Patients' self-reported function, symptoms and health-related quality of life before and 6 months after transcatheter aortic valve implantation and surgical aortic valve replacement

Quality of Life Measures in Aortic Stenosis Research: A Narrative Review

BACKGROUND

Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS.

SUMMARY

We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ).

KEY MESSAGES

There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.

Exploring barriers and facilitators of behavioural changes in dietary intake and physical activity: a qualitative study in older adults undergoing transcatheter aortic valve implantation

PURPOSE

The majority of older patients, scheduled for a cardiac procedure, do not adhere to international dietary intake and physical activity guidelines. The purpose of this study was to explore barriers and facilitators regarding dietary intake and physical activity behaviour change in older patients undergoing transcatheter aortic valve implantation (TAVI).

METHODS

We conducted a qualitative study using semi-structured interviews with patients undergoing TAVI. Interviews were analysed by two independent researchers using thematic analysis, the capability, opportunity and motivation behaviour model was used as a framework.

RESULTS

The study included 13 patients (82 ± 6 years old, 6 females) until data saturation was reached. Six themes were identified, which were all applicable to both dietary intake and physical activity. Three following themes were identified as barriers: (1) low physical capability, (2) healthy dietary intake and physical activity are not a priority at an older age and (3) ingrained habits and preferences. Three following themes were identified as facilitators: (1) knowledge that dietary intake and physical activity are important for maintaining health, (2) norms set by family, friends and caregivers and (3) support from the social environment.

CONCLUSION

Our study found that older patients had mixed feelings about changing their behaviour. The majority initially stated that dietary intake and physical activity were not a priority at older age. However, with knowledge that behaviour could improve health, patients also stated willingness to change, leading to a state of ambivalence. Healthcare professionals may consider motivational interviewing techniques to address this ambivalence.

Patients' motivation to undergo transcatheter aortic valve replacement. A phenomenological hermeneutic study

BACKGROUND

Aortic stenosis is the most common valvular disease, and its prevalence is increasing due to the ageing population. Transcatheter aortic valve replacement (TAVR) is the recommended method when treating frail, older patients. Knowledge of what motivates older patients to undergo TAVR is important, in order to meet patients' expectations.

OBJECTIVE

The study aimed to explore the meaning of older patients' motivation to undergo TAVR.

DESIGN AND METHODS

The design was a qualitative study, analysed using a phenomenological hermeneutic approach. In-depth, semi-structured interviews with open-ended questions were conducted. Participants were selected from a specialist cardiology clinic in Sweden. Eighteen patients, six women and twelve men, aged 66-92, were recruited.

RESULTS

The analysis showed that patients who had agreed to undergo TAVR were deeply affected by their body's failure. Before the TAVR procedure, the participants were limited in their daily activities and experienced that their life was on hold. They experienced that they were barely existing. They were aware of their life-threatening condition and were forced to confront death. Yet despite an advanced age, they still had considerable zest for life. It was very important to them to remain independent in everyday life, and fear of becoming dependent had a strong impact on their motivations for undergoing TAVR.

CONCLUSION

Older patients' motivations to undergo TAVR are strongly influenced by their fear of being dependent on others and their zest for life. Health care professionals need to support these patients in setting realistic and personalised goals.

IMPLICATION FOR PRACTICE

Person-centered care actions could facilitate patients' involvement in the decision about TAVR and strenghten patients' beliefs in their own capabilities, before and after TAVR.

The Trajectory of Nutritional Status and Physical Activity before and after Transcatheter Aortic Valve Implantation

It is suggested that older patients waiting for an elective surgical procedure have a poor nutritional status and low physical activity level. It is unknown if this hypothesis is true and if these conditions improve after a medical procedure. We aimed to determine the trajectory of both conditions before and after transcatheter aortic valve implantation (TAVI). Included patients (n = 112, age 81 ± 5 years, 58% male) received three home visits (preprocedural, one and six months postprocedural). Nutritional status was determined with the mini nutritional assessment—short form (MNA-SF) and physical activity using an ankle-worn monitor (Stepwatch). The median MNA-SF score was 13 (11−14), and 27% of the patients were at risk of malnutrition before the procedure. Physical activity was 6273 ± 3007 steps/day, and 69% of the patients did not meet the physical activity guidelines (>7100 steps/day). We observed that nutritional status and physical activity did not significantly change after the procedure (β 0.02 [95% CI −0.03, 0.07] points/months on the MNA-SF and β 16 [95% CI −47, 79] steps/month, respectively). To conclude, many preprocedural TAVI patients should improve their nutritional status or activity level. Both conditions do not improve naturally after a cardiac procedure.

Fatigue trajectory and its associated factors in patients after cardiac surgery: A longitudinal study

BACKGROUND

Fatigue is associated with multidimensional factors in heart failure patients. Investigating longitudinal changes in fatigue and its association in patients undergoing cardiac surgery is needed to create interventions for improving fatigue during recovery.

AIMS

This study examined the trajectory of fatigue and its associated factors over time in patients undergoing cardiac surgery.

METHODS

This longitudinal study enrolled 125 patients undergoing cardiac surgery in northern Taiwan. Patients completed questionnaires before surgery, at discharge, and at 1, 3 and 6 months post-discharge. Fatigue was measured using the General Fatigue Scale. Generalised estimating equation models were fitted to identify variables associated with fatigue over time. This study complied with the STROBE checklist.

RESULTS

The sample (mean age = 60.70 ± 10.42) was mostly male (68%). High fatigue was found in 73.6% of patients before cardiac surgery and significantly decreased over the six months after discharge. NYHA III/IV, lower haemoglobin level, more symptom distress, poor sleep quality, higher anxiety and depression and lower social and family support were significantly associated with an increase in fatigue levels over time. Compared with before discharge, decreases in sleep quality at 1, 3 and 6 months were significantly associated with an increase in fatigue levels (p < .001). The increases in social support (B = 0.20, p = .016) and family support (B = 0.37, p = .002) at 6 months were significantly associated with an increase in the fatigue scores.

CONCLUSION

Fatigue was common and associated with symptoms, sleep quality, emotion and social support in patients undergoing cardiac surgery. In addition to symptom management, improving sleep quality and social support are important to manage fatigue for the long-term care of patients undergoing cardiac surgery.

RELEVANCE TO CLINICAL PRACTICE

Patient education on symptom management, sleep hygiene and family support is suggested to improve fatigue in patients recovering from cardiac surgery.

Patient and health professional perspectives on participations in a feasibility study on exercise-based cardiac telerehabilitation after transcatheter aortic valve implantation: A qualitative study. (Preprint)

Background

Aortic valve stenosis affects approximately half of people aged ≥85 years, and the recommended surgical treatment for older patients is transcatheter aortic valve implantation (TAVI). Despite strong evidence for its advantages, low attendance rate in cardiac rehabilitation is observed among patients after TAVI. Cardiac telerehabilitation (CTR) has proven comparable with center-based rehabilitation; however, no study has investigated CTR targeting patients after TAVI. On the basis of participatory design, an exercise-based CTR program (TeleTAVI) was developed, which included a web-based session with a cardiac nurse, a tablet containing an informative website, an activity tracker, and supervised home-based exercise sessions that follow the national recommendations for cardiac rehabilitation.

Objective

This study aims to explore patients’ and health professionals’ experiences with using health technologies and participating in the exercise-based CTR program, TeleTAVI.

Methods

This study is a part of a feasibility study and will only report patients’ and health professionals’ experiences of being a part of TeleTAVI. A total of 11 qualitative interviews were conducted using a semistructured interview guide (n=7, 64% patients and n=4, 36% health professionals). Patient interviews were conducted after 8 weeks of participation in TeleTAVI, and interviews with health professionals were conducted after the end of the program. The analysis was conducted as inductive content analysis to create a condensed meaning presented as themes.

Results

Reticence toward using the website was evident with reduced curiosity to explore it, and reduced benefit from using the activity tracker was observed, as the patients’ technical competencies were challenged. This was also found when using the tablet for web-based training sessions, leading to patients feeling worried before the training, as they anticipated technical problems. Disadvantages of the TeleTAVI program were technical problems and inability to use hands-on guidance with the patients. However, both physiotherapists and patients reported a feeling of improvement in patients’ physical fitness. The home training created a feeling of safety, supported adherence, and made individualization possible, which the patients valued. A good relationship and continuity in the contact with health professionals seemed very important for the patients and affected their positive attitude toward the program.

Conclusions

The home-based nature of the TeleTAVI program seems to provide the opportunity to support individualization, autonomy, independence, and adherence to physical training in addition to improvement in physical capability in older patients. Despite technological challenges, basing the relationship between the health professionals and patients on continuity may be beneficial for patients. Prehabilitation may also be considered, as it may create familiarity toward technology and adherence to the training.

Physical activity, dietary intake and quality of life during COVID-19 lockdown in patients awaiting transcatheter aortic valve implantation

Background

The COVID-19 pandemic has led to a national lockdown in the Netherlands, which also affected transcatheter aortic valve implantation (TAVI) patients. The objective of the study was to describe physical activity, dietary intake and quality of life (QoL) in patients on the waiting list for TAVI pre-lockdown and during lockdown.

Methods

Consecutive patients awaiting TAVI at the Amsterdam University Medical Centers, the Netherlands were included. Measurements were self-reported effect of lockdown, physical activity, dietary intake and QoL.

Results

In total, 58 patients (median age 80, interquartile range (IQR) 76–84, 45% female) were observed pre-lockdown and 16 patients (median age 78, IQR 76–82, 25% female) during lockdown. Ten of the 16 patients during lockdown reported a decline in physical activity. However, we observed a median number of 5861 steps a day (IQR 4579–7074) pre-lockdown and 8404 steps a day (IQR 7653–10,829) during lockdown. Median daily protein intake was 69 g (IQR 59–82) pre-lockdown and 90 g (IQR 68–107) during lockdown. Self-rated health on a visual analogue scale was 63 points (IQR 51–74) pre-lockdown and 73 points (IQR 65–86) during lockdown.

Conclusions

More than half of the patients during lockdown reported less physical activity, while we observed a higher number of steps a day, a similar dietary intake and a higher QoL. Therefore, patients on the TAVI waiting list appeared to be able to cope with the lockdown measures.

Monitoring Patients Reported Outcomes after Valve Replacement Using Wearable Devices: Insights on Feasibility and Capability Study: Feasibility Results

Wearable devices (WDs) can objectively assess patient-reported outcomes (PROMs) in clinical trials. In this study, the feasibility and acceptability of using commercial WDs in elderly patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) will be explored. This is a prospective observational study. Participants were trained to use a WD and a smartphone to collect data on their physical activity, rest heart rate and number of hours of sleep. Validated questionnaires were also used to evaluate these outcomes. A technology acceptance questionnaire was used at the end of the follow up. In our participants an overall good compliance in wearing the device (75.1% vs. 79.8%, SAVR vs. TAVR) was assessed. Half of the patients were willing to continue using the device. Perceived ease of use is one of the domains that scored higher in the technology acceptance questionnaire. In this study we observed that the use of a WD is accepted in our frail population for an extended period. Even though commercial WDs are not tailored for clinical research, they can produce useful information on patient behavior, especially when coordinated with intervention tailored to the single patient.

Patients' experiences of the transcatheter aortic valve implantation trajectory: A grounded theory study

Aim

The aim of this study was to explore how patients experienced the recovery process from transcatheter aortic valve implantation.

Design

A qualitative approach where in-depth interviews were used.

Method

Eleven men and eight women undergoing transcatheter aortic valve implantation were individually interviewed 6 months after transcatheter aortic valve implantation. Grounded theory was used for the analysis.

Results

The analysis generated the core concept "A journey of balancing between life-struggle and hope" connected to descriptive, bipolar categories. Before transcatheter aortic valve implantation patients not only felt threatened but also experienced hope. The rehabilitation phase was described as demanding or surprisingly simple. At the 6 months follow-up patients were pleased to return to life, however, still struggling with limitations. To feel hope is essential for transcatheter aortic valve implantation patients' well-being, both before and during the recovery process. It is important that healthcare professionals not only support hopeful thinking but also take time to discuss and prepare patients, talk about concerns and build confidence. Individual plans for rehabilitation should be designed.

Cognitive Outcomes After Transcatheter Aortic Valve Implantation: A Metaanalysis

OBJECTIVES

To quantitatively summarize changes in cognitive performance in individuals with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI).

DESIGN

Metaanalysis.

PARTICIPANTS

Individuals undergoing TAVI (N = 1,065 (48.5% male) from 18 studies, average age ≥80).

MEASUREMENTS

The MEDLINE, EMBASE, and Cochrane Central databases were searched for original peer-reviewed reports assessing cognitive performance using standardized cognitive tests before and after TAVI. Data were extracted for cognitive scores before TAVI; perioperatively (within 7 days after TAVI); 1, 3, and 6 months after TAVI, and 12 to 34 months after TAVI (over the long term). Standardized mean differences (SMDs) were generated using random-effects models for changes in cognition at each time point. Metaregression analyses were conducted to assess the association between population and procedural characteristics and cognitive outcomes. Risk of bias was assessed.

RESULTS

There were no significant changes from baseline in perioperative cognitive performance (SMD = 0.05, 95% confidence interval (CI) = -0.08-0.18; z = 0.75, P = .46), although overall cognitive performance had improved significantly 1 month after TAVI (SMD = -0.33, 95% CI = -0.50 to -0.16; z = 3.83, P < .001). There were no differences in cognitive performance 3 and 6 months after TAVI or over the long term. Cognitive outcomes were not associated with any covariates in regression analyses.

CONCLUSION

Cognitive performance is preserved after TAVI, suggesting TAVI is not detrimental to cognition.