Does quality of life improve in octogenarians following cardiac surgery? A systematic review

The association between preoperative multidisciplinary team care and patient outcome in frail patients undergoing cardiac surgery

OBJECTIVE

To evaluate the influence of preoperative multidisciplinary team (MDT) care on perioperative management and outcomes of frail patients undergoing cardiac surgery.

BACKGROUND

Frail patients are at increased risk for complications and poor functional outcome after cardiac surgery. In these patients, preoperative MDT care may improve outcomes.

METHODS

Between 2018 and 2021, 1168 patients aged 70 years or older were scheduled for cardiac surgery, of whom 98 (8.4%) frail patients were referred for MDT care. The MDT discussed surgical risk, prehabilitation, and alternative treatment. Outcomes of MDT patients were compared with 183 frail patients (non-MDT group) from a historical study cohort (2015-2017). Inverse probability of treatment weighting was used to minimize bias from nonrandom allocation of MDT versus non-MDT care. Outcomes were severe postoperative complications, total days in hospital after 120 days, disability, and health-related quality of life after 120 days.

RESULTS

This study included 281 patients (98 MDT and 183 non-MDT patients). Of the MDT patients, 67 (68%) had open surgery, 21 (21%) underwent minimally invasive procedures, and 10 (10%) received conservative treatment. In the non-MDT group, all patients had open surgery. Fourteen (14%) MDT patients experienced a severe complication versus 42 (23%) non-MDT patients (adjusted relative risk, 0.76; 95% CI, 0.51-0.99). Adjusted total days in hospital after 120 days was 8 days (interquartile range, 3-12 days) versus 11 days (interquartile range, 7-16 days) for MDT and non-MDT patients, respectively (P = .01). There was no difference in disability or health-related quality of life.

CONCLUSIONS

Preoperative MDT care for frail patients undergoing cardiac surgery is associated with alterations in surgical management and with a lower risk for severe complications.

Coronary artery bypass grafting in octogenarians: an Australian experience

BACKGROUND

The aims of this study were to describe early and mid-term morbidity and mortality in octogenarian patients undergoing CABG, to determine if outcomes are comparable to younger patients undergoing the same procedure.

METHODS

We conducted a retrospective analysis of the first 901 patients who underwent cardiac surgery at a large newly established tertiary hospital in Western Australia from February 2015 to September 2019. Inclusion criteria involved all patients undergoing coronary artery bypass grafting. Exclusion criteria included patients who underwent concomitant valve or aortic procedure.

RESULTS

From a cohort of 901 patients, 37 octogenarian patients underwent CABG. Octogenarian patients had a higher rate of post-operative transfusion 35.1% versus 21.4% (P = 0.048), a higher rate of post-op acute kidney injury 40.5% versus 17.2% (P < 0.0001), a higher rate of post-operative atrial arrythmia requiring treatment 40.5% versus 22.5% (P = 0.011) and higher rate of return to theatre (13.5% versus 4.7%, P = 0.018), with bleeding/tamponade being the most likely reason (10.8% versus 2.7%). Octogenarian patients had a longer post-operative length of stay (LOS) with a median LOS of 10 versus 7 days (P < 0.0001). There was no increase in hospital readmission rate, in-hospital mortality or 1 year mortality in octogenarian patients. 24-month and 36-month survivals were 95.2% and 89.6% in octogenarians and 95.3% and 91.5% in the younger group.

CONCLUSIONS

Despite an increase in post-operative morbidity and LOS, there was no difference in hospital readmission, in-hospital mortality or 1 year mortality in octogenarian patients who underwent CABG. CABG is safe and remains an important management option for these patients.

Clinical Outcomes after Multivalve Surgery in Octogenarians: Evaluating the Need for a Paradigm Shift

(1) Background: this study addresses the lack of comprehensive research on outcomes in octogenarians undergoing cardiac surgery for multivalvular disease, emphasizing the need for a critical examination of the intervention's overall worth in this aging population. (2) Methods: By analyzing short-term and mid-term data from 101 consecutive octogenarian patients undergoing multivalve surgery, the study identifies predictors for in-hospital and one-year mortality. (3) Results: In-hospital mortality increased fourfold with the occurrence of at least one postoperative complication. Octogenarians undergoing multivalve surgery experienced an in-hospital mortality rate of 13.9% and an overall one-year mortality rate of 43.8%. Postoperative delirium was identified as an independent risk factor, contributing to elevated risks of both in-hospital and one-year mortality. Prolonged surgical procedure time emerged as an independent risk factor associated with increased in-hospital mortality. Continuous veno-venous hemodialysis showed an independent impact on in-hospital mortality. Both re-intubation and the transfusion of packed red blood cells were identified as independent risk factors for one-year mortality. (4) Conclusions: This study urges a critical examination of the justification for multivalve surgeries in high-risk elderly patients, emphasizing a paradigm shift. It advocates for interdisciplinary collaboration and innovative strategies, such as staged hybrid procedures, to improve therapeutic approaches for this challenging patient group to achieve a better therapeutic outcome for these patients.

The frail patient undergoing cardiac surgery: lessons learned and future perspectives

Frailty is a geriatric condition characterized by the reduction of the individual's homeostatic reserves. It determines an increased vulnerability to endogenous and exogenous stressors and can lead to poor outcomes. It is an emerging concept in perioperative medicine, since an increasing number of patients undergoing surgical interventions are older and the traditional models of care seem to be inadequate to satisfy these patients' emerging clinical needs. Nowadays, the progressive technical and clinical improvements allow to offer cardiac operations to an older, sicker and frail population. For these reasons, a multidisciplinary team involving cardiac surgeons, clinical cardiologists, anesthesiologists, and geriatricians, is often needed to assess, select and provide tailored care to these high-risk frail patients to optimize clinical outcomes. There is unanimous agreement that frailty assessment may capture the individual's biological decline and the heterogeneity in risk profile for poor health-related outcomes among people of the same age. However, since commonly used preoperative scores for cardiac surgery fail to capture frailty, a specific preoperative assessment with dedicated tools is warranted to correctly recognize, measure and quantify frailty in these patients. On the contrary, pre-operative and post-operative interventions can reduce the risk of complications and support patient recovery promoting surgical resilience. Minimally invasive cardiac procedures aim to reduce surgical trauma and may be associated with better clinical outcome in this specific sub-group of high-risk patients. Among postoperative adverse events, the occurrence of delirium represents a risk factor for several unfavorable outcomes including mortality and subsequent cognitive decline. Its presence should be carefully recognized, triggering an adequate, evidence based, treatment. There is evidence, from several cross-section and longitudinal studies, that frailty and delirium may frequently overlap, with frailty serving both as a predisposing factor and as an outcome of delirium and delirium being a marker of a latent condition of frailty. In conclusion, frail patients are at increased risk to experience poor outcome after cardiac surgery. A multidisciplinary approach aimed to recognize more vulnerable individuals, optimize pre-operative conditions, reduce surgical invasivity and improve post-operative recovery is required to obtain optimal long-term outcome.

Preoperative frailty and one-year functional recovery in elderly cardiac surgery patients

OBJECTIVE

Frailty increases risk for morbidity and mortality after cardiac surgery. Its influence on functional outcome is largely unknown. We studied the association of frailty with health-related quality of life and disability after cardiac surgery.

METHODS

A prospective 2-center observational cohort of 555 patients aged 70 years or more undergoing cardiac surgery. A comprehensive frailty assessment was performed before surgery based on 11 individual assessments in physical, mental, and social domains. Frailty was defined as at least 1 positive test in each domain. The primary outcome was health-related quality of life over 1 year, and the secondary outcomes were severe in-hospital complications and disability over 1 year. Adverse functional outcome was defined as the composite of a decreased health-related quality of life and disability.

RESULTS

Physical frailty was most common (91%) compared with mental (39%) or social frailty (42%). Adverse functional outcome occurred in 257 patients (46%) and consisted of decreased physical health-related quality of life in 134 (24%), decreased mental health-related quality of life in 141 (25%), and disability in 120 (22%). Frailty was more common in patients with adverse functional outcome (29%) compared with patients without adverse functional outcome (16%, P < .001). Poor mobility, malnutrition, and polypharmacy were associated with a decreased health-related quality of life over time, whereas impaired physical functioning and higher self-rated health were related to increased health-related quality of life. Disability after cardiac surgery was associated with poor mobility, polypharmacy, dependent living, living alone, and lower self-rated mental health before surgery.

CONCLUSIONS

Mobility, nutrition, medication use, physical functioning, and self-rated health before surgery are associated with health-related quality of life in elderly patients 1 year after cardiac surgery.

Preoperative physical frailty assessment among octogenarians undergoing cardiac surgery: Upgrading the "eyeball" test

OBJECTIVES

There are many well-described, but as yet unproven, physical ability tools to assess frailty. The objective of this study was to evaluate the effectiveness of 4 preoperative physical tests in predicting mortality, morbidity, and functional outcomes among octogenarians undergoing cardiac surgery.

METHODS

Between 2016 and 2019, 200 patients aged 80 years or more undergoing elective cardiac surgery were prospectively recruited. Four physical tests were performed preoperatively: 5-m walk time, timed up-and-go, 5 time sit-to-stand, and handgrip strength tests. The primary end point was a composite of in-hospital mortality, neurologic, and pulmonary complications. Multivariate analysis was performed.

RESULTS

In-hospital mortality was 1.5%. Slow performance on the 5-m walk test (time ≥6.4 seconds) was the only independent predictor of the composite end point among the tests evaluated (odds ratio, 2.70; 95% confidence interval, 1.34-5.45; P = .006). At follow-up, patients with a slow 5-m walk test had a significantly lower midterm survival compared with patients with a normal test result (1-year survival 91.5% vs 98.7%, log-rank P = .03). Mean Physical and Mental Component Scores of the 12-item short form survey were 47.2 ± 8.3 and 53.6 ± 5.9, respectively, which are comparable to those of a general population aged more than 75 years.

CONCLUSIONS

The 5-m walk time test is an independent predictor of a composite of in-hospital mortality and major morbidity, as well as midterm survival. This test could be used as a simple adjunctive preoperative tool for octogenarians undergoing cardiac surgery.

Clinical Results and Quality of Life after Nonelective Cardiac Surgery in Octogenarians

Background We analyzed the short-term and mid-term outcomes as well as the health-related quality of life (HRQOL) of octogenarians undergoing elective and urgent cardiac surgery.

Patients and Methods We retrospectively identified 688 consecutive octogenarians who underwent cardiac surgery at our center between January 2012 and December 2019. A propensity score matching was performed which resulted in the formation of 80 matched pairs. The patients were interviewed and the Short Form-36 survey was used to assess the HRQOL of survivors. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model.

Results The median age of the matched cohort was 82 years (p = 0.937), among whom, 38.8% of patients were female (p = 0.196). The median EuroSCORE II of the matched cohort was 19.4% (10.1–39.1%). The duration of postoperative mechanical ventilation was found to be independently associated with in-hospital mortality (odds ratio: 1.01 [95% confidence interval: 1.0–1.02], p = 0.038). The survival rates at 1, 2, and 5 years was 75.0, 72.0, and 46.0%, respectively. There was no difference in the total survival between the groups (p = 0.080). The physical health summary score was 41 (30–51) for the elective patients and 42 (35–49) for the nonelective octogenarians (p = 0.581). The median mental health summary scores were 56 (48–60) and 58 (52–60), respectively (p = 0.351).

Conclusion Cardiac surgery can be performed in octogenarians with good results and survivors enjoy a good quality of life; however, the indication for surgery or especially for escalation of therapy should always be made prudently, reserved, and in consideration of patient expectations.

Health-Related Quality of Life following Surgery for Native and Prosthetic Valve Infective Endocarditis

Objectives: The objective of this study was to compare the long-term outcomes and health-related quality of life (HRQOL) of patients following surgery for infective native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE). Methods: We retrospectively identified 633 consecutive patients who had undergone surgery for infective endocarditis at our center between January 2005 and October 2018. The patients were interviewed, and the SF-36 survey was used to assess the HRQOL of survivors. Propensity score matching (2:1) was performed with data from a German reference population. Multivariable analysis incorporated binary logistic regression using a forward stepwise (conditional) model. Results: The median age of the cohort was 67 (55–74) years, and 75.6% were male. Operative mortality was 13.7% in the NVE group and 21.6% in the PVE group (p = 0.010). The overall survival at 1 year was 88.0% and was comparable between the groups. The physical health summary scores were 49 (40–55) for the NVE patients and 45 (37–52) for the PVE patients (p = 0.043). The median mental health summary scores were 52 (35–57) and 49 (41–56), respectively (p = 0.961). On comparison of the HRQOL to the reference population, the physical health summary scores were comparable. However, significant differences were observed with regard to the mental health summary scores (p = 0.005). Conclusions: Our study shows that there are significant differences in the various domains of HRQOL, not only between NVE and PVE patients, but also in comparison to healthy individuals. In addition to preoperative health status, it is important to consider the patient’s expectations regarding surgery. Further prospective studies are required.

Quality of life and frailty outcomes following surgical and transcatheter aortic valve replacement

Background

Our objective was to report on the prospective outcomes in the areas of depression, quality of life, angina, and frailty in SAVR and TAVR patients with aortic stenosis undergoing aortic valve intervention.

Methods

We recruited 300 patients across 3 groups (TAVR, SAVR, and CABG) over 12 months. Depression, quality of life, frailty, and angina were assessed followed by propensity score matching.

Results

Using logistical regression when all patient factors considered for all patients who had SAVR and TAVR, the only preoperative factors that impacted on 1 year mortality was hypertension and STS score. Quality of life improvements within each group over 12 months was significant (p value = 0.0001). Depression at 12 months between groups (p value = 0.0395) and within each group was significant (p value = 0.0073 for SAVR and 0.0001 for TAVR). Angina was most frequent in TAVR at 12 months in the QL (p = 0.0001), PL (p = 0.0007), and improvement was significant in the QL (SAVR p = 0.0010, TAVR p = 0.0001) and PL (SAVR p = 0.0002), TAVR p = 0.0007) domains in both groups. Frailty at 12 months improved in both groups, but was greatest in TAVR (p value = 0.00126).

Conclusions

This 12 months follow up of cardiac surgical patients has revealed significant improvement in PROMs and frailty in all groups by 3 months postoperative regardless of surgical or transcatheter approach. Outcome measures of quality of life and frailty could be utilized as a measure of outcome more regularly in patients undergoing aortic valve surgery regardless of approach.

Depressive symptoms, perceived control and quality of life among patients undergoing coronary artery bypass graft: a prospective cohort study

BACKGROUND

Coronary artery bypass graft surgery (CABG) is an intervention directed toward improving the Quality of Life (QoL) for patients with coronary artery disease. Depression can affect QoL negatively among this population. Perceived control (PC) decreased the effect of anxiety on QoL, however, this effect has not been well-studies regarding depression. Therefore, the purpose of this study was to check the effect of depression on QoL among CABG patients and to determine if preoperative PC moderates this effect.

METHODS

This was a prospective observational cohort study conducted on a consecutive sample of 200 patients from three hospitals in Amman, Jordan. Depression Anxiety and Stress Scale, Short-Form Health Survey-36, and Arabic version of the Control Attitude Scale-Revised were used to measure depressive symptoms, QoL and PC respectively. Data were analyzed using t test and step wise multiple regression followed by simple slope analysis.

RESULTS

Postoperative Physical Component Summary (PCS) was better than preoperative PCS (mean ± SD: 38.2 ± 9.4 vs. 36.6 ± 9.5, P < 0.001). Postoperative Mental Component Summary (MCS) was better than preoperative MCS (mean ± SD: 44.3 ± 11.5 vs. 41.4 ± 11.4, P < 0.001). Preoperative depression was higher than postoperative depression; (mean ± SD: 12.8 ± 6.8 vs.11.1 ± 6.7, P < 0.01). Simple slope analysis was significant (simple slope = 0.41, t = 6.1, P < 0.001), indicating the moderating effect of PC.

CONCLUSION

Patients undergoing CABG surgery had poor QoL and high levels of depression. Perceived control moderated this relationship and improve QoL. Assessing depression levels and implantation of interventions to enhance perceived control levels prior to operation might improve QoL.

Post-operative Quality of Life after Full-sternotomy and Mini-sternotomy Aortic Valve Replacement

BACKGROUND

Few longitudinal data exist comparing quality of life (QoL) after full sternotomy aortic valve replacement (fsAVR) vs mini-sternotomy AVR (msAVR) METHODS: 1844 consecutive AVR prospectively enrolled in a European multicentre Registry were dichotomized according to surgical access. A non-parsimonious propensity-score matching selected 187 pairs of fsAVR or msAVR with comparable baseline characteristics. Hospital outcome was compared in the two groups. QoL was assessed with Short Form-36, further detailed in its Physical Component Score (PCS) and Mental Component Score (MCS). QoL was investigated at hospital admission, discharge, 1 month, 6 months and 1 year thereafter.

RESULTS

There were 1654 fsAVR and 190 msAVR in the entire population. fsAVR showed a worse preoperative risk-profile, a longer ICU length of stay (59.7 hours vs 38.8, p=0.002), and a higher life-threatening/disabling bleeding (4.1% vs. 0%; p=0.011); msAVR reported a higher early reintervention for failed index intervention (2.1% vs. 0.5%, p=0.001). QoL showed better PCS and MCS at 1 month after fsAVR, but no temporal-trend differences (PCS group-time p=0.202; MCS group-time p=0.141). Propensity-matched pairs showed comparable baseline characteristics and hospital outcome (p=NS for all endpoints), and comparable improvements of PCS and MCS over time, but no between-group differences over time (PCS group-time p=0.834; MCS group-time p=0.737).

CONCLUSIONS

Patients with similar baseline profiles report comparable hospital outcome and comparable improvement of physical and mental health, up to 1 year after surgery, with both fsAVR and msAVR. As for QoL, mini-sternotomy does not seem to offer any advantage compared to the traditional approach.

Does postoperative cognitive decline after coronary bypass affect quality of life?

OBJECTIVE

This study aimed to explore the influence of coronary artery bypass grafting (CABG) on both postoperative cognitive dysfunction and quality of life (QoL) and the association between the two patient-related outcomes.

METHODS

In a prospective, observational cohort study, patients with elective, isolated CABG were included. Cognitive function was assessed using the Cogstate computerised cognitive test battery preoperatively, 3 days and 6 months after surgery. QoL was measured preoperatively and at 6 months using the RAND-36 questionnaire including the Physical Component Score (PCS) and the Mental Component Score (MCS). Regression analysis, with adjustment for confounders, was used to evaluate the association between postoperative cognitive dysfunction and QoL.

RESULTS

A total of 142 patients were included in the study. Evidence of persistent cognitive dysfunction was observed in 33% of patients after 6 months. At 6 months, the PCS had improved in 59% and decreased in 21% of patients, and the MCS increased in 49% and decreased in 29%. Postoperative cognitive changes were not associated with QoL scores.

CONCLUSIONS

Postoperative cognitive dysfunction and decreased QoL are common 6 months after surgery, although cognitive function and QoL were found to have improved in many patients at 6 months of follow-up. Impaired cognitive function is not associated with impaired QoL at 6 months.

TRIAL REGISTRATION NUMBER

NCT03774342.

Preoperative functional status is associated with discharge to nonhome in geriatric individuals

INTRODUCTION

Discharging older individuals to rehabilitation facilities is associated with adverse outcomes, including readmission or increased mortality rate. As preoperative functional status is an important factor impacting patient outcome, we hypothesized that this would be associated with patient disposition to nonhome locations.

MATERIALS AND METHODS

A retrospective analysis was performed using data from the 2013-2018 American College of Surgeons National Surgical Quality Improvement Program, including targeted variables from the Geriatric Pilot Project. Patients aged 65 and older in 33 institutions across the nation were included (n = 44,219). Preoperative functional status was categorized as independent, partially dependent, and dependent. The primary outcome was home versus nonhome disposition. Nonhome was defined as rehabilitation facility and nursing home. Descriptive analyses were performed. Variables associated with postoperative discharge to nonhome were identified using logistic regression.

RESULTS

The largest percentage of operations was orthopedics (40.8%), followed by general surgery (29.2%) and vascular operations (10.0%). The majority of the patients were independent before operations (93.1% independent, 6% partially dependent, and 0.9% totally dependent). In regression analyses, patients who were partially dependent preoperatively had five times higher odds of discharging to nonhome, compared to patients who were independent (odds ratio [OR] 5.04, p < 0.01). Similarly, patients who were totally dependent had 3.2 higher odds of discharging to nonhome than patients who were independent (OR 3.22, p < 0.01).

CONCLUSION

Better preoperative functional status is associated with patient discharge to home in older adults. Preoperative interventions aimed at improving functional status, such as prehabilitation, may be beneficial in improving patient outcomes.

Surgical Aortic Valve Replacement in the Elderly: It Is Worth It!

To evaluate survival and quality of life of octogenarians after surgical aortic valve replacement (SAVR), up to 10 year of follow-up. Retrospective observational study on octogenarians operated for an isolated or combined SAVR in 2 centers between 2005 and 2011. Preoperative data were collected for each patient and updated regularly with last follow-up on July 2018. Early postoperative course was assessed for all patients. The primary outcome was late survival after discharge. Health-related quality of life was evaluated in all surviving patients using the Short-Form 12 questionnaire. Nine hundred and nine patients were included. The median age was 82 ± 2.6 years, with 400/909 females (44%). Isolated AVR was performed in 452/909 patients (49.7%). Early in-hospital mortality occurred in 71/909 patients (7.8%). Mean follow-up was 5.9 ± 3.4 years. Survival at 2, 5, and 10 years in the overall cohort was 89%, 70%, and 28%, respectively, without significant difference between isolated or combined AVR. Survival was significantly higher in patients with a Euroscore <8% (P< 0.0001). Multivariate analysis found that older age at surgery, diabetes, history of myocardial infarction, atrial fibrillation and chronic renal failure were predictors of long-term mortality. Finally, the SF-12 physical score was 40.7 ± 10.4 and mental and emotional score was 52.7 ± 8.6 at last follow-up, which falls within the expected range for the general population (50 ± 10) with comparable age. SAVR remains an effective treatment for aortic valve disease in octogenarians, not only increasing life expectancy but also conferring a long-standing quality of life with excellent valve durability.

Determinants of non-recovery in physical health-related quality of life one year after cardiac surgery: a prospective single Centre observational study

BACKGROUND

Recent studies show that substantial percentage of patients experienced worsening of health related quality of life (HRQoL) 1 year after cardiac surgery. The aim of this study is to identify risk factors that interfere with improvement of HRQoL.

METHODS

From December 2015 till July 2017 a prospective single centre observational study was carried out in 1920 patients participated who underwent non-salvage cardiac surgery. All patients were requested to complete a Short Form 36 (SF-36) questionnaire before and 1 year after surgery. Primary aim of the study was to identify risk factors for non-recovery in the physical domain of the SF-36 in all cardiac surgery patients. Secondary aim was to identify identical risk factors in patients with isolated coronary artery bypass grafting.

RESULTS

After cardiac surgery, the questionnaires for physical and mental health were completed by respectively 803 and 807 patients. Median age was 69[62-75] years, and 77% was male. In comparison to the preoperative status, 176 patients (21.9%) did not display an improvement in the SF-36 physical domain score 1 year after cardiac surgery. In a multivariate analysis independent risk factors for non-recovery in the SF-36 physical domain were baseline SF36 physical domain score (OR 0.954[0.942-0.965], P < 0.001), diabetes (OR 0.437 [0.265-0.720], P 0.001), female sex (OR 0.492 [0.307-0.789], P 0.003), post-operative infection (OR 0.240 [0.109-0.525], P < 0.001) and PCI within 1 year (OR 0.113 [0.036-0.349], P < 0.001) For isolated CABG, 23.2% of patients did not display an improvement in the physical domain score and risk factors appeared to be identical.

CONCLUSIONS

Twenty two percent of all cardiac surgery patients did not show an improvement in the physical domain score of the HRQoL between the preoperative period and 1 year after surgery. Independent risk factors for non-recovery after cardiac surgery were baseline SF-36 physical domain score, diabetes, female sex, any postoperative infection and the need for PCI in the first year. Further research is needed to tailor the patient selection procedure prior to surgery and potentially modify risk factors in the perioperative process.

TRIAL REGISTRATION

Due to type of study not applicable. https://www.ccmo.nl/metcs/erkende-metcs/regionale-toetsingscommissie-patientgebonden-onderzoek .

Effect of Cardiac Surgery on Health-Related Quality of Life in Patients Aged 75 Years or Older: A Prospective Study

BACKGROUND

Health-related quality of life (HRQoL) of patients, aged 75 years or older, was measured before and at 12 weeks after cardiac surgery using a generic tool (SF12 version 2).

METHODS

This was a single centre, prospective study of patients aged 75 years or older who had any type of cardiac surgery. The instrument was self-administered preoperatively and by interviewer administered via telephone at 12 weeks.

RESULTS

Sixty-six (66) of the 81 participants approached were eligible and agreed to participate. Mean age was 79.2 years, 17 participants were female (25.8%), 56 participants were New Zealand European (84.8%) and the mean Euroscore II score was 4.0. Sixty (60) participants (90.9%) provided data at follow-up. All mean HRQoL domain scores significantly improved by 12 weeks after surgery. The pattern of gain was similar for ages 75-79 and 80 years and older. The changes in the physical and mental component summary (PCS, MCS) scores were statistically significant and the mean scores were proximate to or better than age group norms at 12 weeks. The number of patients with a PCS score at or above age group norms improved from 16.4% to 56.6% while the number of patients whose MCS scores were at or above age group norms improved from 55.7% to 81.6%. Health utility values also significantly improved.

CONCLUSIONS

Cardiac surgery in older patients is associated with significantly improved physical and mental health-related quality of life at 12 weeks after procedure.

Anxiety and health-related quality of life after cardiac surgery

Introduction

The aim of this study was to investigate the effect of elective cardiac surgery on health-related quality of life (HRQoL).

Material and methods

One hundred and eight (35 women and 73 men, mean age 62.3 ±12.7 years) patients undergoing open heart surgery were enrolled in the study. Physical and mental domains of quality of life were measured using the 36-item Medical Outcomes Short-Form Health Survey (SF-36) self-administered questionnaire, and anxiety symptoms were assessed using the Spielberger State-Trait Anxiety Inventory (STAI). At baseline 108 patients filled out the SF-36 and STAI, and 102 patients at 6-month follow-up.

Results

It was found that there was significant improvement in three out of eight health domains: physical functioning (p < 0.02), role physical (p < 0.01), and social functioning (p < 0.04), at 6-month follow-up. The two STAI sub-scores: the State Anxiety Inventory and the Trait Anxiety Inventory were found to be high (≥ 40) both preoperatively and 6 months postoperatively. Postoperatively there was not any statistically significant decrease in the levels of anxiety.

Conclusions

This study suggests that the assessment of psychosocial factors, particularly the ongoing assessment of anxiety, could help in risk stratification and prediction of functional status and HRQoL in patients after cardiovascular surgery. Furthermore, the assessment of preoperative well-being should be integrated in routine care in order to identify and support patients with higher levels of anxiety.

Assessment of the Quality of Life in Patients before and after Coronary Artery Bypass Grafting (CABG): A Prospective Study

The aim of this study was to examine the quality of life and to report on the utility and QALY measures in patients before and after coronary artery bypass grafting (CABG); to investigate whether the SF-12 is comparable with the SF-36 for measuring health-related quality of life of patients with CABG; and to determine the impact of individual predictors on poor quality of life assessment after rehabilitation. This prospective study was conducted between January 2017 and December 2018 at the University Hospital Center Osijek, at three time points: pre-operation, 1 month after surgery, and after rehabilitation. The study was conducted with the SF-36 and SF-12 health questionnaires on 47 participants. After rehabilitation, there was a significant improvement in all domains of quality of life. The highest score was given to the change in pain (BP); mean scores were 63.8 (95% CI 56.9 to 70.6) (p = 0.001). The lowest grade (the lowest quality) after rehabilitation was in the domain of limitations due to physical difficulties (RP); arithmetic mean was 48.5 (95% CI 41 to 55.9) (p < 0.001). Quality-adjusted life-year was 0.41 (95% CI 0.38–0.44) after the CABG. The results of this study show that patients with coronary heart disease have poor quality of life before surgery. One month after the surgery, the quality of life improved, but was still inadequate. One year after surgery, satisfactory results were obtained in almost all subscales. The SF-36, SF-12, and its components, can be used effectively in patients with CABG. Age, gender, lifestyle, and risk factors in our sample of participants are not predictors of poor quality of life assessment after rehabilitation.

An Evidence-Based Perspective on Movement and Activity Following Median Sternotomy

Cardiac surgery via median sternotomy is performed in over 1 million patients per year worldwide. Despite evidence, sternal precautions in the form of restricted arm and trunk activity are routinely prescribed to patients following surgery to prevent sternal complications. Sternal precautions may exacerbate loss of independence and prevent patients from returning home directly after hospital discharge. In addition, immobility and deconditioning associated with restricting physical activity potentially contribute to the negative sequelae of median sternotomy on patient symptoms, physical and psychosocial function, and quality of life. Interpreting the clinical impact of sternal precautions is challenging due to inconsistent definitions and applications globally. Following median sternotomy, typical guidelines involve limiting arm movement during loaded lifting, pushing, and pulling for 6 to 8 weeks. This perspective paper proposes that there is robust evidence to support early implementation of upper body activity and exercise in patients recovering from median sternotomy while minimizing risk of complications. A clinical paradigm shift is encouraged, one that encourages a greater amount of controlled upper body activity, albeit modified in some situations, and less restrictive sternal precautions. Early screening for sternal complication risk factors and instability followed by individualized progressive functional activity and upper body therapeutic exercise is likely to promote optimal and timely patient recovery. Substantial research documenting current clinical practice of sternal precautions, early physical therapy, and cardiac rehabilitation provides support and the context for understanding why a less restrictive and more active plan of care is warranted and recommended for patients following a median sternotomy.

The impact of surgical aortic valve replacement on quality of life-a multicenter study

OBJECTIVES

To explore the effect of surgical aortic valve replacement on quality of life and the variance with age, particularly in patients at risk of deterioration.

METHODS

In an observational, multicenter, cohort study of routinely collected health data, patients undergoing and electively operated between January 2011 and January 2015 with pre- and postoperative quality of life data were included. Patients were classified into 3 age groups: <65, 65-79, and ≥80 years. Quality of life was measured at baseline and at 1-year follow-up using the Short-Form Health Survey-12 or SF-36. We defined a >5-point difference as a minimal clinically important difference. Multivariable linear regression analysis, with adjustment for confounders, was used to evaluate the association between age and quality of life.

RESULTS

In 899 patients, mean physical health increased from 55 to 66 and mental health from 60 to 66. A minimal clinically important decreased physical health was observed in 12% of patients aged <65 years, 16% of patients aged 65-79 years, and 22% of patients aged ≥80 years (P = .023). A decreased mental health was observed in 15% of patients aged <65 years, 22% of patients aged 65-79 years, and 24% aged ≥80 years (P = .030). Older age and a greater physical and mental score at baseline were associated with a decreased physical and mental quality of life (P < .001).

CONCLUSIONS

Patients surviving surgical aortic valve replacement on average improve in physical and mental quality of life; nonetheless, with increasing age patients are at higher risk of experiencing a deterioration.

Quality of life 10 years after cardiac surgery in adults: a long-term follow-up study

Background

Quality of life (QoL) is a multifactorial concept that assesses physical and mental health. We prospectively studied the quality of life of patients undergoing coronary artery bypass graft (CABG) surgery using the Short-Form 36-item questionnaire (SF-36) up to 10 years after surgery.

Methods

Between January 2000 and December 2002, all patients undergoing elective isolated CABG in the cardiac & thoracic surgery department of a large university hospital in Eastern France underwent initial QoL evaluation with the SF-36. The same questionnaire was mailed to every patient annually (± 2 weeks around the date of surgery) up to 10 years after their operation. We recorded socio-demographic and clinical variables at inclusion. Predictors of impaired QoL at 10 years were identified by logistic regression.

Results

A total of 272 patients (213 men, 59 women) were enrolled; mean age at inclusion was 65 ± 10 years. At 10 years post-surgery, 81 patients had died (29.7%). The physical component summary (PCS) score was significantly higher at 5 years after surgery than at baseline (p < 0.01), and significantly lower at 10 years than at 5 years (p < 0.01), although there remained a significant difference between 10-year PCS and baseline score (p = 0.004). The mental component summary (MCS) score was significantly higher at 5 years than at the time of surgery (p < 0.001), and remained significantly higher compared to baseline at 10 years after surgery (p = 0.010). By multivariate analysis, diabetes and dypsnea were both associated with worse PCS at 10 years, while lower age was associated with better 10-year PCS. Only diabetes was associated with impaired MCS at 10 years.

Conclusions

Cardiac surgery appears to durably and positively affect both physical and mental components of quality of life.

Electronic supplementary material

The online version of this article (10.1186/s12955-019-1160-7) contains supplementary material, which is available to authorized users.

Changing clinical profiles and in-hospital outcomes of octogenarians undergoing cardiac surgery over 18 years: a single-centre experience†

OBJECTIVES

With an ageing population, increasing numbers of octogenarians are undergoing high-risk cardiac surgery. We examine the changing characteristics and in-hospital outcomes for octogenarians over an 18-year period.

METHODS

Clinical data from our prospective database for all octogenarians who had cardiac surgery from March 1999 through May 2016 were reviewed. We examined trends, risk profiles and in-hospital outcomes over 3 eras, namely early (1999-2004), middle (2005-2010) and late (2011-2016). A multivariable analysis was performed to identify independent predictors for adverse outcomes.

RESULTS

There were 1022 patients aged 80-94 years in our study cohort. The octogenarian population increased progressively from early to late eras (4.5%, n = 255 vs 7.1%, n = 321 vs 9.3%, n = 446), as the average logistic EuroSCORE predicted mortality (9% vs 9.7% vs 10.1%, P < 0.01). On the contrary, observed mortality declined substantially (9.4% vs 7.8% vs 4.7%, P = 0.04) over this period. While cardiac morbidity and respiratory comorbidities were more prevalent in the late era, chronic renal failure was more frequent in the early era. Over time, more procedures were performed electively (P = 0.05). Common operations across all eras were coronary artery bypass grafting (CABG), aortic valve replacement and CABG + aortic valve replacement. Emergency operation [odds ratio (OR) 4.96, 95% confidence interval (CI) 1.51-16.35; P < 0.01], poor ejection fraction (OR 3.38, 95% CI 1.80-6.32; P < 0.01) and bypass time (OR 1.01, 95% CI 1.00-1.02; P < 0.01) were predictors of in-hospital mortality. The late era of surgery (OR 0.41, 95% CI 0.23-0.73; P < 0.01) was associated with reduced mortality risk.

CONCLUSIONS

The operative outcome in this growing surgical population is steadily improving despite the increasing prevalence of comorbidities, and surgery should be performed electively as much as possible.

Predictors of Health-Related Quality of Life for Mental Health Status in Patients After Carotid Endarterectomy

OBJECTIVE

To evaluate the health-related quality of life (HRQoL) in patients with carotid stenosis and identify the predictive factors that affect the mental health status in patients after carotid endarterectomy (CEA).

METHODS

A retrospective study was conducted of all patients presenting with carotid stenosis treated with CEA. Clinical data and demographics were collected for logistic regression analysis. The Short-Form General Health Survey Questionnaire (SF-36) and minimum clinically important difference were used to evaluate the mental health status of patients after CEA.

RESULTS

Between January 2015 and September 2017, a total of 224 patients were enrolled in this study. At baseline, mean SF-36 scores for physical component summary (PCS) (60.1 ± 26.3) and mental component summary (MCS) (59.9 ± 23.1) were significantly lower in patients with carotid disease than the urban population (P < 0.001). After CEA, the SF-36 scores for PCS (62.5 ± 21.7) and MCS (68.4 ± 18.7) were increased. However, only the improvement of MCS achieved minimum clinically important difference. After multiple logistic regression analysis, contralateral stenosis ≥50% (odds ratio [OR] 0.266, 95% confidence interval [CI] 0.141-0.517) and hoarseness (OR 0.160, 95% CI 0.040-0.644) had negative effects on MCS. Dizziness improvement had positive effects on MCS (OR 2.882, 95% CI 1.569-5.298).

CONCLUSIONS

Contralateral stenosis, dizziness improvement, and hoarseness may be the predictive factors that affect the mental health status in patients after CEA.

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.

Cardiac rehabilitation for patients having cardiac surgery: a systematic review

INTRODUCTION

Cardiac rehabilitation (CR) is recommended for all cardiac patients including patients after cardiac surgery. Since the effect of CR after cardiac surgery has not been well established yet, we conducted a systematic review on the effects of CR for patients after cardiac surgery compared to treatment as usual.

EVIDENCE ACQUISITION

A systematic review of randomized clinical trials (RCTs), quasi-randomized and prospective observational studies in The Cochrane Library, PubMed/MEDLINE and EMBASE was undertaken until October 18th, 2017. Adults after any kind of cardiac surgery were included. Primary outcome was all-cause mortality, other outcomes were serious adverse events, health-related quality of life, work participation, functioning and costs/cost-effectiveness. Risk of bias was evaluated, and the quality of evidence was assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria.

EVIDENCE SYNTHESIS

Eighteen RCTs and 15 observational studies were included. Low risk of bias was only observed in one observational study. Meta-analysis of RCTs suggested no significant difference of CR compared to control on mortality (random-effects relative risk (RR) 0.93 (95% CI: 0.40-1.81), while observational studies suggested statistically significant beneficial effect associated with CR (random-effects RR=0.49, 95% CI: 0.35 - 0.68). CR did not significantly affect any of the other outcomes. Due to the limited data TSA could not be performed.

CONCLUSIONS

The body of evidence does not allow us to reach any reliable conclusions about the effectiveness of CR following cardiac surgery. Future trials need to be conducted with low risks of bias and clearly defined outcomes.

Systematic review of preoperative physical activity and its impact on postcardiac surgical outcomes

OBJECTIVES

The objective of this systematic review was to study the impact of preoperative physical activity levels on adult cardiac surgical patients' postoperative: (1) major adverse cardiac and cerebrovascular events (MACCEs), (2) adverse events within 30 days, (3) hospital length of stay (HLOS), (4) intensive care unit length of stay (ICU LOS), (5) activities of daily living (ADLs), (6) quality of life, (7) cardiac rehabilitation attendance and (8) physical activity behaviour.

METHODS

A systematic search of MEDLINE, Embase, AgeLine and Cochrane library for cohort studies was conducted.

RESULTS

Eleven studies (n=5733 patients) met the inclusion criteria. Only self-reported physical activity tools were used. Few studies used multivariate analyses to compare active versus inactive patients prior to surgery. When comparing patients who were active versus inactive preoperatively, there were mixed findings for MACCE, 30 day adverse events, HLOS and ICU LOS. Of the studies that adjusted for confounding variables, five studies found a protective, independent association between physical activity and MACCE (n=1), 30-day postoperative events (n=2), HLOS (n=1) and ICU LOS (n=1), but two studies found no protective association for 30-day postoperative events (n=1) and postoperative ADLs (n=1). No studies investigated if activity status before surgery impacted quality of life or cardiac rehabilitation attendance postoperatively. Three studies found that active patients prior to surgery were more likely to be inactive postoperatively.

CONCLUSION

Due to the mixed findings, the literature does not presently support that self-reported preoperative physical activity behaviour is associated with postoperative cardiac surgical outcomes. Future studies should objectively measure physical activity, clearly define outcomes and adjust for clinically relevant variables.

REGISTRATION

Trial registration number NCT02219815. PROSPERO number CRD42015023606.

The impact of frailty on functional survival in patients 1 year after cardiac surgery

OBJECTIVE

This study determined whether frailty provides incremental value to the European System for Cardiac Operative Risk Evaluation II in identifying patients at risk of poor 1-year functional survival.

METHODS

This prospective study in patients undergoing cardiac surgery defined frailty using 3 common definitions: (1) the Modified Fried Criteria; (2) the Short Physical Performance Battery; and (3) the Clinical Frailty Scale. The primary outcome was functional survival, defined as being alive at 1 year postsurgery with a health-related quality of life score greater than 60 on the EuroQol-Visual Analogue Scale.

RESULTS

Of the 188 participants, 49.5%, 52.6%, and 31.9% were deemed frail according to the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale, respectively. The median age of our cohort was 71.0 years (29.3% female). The probability of functional survival at 1 year for the entire cohort was 73.9%. After adjusting for the European System for Cardiac Operative Risk Evaluation II, patients deemed frail under the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale had an increased odds ratio for poor functional survival of 3.44, 3.47, and 2.08, respectively. When compared with the European System for Cardiac Operative Risk Evaluation II alone, the Modified Fried Criteria, Short Physical Performance Battery, and Clinical Frailty Scale showed an absolute improvement in the discrimination slope of 6.7%, 6.5%, and 2.4% with a category-free classification improvement of 59.6%, 59.2%, and 35.1%, respectively.

CONCLUSIONS

Preoperative frailty was associated with a 2- to 3.5-fold higher risk of poor functional survival 1 year after cardiac surgery. The addition of frailty to the European System for Cardiac Operative Risk Evaluation II provides incremental value in identifying patients at risk of poor functional survival 1 year postsurgery, regardless of frailty definition.

Health-Related Quality of Life after Coronary Revascularization: A systematic review with meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to summarize evidence and determine the impact of coronary revascularization (CR) on cardiac patients' Health-Related Quality of Life (HRQoL), highlighting factors that may affect this outcome in patients.

METHODS

A systematic search of Medline (Pubmed), EMBASE, Cochrane Library, Sciverse (Science Direct and Scopus) and PsycInfo was conducted to identify studies published from January 2000 to December 2012. Data were analyzed using MIX 2.0 Pro and SPSS 20.

RESULTS

Thirty-four longitudinal studies met the inclusion criteria; these studies included 15,992 patients, of whom 8,027 had undergone PCI, 6,348 had undergone CABG and 1,617 had received medication treatment. Moderate long-term effect sizes were revealed for both CR procedures. Both percutaneous coronary interventions (PCI) and coronary artery bypass graft surgery (CABG) had significantly greater effects on HRQoL than did medication; however, the CR procedures did not differ significantly from each other. Moderators included the type of instrument used to assess HRQoL and the study quality. Benefits related to physical functioning were greater than those related to psychosocial functioning in patients treated with CABG.

CONCLUSIONS

Empirical research highlights the positive effect of CR on patient HRQoL. Researchers should carefully select the instrument they use to measure HRQoL, as this may affect the results and thus conclusions. More RCTs and between-group studies employing pre-post designs should be conducted before clear conclusions can be drawn.

Hospital mortality of patients aged 80 and older after surgical repair for type A acute aortic dissection in Japan

To evaluate whether patients aged 80 and older have higher risk of hospital mortality after repair of type A acute aortic dissection (TAAAD).Emergency surgery for TAAAD in patients aged 80 and older remains a controversial issue because of its high surgical risk.Data from patients who underwent surgical repair of TAAAD between April 2011 and March 2013 were retrospectively extracted from the Japanese Diagnosis Procedure Combination database. The effect of age on hospital mortality was evaluated using multivariate logistic regression analysis.A total of 5175 patients were enrolled. The mean age of patients was 67.1 ± 13.0 years, and the male:female ratio was 51:49. Patients aged 80 and older more frequently received tracheostomy than their younger counterparts (9.5% vs 5.4%, P <0.001). Intensive care unit and hospital stays were significantly longer in the elderly cohort versus the younger cohort (7.6 vs 6.7 days, P <0.001, and 42.2 vs 35.8 days, P <0.001, respectively). Logistic regression analysis showed that age ≥80 years was significantly associated with a higher risk of hospital mortality (adjusted odds ratio, 1.62; 95% confidence interval, 1.28-2.06; P <0.001). In linear regression analysis, age ≥80 years was also significantly associated with longer hospital stay (P = 0.007).In a large, nationwide, Japanese database, patients aged 80 and older were at increased risk of hospital mortality and length of hospital stay.

Expectation and Quality of Life after Aortic Valve Replacement over 85 Years of Age Match those of the Contemporary General Population

Background

In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS.

Methods

Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics.

Results

Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population.

Conclusions

Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.