European Journal of Cardio-Thoracic Surgery Advance Access published April 7, 2015

REVIEW

European Journal of Cardio-Thoracic Surgery (2015) 1–21 doi:10.1093/ejcts/ezv119

Quality of life after intervention on the thoracic aorta Omar A. Jarral*, Emaddin Kidher, Vanash M. Patel, Bao Nguyen, John Pepper and Thanos Athanasiou Department of Surgery and Cancer, Imperial College London, London, UK * Corresponding author. Department of Surgery and Cancer, Imperial College London, London W2 1NY, UK. Tel: +44-7855773118; e-mail: [email protected] (O.A. Jarral). Received 15 December 2014; received in revised form 12 February 2015; accepted 24 February 2015

Abstract Surgery on the thoracic aorta is challenging and historically associated with significant mortality and morbidity. In recent times, there has been increased emphasis on the importance of health-related quality of life (HRQOL) measures. It is seen as a development beyond isolated markers of outcome such as operative mortality and is particularly applicable to aortic surgery given the number of asymptomatic patients operated on (for prognostic grounds), and rapidly advancing endovascular technologies which require proper assessment. This systematic review provides an outline of all available literature detailing HRQOL in patients receiving intervention (both open and endovascular) on the thoracic aorta. In total, 30 studies were identified encompassing 4746 patients undergoing a variety of procedures from aortic root replacement to thoracoabdominal aortic aneurysm repair. While there were deficiencies in the underlying literature such as lack of baseline HRQOL assessment, the majority of the studies confirm that HRQOL after major aortic surgery (including on the elderly and in emergency situations) is acceptable and compares well to matched general populations. Strategies for improving the HRQOL in aortic surgery are summarized and include the need for surgeons to plan cerebral protection methods more carefully and to develop operative strategies to avoid reoperation or reintervention, as this is associated with deterioration of long-term HRQOL. Randomized studies measuring baseline and follow-up HRQOL at specific set points are needed. Innovative research methods could be employed in future studies with the aim of correlating HRQOL with imaging or physiological/inflammation biomarkers, or other end points such as aortic stiffness or wall shear stress to characterize disease progression and prognosis. Keywords: Quality of life • Outcomes • Ascending aorta • Aortic root • Aortic arch • Descending thoracic aorta • Thoracoabdominal aorta

INTRODUCTION Operating on the thoracic aorta can be a formidable challenge requiring experience, strong technical skills and attention to detail in managing multiorgan protection. Historically, procedures have been associated with significant morbidity and mortality. This has negatively affected the perception and perhaps decision-making of patients, surgeons and referring clinicians. The situation has improved significantly over the last 20 years with some specialist centres reporting operative mortality rates of less than 10% for type A dissection repair in octogenarians [1] and paraplegia rates of less than 6% following thoracoabdominal aneurysm (TAA) repair [2, 3]. The reason for these improvements is multifactorial but includes: (i) the introduction of right subclavian/axillary, innominate or left common carotid cannulation, (ii) the use of continuous antegrade cerebral perfusion, (iii) a stronger appreciation of the anatomy of the brain and spinal cord (e.g. significance of right vertebral artery hypoplasia), (iv) a better understanding of the physiology and deleterious effects of ischaemia and deep hypothermic circulatory arrest (DHCA) [4] and (v) the use of the frozen elephant trunk technique has benefited patients with extended aortic pathology by reducing the need for

second-stage procedures and their associated mortality in the interim period [5]. In recent times, there has been a significant increase in the importance of health-related quality of life (HRQOL), defined as a ‘multi-dimensional assessment of an individual’s perception of the physical, psychological and social aspects of life that can be affected by a disease process and its treatment’ [6]. It is required for any meaningful analysis of cost-effectiveness and is seen by many as an accurate marker of patient-centred care. Thus, it has great potential to improve healthcare [7]. It is particularly applicable to aortic surgery given the number of asymptomatic patients operated on for prognostic grounds (e.g. Marfan syndrome), the presence of rapidly evolving stent technology (endovascular treatment of thoracic aortic disease, TEVAR), which require more robust technology assessment and guidelines, and in clinical situations such as two-stage aortic procedures where patient compliance is critical. This study aims to provide readers with a systematic overview of all available literature detailing HRQOL in patients undergoing intervention on the thoracic aorta. This will highlight key factors influencing HRQOL outcomes and enable recommendations to be made for clinical practice and future research.

© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

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Cite this article as: Jarral OA, Kidher E, Patel VM, Nguyen B, Pepper J, Athanasiou T. Quality of life after intervention on the thoracic aorta. Eur J Cardiothorac Surg 2015; doi:10.1093/ejcts/ezv119.

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MATERIALS AND METHODS

Study objectives, design and population

Search strategy

The 30 studies included comprised a total of 4746 patients (range 10–917). Twenty-seven studies were retrospective cohorts [1, 4, 10, 11, 13, 15, 16, 18–37], two were prospective cohorts [12, 14] and one was a prospective randomized controlled trial [17]. All studies included patients who underwent intervention during the period from 1994 to date, apart from 5 in which patients from before this period (up to 1983) were included [13, 16, 31, 32, 34]. Seventeen of the studies (57%) originated from Europe, 9 (30%) from the USA and 4 (13%) from Australasia. To improve clarity and the ease of reading, the above studies were categorized into the following categories.

This study was performed in accordance with the guidelines for the ‘Preferred Reporting Items for Systematic reviews and Meta-Analyses’ (PRISMA) [8]. A systematic search was carried out using PubMed up until November 2014 using the following search terms: (‘quality of life’) AND (‘aortic surgery’ or ‘root replacement’ or ‘arch replacement’ or ‘descending aorta’ or ‘thoracoabdominal’ or ‘ascending aorta’ or ‘thoracic aorta’ or ‘aortic aneurysm’ or ‘TEVAR’ or ‘aortic arch’ or ‘Ross procedure’ or ‘pulmonary autograft’ or ‘type a dissection’ or ‘type b dissection’). Reference lists of selected papers were also hand searched to check for further suitable articles.

Inclusion and exclusion criteria Studies in English reporting HRQOL outcomes in adults undergoing intervention (both open and endovascular) of the thoracic aorta were included, i.e. surgery of the ascending aorta, aortic arch, descending thoracic aorta and of the thoracoabdominal aortic segment. Studies focusing purely on aortic valve replacement (e.g. isolated aortic homograft valve replacement) were excluded unless concomitant surgery was performed on the aortic root or ascending aorta.

Outcomes of interest and data extraction Two reviewers (Omar A. Jarral and Thanos Athanasiou) identified relevant articles and reviewed the full texts to check whether they met the above criteria. Conflicts between the reviewers were discussed in person until complete agreement was reached with inter-rater agreement reliability estimated to be over 90%. The following information was extracted from each study: author, year of publication, period of data collection, research type, study objective and number of subjects, surgical centre location, key patient characteristics as reported by authors, evidence of preoperative HRQOL assessment, follow-up period, HRQOL instrument used, follow-up completion rates, key non-HRQOL outcomes as reported by authors, main findings related to HRQOL and the overall quality of the study (Table 1).

Quality scoring The methodological quality of included studies was assessed using a method previously described by Mols et al. [9] and subsequently adapted by Baig et al. [6]. This scoring system uses a standardized checklist of 10 items (Fig. 1). Studies scoring ≥8 were considered to be of ‘high quality’, a score in the range 5–7 ‘moderate quality’ and 75 and peripheral vascular disease.

Coronary artery disease —98.5% Urgent surgery—12.7%

Predictive factors of reduced QoL after surgery were: postoperative paraplegia/CVA and reoperation.

Di Luozzo et al. (2013) [15] 2002–08

Retrospective review of QoL of 93 patients over the age of 70 undergoing open repair of

Mount Sinai School of Medicine, New York, USA

Mean age at operation 75 ± 4.1 years, 51% male. Replacement of descending thoracic

No

4.1 (range 1.1–7.1) years

SF-36 81%

In-hospital mortality rate was 13.5% for isolated DTA replacement and 15.5% for TAAA replacement.

Neither TAA extent (I–IV) nor operative urgency influenced long-term QoL Across all QoL domains, respondents scored slightly lower than the matched US population. However, these differences were not

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1987–2005

HRQOL instrument used Follow-up completion rate (%)

Prospective cohort study

Crawford et al. (2008) [13]

Follow-up period

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Continued

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Table 2: Continued Author, year of publication, study period and study type

Retrospective cohort

1983–2001

Surgical centre

Patient characteristics

Preoperative HRQOL assessment

Follow-up period

HRQOL instrument used

Key outcomes

Main findings related to HRQOL

Quality score

Follow-up completion rate (%) descending aortic aneurysm or TAAA

Assessment of HRQOL in long-term survivors of TAAA repair (n = 13)

aorta in 23.7% and thoracoabdominal aorta in 76.3%

University Hospital of Trondheim, Norway

Mean age at follow-up was 67.4 years (44.4–78.3).

One-year survival rate was 69% and 5-year survival rate was 45%.

No

6.2 (range 1.3–14.1) years

A ‘vascular specific questionnaire’

Median aneurysm diameter 7 cm.

Retrospective cohort

SF-36 and

Acute respiratory distress syndrome was a predictor of in-hospital mortality and 1-year mortality Not reported

85% Crawford classification: 4 had Type 2, 4 had Type 3 and 3 had Type 4.

significant except in the vitality domain

The patients’ SF-36 scores were generally poorer than that of the healthy population in both physical and mental dimensions but comparable in other domains.

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Patients who had an uncomplicated postoperative course all reported general health status comparable with their preoperative status.

One emergency presentation (rupture)

Patients who had a complicated postoperative course generally scored lower in the physical dimensions.

Zierer et al. (2006) [37] 1998–2003

QoL assessment in patients undergoing elective thoracic aortic replacement (n = 110).

Washington University School of Medicine, USA

Mean age was 67 ± 9 years and 49% were male

No

35 ± 20 months

SF-36 84%

No perioperative deaths in the ascending or descending groups, but there were 4 deaths (8%) following TAA replacement.

According to disease-specific questions, impotence and pain were reported as major long-term postoperative problems Return to normal activity level was independent of age and procedure. Psychological QoL at follow-up was similar between the groups, but

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Eide et al. (2005) [16]

Study intent and number of patients

Retrospective cohort study

Twenty-nine patients (26%) underwent ascending aortic, 33 (30%) descending aortic and 48 (44%) TAA aneurysm replacement

Overall survival rate was 79 ± 4% at 2 years and 70 ± 5% at 4 years, but was significantly lower with thoracoabdominal versus ascending or descending aortic aneurysms.

Age did not impact QoL, but older patients had improved psychological QoL. Multivariate analysis identified two factors to be independent predictors of impaired late functional status at 12 months: NYHA III or IV and COPD. For the entire group, psychological QoL scores were similar to the age-matched US population, but physical scores were diminished

HRQOL: health-related quality of life; QoL: quality of life; KAS: the Karnofsky activity scale; IIRS: illness intrusiveness rating scale; TAA: thoracoabdominal aneurysm; CVA: cerebrovascular accident; TAAA: thoracoabdominal aortic aneurysm; DTA: descending thoracic aorta.

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Multivariate analysis identified thoracoabdominal aneurysm, advanced age, chronic renal failure and congestive heart failure as predictors of late death

physical QoL was lower after thoracoabdominal aneurysm versus ascending/descending aortic aneurysms.

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Table 3: Studies focusing on endovascular interventions on the thoracic aorta Author, year of publication, study period and study type

Study intent and number of patients

Dick et al. (2008) [14]

Outcome and QoL assessment after open surgical (n = 70) and endovascular (n = 52) intervention on the descending thoracic aorta

2001–05

Surgical centre

University Hospital Bern, Switzerland

Retrospective cohort

Follow-up period

HRQOL instrument used

Key outcomes

Main findings related to HRQOL

Quality score

Evaluation of long-term effects of University of LSA coverage (n = 32) versus Texas Medical non-coverage (n = 50) during School, USA TEVAR on symptoms and return to normal activity in traumatic aortic injury patients

Mean age was significantly higher in TEVAR patients (69 ± 10 vs 62 ± 15 years) as was the proportion of patients undergoing emergency intervention. Average aneurysm diameter significantly larger in the open group (6.8 ± 1.6 vs 5.6 ± 1.6 cm) Not reported specifically in the group undergoing QoL assessment

No

34 ± 18 months

SF-36 and HADS questionnaire 61%

No

4.1 ± 3.7 years

DASH SF-12 63%

Mean age of 46.7 ± 21.7 years (significantly lower age in the LSA uncovered group)

No

3.35 ± 1.9 years

SF-12 ‘LSA questionnaire’ Not reported

Perioperative mortality rates were comparable: 9% (open) and 8% (TEVAR).

Across all domains there was no significant difference in QoL at follow-up when Length of stay significantly higher comparing open and in the open group: 18.3 ± 12.0 TEVAR techniques vs 11.6 ± 9.6 days

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Left arm ischaemia was observed In comparing patients with 4 in 1 patient who required left occluded versus patent carotid to subclavian bypass. LSA, the physical and mental component After TEVAR, 4 of the patients summary of the SF-12 who did not undergo primary and the DASH scores LSA revascularization (3.1%) were comparable and the developed stroke and 2 incidence of left arm patients (1.6%) had paraplegia. ischaemia is low. All but one of these patients had patent LSAs However, during subgroup analysis, in patients with traumatic aortic injury, the PCS was superior when the LSA was patent Not reported No significant difference in 6 SF-12 physical health scores between the two groups. The covered LSA group had significantly better mental health scores. No difference in LSA symptoms between the two groups or in the ability to return to normal activities

HRQOL: health-related quality of life; TEVAR: endovascular treatment of thoracic aortic disease; HADS: Hospital anxiety and depression score; LSA: left subclavian artery; DASH: disabilities of the arm, shoulder and hand; PCS: physical component score; SF-12: 12-item short form health survey.

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Klocker et al. (2014) Report on the incidence of left Medical [22] arm ischaemia, left arm University function and QoL after TEVAR Innsbruck, 1996–2014 by stent grafting with and Austria without coverage of the LSA. Retrospective cohort A total of 138 patients underwent TEVAR, of whom 68 had degenerative aneurysm, 38 traumatic aortic injuries and 36 type B dissection. Seventy-three of these had LSA coverage, of which 9 had LSA revascularization

2005–12

Preop HRQOL assessment

Follow-up completion rate (%)

Post hoc analysis of prospectively collected series

McBride et al. (2014) [29]

Patient characteristics

Table 4: Studies focusing on aortic surgery in the elderly Author, year of publication, study period and study type

Study intent and number of patients

Surgical centre Patient characteristics

Preop HRQOL assessment

Follow-up period

HRQOL instrument used

Key outcomes

Main findings related to HRQOL

Quality score

No hospital deaths in the surgical group. Reoperation for bleeding in 2, prolonged ventilation in 4.

7 Among the survivors at midterm, the QoL was similar between those in the surgical group and those in the medical group

Follow-up completion rate (%) Kurazumi et al. (2014) [26] 2003–12

Yamaguchi University School of Medicine, Japan

Similar baseline patient characteristics between the two groups

No

31.7 ± 26.1 months

SF-36 57.1%

The 5-year survival rate was 61.5% in the surgical group (comparable to an age- and sex-matched general population) and 14.2% in the medical group (significantly lower than a matched population)

‘Frail’ individuals were excluded. In the surgical cases: conventional total arch replacement in 15, debranched TEVAR in 2 and chimney TEVAR in 3 Oda et al. (2004) Investigation into the QoL in Tohoku University, elderly (>65 years) [31] Japan following thoracic aortic surgery (n = 150). 1987–99 Retrospective cohort

Aortic root replacement was performed in 5 (4.5%), interposition graft in 23 (20.7%), total arch replacement in 44 (39.7%), replacement of the thoracic descending aorta in 30 (27.0%) and TAA repair in 9 (8.1%)

Mean age 70.6 ± 4.2 years, No 38.7% were female. 39.6% of patients presented with an aortic dissection

62 (range 13–167) SF-36 months 74%

Overall in-hospital mortality rate was 15.1% and there were no postoperative strokes

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Some measures (physical functioning, role physical, social functioning and role emotional) of QoL after thoracic aortic surgery were lower when compared with a matched normal population, although this seemed to affect younger subgroups more.

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Retrospective cohort

QoL assessment in 47 patients over the age of 80 referred with aortic arch pathology who ideally required surgery (>6 cm): 20 operated on and 27 treated medically (patient choice).

QoL with a prolonged ACP time (>120 min) was associated with significantly lower scores in the dimension of role physical in SF-36. Operative urgency, type of operation and presence of type A dissection did not influence QoL outcomes

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Continued

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Table 4: Continued Author, year of publication, study period and study type

Study intent and number of patients

Surgical centre Patient characteristics

Preop HRQOL assessment

Follow-up period

HRQOL instrument used

Key outcomes

Main findings related to HRQOL

Quality score

Follow-up completion rate (%) Santini et al. (2006) [34] 1990–2004

Tang et al. (2013) [1] 2005–11 Retrospective cohort study

University of Verona, Italy

Mean age was 78 ± 3 years, 52.5% were male and 22.5% had cardiogenic shock on admission

No

Westchester Medical Centre, New York, USA

Octogenarians’ average age was 85 (range 80– 91) years. The younger group had an average age of 60 (range 30–79 years).

No

44 ± 38 months

RAND-36 100%

Surgical procedures were: interposition graft (85%), root replacement (12.5%) and interposition graft with AVR in 2.5%

Comparison of outcomes following type A dissection repair in octogenarians (n = 21) and those aged less than 80 (n = 101). Procedures consisted of 71 ascending/hemiarch replacements, 22 Bentall procedures, 2 David procedures, 4 Wheat procedures and 2 total arch replacements

The two groups had similar preoperative characteristics, but the younger group experienced significantly more malperfusion and had a significantly longer DHCA time

17 ± 16 months in octogenarians and 20 ± 18 months in the younger group

RAND-36 84%

QoL revealed a generalized 6 In-hospital mortality rate perception of was 30% and neurological independence and impairment occurred well-being, comparable in 20%. to an age-matched population. Cardiac tamponade emerged as the only Seventy-four percent of predictor of in-hospital survivors were in NYHA mortality. class 1 For discharged patients, actuarial survival rate at 1, 5 and 7 years was 93 ± 5, 80 ± 8, and 80 ± 8%, respectively The overall in-hospital 8 Physical functioning was mortality rate was 9% and significantly better in the the stroke rate was 5%. younger group, whereas emotional health scores Among the octogenarians, in the octogenarian there were no in-hospital group were better than deaths. those of the younger patients There was no difference in postoperative outcomes between the two groups

HRQOL: health-related quality of life; TEVAR: endovascular treatment of thoracic aortic disease; QoL: quality of life; TAA: thoracoabdominal aneurysm; ACP: antegrade cerebral perfusion; AVR: aortic valve replacement; NYHA: New York Heart Association grading of shortness of breath; DHCA: deep hypothermic circulatory arrest.

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Retrospective cohort

Clinical outcome and QoL analysis in 40 patients aged 75 and older undergoing type A dissection repair.

Table 5: Studies focusing on neurological outcomes and cerebral protection only Author, year of Study intent and number of publication, patients study period and study type

Surgical centre

Immer et al. (2004) [4]

University Hospital Berne, Switzerland

1994–2002

Preop HRQOL assessment

Follow-up period

HRQOL instrument used

Key outcomes

Main findings related to HRQOL

Quality score

Follow-up completion rate (%) Mean age of patients was 60.8 ± 13.3 years of whom 74% were male.

No

2.4 ± 1.2 years

SF-36 86.7%

167 patients had type A dissection and 187 had an aortic aneurysm

A total of 363 patients undergoing surgery of the thoracic aorta with DHCA. These were split into DHCA times of 30 min DHCA group (33.9%). Average QoL score was significantly better with the use The use of ACP did not reduce of ACP, independent of the the incidence of neurological duration of DHCA. The use of events ACP, however, improved the averaged QoL score at each time period and allowed DHCA to be extended up to 30 min, without impairment in midterm QoL.

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When DHCA time increased above 20 min, these patients had a QoL at follow-up significantly lower than an ageand gender-matched standard population in the domains of physical functioning, social functioning and vitality.

Immer et al. (2008) [20] 1994 onwards Retrospective cohort study

To assess the impact of continuous cerebral perfusion via the RSA on immediate outcome and QoL. Total of 567 consecutive patients who underwent surgery of the aortic arch using DHCA. Divided into three groups based on

University Hospital Berne, Switzerland

Preoperative characteristics were ‘similar’ in all three groups, although there were significantly more type A dissections in the group receiving CCP

No

2.4 ± 1.2 years

SF-36 80.0%

Major perioperative cerebrovascular injuries were observed in 1.1% of patients with CCP via the RSA compared with 9.8% with selective ACP and 6.5% in the group with no ACP (all significant)

QoL was superior in patients with thoracic aortic aneurysms when compared with those with acute type A dissections, but this is likely to be related to the DHCA time and not the type of the disease 9 Average QoL scores up to 20 min of DHCA were similar in all three groups and also comparable to an age- and sex-matched standard population.

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Retrospective cohort study

Assessment of the impact of DHCA duration and the potential impact of ACP on midterm QoL.

Patient characteristics

Average QoL after a DHCA time of 30–50 min with CCP through the RSA was significantly higher than with selective ACP. In

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Continued

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Table 5: Continued Author, year of Study intent and number of publication, patients study period and study type

Surgical centre

Patient characteristics

Preop HRQOL assessment

Follow-up period

HRQOL instrument used

Key outcomes

Retrospective cohort

addition, postop QoL without CCP in this time group was significantly lower than a standardized population. The QoL limitations found above were mainly found in the aspects of vitality and social and physical function.

University Medical Centre Regensburg, Germany

All patients underwent replacement of the ascending aorta, combined with hemiarch (n = 33) or total (n = 46) arch replacement.

Krahenbuhl et al. Assessment of the influence of TND (confusion, delirium (2008) [24] and agitation with a GCS of 1996–2005 6 cm arch aneurysms, and found that in those operated on (20 patients), both HRQOL and 5-year survival was comparable to an age- and sex-matched population. While these findings must be interpreted in the context of the quality and sample size of the studies, they suggest that clinicians should not be dismissive about long-term HRQOL in patients undergoing major and emergency aortic surgery over the age of 80. Surely it is not age alone, but comorbidity which is the incremental factor.

Cerebral protection and neurological outcomes Neurological injury (in particular, paraplegia) is a complication dreaded by patients and clinicians due to its potential impact on short- and long-term outcomes. Krahenbuhl et al. assessed the influence of temporary neurological dysfunction (TND; confusion, delirium or agitation) in 917 patients undergoing proximal aortic surgery. In the 9.8% of patients who suffered from TND, HRQOL was significantly impaired in all domains except that of bodily pain. Predictors for TND included older age, preoperative haemodynamic compromise and the use of DHCA. In patients who did not suffer from TND, follow-up HRQOL was comparable to a normal population [24]. Four studies reported HRQOL in relation to the type of cerebral protection strategy used [4, 20, 23, 25]. Three of these originated from the same centre (University Hospital Berne) and while the patient populations overlapped, each study examined a different question. Immer et al. [4] demonstrated that, in 363 consecutive patients undergoing proximal aortic surgery, the prolonged use of DHCA (i.e. over 20 min) was associated with impaired HRQOL at follow-up when compared with a normal population. They developed on this in further studies associating the use of right subclavian cannulation (with continuous and bilateral cerebral protection) with the most superior mid-term HRQOL, comparable to a normal population [20, 25]. Interestingly, in the latest of the three studies by the University of Berne [44], incidence of postoperative neurological dysfunction was similar in all four DHCA protection strategies (i.e. DHCA alone, selective antegrade cerebral perfusion, right axillary antegrade cerebral perfusion and right axillary perfusion with an additional catheter in the left carotid artery) yet HRQOL was significantly higher in the latter group (especially in physical functioning, social functioning and vitality—all markers of everyday activity). This potentially suggests that HRQOL instruments can be more sensitive in highlighting long-term neurological function than clinical evidence of neurological dysfunction. The above findings are not surprising considering that in animal models, at a temperature of 20°C, 20% of brain metabolism is still present. Even at a temperature of 8°C (at which cerebral autoregulation will have been lost), 11% of activity is present, suggesting the possibility of incomplete protection and diffuse brain injury if DHCA alone is used [4]. Other animal models have also shown a reduced apoptosis rate in the hippocampus and preserved oxygen tension with the addition of ACP [45–47]. Based on this, right axillary cannulation with bilateral continuous cerebral

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protection seems to be the most simple and effective method of cerebral protection. Controversy surrounds the specific technique of cannulation used, and the incidence of right arm dysfunction (up to 20%) and brachial plexus injury ( probably 2%) must be taken into account [20]. Side-graft cannulation may be more acceptable because of its lower complication rate [48, 49].

Study limitations The analysis in this review must be interpreted with an understanding of the limitations of the studies included. Of the 30 studies, 27 were retrospective and only 1 contained an element of randomization. The lack of the experimental element of randomization leads to differences in the baseline characteristics of patients (which have been highlighted where appropriate in the tables). Given the multiple comorbidities in patients with thoracic aortic disease, this makes the area particularly prone to heterogeneity. Without randomization, there is also lack of adjustment for individual surgeon-related morbidity in techniques known to have a long learning curve and wide variation in specific techniques employed. A number of patients were operated on over 20 years ago, since when the overall management of patients has changed significantly. While the overall mean follow-up was 81.1%, only one study reported baseline HRQOL and both the instruments (17 different instruments used) and follow-up time period varied significantly between the studies. This makes comparison of outcomes particularly challenging. Of the 30 studies, only 40% were rated as high quality and only one of the studies (which was randomized) scored full marks. Bias is likely to be an issue at both the institutional and responder level. Patients with the poorest HRQOL are unlikely to respond to postal and telephone surveys leading to artificially elevated results. Institutions are also likely to introduce bias by not reporting poor outcomes and making more effort in publishing and presenting those they are particularly proud of (a number of studies in this review are from the same institution).

Suggestions for future research Despite HRQOL cardiac surgery outcomes appearing in the literature around 40 years ago [50], it is surprising to see that there is only one prospective randomized trial reporting such outcomes in patients undergoing aortic surgery [17]. Given that patients value HRQOL so significantly, it is important that all future aortic trials include baseline and postoperative (at specified time points) HRQOL assessment. SF-36 was the most popular instrument used in this study and has previously been recommended in the assessment of CABG patients [6]. Aortic surgery has its own peculiarities and while there has been a consensus on the need for more data collection [51], no mention has been made of which instruments should be used for HRQOL data collection. Technology has advanced significantly over the last decade and clinicians must perform more innovative HRQOL analysis, e.g. through the use of wrist-worn accelerometers [52] or the correlation of HRQOL data with biomarkers or computational modelling findings such as aortic shear wall stress and pulse wave velocity [53, 54]. It is critical that the above issues are addressed so that aortic surgeons are equipped in an evidence-based way to face increased expectation of excellent results (even in the high-risk

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patients) and the predicted increase in aortic surgery, which will come with the increasingly aged western population [55]. This increase will also demand a thorough assessment of the efficacy of techniques which are more frequently being employed (i.e. endovascular and hybrid techniques). A summary framework of the factors influencing HRQOL in aortic surgery based on the studies included is shown in Fig. 3.

CONCLUSIONS HRQOL following aortic surgery on the whole is acceptable and often comparable (even in the elderly and high-risk patients) to a healthy age- and sex-matched population. Baseline characteristics of patients with descending thoracic aortic disease tend to be poorer and this may be related to the multiple comorbidities these patients tend to have. There is only one prospective randomized trial in the whole of the aortic surgery literature examining HRQOL outcomes. This probably reflects the fact that it is seen as a ‘soft’ outcome in current evidence-based aortic policymaking. This represents a misunderstanding of the utility of HRQOL, as preservation or improvement should be the principal goal of all elective aortic surgery. To be completely candid with patients, aortic surgeons must understand HRQOL outcomes when obtaining the consent of patients for such major procedures [56].

Funding This research supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Imperial College Healthcare NHS Trust and Imperial College London.

[12]

[13]

[14]

[15]

[16]

[17]

[18]

[19]

[20]

[21]

[22]

Conflict of interest: none declared. [23]

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AORTIC SURGERY

O.A. Jarral et al. / European Journal of Cardio-Thoracic Surgery

Quality of life after intervention on the thoracic aorta.

Surgery on the thoracic aorta is challenging and historically associated with significant mortality and morbidity. In recent times, there has been inc...
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