QoL and postoperative QoL and (2) if the drop-outs were correlated to age, risk and preoperative QoL.

Results

There is a statistically significant correlation between postoperative QoL and both age (p = 0.029) and risk (p = 0.002). Both relations have a negative Pearson’s r. There is also a statistically significant (p = 0.0001) correlation between pre- and postoperative QoL, now with a positive Pearson’s r. The percentage of drop-outs increases in a statistically significant manner with an increased risk (p = 0.001), older age (p = 0.001) and a low preoperative QoL (EQ-5D, p = 0.001 and EQ-VAS, p = 0.003).

Conclusion

We conclude that QoL post cardiac surgery is overestimated, certainly for older, high risk patients and patients with a low preoperative QoL.

The evolution of cardiovascular surgery in elderly patient: a review of current options and outcomes

Due to the increase in average life expectancy and the higher incidence of cardiovascular disease with advancing age, more elderly patients present for cardiac surgery nowadays. Advances in pre- and postoperative care have led to the possibility that an increasing number of elderly patients can be operated on safely and with a satisfactory outcome. Currently, coronary artery bypass surgery, aortic and mitral valve surgery, and major surgery of the aorta are performed in elderly patients. The data available show that most cardiac surgical procedures can be performed in elderly patients with a satisfactory outcome. Nevertheless, the risk for these patients is only acceptable in the absence of comorbidities. In particular, renal dysfunction, cerebrovascular disease, and poor clinical state are associated with a worse outcome in elderly patients. Careful patient selection, flawless surgery, meticulous hemostasis, perfect anesthesia, and adequate myocardial protection are basic requirements for the success of cardiac surgery in elderly patients. The care of elderly cardiac surgical patients can be improved only through the strict collaboration of geriatricians, anesthesiologists, cardiologists, and cardiac surgeons, in order to obtain a tailored treatment for each individual patient.

Health-related quality of life after cardiac surgery--the effects of age, preoperative conditions and postoperative complications

BACKGROUND

Factors influencing the postoperative health-related quality of life (HRQOL) after cardiac surgery have not been well described yet, mainly in the older people. The study's aim was to explore differences in clinical conditions and HRQOL of patients before and after cardiac surgery taking into account the influence of age and to describe factors influencing changes of HRQOL in the postoperative period.

METHODS

This was a prospective consecutive observational study with two measurements using the SF-36 questionnaire before surgery and 1 year after surgery. It considered main clinical characteristics of participants prior to surgery as well as postoperative complications.

RESULTS

At baseline assessment the study considered 310 patients, predominantly male (69%). Mean age was 65 (SD 10.4) years and 101 patients (33%), who were older than 70, constituted the older group. This older group showed greater comorbidity, higher cardiac operative risk and lower HRQOL in the preoperative period as well as a higher prevalence of postoperative complications than the younger group. Thirty-day mortality was 1.4% in the younger group and 6.9% in the older group (p < 0.001). One year mortality was 3.3% in the younger group and 10.9% in the older group (p < 0.001). There was a significant improvement in all 8 health domains of the SF-36 questionnaire (p < 0.001) in the overall sample. There was no significant difference in change in a majority of HRQOL domains between the younger and the older group (p > 0.05). Logistic multivariate analysis identified a higher values of preoperative PCS (Physical component summary) scores (OR 1.03, CI 1.00 - 1.05, p = 0.0187) and MCS (Mental component summary) scores (OR 1.02, CI 0.997 - 1.00, p = 0.0846) as the only risk factors for potential non-improvement of HRQOL after cardiac surgery after correction for age, gender and type of surgery.

CONCLUSIONS

Older patients with higher operative risk have lower preoperative HRQOL but show a similar improvement in a majority of HRQOL domains after cardiac surgery as compared with younger patients. The multivariate analysis has shown the higher preoperative HRQOL status as a only significant factor of potential non-improvement of postoperative HRQOL.

Comprehensive prospective cognitive and physical function assessment in elderly patients undergoing transcatheter aortic valve implantation

OBJECTIVE

Transcatheter aortic valve implantation (TAVI) is occasionally associated with stroke and silent cerebral ischemia, which may affect cognitive and functional performance. The aim of this study was to evaluate the changes in cognitive performance and functional status following TAVI.

METHODS

We performed a comprehensive prospective functional, cognitive and quality of life (QOL) evaluation in consecutive patients who underwent TAVI using the CoreValve device (Medtronic Inc.). The evaluation was performed at baseline and 1 month after the procedure and included the 36-item Short-Form Health Survey for QOL assessment, Mini-Mental State Examination (MMSE), quantitative clock drawing test (Rouleau), color trails test, Cognistat evaluation, Barthel Index and Duke Activity Status Index.

RESULTS

A total of 36 patients completed the full pre- and post-TAVI evaluation. Mean age was 82.2 ± 4.2 years (52.8% men); 94.5% of patients had low functional class (New York Heart Association III/IV), and 13.9% had prior stroke. After the procedure, all patients had improved functional status and valve hemodynamics. At 1 month, there was a significant improvement in the MMSE and Cognistat evaluations (from 25.9 ± 3.3 to 27.6 ± 2.4, p < 0.001, and from 5 ± 1 to 5.7 ± 0.7, p = 0.001, respectively).

CONCLUSIONS

Our preliminary results of a comprehensive assessment of patients undergoing TAVI indicate favorable results for both functional performance and cognitive function early after the procedure.

Health-related quality of life and functional outcome in cardiac surgical patients aged 80 years and older: a prospective single center study

BACKGROUND

An increasing number of octogenarians are referred for cardiac surgical procedures. In this subset of patients, information on the health-related quality of life (HrQoL) is critical for decision making. However, there is a paucity of prospective data. Thus, we sought to prospectively evaluate the HrQoL in octogenarians undergoing cardiac surgery.

METHODS

A prospective HrQoL analysis was performed in 106 elective patients (median age 83.0 ± 2.6 years, range 80-91.8 years, 59.4% male) undergoing cardiac surgery. The standardized SF-36 Health Survey questionnaire was answered preoperatively, and three and 12 months postoperatively. Preoperative data, perioperative outcome, and postoperative morbidity were analyzed.

RESULTS

SF-36 scores for physical functioning (44.3 ± 2.3 vs. 52.0 ± 2.7; p < 0.001), role physical (25.2 ± 3.3 vs. 41.5 ± 4.1; p < 0.001), bodily pain (57.8 ± 3.2 vs. 70.7 ± 2.8; p < 0.01), general health (54.9 ± 1.7 vs. 59.6 ± 1.7; p < 0.001), vitality (41.1 ± 2.1 vs. 50.6 ± 2.1; p < 0.001), and mental health (67.5 ± 2.0 vs. 72.4 ± 1.9; p < 0.05) significantly improved from baseline to three months. Social functioning (75.4 ± 2.6 vs. 76.1 ± 2.5; p = 0.79) and role emotional (56.8 ± 4.5 vs. 58.0 ± 4.6; p = 0.29) improved slightly without reaching statistical significance. Correspondingly, at three months, physical component scores increased significantly compared to baseline (34.3 ± 1.0 vs. 39.4 ± 1.0; p < 0.001). SF-36 scores remained stable between three months and one year. No significant change was seen in the mental component score from baseline to three months (48.6 ± 1.2 vs. 49.8 ± 1.1; p = 0.18).

CONCLUSIONS

Physical HrQoL is significantly improved in octogenarians three months after cardiac surgery remaining stable at one year postoperatively when compared to baseline.

Increased perioperative b-type natriuretic peptide associates with heart failure hospitalization or heart failure death after coronary artery bypass graft surgery

BACKGROUND

Heart failure (HF) is a leading cause of hospitalization and mortality. Plasma B-type natriuretic peptide (BNP) is an established diagnostic and prognostic ambulatory HF biomarker. We hypothesized that increased perioperative BNP independently associates with HF hospitalization or HF death up to 5 yr after coronary artery bypass graft surgery.

METHODS

The authors conducted a two-institution, prospective, observational study of 1,025 subjects (mean age = 64 ± 10 yr SD) undergoing isolated primary coronary artery bypass graft surgery with cardiopulmonary bypass. Plasma BNP was measured preoperatively and on postoperative days 1-5. The study outcome was hospitalization or death from HF, with HF events confirmed by reviewing hospital and death records. Cox proportional hazards analyses were performed with multivariable adjustments for clinical risk factors. Preoperative and peak postoperative BNP were added to the multivariable clinical model in order to assess additional predictive benefit.

RESULTS

One hundred five subjects experienced an HF event (median time to first event = 1.1 yr). Median follow-up for subjects who did not have an HF event = 4.2 yr. When individually added to the multivariable clinical model, higher preoperative and peak postoperative BNP concentrations each, independently associated with the HF outcome (log10 preoperative BNP hazard ratio = 1.93; 95% CI, 1.30-2.88; P = 0.001; log10 peak postoperative BNP hazard ratio = 3.38; 95% CI, 1.45-7.65; P = 0.003).

CONCLUSIONS

Increased perioperative BNP concentrations independently associate with HF hospitalization or HF death during the 5 yr after primary coronary artery bypass graft surgery. Clinical trials may be warranted to assess whether medical management focused on reducing preoperative and longitudinal postoperative BNP concentrations associates with decreased HF after coronary artery bypass graft surgery.

A 12-year follow-up on the changes in health-related quality of life after coronary artery bypass graft surgery

OBJECTIVES

Improvement in quality of life (QoL) and survival benefit are the primary objectives of coronary artery bypass graft (CABG) surgery. The profile of patients undergoing isolated CABG has altered towards higher age with more preoperative comorbidities. Thus, the importance of QoL over the quantity of life among elderly patients is getting more emphasized. In this study, our main goal was to evaluate the long-term changes in QoL, overall performance status and symptomatic status after the CABG.

METHODS

Comprehensive data of 508 patients who underwent isolated CABG in a single institution were prospectively collected. The RAND-36 Health Survey (RAND-36) was used as an indicator of QoL. Karnofsky dependency category was used to evaluate overall performance status, and symptomatic status was assessed using New York Heart Association (NYHA) class. All assessment were made preoperatively and repeated 1 year and 12 years later. The follow-up of the study cohort was complete in 95 and 84% of the alive patients at 1 year and 12 years, respectively. Analysis was based mainly on three age groups: ≤64 years (282 patients), 65-74 years (175 patients) and ≥75 years (51 patients).

RESULTS

Thirty-day, 1-year and 10-year survival rates were 98, 97 and 79%, respectively. Twelve years after the surgery significant improvement (P<0.05) was seen in all but one RAND-36 dimensions of the QoL (general health, P=0.76) as well as in functional capacity (P<0.001) and NYHA class. All age groups showed improvements in RAND-36 physical component summary (PCS) and mental component summary (MCS) scores compared with the preoperative values. The youngest subgroup maintained their physical and mental health status best, whereas older subgroups had more pronounced decreases in their PCS and MCS scores.

CONCLUSIONS

Despite an ongoing deterioration 12 years after the CABG, there was significant improvement in most dimensions of the QoL and functional capacity in comparison with the preoperative values. The elderly gain less long-term benefit from CABG regarding the QoL and survival.

Myocardial revascularization for the elderly: current options, role of off-pump coronary artery bypass grafting and outcomes

The increase in life expectancy has confronted cardiac surgery with a rapidly growing population of elderly patients requiring surgical myocardial revascularization. Recent advances in surgical and anesthetic techniques and improvements in postoperative care have made coronary artery bypass grafting an established therapeutic option for the treatment of coronary artery disease in this group of patients. However, conventional coronary artery bypass grafting on cardiopulmonary bypass is associated with significant risk and related morbidity and mortality in the elderly. In recent years off-pump coronary artery bypass grafting has emerged as a safe and less invasive strategy for surgical myocardial revascularization. Off-pump coronary artery bypass grafting by avoiding the deleterious effects of cardiopulmonary bypass can offer potential benefits to elderly patients requiring surgical myocardial revascularization. This review article provides an overview of the age-related cardiovascular changes, epidemiology of coronary artery disease in the elderly and focuses on outcomes of surgical myocardial revascularization with special emphasis on the impact of off-pump coro-nary artery bypass surgery in the elderly.

The effect of aortic valve replacement on quality of life in symptomatic patients with severe aortic stenosis

BACKGROUND

Although symptomatic patients with severe aortic stenosis have a high disease burden and guidelines recommend aortic valve replacement, many are treated conservatively. This study describes to what extent quality of life is changed by aortic valve replacement relative to conservative treatment.

METHODS

This observational study followed 132 symptomatic patients with severe aortic stenosis who were subjected to an SF-36v2TM Health Survey.

RESULTS

At baseline 84 patients were treated conservatively, 48 were referred for aortic valve replacement. In the conservatively treated group 15 patients died during a mean follow-up of 18 months (Kaplan-Meier survival was 85 % and 72 % at one and 2 years respectively) and 22 patients crossed over to the surgical group. Of the resulting 70 patients in the surgical group 3 patients died during a mean follow-up of 11 months (survival 95 % at 1 year). Physical functioning, vitality and general health improved significantly 1 year after aortic valve replacement. In conservatively treated patients physical quality of life deteriorated over time while general health, vitality and social functioning showed a declining trend. Mental health remained stable in both groups.

CONCLUSIONS

Aortic valve replacement improves physical quality of life, general health and vitality in patients with symptomatic severe aortic stenosis. Besides having a low life expectancy, conservatively treated patients experience deterioration of physical quality of life. Health surveys such as the SF-36v2TM can be valuable tools in monitoring the burden of disease for an individual patient and offer additional help in treatment decisions.

Temporal trends in the incidence of surgical site infections in patients undergoing coronary artery bypass graft surgery: a population-based cohort study, 1993 to 2008

OBJECTIVE

To determine the incidence of and temporal trends in surgical site infections (SSIs) in patients undergoing coronary artery bypass graft (CABG) surgery.

METHODS

A population-based cohort study was conducted to describe the epidemiologic features of SSI in Olmsted County, Minnesota, between January 1, 1993, and December 31, 2008, using the Rochester Epidemiology Project. Period-specific incidence rates (in-hospital or within 30 days outside the hospital) were calculated. Logistic regression analysis was used to adjust for potential confounders that could affect temporal trends in SSI incidence rates.

RESULTS

During the 16-year study, of 1424 residents of Olmsted County who underwent CABG surgery, 1189 (83%) had isolated CABG and 235 (17%) had combined CABG and valve surgery. The overall SSI incidence rate was 7.0% (95% confidence interval [CI], 5.7%-8.4%). The incidence rate of superficial sternal SSI was 2.0% (95% CI, 1.2%-2.7%) and of deep sternal SSI was 1.5% (95% CI, 0.9%-2.2%). The leg harvest site infection rate was 3.6% (95% CI, 2.6 %-4.5%). The incidence rate decreased over time with a statistically significant linear trend. The adjusted odds ratio (95% CI) of SSI showed a decreasing linear trend: 0.39 (0.19-0.81) vs 0.50 (0.27-0.93) vs 0.83 (0.48-1.42) vs reference for 2005-2008 vs 2001-2004 vs 1997-2000 vs 1993-1996.

CONCLUSION

In this population-based surveillance study of patients undergoing CABG surgery, the incidence of SSI decreased markedly between 1993 and 2008 in patients in Olmsted County. The factors responsible for this decrease are the focus of ongoing investigations.

Coronary artery bypass: predictors of 30-day operative mortality in Jordanians

To determine the risk factors and rate of 30-day operative mortality among Jordanian patients undergoing isolated coronary artery bypass surgery, we reviewed the records (January, 2005 to July, 2009) of 1,046 consecutive patients. Demographic and perioperative data were analyzed by univariate and multivariate analysis. The 30-day operative mortality rate was 5.9%. Significant independent predictors of death were age>65 years, female sex, heart failure, ejection fraction≤35%, prolonged inotropic support, mechanical ventilation>12 h, postoperative pneumonia, and postoperative stroke. The 30-day operative mortality rate was comparable to that reported in other countries.

Will cardiac surgery improve my quality of life?: Visual analogue score as a first step in preoperative counseling

BACKGROUND.: The intention of this study is to analyse the correlation between a visual analogue scale (VAS) and the most common preoperative comorbidity and cardiac variables in patients undergoing elective cardiac surgery. This VAS is simple, easy to register and can be used as a global measurement of quality of life (QOL). METHODS.: Preoperative assessment of QOL in 1351 patients, 979 men and 372 women, with a mean age of 64.5+/-10.5 (18-88), undergoing elective cardiac surgery between January 2003 and December 2005. QOL was measured by the EuroQol questionnaire. RESULTS.: The mean VAS was 58.7+/-20.9, range 3 to 100. Univariate analysis showed a difference for sex (p=0.000), and NYHA (p=0.009) between patients with an isolated CABG and those with a combined revascularisation (p=0.05). Stepwise logistic regression analysis identified female gender (p=0.00), NYHA (p=0.00) and valve disease (p=0.03) as independent variables for a low QOL. The correlation between NYHA and QOL was low (r=-0.09, p=0.003). CONCLUSION.: The clinical consequence is that using this simple VAS we can identify patients with a good QOL. If these patients present for high-risk surgery, with a better quality of life as primary indication, more extended counselling regarding their QOL is recommended. (Neth Heart J 2007;15:51-4.).

Coronary artery bypass grafting: 30-day operative morbidity analysis in 1046 patients

Background

To determine the rate and risk factors of three operative complications (renal failure, pneumonia, and sternal wound infection) within 30 days after isolated coronary artery bypass surgery.

Methods

Medical records of 1,046 consecutive patients between the years 2005 and 2009 were reviewed. Demographic data and peri-operative information were collected and analyzed. Univariate and multivariate analysis between different variables were performed.

Results

Of all patients 3.6% developed pneumonia, 5.9% developed acute renal failure and 8.5% developed sternal wound infection. Independent predictors of acute renal failure were age > 65 years (P = 0.030), pre-operative renal impairment (P < 0.005), peripheral vascular disease (P = 0.005), emergency surgery (P = 0.043), blood transfusion (P = 0.002) mechanical ventilation > 12 hours (P < 0.005) and prolonged inotropic support (P = 0.035). Pneumonia independent predictors were female gender (P < 0.005), diabetes mellitus (P = 0.024), peripheral vascular disease (P = 0.012), emergency surgery (P = 0.007), blood transfusion (P = 0.001), mechanical ventilation > 12 hours (P = 0.005) and prolonged inotropic support (P < 0.005). Sternal wound infection independent predictors were diabetes mellitus (P = 0.017), intra- and post-operative blood transfusion (P < 0.005), and prolonged inotropic support (P = 0.006).

Conclusion

Age, female gender, history of diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, renal impairment, emergency surgery, per-operative blood transfusion, mechanical ventilation > 12 hours and prolonged inotropic support are associated with the 30-day complication after on-pump isolated coronary artery bypass grafting surgery.

Prognostic value of preoperative quality of life on mortality after isolated elective myocardial revascularization

OBJECTIVES

This study evaluates whether a low preoperative quality of life (QoL), measured with the EuroQoL instruments EQ-5D and EQ-visual analogue scale (VAS) can be used as a predictor of mortality after elective isolated myocardial revascularization.

METHODS

A total of 2501 patients, with a mean age of 65.3 ± 9.4 (range 18-93) years and a mean additive EuroSCORE of 2.7 ± 2.1 (0-12), undergoing an elective isolated coronary artery bypass graft between January 2002 and June 2011 completed preoperative EQ-5D and EQ-VAS.

RESULTS

Hospital mortality [1.0% (25/2501 patients)] and 30-day mortality [1.2% (29/25 patients)] were the studied outcomes. The EQ-5D was 0.69 ± 0.26 (-0.30 to 1.0) with a median of 0.77 and the EQ-VAS was 59.7 ± 22.4 (0-100) with a median of 60. Regression analysis showed a significant correlation between hospital mortality and EQ-5D (P = 0.016) and EQ-VAS (P = 0.033). There is a significant correlation between 30-day mortality and EQ-5D (P = 0.048), but not for EQ-VAS (P = 0.06). The c-statistics (95% confidence interval) for EQ-5D and EQ-VAS for predicting hospital mortality are 0.36 (0.24-0.46) and 0.33 (0.23-0.42), respectively. The c-statistics for predicting 30-day mortality are 0.39 (0.30-0.49) for EQ-5D and 0.35 (0.26-0.44) for EQ-VAS.

CONCLUSIONS

Based on these results, we conclude that, in isolation, poor low preoperative EQ-5D and EQ-VAS scores do not contribute to deciding which patients should undergo cardiac surgery.

Health-related quality of life in Australian survivors of critical illness

OBJECTIVE

To document health-related quality of life of an Australian sample of intensive care unit survivors 6 months after intensive care unit discharge and compare this with preadmission health-related quality of life, health-related quality of life of national population norms, and international samples of intensive care unit survivors.

DESIGN

Prospective observational single-center study.

SETTING

Eighteen-bed medical-surgical tertiary intensive care unit of an Australian metropolitan hospital.

PATIENTS

Of the 122 eligible patients, 100 were recruited (intensive care unit length of stay >48 hrs, age >18 yrs, not imminently at risk of death) and the final sample comprised 67 patients, age (median [interquartile range], 61 yrs [49-73 yrs]), 60% male admitted to the intensive care unit for a median [interquartile range] 101 hrs (68-149 hrs). Normative age- and sex-matched Australian Short-Form 36 data from the Australian Bureau of Statistics, selected international cohorts of intensive care unit survivors, and their respective national age-matched normative data were included for comparison.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Sixty-seven participants provided responses to questions rating health-related quality of life (Australian Short-Form 36) at preadmission (on admission to the intensive care unit or through retrospective recall as soon as able) and 6 months after intensive care unit discharge. Ten additional participants were unable to provide study data without proxy input and were excluded from analysis. Participants reported clinically meaningful improvements in bodily pain (p = .001), social functioning (p = .03), role-emotional domains of the Short-Form 36 (p = .04), and mental component summary score (p = .01) at 6 months after intensive care unit discharge, mostly attributable to the patients undergoing cardiac surgery, whereas remaining Short-Form 36 domains showed no difference between preadmission and 6 months (p > .05). Participants reported clinically meaningful decrements in preadmission Short-Form 36 data compared with the Australian normative population with role-physical (p < .001) and physical functioning (p < .001) most affected at follow-up. Health-related quality of life in this sample was comparable with international samples of intensive care unit survivors.

CONCLUSIONS

Although the majority of health-related quality of life domains did not differ between preadmission and 6-month follow-up, participants reported significant and clinically meaningful improvements in pain and mental health at follow-up. Critical illness survivors' health-related quality of life remained within 1 sd of Australian norms at follow-up and physical function health-related quality of life was most affected. Health-related quality of life in these Australian survivors of the intensive care unit was comparable with international survivors 6 months after intensive care unit admission.

Increased peak postoperative B-type natriuretic peptide predicts decreased longer-term physical function after primary coronary artery bypass graft surgery

BACKGROUND

Increased peak postoperative B-type natriuretic peptide (BNP) is associated with increased major adverse cardiovascular events and all-cause mortality after coronary artery bypass graft (CABG) surgery. Whether increased postoperative BNP predicts worse postdischarge physical function (PF) is unknown. We hypothesized that peak postoperative BNP associates with PF assessed up to 2 yr after CABG surgery, even after adjusting for clinical risk factors. including preoperative PF.

METHODS

This two-institution prospective cohort study included patients undergoing primary CABG surgery with cardiopulmonary bypass. Short Form-36 questionnaires were administered to subjects preoperatively and 6 months, 1 yr, and 2 yr postoperatively. Short Form-36 PF domain scores were calculated using the Short Form-36 norm-based scoring algorithm. Plasma BNP concentrations measured preoperatively and on postoperative days 1-5 were log(10) transformed before analysis. To determine whether peak postoperative BNP independently predicts PF scores 6 months through 2 yr after CABG surgery, multivariable longitudinal regression analysis of the postoperative PF scores was performed, adjusting for important clinical risk factors.

RESULTS

A total of 845 subjects (mean ± SD age, 65 ± 10 yr) were analyzed. Peak postoperative BNP was significantly associated with postoperative PF (effect estimate for log(10) peak BNP, -7.66 PF score points [95% CI, -9.68 to -5.64]; P = <0.0001). After multivariable adjustments, peak postoperative BNP remained independently associated with postoperative PF (effect estimate for log(10) peak BNP, -3.06 PF score points [95% CI, -5.15 to -0.97]; P = 0.004).

CONCLUSIONS

Increased peak postoperative BNP independently associates with worse longer-term PF after primary CABG surgery. Future studies are needed to determine whether medical management targeted toward reducing increased postoperative BNP can improve PF after CABG surgery.

Improvements in health-related quality of life before and after isolated cardiac operations

BACKGROUND

Our study compared health-related quality of life (HRQOL) among cardiac surgical patient groups before and after cardiac operations for isolated surgical procedures and examined cardiac surgical patient HRQOL within the context of United States population norms.

METHODS

Of 2524 patients undergoing cardiac operations, 370 underwent isolated procedures (coronary artery bypass grafting, 136; aortic valve repair or replacement, 96; mitral valve repair or replacement, 92; Maze procedures, 46) between April 18, 2004, and June 30, 2008. They completed Short Form 36 questionnaires at baseline, at 3, 6, and 12 months postoperatively, and annually thereafter. Statistical analyses included χ(2), analysis of variance, longitudinal modeling, and longitudinal multivariable analyses.

RESULTS

Overall, the 370 cardiac surgical patients were 61.5 ± 11.9 years old, 70% men, and 76% white. Significant baseline differences in HRQOL existed among the cardiac surgical groups. Physical and mental components of the Short Form 36 improved from baseline to within 3 to 6 months postoperatively and remained stable through 3 years for all groups. When demographic and clinical covariates were held constant, the effect of cardiac surgical type on postsurgical HRQOL changes was not significant.

CONCLUSIONS

HRQOL improves early after cardiac operations and remains relatively constant long-term, independently of procedure type.