Age does not limit quality of life improvement in cardiac valve surgery

Health related quality of life of patients following mechanical valve replacement surgery for rheumatic mitral stenosis in Tanzania

BACKGROUND

The assessment of outcomes of interventions based on the patient's perspective using patient-reported outcome measures (PROMs) has been increasingly highlighted in clinical practice. However, health related quality of life (HRQoL), one of the common constructs measured by PROMs remain unknown among patients after heart valve replacement (HVR) in Tanzania.

OBJECTIVES

To assess the HRQoL amongst patients operated on for rheumatic mitral stenosis at Jakaya Kikwete Cardiac Institute (JKCI).

METHODS

A prospective study of patients operated on due to rheumatic mitral stenosis at JKCI from January 2020 to April 2021 was undertaken. The HRQoL was assessed by using the MacNew questionnaire, addressing three domains (physical, emotional, and social function); the score ranges from 0 to 7. We categorized HRQoL as low (mean score ≤ 4.9), moderate (5-6) and high (> 6). We analysed several sociodemographic and clinical variables for HRQoL.

RESULTS

Out of 54 patients, there were 34 females and 20 males. Their mean (± SD) age was 37.98 (± 12.58) years. The reliability of translated Kiswahili version of MacNew was good. The mean (± SD) global scores were 3.47 ± 0.59, 4.88 ± 0.71 and 6.14 ± 0.50 preoperatively, at 3 months and 6 months respectively (p-values < 0.001 preoperatively vs. 3 months, preoperatively vs. 6 months and at 3 months vs. 6 months). The median of individual mean difference HRQoL score pre-operatively and at 6 months was 2.67. The preoperative and 6 months mean difference HRQoL scores were higher among patients with vs. without atrial fibrillation (2.95 ± 0.59 vs. 2.45 ± 0.53, p = 0.003) and those on anticoagulants (preoperatively) vs. not on anticoagulants (3.14 ± 0.58 vs. 2.57 ± 0.57, 0.009). The mean difference HRQoL scores were similar for sociodemographic and other clinical parameters, including those with stroke vs. without stroke.

CONCLUSION

Six months after HVR the overall MacNew HRQoL scores improved markedly. This improvement in HRQoL was regardless of the presence of comorbidities (e.g. stroke and atrial fibrillation) which underscores the importance of considering valvular surgery if they fit the criteria. Clinicians and researchers in low-resource settings should collaborate to promote the utilization of PROMs in the routine care of patients.

Quality of life: modified triple-branched stent graft implantation versus frozen elephant trunk technique

Objective

To compare the effects of modified triple-branched stent implantation and frozen elephant trunk technique on the quality of life (QoL) of acute Stanford Type A aortic dissection (AAAD) patients at different follow-up times.

Methods

Data from 175 AAAD survivors was collected which were divided into two groups according to different surgical techniques: (group A): modified triple-branched stent graft implantation; (group B): frozen elephant trunk. The SF-36 were used to assess the QoL at discharge (AD), the third postoperative month (POM3), and the twelfth postoperative month (POM12).

Results

(1) The total scores at each time of both groups showed lower than the normal level; Group A scored higher than group B at some time points in terms of some items (role physical, role emotion and mental health; all P = 0.000), and some items at POM3 or POM12 scored higher than at discharge (role physical, social function; both P = 0.000). (2) There were less patients with heavy self-perceived burden in group A than group B at discharge (P = 0.032) and patients with heavy self-perceived burden decreased over time. (3) Young postoperative AAD patients (P = 0.002) in group B (P = 0.005) with heavy self-perceived burden (P = 0.000), acute renal failure (P = 0.008), long LOS (P = 0.026) and blood loss (> 1000 mL/24 h) (P = 0.039) seemed to get a worse QoL.

Conclusion

The impact on QoL of the modified triple-branched stent graft implantation technique seemed to be better than those of frozen elephant trunk surgery in role physical, role emotion and mental health.

Comparison of Long-Term Outcomes of Patients Having Surgical Aortic Valve Replacement With Versus Without Simultaneous Coronary Artery Bypass Grafting

Coronary artery disease is a common co-morbidity of aortic stenosis. When needed, adding coronary artery bypass grafting (CABG) to surgical aortic valve replacement (SAVR) is the standard treatment method, but the impact of concomitant CABG on long-term outcomes is uncertain. We compared long-term outcomes of SAVR patients with and without CABG. Hospital survivors aged ≥50 years discharged after SAVR ± CABG in Finland between 2004 and 2014 (n = 6,870) were retrospectively studied using nationwide registries. Propensity score matching (1:1) was used to identify patients with comparable baseline features (n = 2,188 patient pairs, mean age 73 years). The end points were postoperative 10-year major adverse cardiovascular outcome (MACE), all-cause mortality, stroke, major bleeding, and myocardial infarction. Median follow-up was 6 years. Cumulative MACE rate (39.5% vs 35.6%; hazard ratio [HR] 1.04; p = 0.677) and mortality (32.7% vs 31.0%; HR 1.03; p = 0.729) after SAVR were comparable with or without CABG. Myocardial infarction was more common in patients with CABG (13.4% vs 6.9%; HR 1.47; p = 0.0495). Occurrence of stroke (15.1% vs 13.5%; p = 0.998) and major bleeding (20.0% vs 21.9%; p = 0.569) were comparable. There was no difference in gastrointestinal (8.1% vs 10.3%; p = 0.978) or intracranial bleeds (6.0% vs 5.5%; p = 0.794). The use of internal mammary artery in CABG did not have an impact on the results. In conclusion, matched patients with and without concomitant CABG had comparable long-term MACE, mortality, stroke, and major bleeding rates after SAVR. In conclusion, our results indicate that need for concomitant CABG has limited impact on long-term outcomes after initially successful SAVR.

Impact of balloon mitral valvotomy on quality of life and psychiatric morbidity in patients with severe mitral stenosis

OBJECTIVES

To evaluate the quality of life (QoL), psychiatric comorbidities in patients with rheumatic heart disease-mitral stenosis (RHD-MS), and the impact of balloon mitral valvotomy (BMV) on the QoL and psychiatric morbidity.

MATERIALS AND METHODS

Fifty consecutive patients of RHD-MS were evaluated for QoL and psychiatric morbidity prior to BMV and at 3 months after the procedure.

RESULTS

The mean age of the study sample was 34.9 years (standard deviation, 11.1 years). At baseline assessment, majority (94%) had New York Heart Association Class II/III symptoms and QoL scores below average, that is, 50. About two-fifth (19 out of 50) of the patients had one or more psychiatric comorbidity, that is, depression (32%), anxiety (16%), and somatoform disorder (12%). Those with psychiatric comorbidity had poor QoL scores in social, emotional, and mental subscales (P < 0.05) at the baseline. At 3-month follow-up, there were significant improvement in symptoms and transmitral pressure gradients (P < 0.05), QoL scores (P < 0.05), and psychiatric comorbidities (P < 0.05) after BMV. Improvements in QoL were irrespective of the baseline psychiatric comorbidity.

CONCLUSIONS

High prevalence of psychiatric illness and poor QoL scores were observed in patients with RHD-MS. BMV significantly improves the QoL and psychiatric comorbidities.

Prognosis of Prolonged Intensive Care Unit Stay After Aortic Valve Replacement for Severe Aortic Stenosis in Octogenarians

OBJECTIVES

Octogenarians considered for cardiac surgery encounter more complications than other patients. Postoperative complications raise the question of continuation of high-cost care for patients with limited life expectancy. Duration of hospitalization in intensive care after cardiac surgery may differ between octogenarians and other patients. The objectives were evaluating the mortality rate of octogenarians experiencing prolonged hospitalization in intensive care and defining the best cut-off for prolonged intensive care unit length of stay.

DESIGN

A single-center observational study.

SETTING

A postoperative surgical intensive care unit in a tertiary teaching hospital in Paris, France.

PARTICIPANTS

All consecutive patients older than 80 years considered for aortic valve replacement for aortic stenosis were included.

MEASUREMENTS AND MAIN RESULTS

Mortality rate was determined among patients experiencing prolonged stay in intensive care with organ failure and without organ failure. An ROC curve determined the optimal cut-off defining prolonged hospitalization in intensive care according to the occurrence of postoperative complications. Multivariate analysis determined risk factors for early death or prolonged intensive care stay. The optimal cut-off defining prolonged intensive care unit length of stay was 4 days. Low ventricular ejection fraction (odds ratio [OR] = 0.95; 95% confidence interval [CI] 0.96-0.83; p = 0.0016), coronary disease (OR = 2.34; 95% CI 1.19-4.85; p = 0.014), and need for catecholamine (OR = 2.79; 95% CI 1.33-5.88; p = 0.0068) were associated with eventful postoperative course. There was not a hospitalization duration beyond which the prognosis significantly worsened.

CONCLUSIONS

Prolonged length of stay in ICU without organ failure is not associated with increased mortality. No specific duration of hospitalization in intensive care was associated with increased mortality. Continuation of care should be discussed on an individual basis.

Recent advances in transcatheter aortic valve replacement for high-risk patients

Aortic stenosis is the most common valvular heart disease of old age. Patients with severe aortic stenosis who develop symptoms have a very poor prognosis without valve intervention. Surgical aortic valve replacement has historically been the only treatment option for these patients. However a significant minority are considered inoperable or at high surgical risk and therefore are refused or decline surgery. In recent years, transcatheter aortic valve replacement has emerged as an alternative treatment option in these high-risk patients. The aim of this review is to summarize the current role of transcatheter aortic valve replacement in contemporary clinical practice including recent advances in technological and procedural aspects and then discuss future directions.

NR2 antibody is associated with quality of life in aortic valve replacement

BACKGROUND

The relationship between the potential brain injury biomarker N-methyl-D-aspartate receptor antibody and quality of life has never been assessed.

METHODS

We measured serum N-methyl-D-aspartate receptor antibody levels preoperatively in patients undergoing aortic valve replacement. Quality of life was scored using the Short Form-36 and European Quality of Life 5-Dimensions questionnaires pre- and postoperatively. We analyzed the antibody levels as a continuous variable and as a dichotomous variable with 1.8 ng mL(-1) as the cutoff.

RESULTS

Fifty-two patients (15 females) with a mean age of 71 ± 8.4 years were recruited for this study. Forty-eight (92%) patients attended the follow-up visit (405 ± 161 days). No mortality or severe neurological event was recorded. In both quality-of-life instruments, the low antibody level group (n = 35) had significantly better scores than the high antibody level group (n = 17) preoperatively. Postoperatively, the scores for both groups improved; however, the low antibody level group continued to score significantly better in most of the physical and mental health domains (p = 0.04 to <0.001). Multiple regression analyses revealed that antibody level and the 1.8 ng mL(-1) cutoff were independently related to quality of life (pre- and postoperatively).

CONCLUSIONS

Higher N-methyl-D-aspartate receptor antibody levels in aortic valve replacement patients are independently related to poorer quality of life pre- and postoperatively.

How to approach aortic valve disease in the elderly: a 25-year retrospective study

OBJECTIVE

In the last decade, the number of elderly patients suffering from aortic valve disease has significantly increased. This study aimed to identify possible factors that could affect surgical and long-term outcomes in the light of a literature review regarding the management of aortic valve disease in the elderly.

METHODS

Between January 1990 and December 2012, a total of 114 patients (64 males, 50 females; mean age 76.6 ± 3.6 years; range 70-87 years) with aortic valve replacement (AVR) alone, or combined with coronary artery bypass grafting (CABG) or mitral surgery in our hospital, were retrospectively analysed.

RESULTS

In-hospital mortality was seen in 19 patients. The major causes of in-hospital mortality were low-cardiac output syndrome in eight patients (42.1%), respiratory insufficiency or infection in six (31.5%), multi-organ failure in four (21%), and stroke in one patient (5.2%). The main postoperative complications included arrhythmia in 26 patients (22.8%), renal failure in 11 (9.6%), respiratory infection in nine (7.9%), and stroke in three patients (2.6%). The mean length of intensive care unit and hospital stays were 6.4 ± 4.3 and 18 ± 12.8 days, respectively. During follow up, late mortality was seen in 28 patients (29.4%). Possible risk factors for long-term mortality were type of prosthesis, EuroSCORE ≥ 15, postoperative pacemaker implantation, respiratory infection, and haemodialysis. Among 65 long-term survivors, their activity level was good in 53 (81.5%) and poor in two.

CONCLUSIONS

Our study results demonstrated that an individually tailored approach including scheduled surgery increases short- and long-term outcomes of AVR in patients aged ≥ 70 years. In addition, shorter cardiopulmonary bypass time may be more beneficial in this high-risk patient population.

Survival and quality of life in an elderly cardiac surgery population: 5-year follow-up

OBJECTIVES

As survival after cardiac surgery has become very satisfactory even in elderly patients, more attention is being directed towards improved health-related quality of life (HRQOL). However, longitudinal prospective cohort studies describing HRQOL after cardiac surgery are still scarce. The purpose of this study was to explore HRQOL and survival in patients undergoing cardiac surgery after 5 years, emphasizing on older patients (≥75 years).

METHODS

In a prospective population-based study, 534 patients (23% ≥75 years, 67% males) were consecutively included before surgery. HRQOL and medical and sociodemographic variables were measured by questionnaires at baseline, 6 and 12 months after surgery and again after 5 years. HRQOL was measured by the Short-Form 36 Health Survey (SF-36).

RESULTS

Four hundred and fifty-eight patients were alive after 5 years, with a response rate of 82%. Older patients had lower 5-year survival than younger patients (P = 0.042), but it was similar to that of the general population. After 5 years, both older and younger patients had slightly lower scores on some SF-36 dimensions, compared with scores after 6 and 12 months. However, on seven of eight subscales of the SF-36, the scores after 5 years were still higher than before surgery. Older patients improved less from baseline to the follow-up, and had more profound reductions in scores from 12 months to 5 years on three subscales; physical functioning (P = 0.013), role physical (P < 0.001) and vitality (P = 0.036).

CONCLUSIONS

HRQOL improved from baseline to 6 months postoperatively, and remained relatively stable 5 years after cardiac surgery even in elderly patients. The study showed that survival and HRQOL can match that of the general population.

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.

Quality of life after transcatheter aortic valve implantation and surgical replacement in high-risk elderly patients

AIM

The aim of this study was to compare the quality of life after transcatheter aortic valve implantation (TAVI) and surgical replacement (SAVR) at one year.

METHODS

The study included 45 consecutive high-risk patients (average age 82.0 years; logistic Euroscore 22.3%) with symptomatic severe aortic stenosis allocated to TAVI transfemoral, TAVI transapical using the Edwards-Sapien valve or SAVR with the Edwards Perimount bioprosthesis (n=15 in each). The pre-operative characteristics were similar except for more myocardial infarctions in TAVI. The quality of life was assessed using the standardized EQ-5D questionnaire at baseline and on days 30, 90 and 360. The protocol was approved by the local ethics committee and an informed consent was signed. A total of 7 patients (15.5%) died during follow-up.

RESULTS

At baseline no significant differences in any of the quality-of-life parameters were found except for usual activities described as "best" (46.7% in SAVR vs. 10.0% in TAVI; P=0.002). At 30 and 90 days surviving patients were similar and at 360 days only the anxiety/depression score was "best" in 83.3% SAVR vs. 59.1% (P=0.046). Functional status improved in all patients (NYHA class I-II in 13.3% at baseline vs. 78.9% at 360-days) and the general health median significantly improved in TAVI patients (from 50 to 67; P=0.001) with a positive trend in SAVR patients (P=0.060).

CONCLUSIONS

At one year, the general quality of life of high-risk patients had significantly improved after transcatheter aortic valve implantation with a positive trend in surgically treated patients.

Coronary artery bypass grafting associated to aortic valve replacement in the elderly: survival and quality of life

Myocardial ischemia is often associated to aortic valve stenosis in the elderly. Aim of this study was to evaluate the impact on survival and quality of life of CABG associated to aortic valve replacement in the septuagenarians and octogenarians.

Between January 1991 and January 2010, 520 patients ageing > 70 years underwent aortic valve replacement with a mechanical prosthesis in two Institutions. They were divided into 2 groups: Group A included 406 patients undergoing isolated aortic valve replacement; Group B 114 patients receiving aortic valve replacement and CABG. A comparative analysis of long-term survival and quality of life (SF-36 test) was performed.

Mean age was 74.2 ± 3.6 years (74.3 ± 3.6 in Group A, 74 ± 3.3 in Group B; p = 0.33). Hospital mortality was 9.5% (46 patients). Twenty-nine (7.8%) in Group A and 17 in Group B (15.2%)(p = 0.019). Actuarial survival was 88.5% ± 0.015 at 1 year, 81.9% ± 0.02 at 5 years, 76.6% ± 0.032 at 10 and 57.3 ± 0.1 at 15 years. Ten-year survival was 77% ± 0.034 in Group A and 77.8% ± 0.045 in Group B (p = 0.2). Multivariate analysis did not reveal associated CABG as a predictor of long term mortality. The scores obtained in the SF-36 test were similar in the two groups and significantly higher than those of the general population matched for country, age and sex (p < 0.001 in all domains).

Associated CABG determines a significant increase of hospital mortality in the elderly undergoing aortic valve replacement. Survivors did not show differences in long-term outcome and quality of life according to the presence of associated CABG.

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.

Poor performances of EuroSCORE and CARE score for prediction of perioperative mortality in octogenarians undergoing aortic valve replacement for aortic stenosis

BACKGROUND AND OBJECTIVE

Although results of cardiac surgery are improving, octogenarians have a higher procedure-related mortality and more complications with increased length of stay in ICU. Consequently, careful evaluation of perioperative risk seems necessary. The aims of our study were to assess and compare the performances of EuroSCORE and CARE score in the prediction of perioperative mortality among octogenarians undergoing aortic valve replacement for aortic stenosis and to compare these predictive performances with those obtained in younger patients.

METHODS

This retrospective study included all consecutive patients undergoing cardiac surgery in our institution between November 2005 and December 2007. For each patient, risk assessment for mortality was performed using logistic EuroSCORE, additive EuroSCORE and CARE score. The main outcome measure was early postoperative mortality. Predictive performances of these scores were assessed by calibration and discrimination using goodness-of-fit test and area under the receiver operating characteristic curve, respectively.

RESULTS

During this 2-year period, we studied 2117 patients, among whom 134/211 octogenarians and 335/1906 nonoctogenarians underwent an aortic valve replacement for aortic stenosis. When considering patients with aortic stenosis, discrimination was poor in octogenarians and the difference from nonoctogenarians was significant for each score (0.58, 0.59 and 0.56 vs. 0.82, 0.81 and 0.77 for additive EuroSCORE, logistic EuroSCORE and CARE score in octogenarians and nonoctogenarians, respectively, P < 0.05). Moreover, in the whole cohort, logistic EuroSCORE significantly overestimated mortality among octogenarians.

CONCLUSION

Predictive performances of these scores are poor in octogenarians undergoing cardiac surgery, especially aortic valve replacement. Risk assessment and therapeutic decisions in octogenarians should not be made with these scoring systems alone.

Quality of life after aortic root surgery: reimplantation technique versus composite replacement

BACKGROUND

Recent studies indicate the safety of the aortic valve reimplantation technique (David operation) in the long-term follow-up. The aim of this study was to compare the results of the David operation with those of the aortic composite replacement procedure, with the focus on quality of life (QoL).

METHODS

Within a 6-year period, 143 patients received either an aortic composite replacement (composite group, n = 67) or the David-I operation (David group, n = 76). The QoL of 108 patients (87% of the living patients) was evaluated postoperatively by the 36-Item Short Form Health Survey. A subgroup analysis of QoL excluded patients with aortic stenosis and type A acute aortic dissection.

RESULTS

Hospital survival rates (89.6% versus 97.4%, p = 0.102), as well as actuarial 1-year survival rate (86.6% versus 91.9%) and 3-year survival rate (81.1% versus 91.9%) proved more successful among the David group. Incidences of serious adverse events during the follow-up period (10.8% versus 28.3%, p = 0.008) were higher for patients of the composite group. The QoL was found to be compromised for patients of the composite group, in relation to all criteria outlined in the 36-Item Short Form Health Survey. Subgroup analysis without patients with dissection and aortic stenosis demonstrated a significantly better postoperative QoL for patients of the David group. Patients belonging to the composite group were more frequently compromised by prosthetic valve noise (p < 0.001).

CONCLUSIONS

This study demonstrates the superiority of the aortic valve reimplantation compared with the aortic composite replacement, regarding both clinical outcome and postoperative QoL.

Quality of life among patients undergoing transcatheter aortic valve implantation

BACKGROUND

Transcatheter aortic valve implantation (TAVI) has been introduced to offer a new treatment option for patients who are not eligible for conventional aortic valve replacement. Especially in this subset of patients, the expected improvement of quality of life (QoL) after valve implantation will be critical for decision-making for TAVI.

METHODS

We performed a prospective analysis of 99 patients (41 male) aged 82 years (range 57-94 years) who underwent TAVI. For assessment of QoL, the Short Form 36 Health Survey Questionnaire was used preoperatively and 3 months after TAVI.

RESULTS

Thirty-day mortality rate was 10.1%. The Short Form 36 Health Survey Questionnaire scores for physical functioning (34.7 +/- 2.8 vs 48.5 +/- 3.4, P < .001), bodily pain (61.7 +/- 3.1 vs 73.2 +/- 2.9, P < .01), general health (47.1 +/- 1.9 vs 54.1 +/- 2.3, P < .01), and vitality (37 +/- 2.8 vs 46.1 +/- 2.7, P < .01) increased significantly 3 months after TAVI compared with preoperative scores. No significant changes were found for role-physical (21.7 +/- 4.1 vs 31.1 +/- 5.1, P < .08), social functioning (74.6 +/- 3.4 vs 74.6 +/- 3.1, P = 1), and mental health (63 +/- 2.9 vs 67.4 +/- 2.2, P = .17) 3 months after TAVI. Only the score for role-emotional (69.3 +/- 5.6 vs 51.7 +/- 6, P = .02) decreased significantly 3 months after TAVI compared with the preoperative score. Corresponding to these results, the physical health summarized score (31.2 +/- 1.2 vs 38.6 +/- 1.6, P < .001) was significantly increased 3 months after TAVI compared with the preoperative score, whereas the mental health summarized score (48.5 +/- 1.8 vs 47.3 +/- 1.7, P = .5) showed no changes.

CONCLUSION

In patients who are not eligible for conventional aortic valve replacement, TAVI leads to a considerable QoL improvement within 3 months after valve implantation.

Critical review of health-related quality of life studies of patients with aortic stenosis

BACKGROUND

While studies of health-related quality of life (HRQOL) are increasing among cardiovascular patients, very few have examined HRQOL in persons with aortic stenosis (AS).

PURPOSE

A critical review of studies (1997-2008) of HRQOL in persons with AS was conducted to summarize findings and identify clinical and research implications.

RESULTS

Twenty-eight studies were identified, all of which were quantitative and evaluated HRQOL after aortic valve replacement (AVR). No studies conducted by nurses or studies measuring HRQOL in persons who did not undergo AVR were found. The literature focused on age and type of valve as variables influencing HRQOL postoperatively. Although results varied, elderly patients often scored similar or better than comparison groups. Health-related quality of life was found to be affected by valve noise and anticoagulation rather than the specific valve type when comparing patients receiving biological versus mechanical valves.

CONCLUSIONS

Selection for surgery should not be based on age alone. Early consideration should be given to symptoms prior to surgery because of evidence that patients with fewer symptoms preoperatively have better HRQOL after AVR. Anticoagulation status should be evaluated as an independent variable of HRQOL in future studies.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Researchers need to augment generic HRQOL measures with disease-specific items that may pertain to life areas affected by AS, such as audible valve click, wound healing, and dyspnea. Future research should be inclusive of AS patients who do not undergo surgery. Nurses in a variety of roles can work independently or within a multidisciplinary team to provide interventions for the promotion of HRQOL for patients across all stages of the AS disease process.

Percutaneous transcatheter aortic valve implantation: Evolution of the technology

Aortic stenosis (AS) is currently the most common valvular abnormality in developed countries. The gold standard treatment of severe symptomatic AS is surgical aortic valve replacement. Mechanical valves were initially the prostheses of choice; with improvement of surgical technique and results, and increased durability of bioprosthetic valves, there has been a trend toward increasing use of bioprostheses. Concurrently, percutaneous technology has advanced exponentially, and the first human percutaneous aortic valve replacement (PAVR) became a reality in 2002. Various groups have now reported their early experiences with PAVR using different technologies. This new treatment modality is evolving very rapidly. There are currently 2 devices being used in clinical trials; several more devices have first-in-man results and others in preclinical development. It appears that PAVR will most likely become a viable option for selected patients in the near future. For these technologies to continue to improve and benefit patients, cross-specialty teamwork is vital. Treatment of severe AS will greatly evolve as these new and emerging technologies improve. Enhancement in device designs and increasing operator experience will make this technology safer and allow its application to a wider patient population.

Health-related quality of life after cardiac surgery

Health-related quality of life (HRQOL) assessments are designed to reflect a patient's perspective of how a disease has affected their overall health status. Patient-centered outcomes are of value both for risk assessment and as an outcome measure. Strategies for analyzing HRQOL data are inconsistent primarily because the data frequently do not meet underlying assumptions of traditional methods for statistical analyses and require a careful analytic approach.

Prospective assessment of quality of life of octogenarians after cardiac surgery: factors predicting long-term outcome

Our objective was to assess the long-term prognosis and quality of life (QoL) of elderly patients after cardiac surgery. The Nottingham Health Profile (NHP) QoL data were recorded from 104 patients who were older than 70 years at the time of primary cardiac surgery in 1993. All living patients were controlled at 15+/-3.2 months and 8.2+/-0.27 years after discharge. The 1-year, 5-year and actual survival rates were 94%, 76%, and 59%, respectively. Risk factors for death were urgency of the operation (relative risk ratio, 2.0; 95% confidence interval, 1.2-3.6), ejection fraction below 50% (2.1; 1.1-3.9), and preoperative renal failure (2.1; 1.0-4.0). Cardiac operated octogenarians took advantage from age and sex matched reference populations at 15 months in the NHP dimension of pain (P=0.001). The QoL decreased gradually during the follow-up similarly in both groups in dimensions describing energy (P=0.001), pain (P=0.003), and mobility (P=0.042). Diabetes, low energy score and high pain score at 15 months, treatment in intensive care unit >3 days, and duration of symptoms >120 days preoperatively were associated with impaired QoL. Survival and QoL were similar for cardiac operated octogenarians and age and sex matched controls at 15 months and 8.2 years after cardiac surgery.

Optimum management of elderly patients with calcified aortic stenosis

Increased life-expectancy has led to a growing elderly population frequently presenting with aortic stenosis. This review focuses on the pathogenesis of calcific aortic stenosis, diagnosis and possible ways to halt the progression to severe symptomatic aortic stenosis, methods of assessing symptoms and severity, and modalities and timing of aortic valve replacement. At present the treatment of aortic stenosis for the majority of patients is surgical, and any patient with symptomatic severe aortic stenosis should be considered for aortic valve replacement. This article also discusses the role of emerging techniques of closed heart valve implantation either transfemoral or transapical, and which patients might be candidates for these new approaches to the treatment of aortic stenosis in the elderly population.

Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis

BACKGROUND

We investigated whether mitral valve repair (MVP) is superior to mitral valve replacement (MVR) in terms of survival and quality of life during the long-term follow-up.

METHODS

One hundred eighty-four consecutive patients underwent MVP or MVR for mitral regurgitation with or without concomitant coronary artery bypass grafting. Clinical data were recorded prospectively, and the data for the Nottingham Health Profile quality-of-life analysis was collected cross-sectionally. Propensity score analysis was used for the study group matching.

RESULTS

The mean follow-up time was 7.3 +/- 1.4 years. After adjustment for baseline characteristics by the propensity score method, there was a statistically significant survival benefit for the patients who underwent MVP (p = 0.02). Risk factors for death were preoperative unstable angina pectoris (relative risk ratio, 4.4; 95% confidence interval, 2.2 to 8.8), age older than 60 years (relative risk ratio, 1.1; 95% confidence interval, 1.0 to 1.1), use of mitral prosthesis (relative risk ratio, 2.7; 95% confidence interval, 1.4 to 5.3), preoperative renal insufficiency (relative risk ratio, 1.0; 95% confidence interval, 1.0 to 1.007), and preoperative cerebrovascular disorder (relative risk ratio, 2.7; 95% confidence interval, 1.0 to 5.3). The quality of life of the MVP and MVR groups did not differ from each other, but the MVP and the MVR patients had lower energy and mobility scores than an age- and sex-matched reference population.

CONCLUSIONS

Survival is longer after MVP than after MVR. The quality of life of MVP and MVR patients does not differ from each other. In terms of most quality-of-life variables, patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population. Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population.

Surgical innovations: impact on the quality of life of the older patient

As surgery has been extended into the elderly population, health-related quality of life (HRQOL) has been appropriately added as a parameter to evaluate surgical success. Surgery remains of significant risk in older patients, and an estimate of the type of outcome, including morbidity, mortality, and HRQOL can aid in that decision. New techniques, such as laparoscopic or minimally invasive surgery show great promise for reduction in perioperative stress and improved HRQOL in younger patients, but have not been extensively used in the older and frail patients for whom the benefits potentially may be greater.

Cardiac surgery in the elderly: indications and management options to optimize outcomes

The elderly have increasingly benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of their lives and of optimal preoperative preparation of patients is emphasized.

Operative and long-term survival of elderly is significantly improved by mitral valve repair

BACKGROUND

We review our 10-year experience of mitral valve (MV) repair in comparison with MV replacement in the elderly for floppy mitral valves/mitral valve prolapse (FMV/MVP). The use of MV repair for this entity has not been fully utilized by surgeons.

METHODS

Two hundred ninety-two consecutive patients aged > or = 70 years receiving mitral surgery for regurgitation due to FMV/MVP were reviewed from our prospective database between January 1, 1992, and December 31, 2002. Patients receiving concomitant coronary artery bypass grafting (CABG) were included. Two hundred eighteen patients underwent repairs and 74 replacements. Postoperative and long-term follow-up data were obtained. Mean follow-up time for survivors was 6.2 +/- 2.5 years for MV repair and 6.8 +/- 2.7 years for MV replacement.

RESULTS

Patients with isolated MV repair showed lower inhospital mortality compared with MV replacement (0.7% vs 13.9%, P = .002) with reduced length of stay (8.7 +/- 7.6 vs 9.6 +/- 5.2 days, P = .049). There was improvement in 5-year mortality favoring repair versus replacement (81% +/- 3% vs 63% +/- 3%, P = .001). With concomitant CABG, there was minimal difference in survival up to 5 years. Freedom from valve replacement was 93.9% +/- 1.3% for MV repair and 98.2% +/- 0.4% for MV repair with CABG at 10 years. Mitral valve repair was an independent protector of long-term mortality within multivariate correlates (hazard ratio 0.43, 95% CI 0.19-0.97, P = .041).

CONCLUSIONS

In elderly patients, MV repair reduced in-hospital mortality and length of stay and increased long-term survival. With concomitant CABG, survival was similar to replacement. The preferred option for elderly patients with FMV/MVP is MV repair, especially in those without coronary artery disease.

Quality of life in advanced heart failure: role of mitral regurgitation

BACKGROUND

Quality of life is increasingly used as an important end point in clinical trials of treatments for heart failure; thus, relationships between traditional clinical variables and quality of life need to be understood. Baseline data from an ongoing multi-institutional study of a surgically implanted cardiac support device (CorCap, Acorn Cardiovascular, Inc, St Paul, MN) positioned around the heart to halt progression of remodeling in patients with cardiomyopathy provide an opportunity to study the relationship between mitral regurgitation (MR) and quality of life in a group of relatively young patients.

OBJECTIVE

The objective of this study was to determine whether the degree of MR correlates with quality of life in patients presenting with significant symptoms of heart failure.

METHODS

Baseline MR was assessed by echocardiography and patients were stratified according to whether there was a clinical indication for mitral valve surgery. The effect of heart failure on quality of life was measured by the Minnesota Living with Heart Failure questionnaire (MLHF). The New York Heart Association class, exercise performance measured by peak oxygen consumption and the 6-minute walk test, and the SF-36 physical function measure were analyzed as potential mediating variables.

RESULTS

Mean MR grade was 2 +/- 1.5 on a 0-to-4 (worst) scale (n = 260) and ejection fraction averaged 27% +/- 9%. Most patients (82%) had New York Heart Association class III symptoms. Peak oxygen consumption averaged 14.7 +/- 4.3 mL/kg per minute and average walking distance was 348 +/- 83 m. Median (quartile range) SF-36 physical function was 35 (20-50) on a 0-to-100 (best) scale. Median MLHF score was 61 (47.5-77) on a 0-to-105 (worst) scale. The degree of MR and having an indication for mitral valve repair were not associated with the patients' quality of life. Controlling for symptoms and functional measures, older age was independently associated with better quality of life.

CONCLUSIONS

The degree of MR was not related to MLHF scores, suggesting that surgery to reduce MR might not have predictable effects on quality of life. Further studies are needed to understand why younger patients reported worse quality of life and how this observation could impact therapy.

Impact of Prosthesis–Patient Size on Functional Recovery After Aortic Valve Replacement

Background— Prosthesis–patient size mismatch results when an implanted prosthetic aortic valve is of insufficient size for a patient’s body surface area. The relation between prosthesis–patient size and functional capacity and adverse postoperative outcome is inconsistent. Our objectives were to examine the impact of valve replacement, continuous prosthesis–patient size, and other factors on functional recovery after aortic valve replacement (AVR) with the Duke Activity Status Index (DASI).

Methods and Results— From June 15, 1995, through May 14, 1998, 1108 patients underwent AVR after completing a DASI survey. Of these, 1014 completed a postoperative DASI survey at an average of 8.3 months postoperatively. Logistic ordinal regression was used to examine the influence of demographic variables, comorbidities, baseline DASI scores, indexed valve orifice area, standardized orifice size, and postoperative morbid events on postoperative DASI. There was overall improvement in postoperative functional recovery reflected by median preoperative and postoperative DASI scores of 29 and 46, P <0.001, respectively. Neither indexed orifice area, P =0.94, nor standardized orifice size, P =0.96, was associated with functional recovery. Female sex, increasing age, elevated serum creatinine, increased central venous pressure, and red blood cell transfusion were factors associated with poor postoperative functional recovery.

Conclusions— A majority of patients report improvement in functional quality of life early after AVR. Similar functional recovery was demonstrated for patients along the full spectrum of valve sizes indexed to body size, even for values considered to represent severe mismatch for patient size. Factors other than prosthesis–patient size influence functional quality of life early after AVR.