Medium-term survival and quality of life of Swedish octogenarians after open-heart surgery

OBJECTIVE

Operative mortality after open-heart interventions in the octogenarian population is relatively well known. Less has been reported on the medium term survival and quality of life of this growing subgroup of patients.

METHODS

One hundred and eighty-three consecutive patients aged between 80 and 84 years when they underwent open-heart surgery between January 1995 and June 2000 were retrospectively analysed. The patients were followed up for 36 months as regards survival and compared, after matching for age and gender, to survival in the general Swedish population. The health-related quality of life (HRQOL) of surviving patients was assessed in February 2001 using the SWED-QUAL questionnaire. After matching for differences by age and gender, survival results were compared to Swedish national survival data, and functioning and well-being to the corresponding national norm data. Pre-, intra- and post-operative variables were evaluated as predictors for mortality, survival and quality of life.

RESULTS

The 30-day mortality rate was 4.6% (n = 8). The 36-month survival rate, that was 85.6%, did not differ significantly (P = 0.078) from that of a cohort of the Swedish population matched for age and gender. There was no significant difference in survival between male and female patients (P = 0.545). Systemic hypertension was the only variable found to be a statistically significant predictor of 36-month mortality (P = 0.009). As concerns HRQOL, patients had significantly better physical functioning, satisfaction with physical functioning, relief of pain and emotional well-being (P < 0.01) and similar quality of sleep (P = 0.106) as the normal population. Male patients and male normal population responders had similar HRQOL (P > 0.05) while female patients reported significantly better HRQOL than their population counterparts on all five dimensions (P < 0.01).

CONCLUSIONS

Patients 80-84 years of age may be operated on with acceptable operative mortality and benefit from improved functioning and well-being. Survival and quality of life after open-heart surgery among patients aged 80-84 years of age are comparable to, or even better than in the general Swedish population.

[Clinical and organizational problems related to cardiological rehabilitation units]

The characteristics of patients admitted to cardiac rehabilitation units have progressively changed and are now represented by older age and clinical instability, with a higher percentage of females than in the past. Moreover, the demand of admission to cardiac rehabilitation departments has increased as a consequence of the extension of cardiac surgical procedures to older patients with frequent comorbidity. At the same time, the need of a shorter hospitalization in the acute hospital units has contributed to more frequent requests for cardiac rehabilitation admission. Cost factors and problems of organization have also contributed to the typology of the patients now admitted for cardiac rehabilitation. The data of patients admitted to the Cardiac Rehabilitation Unit of the Don Gnocchi Hospital in Milan are reported too: these data confirm the actual change in the typology of patients with respect to the past; the possible explanations and reasons, as well as the increased average age of the population and the increased number of surgical interventions in the elderly and females are also evaluated. Moreover, the programs and the rehabilitative aims have been consequently changed. Finally, even the use of non-invasive alternatives to ergometric tests is here discussed.

Rapidly progressive idiopathic dilation of the right atrium in infancy associated with dynamic obstruction of the airways

We present a young infant with rapidly progressive idiopathic dilation of the right atrium, complicated by symptomatic and dynamic obstruction of the airways secondary to proximal obstruction which was reversed subsequent to surgical reduction of the right atrium. We discuss the surgical implications of the distorted cardiac anatomy, along with post-operative complications, which included refractory arrhythmias.

Functional and psychological recovery during intensive hospital rehabilitation following cardiac surgery in the elderly

The recovery process in the elderly after cardiac surgery is influenced not only by clinical cardiac conditions, but also by comorbidity, cognitive decline and disability. We evaluated the relationship between clinical objective and self-perceived factors and their influence on functional recovery in 204 consecutive, over-70s pts who were admitted into an intensive hospital rehabilitation program following cardiac surgery. The variables taken into consideration were: comorbidity (Charlson index), length of hospital stay and complications in cardiac surgery and rehabilitation, disability (nursing needs score index), functional status (6-min walking test), left ventricular EF, number of training sessions, self-perceived health status (EuroQol questionnaire), emotional impairment (anxiety/depression, CBA-2.0/interview).

RESULTS

Functional capacity: the distance walked was 198 +/- 103 m at admission and 287 +/- 121 m at discharge (p < 0.0001). Only the nursing needs score index resulted as a weak, independent predictor of the distance walked at admission (r2 = 0.14, p < 0.001, beta = 0-.21), which (beta = 0.49), together with complications during rehabilitation (beta = -0.15), self-perceived health status at discharge (beta = 0.15) and number of training sessions (beta = 0.20), was independently correlated with the distance walked at time of discharge (r2 = 050, p < 0.0001). Patients mood: anxiety correlated with depression. Emotional scores did not correlate with functional measures. Patients self-perceived health status: only the nursing needs score index was a weak, independent predictor of well-being at entry (r2 = 0.15, p < 0.0001, beta = -0.29), which, in turn, was the only predictor of perception at discharge (r2 = 0.33, p < 0.0001, beta = 0-.42).

CONCLUSIONS

In an intensive hospital rehabilitation program following cardiac surgery in patients over 70 a) there was no correlation between clinical and psychological variables; b) anxiety and depression were associated, but neither influenced the recovery process nor correlated to health status perception; c) functional impairment was strongly influenced by nursing needs which also affected the self-perceived health status; d) both functional and perception recovery were influenced by disability at time of admission and reacted positively after rehabilitation.

Women and cardiac rehabilitation after heart surgery: patterns of referral and adherence

This cross-sectional, descriptive study examined patterns of referral of women to cardiac rehabilitation programs after heart surgery, their adherence to those programs, and whether their participation differed according to their age ranges. A Cardiac Rehabilitation Participation questionnaire was mailed to 157 women who were selected from the records of 4 hospitals and 7 physician groups. Of the 157 women, 122 had been referred to a cardiac rehabilitation program. Ten (8.3%) of 122 did not attend the program at all, and 25 (29%) did not attend as often as had been recommended. Women who had bypass surgery were more likely to have been referred than were those who had valvular surgery. Patterns of referral and adherence were similar in older women (66 years or older) to the patterns for women in midlife (32 to 65 years). Study participants indicated that health, convenience, work or time constraints, or personal preferences were factors that most interfered with their attending the programs. Age was not a factor.

Post-surgical cardiac patients receive new level of care

VNA Home Health Systems in Orange County, California provides intermittent home care for homebound and critically ill patients. The VNA administration recognized the advantages of clinicians using a pocket-sized cardiac monitor. Eager to continually adopt technologies that improve their level of care, the pocket-sized cardiac monitor was a logical addition to VNA's PDA-based clinical tools.

Why offer home cardiac recovery care?

Why offer cardiac recovery specialty programs in home care? The answer to this question lies in the issue related to nursing professionals' obligation to provide best practice for all patients. Home cardiac care that complies with best-practice, evidence-based guidelines, derives the best patient outcomes. A comprehensive and best-practice approach to care is simply what every patient recovering from a cardiac event deserves.

Exercise and sports participation after surgery for congenital heart disease: the European perspective

The success of surgery for congenital heart disease which has been performed since many years has created a population of patients who require careful follow-up in order to determine their clinical progress and to establish the type and intensity of physical activity which they can safely perform. The authors illustrate the opinion of the European Community regarding children, sport and organizational aspects and also problems concerning the management of pediatric cardiac patients in Europe and Italy. Cardiological and surgical aspects are considered together with the practice of physical activity, with emphasis upon the differences between the various countries. Particular attention is paid to the Italian legislation regarding the certification to participate in competitive or non-competitive sport in such a population of patients. Great importance is given to pediatric cardiac rehabilitation programs which aim at improving the aerobic fitness of patients operated upon for complex congenital heart disease and at illustrating their own cardiovascular limitations so that they can perform physical exercise with the utmost safety.

Functional status and quality of life in long-term survivors of cardiac arrest after cardiac surgery

OBJECTIVE

To assess long-term survival, functional status, and quality of life in patients who experienced cardiac arrest after cardiac surgery.

DESIGN

Prospective, observational study.

SETTING

An 18-bed, adult cardiac surgery intensive care unit in a tertiary teaching center.

PATIENTS

Twenty-nine cardiac surgery patients who suffered an unexpected cardiac arrest in the immediate postoperative period.

INTERVENTIONS

The New York Heart Association classification and a questionnaire based on the Nottingham Health Profile were used to evaluate functional status and quality of life 4 yrs after hospital discharge.

MEASUREMENTS AND MAIN RESULTS

Of the 29 patients who experienced cardiac arrest during the first 24 hrs after cardiac surgery, 27 patients (93%) were successfully resuscitated and 23 patients (79%) survived to hospital discharge. Evaluation 4 yrs postdischarge showed that, of the 29 patients, 16 patients (55%) were still alive (long-term survivors). Functional status assessment of long-term survivors revealed that 12 patients (75%) were grouped in New York Heart Association class I, 3 patients (19%) in class II, and 1 patient (6%) in class III. None of them had a neurologic deficit. They all were living independently at home, without need of any nursing care. No patient reported any abnormal emotional reactions, and six patients (38%) had mild sleep disturbances, such as early awaking. Regarding activities of daily living, 20% returned to work, 94% were able to look after their home, 96% had a social life, 63% were sexually active, 81% were involved in their hobbies, and 75% had gone on holidays.

CONCLUSIONS

Cardiac surgery patients who experience an unexpected cardiac arrest in the immediate postoperative period have a 55% chance of being alive 4 yrs postdischarge. The majority of these long-term survivors has a good outcome with respect to functional status and quality of life.

Characterization of post-discharge atrial fibrillation following open-heart surgery in uncomplicated patients referred to an early rehabilitation program

BACKGROUND

Atrial fibrillation (AF) is frequently observed after open-heart surgery, following discharge from the cardiac surgery clinic. Compared to those usually reported in the early postoperative period, this arrhythmia is delayed in onset and is often a cause of re-hospitalization. Post-discharge AF has never been characterized in the literature.

METHODS

We retrospectively analyzed post-discharge AF occurring within 30 days of coronary artery bypass graft or of valvular procedures in 376 patients referred to an early postoperative rehabilitation program. To investigate the probability of the persistence of post-discharge AF, we prospectively examined 232 patients who had undergone valvular procedures.

RESULTS

An arrhythmia was recognized in 61/376 patients (16%), resulted in worsening of the NYHA functional class in 27 (44%) and in life-threatening hemodynamic effects requiring urgent cardioversion in 5 (8%). Events were predicted by the occurrence of postoperative AF (6-fold higher risk), left ventricular hypertrophy, an enlarged left atrium and valvular pathology (3-fold) and by the lack of beta-blocker protection (5-fold). AF persisted in 20/232 (9% of the study population, 18% of patients who had post-discharge AF) and had a relevant impact on the patient's clinical status. Predictors of events were older age, an enlarged left atrium and a lower left ventricular ejection fraction.

CONCLUSIONS

Post-discharge AF following open-heart surgery is frequent in patients undergoing valvular procedures and often persists over time. The clinical impact of the arrhythmia is relevant, it might cause re-hospitalizations in many circumstances and, consequently, may have an impact on hospital resources. Events are much less frequent in patients taking beta-blockers than in those who do not, and they can be predicted by simple variables observed in the early stages after surgery.

Patients' and carers' perceptions of factors influencing recovery after cardiac surgery

Stress and anxiety experienced by patients following myocardial infarction are well documented. Moreover, partners feel distress when they realize that they must assume responsibility for day-to-day care once the period of hospitalization is over. However, despite the trend towards early hospital discharge and the role which carers appear to be expected to undertake during the recovery of patients who have had cardiac surgery, few studies have been undertaken with this group outside the United States of America. This omission was filled by a descriptive survey with 60 patients and carers following cardiac surgery. Data were obtained during early recovery (1 week after hospital discharge) and 6 weeks later. The results indicated that carers assumed a heavy burden once the patient had left hospital and were less satisfied with the timing of discharge than the patients. Information provided by nurses was consistently rated more highly than information provided by doctors or physiotherapists but there was scope for increasing input with both groups. High levels of satisfaction with the information provided by health professionals were associated with lower scores on the Hospital Anxiety and Depression Scale. More qualitative, in-depth studies to explore the precise needs of patients and their carers are needed to ensure that in future both groups are better prepared.

Effect of exercise-based cardiac rehabilitation on mobility and self-esteem of persons after cardiac surgery

This study adopted an experimental design with using a nonequivalent, posttest only control group to study the rehabilitation outcomes of 152 persons who received cardiac surgery. 37 subjects in a rehabilitation group participated in a 2-mo. exercise-based cardiac rehabilitation programme, and another 115 subjects who did not attend the programme formed the control group. The subjects' self-esteem was measured on the Adult Source of Self-esteem Inventory by Elvoson and Fleming, and their mobility skill was measured by a simple mobility test based on New York Heart Association Classification. Analysis of covariance (with covariance analysis of the subjects' age, years of education, occupational skill, and mobility skill) indicated that the experimental group scored higher on positive self esteem and showed significantly better improvement in mobility skill. The exercise-based cardiac rehabilitation programme positively affected physical and psychological outcomes. Also, subjects' self-esteem was significantly correlated with their mobility skills (r=.21, p<.05) among those aged under 60 years (n=96) but not among those aged 60 or above (n=53).

Implementation strategy: one-stop recovery for cardiac surgical patients

"Fast-track" or "rapid recovery" for cardiac surgical patients is enjoying widespread use due to its benefits of increased patient comfort, enhanced quality of care, and cost-savings. Successful implementation of a fast-track program, however, may be challenged by physicians, the institution, or patients and their families. One-Stop Recovery is a fast-track program that emphasizes the benefits of traditional rapid recovery programs while addressing potential challenges.

Use of telephone follow-up for post-cardiac surgery patients

Telephone follow-up has been used in a variety of settings as a means of supporting patients post-discharge. This paper describes the implementation of a telephone follow-up service for cardiac surgical patients, both to monitor their progress and to bridge the gap between home and hospital. Surgical unit nurses called 1594 patients between May 1995 and October 1997. These calls were made a month after each patient had been discharged and a specially designed form was used as a guideline for the calls. This covered three main aspects of their recovery: discharge monitoring; medical problems; and convalescence problems. As well as providing a framework for the calls, the forms were then used for data collection. The forms were audited on a monthly basis with the results being communicated to the ward staff. Data gathered from the calls have highlighted areas where patient education needs to be improved, e.g. pain control, and this has been addressed. In October 1996, an evaluation of the service was performed. One hundred patients were sent a postal questionnaire asking for their views on the telephone service. Eighty-two of these were returned and the results of this survey are also contained in this report. Over time, the number of patients called each month has increased; information regarding support post-discharge has improved and the form used for calls has been revised to make the questions more appropriate.

Creating cost-efficient initiatives in social work practice in the cardiac program of an acute care hospital

All three cost-saving initiatives--the creation of a one-page application form to streamline the rehabilitation application process, the use of the resource specialist to assist with applications, and the development of an information package on cardiac rehabilitation--reflect a process whereby a creative idea, generating planning, activities, and follow-up resulted in a measurable effective change in practice. This process truly translated strategy into action (Kaplan, 1996) and is vital to the current rethinking in health care of how best to do our work (Coan, 1994). Because of this process, social workers in the cardiovascular surgical division of the cardiac program are better equipped to respond to the psychosocial needs of a growing cardiac population in a fiscally restrained environment.

An interdisciplinary approach to the rehabilitation of open-heart surgical patients

Quite often nurses in environments other than the immediate postoperative setting are responsible for the well-being of patients who have had open-heart surgery (OHS). These patients may be admitted to rehabilitation or home healthcare settings as early as 1 week after surgery. They may be deconditioned because of postoperative complications such as a cerebrovascular accident or cardiopulmonary compromise. Rehabilitation nurses in inpatient or home health environments are key members of the interdisciplinary team in terms of establishing standards of care for OHS patients after surgery. Coordinating care within an interdisciplinary team reduces fragmentation of care, improves patient outcomes, and enhances patient, family, staff, and physician satisfaction. This article focuses on empowering rehabilitation nurses as leaders and members of interdisciplinary teams as they establish standards for coordinating the postoperative care of OHS patients.

[Supervised cardiac rehabilitation for the patients with the disturbance of the motor function after cardiac surgery: the significance of physical therapists' participation]

There are sporadic instances of patients with the motor function disturbance of non-cardiac origin after cardiac surgery, and these patients may need prolonged post-operative cardiac rehabilitation. We established our cardiac rehabilitation program for post-operative patients and a total of 124 patients underwent the post-operative cardiac rehabilitation program (male 73, female 51, average age 60). Among them, 12 patients (9.7%) received the physical therapy for the disturbance of motor function post-operatively. These 12 patients were retrospectively studied. Physical therapies performed were the exercise therapy to improve the range of motion to prevent contracture in 3 patients with peroneal nerve palsy and drop foot, the exercise therapy for pre-operative or post-operative hemiplegia in 6 patients, the instruction of exercise for lumbago in 1 patient with spinal cord disease, respiratory physical therapy in 1 patient, and myotherapy for arthritis in 1 patient. Treatment with physical therapy was very useful in rehabilitating these patients. Active participation of physical therapists in cardiac rehabilitation for patients with the disturbance of motor function after cardiac surgery is possible. It is expected that their participation may improve the quality of life in this subset of patients.