Quality of Life After Cardiac Surgery: Underresearched Research

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doi:10.1510/icvts.2011.

276311

Interactive CardioVascular and Thoracic Surgery 13 (2011) 511-515


www.icvts.org

State-of-the-art - Cardiac general


Quality of life after cardiac surgery: underresearched research
Luc Noyeza,*, Marieke J. de Jagera, Athanasios L.P. Markoub
a
Department of Cardio-Thoracic Surgery, Heart Center, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands

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b
Cardio Thoracic Surgery – 10.500, Isala Clinics, De Weezenlanden, 8000 GK Zwolle, The Netherlands

Received 2 May 2011; received in revised form 13 July 2011; accepted 18 July 2011

Abstract

Improved quality of life is a major goal for cardiac surgery. This review concerns 29 articles published between January 2004 and December
2010. Only nine studies present preoperative and postoperative registered quality of life data. These studies have a short follow-up and a
limited number of patients included. Most other studies starts at a certain point in the follow-up and compare different patient groups or
techniques, but do not evaluate postoperative vs. preoperative quality of life. In an era of evidence-based medicine, there is a lack of major
and well-organized clinical studies dealing with quality of life after cardiac surgery. Based on this review, five requirements for ‘good’ studies
on this subject can be formulated: information about the total number of patients that could be included; the number of patients actually
included; information about preoperative quality of life; information on what was done about patients with missing data; and at least mini-
mum information about demographics, co-morbidity and the cardiac risk of patients who were not included or who dropped out. These points
seem to us to be essential for validation of the results presented.
 2011 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.

Keywords: Coronary artery bypass graft; Heart valve; Outcomes; Quality of life

1. Introduction 2. Methods

Although improved quality of life (QoL) is a major objec- Using PubMed, we performed a search for articles con-
tive of cardiac surgery [1, 2], there are few reports con- cerning QoL before and after cardiac surgery, restricting the
cerning QoL after cardiac surgery. QoL relates to more than search to publications between January 2004 and December
just the presence of symptoms of disease or the side effects 2010. The search command is presented in Table 1.

State-of-the-art
of a treatment or surgery; it is based on how patients per-
ceive and experience these manifestations in their daily 3. Results
life. QoL covers a broad range of experiences related to
overall well-being. This means that QoL is based on subjec- Thirty-three papers were found using the PubMed search
tive functioning in relation to personal expectations and is [3–6, 10–38]. For this review, we excluded the four stud-
defined by subjective experiences and perceptions. ies generated by our own group [3–6]. The other 29 stud-
During the past five years, our group has published several ies were screened for the three respective study points
studies concerning QoL after cardiac surgery [3–6]. However, [10–38]. Table 2 summarizes our results. Beside the study
when elaborating the discussions of these studies, we were authors, the effective number of patients with QoL informa-
confronted by several curious observations concerning the tion, the follow-up period, the mean, median or range, the
number of patients, the follow-up time and the availability knowledge of preoperative QoL information (yes or no) and
of preoperative QoL data. Those who reviewed our studies the primary intention of the study are presented.
have also, and rightly so, been critical of these aspects. Only nine out of 29 (31%) studies present preoperative
This review focuses on these three points, because they QoL data and compare these with the postoperative data
are of fundamental value for the conclusions of studies [16, 19, 22, 24, 29–31, 36, 38]. The other 20 studies start
concerning QoL after cardiac surgery. It must be clear that with a number of patients that were identified only post-
we will not discuss the different QoL questionnaires or the operatively. The follow-up period in these studies varies
methodology of analyses, because other papers deal with between a couple of months and several years. However,
these subjects [7–9]. the term ‘follow-up’ is rather misleading because it was
only after identifying the surviving patients at that point
of follow-up that the patients were invited to fill out a QoL
*Corresponding author. Department of Cardio-Thoracic Surgery, Heart
Center, Radboud University Nijmegen Medical Center – 677, PO Box 9101, 6500
questionnaire. Afterwards, the resulting data were primarily
HB Nijmegen, The Netherlands. Tel.: +31-24-3613711; fax: +31-24-3540129. used for a comparison between different techniques – off-
E-mail address: l.noyez@ctc.umcn.nl (L. Noyez). pump vs. on-pump [13, 22, 24], mechanical vs. biological
 2011 Published by European Association for Cardio-Thoracic Surgery
512 L. Noyez et al. / Interactive CardioVascular and Thoracic Surgery 13 (2011) 511-515

Table 1.  PubMed search command Only three studies start with a description of the initial
group of patients, although none of these studies provides
 #1 Quality of life [MESH]
 #2 SF 36/Short form 36 [Title/Abstract] information about the operative risk and/or preoperative
 #3 EuroQol/EQ-5D [Title/Abstract] QoL of the patients who were not included [19, 22, 29].
 #4 Thoracic surgery [MESH] AND #1 OR #2 OR #3 The three studies do show that the group of patients that
 #5 Cardiac surgery [Title/Abstract] AND #1 OR #2 OR #3 was actually studied is only a small part of the number of
 #6 Heart surgery [Title/Abstract] AND #1 OR #2 OR #3
 #7 Coronary artery bypass [MESH] AND #1 OR #2 OR #3
patients who could have been included in the study [19]:
 #8 Aortic valve replacement [Title/Abstract] AND #1 OR #2 OR #3 168/256 (65%), six months’ follow-up; [22]: 120/206 (58%),
 #9 Mitral valve replacement [Title/Abstract] AND #1 OR #2 OR #3 three months’ follow-up; [29]: 185/422 (44%), six months’
#10 Tricuspid valve replacement [Title/Abstract] AND #1 OR #2 OR #3 follow-up).
#11 Aortic root replacement [Title/Abstract] AND #1 OR #2 OR #3
#12 Ascending aortic replacement [Title/Abstract] AND #1 OR #2 OR #3

Limits: Published in the last five years, English. 4. Discussion

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This review shows that information about QoL after car-
diac surgery is limited, not only because the number of
valve implantation [10, 26, 34] – or different patients studies is small, but also because the set-up of the studies
groups – male vs. female, older than 70 years vs. younger differs widely. One reason is that QoL seems to be only a
patients, as indicated in Table 2. Here, only patients who ‘soft’ end point in comparison with survival. Soft end points
survived the ‘follow-up period’ and whose registered QoL are difficult to evaluate and highly individual. QoL covers
data were complete were included in the analysis. several domains, each affecting the others. Furthermore,
As already mentioned, only nine studies present pre- and the point of departure is different for each patient, as are
postoperative QoL data. These studies have a slightly shorter their expectations of the operation. Yet, in contrast to sur-
follow-up time, from three months to one year, than the vival studies, which start with a number of living patients
previously described group. Six of these nine studies only and compare that to the number of patients still alive at a
give information about the number of patients included in certain moment postoperatively, most QoL studies do not
the study [16, 24, 31, 36, 38]. They give no information on start with preoperative QoL data. Instead, QoL is used (or
the total number of patients that could have been included misused) to compare the effect of, for example, different
in the study, nor do they provide reasons for their exclusion. techniques on the QoL of the patients.

Table 2.  Quality of life (QoL) and cardiac surgery

Study (reference) Number of Follow-up period Preoperative Study intent


patients QoL

Aboud et al. [10]  136   2 years No Mechanical vs. biological valve replacement and in different age groups
Accola et al. [11]  529   9 months–18 years No Valve replacement, male vs. female in patients aged ≥65 years
Akhyari et al. [12]  38   3.2 and 4.2 years No Bentall vs. Ross procedure
Ascione et al. [13]  328   3 years No Off-pump vs. on-pump
Barry et al. [14] 1072   6 months No QoL predischarge vs. six months postoperatively in CABG patients
Bjessmo and Sartipy [15]  210 10 years No Elective vs. acute CABG
Bonaros et al. [16]  120   6 months Yes Robotically assisted vs. standard CABG
Bradshaw et al. [17] 2051 10 years No Survivors postCABG with or without angina
Dunning et al. [18]  621 10 years No Relation between preoperative data, operative data and QoL 10 years
postoperatively
El Baz et al. [19]  168   6 months Yes Difference in QoL related to the use or otherwise of a clinical pathway
Fukuoka et al. [20]  206   1 year No Identify elderly ≥65 years after PCI/CABG at risk for poor QoL
Gjeilo et al. [21]  203   3 years No <70 years vs. ≥70 years and female vs. male in CABG patients
Jensen et al. [22]  99   3 months Yes On-pump vs. off-pump
Jideus et al. [23]  126 20 months No CABG patients with vs. without SWI
Kapetanakis et al. [24]  191   6 months Yes On-pump vs. off-pump
Kurlansky et al. [25]  597   4.7 years No Isolated valve replacement vs. valve replacement+CABG
Kurlansky et al. [26]  634   5.33 years No Mechanical vs. biological valve replacement
Kurlansky et al. [27]  390   5.33 and 4.3 years No Aortic valve replacement vs. combined aortic valve+CABG in elderly
patients (>65 years)
Lee [28]  109   5 years No Identification of determinants of QoL after CABG
Lie et al. [29]  185   6 months Yes Impact of a home-based intervention program on QoL
Nogueira et al. [30]  202   1 year Yes On-pump vs. off-pump, <65 years vs. ≥65 years
Rimington et al. [31]  204   1 year Yes Outcome after valve replacement
Sedrakyan et al. [32]  72 18 months No Mitral valve repair vs. replacement
Stalder et al. [33]  172 26.6 months No Ascending aortic disease with or without disease of the aortic valve
Vicchio et al. [34]  121   3.4 years No Tissue vs. mechanical valve replacement in octogenarians
Vigano et al. [35]  56   5 years No QoL after tricuspid valve surgery
Zhao et al. [36]  171   1 year Yes Mitral valve repair vs. replacement
Folkman et al. [37]  126   1 year No Aortic valve replacement with or without CABG in octogenarians
Taillefer et al. [38]  82   3 months Yes Mechanical vs. biological valve replacement and male vs. female

CABG, coronary artery bypass grafting; PCI, percutaneous coronary intervention; SWI, sternal wound infection.
L. Noyez et al. / Interactive CardioVascular and Thoracic Surgery 13 (2011) 511-515 513

The results, however, are very questionable. For one thing, not the absence of good prospective studies, but more the
there is no information about preoperative QoL. Second, absence of QoL information studies. The reality is that, in
patients are selected at a certain moment postoperatively, cardiac surgery, prospective studies constitute the minority
and only those patients that meet the study criteria – com- of our outcome research. Methodologically, it would be also
plete QoL information – are eventually included in the very difficult to obtain good QoL data that would answer
evaluation. If we compare this with a simple survival analy- clinical questions. For example, if one wanted to study
sis, this means that, at a certain moment postoperatively, the impact of arterial grafting on QoL, one would need
a number of surviving patients would be identified and a to follow-up a few thousand patients for up to 10 years.
conclusion about survival made based on only the patients Another important, but insoluble, question is of course to
meeting the study criterion – survival. This should mean what degree the difficulties described and the lack of QoL
100% survival. Another point is that several of these studies information affect our surgical practice and knowledge.
pretend to have a long follow-up period. These studies are, The lack of major and well-organized clinical studies deal-

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however, also misleading. The patients included have a cer- ing with QoL after cardiac surgery is understandable, but
tain follow-up period, but QoL information is provided only it is a pity that many of the existing studies do not provide
at one moment: the studies do not provide information on real information about the impact of cardiac surgery on
how QoL has changed during the follow-up period. patients’ QoL.
The few studies that start with preoperative QoL assess- In spite of these objections, but based on our findings from
ment and go on to compare this to a postoperative QoL reg- our review, we formulate five minimal basic requirements
istration have a problem of a different kind, since they can to increase the value of studies concerning QoL after car-
only include patients with complete pre- and postoperative diac surgery. Information should be given on the following:
registration of the QoL data in their final analysis. In these
•• The number of patients that could be included in the
studies, it is important for the preoperative QoL data of
study. This means defining not only the patient popula-
the studied group to be compared to the preoperative QoL
tion, instances of isolated coronary artery bypass graft-
data of the excluded group before the conclusion based on
ing, isolated aortic valve surgery, etc., but also the
the studied data can be generalized to the total popula-
inclusion and/or exclusion criteria.
tion. A striking aspect of these studies is the high drop-out
•• The number of patients with preoperative and postop-
of patients, even at a relatively short follow-up time. In
erative QoL information and, because QoL information
contrast to survival studies, where the only criterion is
is compound, the number of patients with complete QoL
survival – yes or no – these QoL studies make use of QoL
information.
questionnaires based on several domains. Therefore, it is
•• Whether the study has been performed only on patients
important not only that patients reply to the questionnaire,
with complete data and whether imputation methods
but also that they provide a clear and complete reply. This
have been used to handle the missing data.
often proves to be a problem and is an important reason
•• The reason for the missing preoperative QoL data and a
for the high drop-out rate. It is no coincidence that studies
comparison of demographics, co-morbidity, cardiac data
with both pre- and postoperative data have only a limited
and risk stratification of the groups with and without
follow-up.

State-of-the-art
preoperative QoL data.
In our personal experience, we also see a progressive drop-
•• The reason for the missing postoperative QoL data, and
out of patients participating in our yearly organized follow-
a comparison of demographics, co-morbidity, cardiac
up after two or three years’ follow-up [39]. This drop-out
data, risk stratification and even preoperative QoL of
is not the same as ‘lost to follow-up’. Patients reply to the
the groups with and without postoperative QoL data.
questionnaire, however, with incomplete data for evalua-
tion of their QoL. Usually, complete case analysis is per- These five points seem to us to be important for inter-
formed, so all subjects with missing values are excluded. preting a study's results. Information about the percentage
It is a shame that all patients with missing data have to be of patients included, risk stratification of patients included
excluded from a study, and this also decreases the validity vs. not included and information about patients who have
of the study. It is possible to input missing data, but this dropped out is essential for validation of the results.
needs a good knowledge of the imputation models and, if
used, has to be clearly described [40]. 5. Conclusions
Another point, which is not the focus of our review but
something to be aware of nonetheless, is that when the We conclude that there is a need for good clinical trials
follow-up is long, it is questionable whether the QoL ques- concerning QoL after cardiac surgery. As Koch et al. have
tionnaire used gives good information at that specific stated in their review concerning the analytic approach of
moment. For example, QoL might be studied after 10 years QoL data, medical doctors need information on the impact
in a patient population operated on at age of 70 years or of interventions and cardiac operations and on the resulting
older. At the moment of follow-up, the patients will be over QoL, not only to justify their decision to operate, but also
80 years old, an age to which friability questionnaires will to be able to inform their patients about the pro and cons of
probably give more information about QoL than the SF-36 or any cardiac operation [9]. From the patient's point of view,
EuroQoL questionnaire that was used preoperatively. however, it is equally striking that there is no greater call
In an era when evidence-based medicine is of such great for information about postcardiac surgery QoL.
importance, the lack of QoL information after cardiac sur- Based on our review, we suggest that studies present at
gery seems incomprehensible. However, the problem is least preoperative and postoperative registered QoL data
514 L. Noyez et al. / Interactive CardioVascular and Thoracic Surgery 13 (2011) 511-515

and also information about demographics, co-morbidity and survival and quality of life: a prospective cohort study. Ann Thorac Surg
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L. Noyez et al. / Interactive CardioVascular and Thoracic Surgery 13 (2011) 511-515 515

eComment: Quality of life after cardiac surgery: underresearched after cardiac operations and remains relatively constant long-term, indepen-
research dent of procedure type [3].
In conclusion, we agree with Noyez et al. that well-designed prospective
Authors: Georgios Dimitrakakis, Department of Cardiothoracic Surgery, randomised trials should present preoperative and postoperative registered
University Hospital of Wales, Cardiff CF144XW, UK; Ulrich Otto von Oppell quality of life as well [1].
doi:10.1510/icvts.2011.276311A
In their review article (study period 2004 to 2010) regarding the assessment References
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to outcome of patients after mitral valve surgery plus biatrial modified 2011;13:511–515.
radiofrequency Maze procedure using the Medtronic Cardioblate System, vs. [2] von Oppell UO, Masani N, O'Callaghan P, Wheeler R, Dimitrakakis G,
mitral valve surgery plus intensive rhythm control strategy for persistent or Schiffelers S. Mitral valve surgery plus concomitant atrial fibrillation
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tively and 3 months and 1 year after surgery. rhythm control strategy. Eur J Cardiothorac Surg 2009;35:641–650.

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Grady et al. in their study compared health-related quality of life among [3] Grady KL, Lee R, Subacius H, Malaisrie SC, McGee EC Jr, Kruse J, Goldberger
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lated procedures and found that health-related quality of life improves early and after isolated cardiac operations. Ann Thorac Surg 2011;91:777–783.

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