Health-related quality of life after coronary artery bypass grafting: a review of randomized controlled trials.

Objective outcome measures (i.e., survival, mortality, morbidity, complication rate, symptom recurrence, and need for re-interventions) have long been used as benchmarks for successful cardiac surgery, including coronary artery bypass grafting (CABG). Along with these objectively measurable outcome indicators, acquired improvement by cardiac surgery in subjectively experienced health-related quality of life (HRQoL) has gained importance during the last decade in cardiac surgical research. If an increasing proportion of adult patients referred for CABG are elderly, octogenarians or even nonagenarians, the acquired HRQoL benefit from bypass surgery should be considered to be at least as important an outcome measure as potentially marginal improvement in life expectancy or longevity alone. To achieve the maximal HRQoL benefit and to optimize patient selection, a comprehensive analysis and understanding of contributors that affect pre- and postoperative self-perceived HRQoL is essential. These include patient-related characteristics (e.g., demographics and underlying comorbidities), surgical technique-related factors, and healthcare-related attributes. In this paper we review the randomized controlled trials published during the last ten years to analyze the effect of CABG on HRQoL. Specifically, we focus on the differences between the on-pump and off-pump (OPCAB) bypass techniques, investigate the factors that contribute to post-CABG HRQoL, and study post-CABG HRQoL in elderly patients.

Pacemaker therapy after tricuspid valve operations: implications on mortality, morbidity, and quality of life.

BACKGROUND: We studied the incidence and predictors of permanent pacemaker implantation after tricuspid valve operation and its implications on patient outcome in terms of survival, morbidity, and quality of life. METHODS: Between 1992 and 2007, 136 consecutive patients underwent tricuspid valve repair or valve replacement with a biologic valve at Kuopio University Hospital. Comprehensive clinical data were recorded prospectively. Data for the Nottingham Health Profile quality of life analysis were collected cross-sectionally. RESULTS: The mean follow-up time was 7.9 +/- 4.1 years (range, 0.8 to 15.7 years). A pacemaker was implanted in 28 patients (21%); 54% were implanted before hospital discharge. The 10-year survival of patients with a pacemaker was higher (94%) than of patients without a pacemaker (59%; p = 0.050). The need of a pacemaker was related to a significantly higher rate of transient ischemic attacks (30% vs 6%, p = 0.004), strokes (9% vs 4%; p = 0.008), and impaired physical capacity in terms of higher New York Heart Association functional class (p = 0.03) and the quality of life scores describing energy (31 vs 17; p = 0.01) and mobility (32 vs 17; p = 0.005). CONCLUSIONS: The need for pacemaker implantation after tricuspid valve operations was high. Unexpectedly, the life expectancy of the patients who needed a pacemaker postoperatively was higher compared with those who did not. This beneficial effect on mortality was offset by impaired morbidity: patients with a pacemaker experienced a significantly higher rate of thromboembolic complications and impaired quality of life.

Prospective assessment of quality of life of octogenarians after cardiac surgery: factors predicting long-term outcome.

Our objective was to assess the long-term prognosis and quality of life (QoL) of elderly patients after cardiac surgery. The Nottingham Health Profile (NHP) QoL data were recorded from 104 patients who were older than 70 years at the time of primary cardiac surgery in 1993. All living patients were controlled at 15+/-3.2 months and 8.2+/-0.27 years after discharge. The 1-year, 5-year and actual survival rates were 94%, 76%, and 59%, respectively. Risk factors for death were urgency of the operation (relative risk ratio, 2.0; 95% confidence interval, 1.2-3.6), ejection fraction below 50% (2.1; 1.1-3.9), and preoperative renal failure (2.1; 1.0-4.0). Cardiac operated octogenarians took advantage from age and sex matched reference populations at 15 months in the NHP dimension of pain (P=0.001). The QoL decreased gradually during the follow-up similarly in both groups in dimensions describing energy (P=0.001), pain (P=0.003), and mobility (P=0.042). Diabetes, low energy score and high pain score at 15 months, treatment in intensive care unit >3 days, and duration of symptoms >120 days preoperatively were associated with impaired QoL. Survival and QoL were similar for cardiac operated octogenarians and age and sex matched controls at 15 months and 8.2 years after cardiac surgery.

Mitral valve replacement versus repair: propensity-adjusted survival and quality-of-life analysis.

BACKGROUND: We investigated whether mitral valve repair (MVP) is superior to mitral valve replacement (MVR) in terms of survival and quality of life during the long-term follow-up. METHODS: One hundred eighty-four consecutive patients underwent MVP or MVR for mitral regurgitation with or without concomitant coronary artery bypass grafting. Clinical data were recorded prospectively, and the data for the Nottingham Health Profile quality-of-life analysis was collected cross-sectionally. Propensity score analysis was used for the study group matching. RESULTS: The mean follow-up time was 7.3 +/- 1.4 years. After adjustment for baseline characteristics by the propensity score method, there was a statistically significant survival benefit for the patients who underwent MVP (p = 0.02). Risk factors for death were preoperative unstable angina pectoris (relative risk ratio, 4.4; 95% confidence interval, 2.2 to 8.8), age older than 60 years (relative risk ratio, 1.1; 95% confidence interval, 1.0 to 1.1), use of mitral prosthesis (relative risk ratio, 2.7; 95% confidence interval, 1.4 to 5.3), preoperative renal insufficiency (relative risk ratio, 1.0; 95% confidence interval, 1.0 to 1.007), and preoperative cerebrovascular disorder (relative risk ratio, 2.7; 95% confidence interval, 1.0 to 5.3). The quality of life of the MVP and MVR groups did not differ from each other, but the MVP and the MVR patients had lower energy and mobility scores than an age- and sex-matched reference population. CONCLUSIONS: Survival is longer after MVP than after MVR. The quality of life of MVP and MVR patients does not differ from each other. In terms of most quality-of-life variables, patients who undergo mitral valve operations cope similarly to an age- and sex-matched reference population. Only the scores reflecting energy and mobility were lower in the patients who were operated on than in the reference population.

Effects of coronary artery bypass related conduction defects: a 10-year follow-up study.

OBJECTIVES: The aim of this study is to determine the long-term prognostic significance of new permanent conduction defects (CDs) related to coronary artery bypass grafting (CABG), and to assess predisposing factors for increased mortality after CABG. DESIGN: One hundred and eighty patients who underwent an elective CABG without any evidence of preoperative CDs were followed on average for 9.6 years. Long-term outcome was observed in terms of Kaplan-Meier survival analysis, and several potential pre-, intra- and postoperative factors for increased mortality were analysed using the Cox regression model. RESULTS: Sixty-three (35.0%) of the patients developed a new CD (CD+ group) before hospital discharge. Early (<30 days) and long-term (>30 days) survival rates were 98.9 and 86.1%, respectively. The long-term survival in CD+ patients was significantly lower that in CD- patients (77.8% vs 90.4%, p = 0.02). However, cardiac survival in CD+ patients and CD- patients did not differ from each other (88.9% and 92.3%, respectively, p=NS). Five independent predictors for increased all cause mortality were identified: diabetes (relative risk ratio 5.99 [2.43-14.78]), number of distal anastomoses (3.20 [1.30-7.88]), a new intraoperative conduction defect (2.83 [95% CI 1.24-6.49]), preoperative ejection fraction <50% (2.60 [1.08-6.27]) and perfusion time (1.02 [1.01-1.03]). CONCLUSIONS: Excellent survival rates can be obtained 10 years after CABG. CDs were not related to increased cardiac mortality. The appearance of preoperative diabetes, intraoperative perfusion time, number of distal anastomoses performed, CABG derived permanent CDs and low preoperative ejection fraction are associated with higher all cause mortality during the long-term follow-up.

Intraoperative high-rate atrial pacing test as a predictor of atrial fibrillation after coronary artery bypass surgery.

BACKGROUND: Atrial fibrillation (AF) is a common complication after coronary artery bypass grafting (CABG) operations. The aim of this prospective trial was to test the hypothesis that intraoperative high-rate atrial pacing may induce AF by mimicking rapid atrial tachycardia and can identify the patients at risk for postoperative AF. METHODS; Eighty patients having on-pump CABG without additional procedures were included in the study. After cannulation but before initiation of cardiopulmonary bypass two pacing wires were placed on the lateral surface of the right atrium. The right atrium was paced with the rate of 200 beats per minute for 10 seconds. If the patient was in sinus rhythm after the high-rate pacing, the pacing test was repeated with the rate of 250 and finally 300 beats per minute. RESULTS: Postoperatively AF developed in 28 patients (35%). The high-rate atrial pacing test induced AF in 27 patients (33.7%). Of the 28 patients who experienced AF during the postoperative period, 17 patients were inducible in the atrial-pacing test (sensitivity 0.61). Of the 52 patients who did not develop AF postoperatively, 42 patients were not inducible in the atrial-pacing test (specificity of the test was 0.81). Positive and negative predictive values of the test were 0.63 and 0.79, respectively. CONCLUSIONS: The intraoperative high-rate atrial pacing test turned out to be a simple, safe, and fast way to identify the patients at risk for AF after CABG. The diagnostic accuracy of this test is sufficient to identify a group of patients to whom prophylactic treatment could be directed.