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Eur J Cardiothorac Surg 2002;21:10-14
© 2002 Elsevier Science NL

Quality of life after interventions on the thoracic aorta with deep hypothermic circulatory arrest

Department of Cardiovascular Surgery, University Hospital, 3010 Berne, Switzerland

Received 15 September 2001; received in revised form 16 October 2001; accepted 18 October 2001.

* Corresponding author. Tel.: +41-31-632-2376; fax: +41-31-302-2568
e-mail: franzimmer{at}yahoo.de

	Abstract

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Objective: Assessment of quality of life (QL) in patients undergoing major surgical procedures is of increasing interest. We focused on surgery of the thoracic aorta requiring deep hypothermic circulatory arrest (DHCA). Aim of this study was to assess QL after thoracic aortic surgery with DHCA, using the Short Form 36 Health Survey (SF-36) questionnaire. Methods: Between 01/94 and 12/99 212 (59.1%) out of a total of 359 interventions on the thoracic aorta were performed under DHCA, with an early mortality of 13.7% (28 patients). During an average follow-up of 3.2±1.3 years, 27 patients died (15.2%) and five patients (2.8%) were lost. A total of 145 patients (81.9%) had a complete follow-up. Results: 125 of the 145 SF-36 questionnaire handed out were answered correctly (86.2%). In relation to a standard population (z=0), the most important deficits were found in physical function (z=-0.53) and role limitations because of physical health (z=-0.42). Good results were found regarding the aspect of pain (z=0.28), social functioning (z=0.02) and vitality (z=-0.02). Overall QL in patients having been operated for aortic aneurysm was better than for patients with acute type A-dissection. Conclusion: Despite restrictions in physical functioning and role limitation because of physical health, QL in patients after interventions on the thoracic aorta with DHCA is fairly good and, for patients being operated for aortic aneurysm, comparable to an age-matched standard population. Patients having being operated electively for aortic aneurysm enjoyed a better QL than patients having been operated emergently for acute type A dissection.

Key Words: Aortic-surgery • Quality of life • SF-36 • DHCA • Outcome

	1. Introduction

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
Interventions on the thoracic aorta with the use of deep hypothermic circulatory arrest (DHCA) are still associated with important mortality and morbidity, mainly caused by the underlying pathology [1–3]. Despite improvements of the surgical results in the last few years [1] concerning acute type A dissection (Stanford Classification), cerebrovascular and spinal ischemic insults remain the most dreaded complications of aortic surgery with and without DHCA [2–6]. Today mortality and morbidity after different surgical procedures is well known and has been described in several studies. Assessment of quality of life (QL) after major surgical interventions is of increasing interest as preservation or increase of QL should be the principal goal of all medical care [7–10]. Furthermore diminishing health-care finances require tools for resource allocation [11]. Measurement of QL is such a tool. The short form 36 (SF-36) was developed in the medical outcomes study (MOS) and is an established score to assess subjective and health related QL [12–13]. It has been widely used and allows to compare a group of patient with a standard population.

The objective of this study was to determine QL after thoracic aortic surgery with DHCA and compare the results with a standard population and between patients undergoing surgery for acute type A dissection and aneurysm of the thoracic aorta.

	2. Patients and methods

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
2.1. Patients
Between January 1994 and December 1999 359 interventions on the thoracic aorta were performed at our institution. A total of 212 (59.1%) interventions in 205 patients with the use of DHCA. Mean age of the patients was 60.0±14.5 years. A total of 145 patients (70.7%) were male. Twenty-eight patients (13.7%) died during hospitalization. Mortality in patients being operated for acute type a dissection (n=107) was 15.9% and in patients being operated for aortic aneurysm (n=79) was 7.6%. Patients characteristics are displayed in Table 1. During the average follow-up of 3.2±1.3 years 27 patients (15.2%) died and five patients (2.8%) were lost to follow-up. All 145 remaining patients (81.9%) were mailed a SF-36 questionnaire and 125 (86.2%) were answered correctly (Table 2). Fourteen questionnaires were not answered correctly due to language problems of the French and Italian speaking patients, as the SF-36 questionnaire is evaluated in German and was therefore sent in German, three patients were not able to response the questionnaire, two suffering from severe postoperative neurological complications and one patient with a preoperative psychiatric disease, living in an institution. Three patients refused to answer the questionnaire. All of them returned home postoperatively and where contacted by phone.

2.3. Surgical procedures
2.3.1. Aortic repair technique
In 124 patients (60.5%) ascending aortic and hemiarch replacement with a straight Dacron vascular graft was performed. In 65 patients (52.4%) the intervention was combined with an aortic valve replacement (AVR) and/or coronary artery bypass grafting (CABG). A total of 56 patients (27.3%) had composite grafts inserted (Bentall button technique) with hemiarch replacement and 19 patients (9.0%) had descending aortic replacement. In 13 patients (6.1%) miscellaneous interventions were performed (aortic arch replacement, exclusion of an aortic arch aneurysm, etc.). In patients with acute type A aortic dissection tissue glue was used to seal the layers of the aortic wall proximal and/or distal to the interposed graft. Mean operation time was 245±75 min. All patients were operated by the use of DHCA (mean duration 18.6±7.2 min), with a core temperature of less than or equal to 20°C. In this period, no antegrade cerebral perfusion was used. 119 interventions (56.1%) out of the 212 were emergent surgical procedures and in 28 interventions (13.2%) patients were hemodynamical unstable due to pericardial tamponade.

2.4. Statistical analysis
The SF-36 questionnaire was analyzed in accordance to the SF-36 manual and missing values were replaced using the described algorithm in this manual [14]. SF-36 scores are presented as means with 95% confidence intervals (CI). Scores were adjusted for sex and age in order to be comparable with the normal population. Data were analyzed using the StatView 4.1 statistical package (Abacus Concepts, Berkley, CA). We used the Cronbach alpha coefficient to determine internal consistency. In this type of population studies results are reliable if Cronbach's alpha exceed 0.70 [15]. For comparison between groups, the Mann–Whitney U-test and ² test were used for continuous and nominal variables, respectively a P-value of less than 0.05 was considered significant. Results are displayed as mean values with the first standard deviation (1. SD).

	3. Results

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
3.1. SF-36 scores
The study population scores (n=125 patients) are summarized in Fig. 1. Furthermore the subgroup results of patients being operated for acute type A aortic dissection (n=69) and aortic aneurysm (n=49) are displayed in Fig. 1. Patients having been operated for aortic aneurysm showed better results in all test categories. They do significantly better in physical functioning (PF) and physical role functioning (RP) than patients after surgery for acute type A dissection (P<0.01) (Fig. 1). Compared with a standard population the results of the total collective are similar or slightly worse (less than 15 points deficit with 95% CI) for BP, SF, MH and VT. A substantial deficit was found for PF, RP and GH (more than 15 points deficit with 95% CI). The RE score was intermediate (Fig. 2).

View larger version (25K): [in this window] [in a new window]   Fig. 1. SF-36-score for the total collective (n=125), patients being operated for acute type A-dissection (n=69) and patients being operated for aortic aneurysm (n=49). PF=physical functioning; RP=physical role functioning; BP=bodily pain; GH=general health; VT=vitality; SF=social functioning; RE=emotional role functioning; and MH=mental health. Maximum score 100 points.

View larger version (17K): [in this window] [in a new window]   Fig. 2. Comparison with a standard population (z=0) for the total collective (n=125), patients being operated for acute type A-dissection (n=69) and patients being operated for aortic aneurysm (n=49).

	4. Discussion

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 
QL is of increasing interest, especially in patients undergoing major surgical procedures [7–11]. We focused on the aspect of DHCA in patients being operated on the thoracic aorta.

Surgical outcome is similar to other studies [1,2]. Observed morbidities are also in the already reported range [1,2].

A total of 145 patients (96.7%) had a complete follow-up. Out of them 125 (86.2%) answered the SF-36 questionnaire correctly. The results of the 69 patients having been operated on for acute type A dissection and the 49 patients having been operated on for chronic aneurysm of the ascending aorta and/or the aortic arch have been compared. The remaining seven patients with a complete follow-up have been operated for miscellaneous interventions and are part of the total collective, but are not considered in the subgroup-analyses, due to the small number of patients and the heterogeneity of the group. Main reason for not answering the questionnaire were language problems in 14 patients (70%). As the SF-36 is validated in German – most of the Italian and the majority of the French speaking population were not able to response such a questionnaire in a foreign language. We therefore decided not taking into account their results in order not to influence the results by a non-validated translated questionnaire. Two patients (10%) were not able to answer the questionnaire due to severe postoperative neurological complications and four patients (20%), who returned home postoperatively, were contacted by phone, but refused answering the questionnaire. This may be a limitation of the study, as, especially in these two patients suffering from postoperative neurological complication (both after surgery for acute type A dissection), one may assume a poor QL, which will lead to a slight decrease in the overall results of the total collective. As the test was validated by a Swedish group, we have to compare the results to a Swedish standard population, as a comparison with a Swiss population is not available. Looking at social structure and economical background in both countries, differences between a Swedish and a Swiss population are not so important and therefore we can refer to the reported results obtained in a Swedish standard population.

The follow-up is very complete with 96.5% of the survivors having been contacted and with 86.2% of the SF-36 questionnaire answered correctly, data of a representative population can be analyzed.

Overall the subjective QL reported by 125 survivors in comparison with an age-matched standard population (z=0) is good: pain postoperatively (z=0.28), social functioning (z=0.02) and vitality (z=-0.02) (Fig. 2) is fully restored and especially the aspect of pain does not impair QL more than in a standard population. Similar findings were reported by the group of Olsson and co-workers [7], who found no differences between acute versus elective surgery, ascendens versus arch versus descendens procedures and major versus no major complication in a group of 76 patients during a follow-up period of 26 months undergoing different surgical procedures on the thoracic aorta, with a percentage of 52% being operated by the use of DHCA [7]. However, in our study population, patients after operation for acute type A dissection seem to have less good QL, especially concerning physical functioning (PF), physical role function (RP) and bodily pain (BP) (Figs. 1 and 2), which is corroborated by the analysis of the disease specific questions in which 88.6% of the patients being operated for aortic aneurysm had no postoperative sternal pain, compared to 54.3% of the patients being operated for acute type A-dissection (P<0.05). In our opinion, these results reflect the severity of acute type A dissection, mostly requiring emergent surgical procedures, not allowing to anticipate the severity of the disease by the patient, who is therefore very confused about the life-threatening situation and the fact of mostly not being healed from the disease after surviving surgery (rest dissection in the aortic arch and/or the descending aorta), which may require further surgical interventions in the future. Surprisingly, looking at the additional questions, similar results were found in both groups looking at the aspect of anxiety, with a percentage of 74.3% reporting no anxiety after the surgical procedure (P=ns).

Looking at the ability to work 3 months postoperatively, one third of the patients being operated for acute type A dissection were not able to return to work, compared to a percentage of 18% in patients having been operated for aortic aneurysm (P<0.01). As in general, patients having been operated for aortic aneurysm had no physical restrictions and the postoperative course is less eventful, return to work seems to be easier in this type of surgery. Inability to work after surgery for acute type A dissection is mainly found in patients working physically very hard (stone-mason, roofer, joiner), patients with persistent neurological complications and in patients approaching the age of retirement.

Despite restrictions in physical functioning and role limitation because of physical health, the subjective QL in patients who underwent interventions on the thoracic aorta with DHCA is good and comparable to an age-matched standard population. Patients having been operated electively for aortic aneurysm enjoyed after a follow-up period from 3.2±1.3 years better QOL than patients having been operated emergently for acute type A-dissection.

	Footnotes

 
Presented at the joint 15th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 9th Annual Meeting of the European Society of Thoracic Surgeons, Lisbon, Portugal, September 16–19, 2001.

	References

Top Abstract 1. Introduction 2. Patients and methods 3. Results 4. Discussion References

 

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