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ORIGINAL ARTICLE |
1 Depatment of Cardiothoracic Surgery, Herz- und Diabeteszentrum NRW, Bad Oeynhausen, Germany
2 Department of Cardiothoracic Surgery, Friedrich Schiller University, Jena, Germany
Martin Zhong, MD Tel: +3641 9322901 Fax: +3641 9322902 Email: Anas.aboud{at}med.uni-jena.de, Herz- und Diabeteszentrum NRW, Georgstrasse 11, 32545 Bad Oeynhausen, Germany.
ABSTRACT
To assess the quality of life after biological and mechanical aortic valve replacement, data of 136 patients were assessed retrospectively after 2 years of follow-up. Bioprostheses were implanted in 53 patients with a mean age of 74 years, and mechanical prostheses were used in 83 with a mean age of 64 years; there were 47 women and 89 men. Quality of life was evaluated using the Short Form 36-Item Health Survey questionnaire. Physical function scores were significantly better in patients with a mechanical prosthesis. Mental health indices were identical in both groups. Younger patients with mechanical valves and older patients with biological valves had significantly better item scores. In all age groups, men tended to have better scores than women, but a significant difference was noted only in the physical functioning index. The quality of life in patients with mechanical and biological valves was similar at 2 years postoperatively.
Key Words: Aortic Valve • Bioprosthesis • Health Surveys • Heart Valve Prosthesis • Quality of life
INTRODUCTION
Health-related quality of life (QOL) has come to be recognized as having major importance after cardiac surgery.1,2 Improved physical, psychological, and social functioning as well as an overall sense of well-being are related to relief of the main cardiac symptoms and better physical functioning, which typically follow cardiac surgery.1 Advances in procedures and prostheses have improved QOL after cardiac valve replacement, and given better overall post-surgical outcomes.2,3 Major factors that might influence QOL after mechanical valve replacement are the need for anticoagulation and the development of thromboembolism.4 In contrast, valve degeneration and the short-term survival of the valve represent the main concerns in terms of QOL after biological valve replacement.5 Because most cardiac valve procedures are conducted in the elderly, it may be crucial to elucidate the outcomes of biological versus mechanical aortic valve replacement (AVR) in patients of different ages. The aim of this study was to compare QOL scores in patients of different ages and sexes at 2 years after AVR with mechanical or biological prostheses.
PATIENTS AND METHODS
Between January 2001 and December 2002, AVR was carried out in 527 patients in our department. Of these, 136 patients who underwent AVR for isolated aortic valve disease were selected retrospectively; none had concomitant coronary artery disease or a previous cardiac operation. They were divided into 2 groups according to valve type: 83 had a standard mechanical prosthesis, and 53 had a bioprosthesis. Mean ages were 74 years (range, 52–87 years) in patients with a mechanical prosthesis, and 64 years (range, 44–81 years) in those with a bioprosthesis. There were 47 women and 89 men. They were also divided into 4 age groups: <60 years; 60–69 years; 70–79 years; and 
80 years. All operations were carried out under cardiopulmonary bypass with mild systemic hypothermia (32°C) and cardiac arrest. AVR was performed via the standard median sternotomy approach, using the interrupted inverse mattress suture technique. All patients were evaluated at 18–24 months (mean, 21.4 ± 4.6 months) after the operation.
QOL was assessed with the Short Form 36-Item Health Survey (SF-36) tool. Eight dimensions of health were investigated: physical functioning, physical health related to age- and role-specific activities (role-physical), bodily pain, general health, vitality, social functioning, personal feelings of performance in age- and role-specific activities (role-emotional), and mental health. Each dimension was scored on a scale of 0 to 100, with higher scores indicating better health. The number of possible responses per item varied from 2 to 6. Statistical analysis was performed using SPSS standard version 11.0.1 statistical software (SPSS Inc., Chicago, IL, USA). Variables were compared among groups according to type of prosthesis, age, and sex, using the GLM-multivariate function of the SPSS program. A p value <0.05 was considered significant.
RESULTS
There were 3 hospital deaths (<30 days), all in patients >70-years old (overall early mortality, 1.6%). The causes of death were cardiac or multiorgan failure. There were 6 (3.4%) late deaths during follow-up: 4 patients died of stroke, 1 from myocardial infarction, and sudden death occurred in the other. In the age groups 70-years old, early mortality after AVR was 4.47% (3 patients), and late mortality (up to 2 years) was 5.97% (4 patients). Of the 9 deaths, 4 (4.82%) occurred in patients with a mechanical valve and 5 (9.43%) in those with a bioprosthesis. The mortality rates were similar for men (6.89%, 6 patients) and women (6.38%, 4 patients). For women, early mortality was 2.04% (1 patient) and late mortality was 4.08%. The mean SF-36 scores according to valve type at 2 years after surgery are shown in Table 1
. Only physical functioning index and vitality score were significantly better in patients with a mechanical prosthesis. Table 2 shows SF-36 scores according to age group after mechanical valve replacement. QOL was good to very good in all age groups, and there were no significant differences among them. In patients with a bioprosthesis (Table 3), the older age group (80 years) had the highest SF-36 scores, with role-physical index in the 2 oldest age groups significantly better than in the 2 youngest age groups (p = 0.031). Table 4 shows that most QOL scores tended to be higher in males, but only physical functioning index was significantly better (p < 0.05).
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Morbidity and mortality rates evaluate the success of surgery but do not provide information on the physical, functional, emotional, and mental well-being of patients. In recent years, QOL has complemented the usual assessment of surgical results and patient recovery.1,2 Several studies have examined the influence of surgical procedures, age, and sex on QOL.1–3 These established the use of QOL measures in clinical practice as a way of focusing treatment on the patient rather than on the disease. Our mortality rate of 6.6% is comparable with that of other reports, although many of our patients had to be operated on urgently.6 The ages of patients needing AVR has increased continuously over the years. Grunkemeier and colleagues7 reported a mean age of approximately 70 years. Advanced age is a risk factor for early and late mortality after AVR: mortality is in the order of 1% for patients aged 40 years, and 8% for those over 70 years.8 Levinson and colleagues9 reported a mortality rate after AVR of 9.4% in 64 patients >80-years old; however, 29 had an additional coronary bypass operation. In our study, the early mortality was 4.5% for patients 70-years old, but 19.4% of them (13 patients) were older than 80 years (late mortality, 6.0%). This shows that old age alone is not a contra-indication to AVR. The type of prosthesis (mechanical or biological) was not found to affect mortality 15 years after surgery.10 This was confirmed by 2 large randomized studies.11,12 However, postoperative complications are more common after mechanical valve implantation, because of the high risk of bleeding due to anticoagulation.10,12 Our mortality rates after mechanical and biological AVR were 4.8% and 9.4%, respectively; however, the 2 groups differed in age and number of patients. Klodas and colleagues13 reported increased late mortality in women after AVR, although some women in their study had additional graft replacement because of aortic aneurysm, which could have considerably affected the outcome. Our mortality rates for men and women were similar.
The SF-36 questionnaire was used to determine QOL on the basis of previous studies showing its suitability for cardiac surgical patients.14 It explores 8 dimensions of health, and the preoperative and postoperative scores can be easily compared.15 The answer rate of 94% in our study demonstrates that the SF-36 questionnaire is used and accepted easily by patients. Several studies have compared QOL after AVR according to type of valve prosthesis.1–3 Myken and colleagues2 and found no significant difference in QOL after AVR with mechanical and biological valves, but a disadvantage of their study was that different questionnaires were used for each group. Sedrakyan and colleagues16 had similar results, with the advantage of comparing QOL before and after operation. Perchinsky and colleagues3 confirmed these findings, but the ages of their patients were confined to 51–65 years, and they used a shorter version (SF-12) of the QOL questionnaire. We confirmed that there was no significant difference in most QOL indices explored by the SF-36 scales; however, it must be considered that the ages of patients in the 2 groups were different: those with mechanical valves were younger and had less chronic diseases than patients with a bioprosthesis. One important disadvantage in our study is that we did not evaluate preoperative QOL. In other studies, patients were examined pre- and postoperatively.1,16 Chocron and colleagues1 found that 80% of their patients had better QOL scores postoperatively, although it must be mentioned that preoperative QOL can be affected by stress due to the forthcoming operation.
Analysis of QOL among age groups resulted in few significant differences. Cather17 had similar results, also noting that younger patients had more depressive symptoms. Chiappini and colleagues18 concentrated mainly on the physical aspects of QOL and found that 98% of patients older than 80 years were content with postoperative results, in agreement with our findings. They also observed significantly better survival in older patients (>80 years) with a bioprosthesis (81.7%) compared to those with a mechanical valve (56.7%) during 37.1 months of follow-up.18 In comparing QOL after AVR between the sexes, everyday physical activities were less impaired in men. Early mortality after AVR in women over 80-years old has been reported to be higher than that in men, only when body surface area was <1.8 m2.19 Klodas and colleagues13 also noted higher late mortality in women after AVR.
We recommend that some other aspects should be considered in future studies of QOL after AVR. The first is a 3rd party estimation of QOL via patients’ family members. Another is to perform a psychological investigation pre- and postoperatively to interpret the psychosocial side and exclude the effect of preoperative psychosocial disturbances.
REFERENCES
Asian Cardiovasc Thorac Ann 2009;
17:35-38
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102522
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