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Ann Thorac Surg 1999;67:1262-1267
© 1999 The Society of Thoracic Surgeons

Original Articles

Quality of life in survivors of thoracic aortic surgery

Christian Olsson, MDa, Stefan Thelin, MD, PhDa

a Department of Cardiothoracic Surgery, Uppsala University Hospital, Uppsala, Sweden

Accepted for publication October 20, 1998.

Address reprint requests to Dr Thelin, Department of Cardiothoracic Surgery, Uppsala University Hospital, S-751 85 Uppsala, Sweden
e-mail: stefan.thelin{at}thorax.uas.lul.se

Presented at the Poster Session of the Aortic Surgery Symposium VI, New York, NY, April 30–May 1, 1998.


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Background. The results of surgical repair of thoracic aortic lesions are improving. Still, mortality and morbidity are considerable. Outcomes need to be studied in greater detail. We studied quality of life in survivors of thoracic aortic surgery, which has not been reported before.

Methods. During a 5-year period, 115 patients underwent thoracic aortic repair. All mid- to long-term survivors (n = 81; median follow-up time, 26 months) received the Short Form-36 (SF-36) health questionnaire plus specific questions related to surgery. Five patients were lost to follow-up.

Results. Scores for the eight dimensions of SF-36 (range, 0 to 100, 100 reflecting best function) were compared with a normal population. The mean deficits from the norm were bodily pain, 0.1 (95% confidence interval, -3.4 to 3.6) points below norm; mental health, 8.3 (5.7 to 10.9); vitality, 9.5 (6.7 to 12.3); social functioning, 10.1 (6.9 to 13.3); general health, 11.1 (8.5 to 13.7); physical functioning, 16.6 (13.4 to 19.8); role emotional, 20.6 (15.3 to 25.9); and role physical, 30.2 (24.7 to 35.7). Subgroup scores for acute versus elective cases, ascendens versus arch versus descendens procedures, and major complication versus no major complication were not significantly different. Sixty-six percent (50 of 76) stated a general health perception improvement. In 82% (62 of 76), the quality of life improved or was preserved. Ninety-one percent (69 of 76) considered the operation successful.

Conclusions. Considering the seriousness of the conditions, quality-of-life scores after thoracic aortic surgery were acceptable, although lower than in a normal population, except for bodily pain. Postoperative quality of life justifies thoracic aortic surgical repair.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Acknowledgments
 References
 
Results of the surgical treatment of thoracic aortic diseases are improving [1–3]. Discouraging outcomes of conservative management [4] further favors an active surgical approach. Nevertheless, perioperative mortality and morbidity are considerable, and complications potentially devastating, cerebrovascular and spinal ischemic insults being the most dreaded. The surgical procedure and ensuing intensive care could be extensive, technically demanding, and highly resource-consuming.

Increased or preserved quality of life (QoL) of the patient outlines the principal aim of all medical care. With diminishing health-care finances, tools for resource allocation are needed. Measurement of QoL is such a tool. Yet, investigations in the QoL of patients who have been operated on are few. Such investigations are of particular importance in high-risk procedures with potentially serious complications and side-effects. Frequent cardiac operations, eg, coronary artery bypass grafting [5, 6] and valve replacement [7, 8], have been studied in this respect, as has abdominal aortic aneurysm repair [9, 10].

The objective of this retrospective study was to determine the QoL after thoracic aortic surgery, compare it with a normal population and with other cardiovascular diseases, and estimate the impact of perioperative complications on the QoL. These issues have not, to the best of our knowledge, been addressed elsewhere. The study instrument was the Short Form-36 (SF-36) health questionnaire, developed in the Medical Outcomes Study (MOS) [11, 12].


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Acknowledgments
 References
 
Patients and medical records
During the period January 1990 to December 1995, a total of 115 consecutive patients underwent surgical repair of thoracic aortic aneurysm, dissection, or rupture, yielding 121 operations totally. The median elapsed time from surgery to investigation was 26 months (range, 7 to 76 months). As of July 1996, 81 patients were alive. Five patients, 4 nonresponders and 1 who was missing the medical record, were excluded. Thus, data from 76 patients treated with 79 operations were analyzed and are presented in this report.

Health status questionnaires
A proposed concept of a generic health status questionnaire supplemented with disease-specific questions [13] was applied. Patients received the Swedish translation of the SF-36 by mail. A separate set of six specific questions was enclosed (see Appendix). Nonresponders were reminded after 3 months. The SF-36 is well documented and validated in the Swedish context [14]. The SF-36 consists of 36 short questions (items) mirroring health and QoL in eight different aspects (dimensions): bodily pain (abbreviated BP, 2 items); mental health (MH, 5); vitality (VT, 4); social functioning (SF, 2); general health (GH, 5); physical functioning (PF, 10); and role functioning, both emotional (RE, 3) and physical (RP, 4). The role functioning dimensions reflect the impact of emotional and physical disability on work and regular activity (the individual’s normal everyday role). Finally, one separate item registers health transition during the last year. Raw points were transformed, generating a score for each dimension ranging from 0 to 100, with 100 reflecting best functioning. Swedish normal population (n = 8,930) scores [15] were used for comparison. The supplemental questions are reproduced in the Appendix.

Surgical procedures
Aortic repair techniques
A straight Dacron vascular graft was used in 64 (81%) cases. Twelve patients had composite grafts inserted (Bentalll button technique), and 3 patients received a graft and mechanical aortic valve prosthesis separately. Tissue glue was used to seal the layers of the aortic wall proximal or distal to the interposed graft in the majority of dissections.

Cardiopulmonary bypass
Total cardiopulmonary bypass was used in 62 of (78%) operations, partial (distal) bypass for selected operations on the descending or thoracoabdominal aorta in 14. Three cases were managed without cardiopulmonary bypass.

Cerebral and spinal cord protection
Forty-one operations (52%) were performed in deep hypothermia (core temperature less than or equal to 20°C) with circulatory arrest. Eighteen operations were performed in normothermia, and 24 in mild to moderate hypothermia, respectively. Retrograde cerebral perfusion through the superior caval vein was used in 16 cases (20%). In cases of thoracoabdominal aortic aneurysm (TAAA), intercostal artery reimplantation was attempted between T8 and L1. An indwelling catheter for cerebrospinal fluid drainage was placed in a few instances. No other specific spinal cord protection protocol was used.

Statistical analysis
Data were stored and analyzed using the StatView 4.1 statistical package for Macintosh (Abacus Concepts, Berkeley, CA). Calculated SF-36 scores are presented as means with 95% confidence intervals (CIs). When compared with the normal population, scores were adjusted for sex and age, and the resulting score difference with 95% CI was the principal measure. Comparisons with other authors were not adjusted for sex and age differences, and are therefore informative only and should be interpreted with caution. Missing values were replaced using the algorithm in the SF-36 manual [15]. Internal consistency as a measure of questionnaire reliability was determined with the Cronbach alpha coefficient. For population studies, Cronbach’s alpha is required to exceed 0.70 to judge results reliable [16]. Comparing groups, the Mann-Whitney U and {chi}2 tests were used for continuous and nominal variables, respectively. Values of p less than 0.05 were considered statistically significant. Multiple comparisons were adjusted for by the Bonferroni method.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Acknowledgments
 References
 
SF-36 scores
Table 1 summarizes the study population scores, differences from the norm, and Cronbach’s alpha for each separate dimension. Figures 1 and 2 illustrate SF -36 scores for subgroups of surgical anatomy (ascending aorta versus descending aorta versus transverse arch) and urgency (acute versus elective operation), respectively. Answers to specific operation-related questions are shown in Figure 3A through 3C.


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  		Table 1. SF-36 Scores of the Study Population (76 Survivors of Thoracic Aortic Surgery) and Normal Population

 


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  		Fig 1. SF-36 scores in eight dimensions for patients with surgical repair of the ascending aorta ({blacksquare}) versus the descending aorta [including thoracoabdominal aneurysm and rupture] ({square}) versus the transverse aortic arch (•). Means with 95% confidence intervals as error bars. See Methods for score abbreviations.

 


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  		Fig 2. SF-36 scores in eight dimensions for patients undergoing acute ({blacksquare}) versus elective ({square}) operation. Means with 95% confidence intervals as error bars.

 


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  		Fig 3. (A) Distribution of answers regarding patient-reported general health perception after surgery compared with before surgery (Appendix question 1). (B) Distribution of answers regarding patient-reported quality of life after surgery compared with before surgery (Appendix question 3). (C) Distribution of answers regarding patient-reported level of activity after surgery compared with before surgery (Appendix question 2). (D) Distribution of answers regarding patient-reported rating of the operative result (Appendix question 4).

 
Bodily pain (BP) score was not different from that in the normal population. Scores for GH, MH, SF, and VT were significantly lower, but relatively close to normal (less than 15 points deficit with 95% CI), and scores for emotional and physical role functioning (RE and RP, respectively) were substantially lower than the norm (more than 15 points deficit with 95% CI). The PF score was intermediate (16.6 [95% CI, 13.4 to 19.8] points deficit).

Surgical results
Demographic and surgical characteristics of the study population are presented in Table 2. Overall surgical (30-day) mortality was 18% (21 of 115). Total mortality at the time of the study was 30% (34 of 115). The causes of death were 12 cardiac (acute myocardial infarction or intractable heart failure), 9 lethal aortic ruptures (4 intraoperative), 8 cerebrovascular (7 of these after ascending aortic operation), 2 each septic and malignant, and 1 respiratory failure.


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  		Table 2. Study Subject (76 survivors of thoracic aortic surgery) Characteristics: Demographics, Perioperative Data, and Comorbiditya

 
The distribution of patients subjected to a major surgical complication (n = 17) versus those free from major surgical complication and their final outcomes in terms of self-reported current dysfunction is depicted in Figure 4. Major surgical complications were neurologic ischemic insult (12, patients with postoperative confusion listed in Table 2 were not included), recurrent laryngeal nerve damage (3), postoperative esophageal damage, and postoperative femoral artery embolism (1 each). SF-36 scores for the resulting subpopulations are presented in Figure 5. Current dysfunction was arbitrarily divided into none, mild, or severe. Of the 13 patients with severe dysfunction, 7 suffered from paraplegia, 3 from loss of visual acuity, 1 from bilateral lower limb sensory loss, and 1 from a permanent peroneal nerve damage. One patient was included because of hepatitis C virus transmission from a postoperative blood transfusion. Cough, hoarseness, voice alteration, impotence or sexual lust disturbance, sleep disturbances, and faintness or vertigo were considered mild dysfunctions. Any combination of three or more mild dysfunctions motivated classification as severe dysfunction.



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  		Fig 4. Distribution of patients with or without major perioperative complication (see text for definition) to groups of current dysfunction status (severe/mild/no, see text for definition). Compare with Figure 5 for related SF-36 scores.

 


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  		Fig 5. (A) SF-36 scores in eight dimensions for patients with major perioperative complication ({blacksquare}) versus patients with no major perioperative complication ({square}). Means with 95% confidence intervals as error bars. (B) SF-36 scores in eight dimensions for patients with severe ({blacksquare}) versus mild ({square}) versus no current dysfunction ({diamondsuit}). Means with 95% confidence intervals as error bars.

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Acknowledgments
 References
 
Strengths and weaknesses of study
The study population comprised 76 patients, and the response rate to the questionnaire was 94%, which we together judge sufficient for general conclusions and discussion of patterns, although some subgroups were small. Cronbach’s alpha for internal consistency was well above the critical level of 0.70 (Table 1) for all dimensions. Thus, the SF-36 appears to be a useful instrument for measuring health-related QoL in this patient group. The study was performed 7 to 76 months after surgery. There is a possibility of introduction of confounders, especially unrelated concurrent disease, during this period. On the other hand, information is provided on the long-term outcome. By relating questions specifically to the operation, and mapping current disease and dysfunction, we tried to diminish the disadvantages of elongated time perspective. The study was not prospective; consequently no certain conclusions could be made about the impact of the operation itself on the QoL. We believe this is of minor importance because (1) treatment strategies were not compared, (2) a prospective design is nearly impossible if patients sustaining emergency and acute operations (54% in this population) are to be included, and (3) for the latter, operation is imperative as it is performed to save the patient’s life. Certainly, the study is hampered by its heterogeneous composition of diagnoses with different management Table 3.


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  		Table 3. Surgical Procedures, Mortality, and Neurologic Morbidity in 115 Patients Operated on 1990–1995

 
It could be argued, rightfully, that the nonresponders could have lowered the QoL scores of the group, had they been included. They (2 men and 2 women) all had operations of the descending or the thoracoabdominal aorta. Not only were they subjected to difficult operations, according to their records, 2 had complications as well. A perhaps more important flaw is the mortality during the study period. What could really be studied is the QoL in survivors of thoracic aortic surgery, as stated in the title. The impact of this effect—the lack of information on QoL in patients who died before the study—is unknown, but presumably could affect scores negatively. Data were not collected on the morbidity of nonsurvivors, but, notably, 8 patients (26%) succumbed in cerebrovascular accidents.

Surgical outcomes
Three patients undergoing operations on the ascending aorta or the aortic arch sustained a verified recurrent laryngeal nerve damage. They all reported voice alteration, but constituted a minority among the 13 patients reporting this problem. The 3 patients who suffered perioperative paraplegia (all after procedures on the descending aorta) all reported paraplegia as a present dysfunction. Interestingly, 1 of them scored consistently above average in SF-36 and was concordantly optimistic to the specific questions. One of them was well below average in SF-36 scores, and the third was close to the whole-group average. Likewise unpredictable, 10 of 14 patients reporting impotence or sexual lust disturbance had no perioperative complication explaining their complaint. The paraplegic patients, along with an individual suffering from bilateral lower limb sensibility loss, had obvious causes for their reported sexual impairment. Surgical, cardiopulmonary bypass, and neuroprotective technique did not influence mortality, morbidity, or QoL scores.

SF-36 scores and profile
The score profile implies that (1) pain is not a problem to these patients and (2) they do somewhat better mentally than physically, as reflected by high scores in dimensions MH, SF, and VT. The finding of a BP score equal to that in a normal population is somewhat surprising. Not only is the surgical trauma extensive, 10 patients also explicitly reported localized pain as a current problem. This may reflect either insufficient coverage of pain problems in SF-36 (two items), or good patient coping. By comparison, only minor differences could be found between groups of acute versus elective operations, ascendens versus descendens versus arch procedures or current dysfunction versus dysfunction-free. Score differences, even when apparently large, did not reach statistical significance. With larger subgroups, significant differences, for instance between QoL after ascendens versus descendens procedures, might be detected. These findings may be subjected to different interpretations. First, it seems that preoperative QoL risk-stratification, based on well-recognized parameters (in this study lesion localization, diagnosis, and urgency) is not feasible in this patient group. Second, postoperative complications, including neurologic insults, did not appear to affect the long-term QoL, at least not in a predictable fashion. As has been reported for angina [17], it may be the case that unrelated comorbidity is a stronger predictor of QoL than the aortic disease itself or its surgical treatment—in this material, only a fifth (17 of 76) were free from concomitant disease.

The study of score profiles may be more fruitful than merely comparing points. Interestingly, the profile of this population was nearly identical to a population of hypertensive subjects reported elsewhere [18]. The profiles for diabetics, patients with stable angina, or patients subjected to stroke were also quite similar; GH was worse in diabetes and angina, RE and RP were better in hypertension and stroke, respectively [18]. In patients who underwent coronary artery bypass grafting, operation has been shown to improve QoL in a prospective study [6], not readily comparable with these retrospective results. Chocron and colleagues [8] found that 87% of heart surgery patients older than 75 years felt an improvement after surgery, and that 56% walked on a regular basis, which is comparable with 91% of patients in this study rating the operation successful, and 62% returning to at least preoperative activity level. In the study by Rohrer and colleagues [10] in ruptured abdominal aortic aneurysms, these patients differed from elective cases only in one aspect: they scored worse on the question "Do you feel as well as you did before your aneurysm surgery?" Baird and coworkers [9] used SF-36 in their study of QoL after elective abdominal aortic aneurysm repair and found that health deteriorated slightly in all dimensions, with significantly increased pain postoperatively, as opposed to our patients. They too concluded that QoL outcome justified aneurysm repair.

Specific questions
Answers (Fig 3) did not differ between subgroups. It was rewarding that the majority of patients rated their operation quite or rather successful (69 of 76; 91%) and stated that their self-experienced QoL either improved or was maintained by surgery (62 of 76; 82%). Furthermore, the majority reported an improved health perception after the operation (50 of 76; 66%) and a resumption of at least the greater part of preoperative level of activity (47 of 76; 62%). The association of answers to the specific questions and SF-36 scores was homogeneous, and we found the information valuable and a needed complement to the SF-36 scores.

Conclusions
The conditions described in this report are serious: surgical treatment is comprehensive, comorbidity is often present, and sometimes the objective cannot be higher than saving the patient’s life. Considering this, we judge the QoL after thoracic aortic surgery in this group acceptable and justifying surgical repair of thoracic aortic lesions. We could not demonstrate statistically significant differences in SF-36 scores on the basis of acuity, surgical procedure, complication, or dysfunction reported by patients. Hence, preoperative risk-stratification is difficult, and perioperative complications do not necessarily entail worse QoL. Finally, patients were satisfied with their operation and its aftermath, and their reported QoL is on par with, eg, hypertensive subjects, diabetics, and patients who have undergone coronary artery bypass graft operations or abdominal aortic aneurysm repairs.


   Acknowledgments
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
References
 
The study was supported by a grant from the Uppsala County Association Against Heart and Lung Diseases. We sincerely thank our patients for participating in the study.


   Appendix
 
Specific questions added to the SF-36 health questionnaire

  1. Compared with before the operation, how do you judge your general health status now? Much better now than before the operation. Somewhat better now than before the operation. About the same now as before the operation. Somewhat worse now than before the operation. Much worse now than before the operation.
  2. To what extent have you resumed your level of activity after the operation? Completely. To the greater part. To a smaller part. Not at all.
  3. How has your quality of life been affected by the operation? For the better. Neither better nor worse. For the worse.
  4. How do you consider the operation today? Very successful. Quite successful. Not so successful. Not successful at all.
  5. Do you still have any of these complaints after the operation? Cough. Hoarseness or voice alteration. Impotence or sexual lust disturbance. Paralysis. Other present complaints (specify)?
  6. General comments?


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Acknowledgments
 References
 

  1. Svensson L.G., Crawford E.S., Hess K.R., Coselli J.S., Safi H.J. Experience with 1509 patients undergoing thoracoabdominal aortic operations. J Vasc Surg 1993;17:357-370.[Medline]
  2. Fann J.I., Smith J.A., Miller D.C., et al. Surgical management of aortic dissection during a 30-year period. Circulation 1995;92(Suppl 2):II-113-II-121.
  3. Cohn L.H., Rizzo R.J., Adams D.H., et al. Reduced mortality and morbidity for ascending aortic aneurysm resection regardless of cause. Ann Thorac Surg 1996;62:463-468.[Abstract/Free Full Text]
  4. Perko M.J., Nørgaard M., Herzog T.M., Olsen P.S., Schroeder T.V., Pettersson G. Unoperated aortic aneurysm: a survey of 170 patients. Ann Thorac Surg 1995;59:1204-1209.[Abstract/Free Full Text]
  5. McCarthy M.J., Jr, Shroyer A.L., Sethi G.K., et al. Self-report measures for assessing treatment outcomes in cardiac surgery patients. Med Care 1995;33:OS76-OS85.[Medline]
  6. Caine N., Harrison S.C.W., Sharples L.D., Wallwork J. Prospective study of quality of life before and after coronary artery bypass grafting. BMJ 1991;302:511-516.
  7. Phillips R.C., Lansky D.J. Outcomes management in heart valve replacement surgery: early experience. J Heart Valve Dis 1992;1:42-50.[Medline]
  8. Chocron S., Rude N., Dussaucy A., et al. Quality of life after open-heart surgery in patients over 75 years old. Age Ageing 1996;25:3-11.
  9. Baird R.N., Currie I.C., McGrath C., Wilson Y.G., Lamont P.M. Quality of life after elective aneurysm surgery—a prospective study [Abstract]. Cardiovasc Surg 1996;4:662.
  10. Rohrer M.J., Cutler B.S., Wheeler H.B. Long-term survival and quality of life following ruptured abdominal aortic aneurysm. Arch Surg 1988;123:1213-1217.[Abstract]
  11. In: Stewart A.L., Ware J.E., Jr, eds. Measuring functioning and well-being: the medical outcomes study approach. Durham, NC: Duke University Press, 1992.
  12. Ware J.E., Snow K.K., Kosinski M., Gandek B. SF-36 health survey manual and interpretation guide. Boston, MA: New England Medical Center, The Health Institute, 1993.
  13. Cox D.R., Fitzpatrick R., Fletcher A.E., Gore S.M., Spiegelhalter D.J., Jones D.R. Quality-of-life assessment: can we keep it simple?. J R Statist Soc 1992;155:353-393.
  14. Sullivan M., Karlsson J., Ware J.E. The Swedish SF-36 health survey. I. Evaluation of data quality, scaling assumptions, reliability, and construct validity across general populations in Sweden. Soc Sci Med 1995;10:1349-1358.
  15. Sullivan M., Karlsson J., Ware J.E. SF-36 health questionnaire. Swedish manual and interpretation guide. Gothenburg, Sweden: Gothenburg University, 1994.
  16. Bland J.M., Altman D.G. Statistics notes. Cronbach’s alpha. BMJ 1997;314:572.[Free Full Text]
  17. Chen A.V., Daley J., Thibault G.E. Angina patients’ ratings of current health and health without angina: associations with severity of angina and comorbidity. Med Decis Making 1996;16:169-177.[Abstract/Free Full Text]
  18. Lyons R.A., Lo S.V., Littlepage B.N.C. Comparative health status of patients with 11 common illnesses in Wales. J Epidemiol Community Health 1994;48:388-390.[Abstract/Free Full Text]



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