Keywords
Type A aortic dissection - quality of life - aortic surgery - reintervention - multicenter
study
Introduction
Acute Type A aortic dissection (ATAAD) is a life-threatening condition that carries
a high mortality without surgical treatment. Mortality and morbidity after ATAAD repair
are still significant. The International Acute Aortic Dissection Registry reported
18 to 20% mortality after surgery. Associated morbidity such as neurological complications,
renal failure, and long in-hospital stay have strong impact on patients' recovery.[1]
In the United Kingdom in 2020, there were 4,106 deaths registered as aortic aneurysm
and dissection, which in an island of nearly 60 million residents in England and Wales,
is equivalent to 7 per 100,000 population. Mean age was over 60 years, and the majority
were male. Therefore, with an average population of 2 million per region in United
Kingdom, roughly 140 people are expected to die annually from this disease.[2]
Reintervention rate following proximal aortic repair for ATAAD is 20 to 40%, with
5-year mortality reported as 15 to 30% and 10-year mortality as 40 to 50%.[3]
Immediate postoperative results as well as mid and long-term survival after ATAAD
repair have been extensively reported in the literature. Quality of life (QoL) following
ATAAD repair has been reported less extensively using systematic reviews applying
generic QoL questionnaires.[4] QoL with a specific tool designed for ATAAD survivors is yet to be investigated
in detail.
Patients and Methods
Selection Criteria
Invitation to participate was sent to the Aortic Surgery leads in all Cardiothoracic
Surgery units in the country but only eight centres consented to participate.
Once the centre accepted to participate, the patients who underwent ATAAD in that
institution within the last 5 years were identified and those who were alive and contactable
were invited to participate.
We limited the study to 5 years to facilitate clinical data collection and to maximize
recollection of events and experiences pre- and postsurgery. It was mandatory that
both the patient and the clinical questionnaire was completed for each patient. Quesionnaires
were sent and collected between 2021 and 2022. Mean period since ATAAD surgery was
2.4 (0–5) years.
Exclusion criteria were patients who died before the start date of the study, <18
years old, or unable to give consent for any reason.
Systematic Literature Review
We conducted a systematic literature review prior to the study. The search included
all studies on the QoL in cardiac and aortic surgery published on Embase, Medline,
and the Cochrane Library from January 2002 to January 2022, including the terms “Type
A Aortic Dissection,” “Quality of Life,” “re-intervention,” “multicentre study,” and
“survivorship” in English, Spanish, German, and French manuscripts were analyzed for
review. Meta-analysis was not conducted due to the lack of similarities between studies;
however, observational studies and case series studies were included. Study quality
and risk of bias and disagreements were assessed using the Agency for Healthcare Research
and Quality methodology checklist and the Cochrane collaboration tool. The inclusion
criteria followed the P.I.C.O. model. Primary outcomes (eligibility criteria): (1)
identify QoL tools currently used in clinical practice, (2) determine QoL in ATAAD
population, (3) report the key survivorship domains evaluated by these tools. Results
are summarized in [Fig. 1].
Fig. 1 Timeline of the systematic literature review for studies about quality of life in
aortic dissection survivors. From a total of 1,421 studies identified initially, only
24 were fully reviewed after applying the eligibility criteria explained in the methods.
Details of the type of studies are provided on the table. AD, aortic dissection; QoL,
quality of life; TAAD, Type A aortic dissection; TBAD, Type B aortic dissection; TEVAR,
thoracic endovascular aortic repair.
Study Design
The questionnaire was tested and refined with a relevant patient public involvement
group from the UK Aortic Dissection Awareness survivors' group. Ethical approval from
IRAS (Integrated Application System) was obtained in 2021(REC reference: 21/WM/0071).
Data were collected via two methods: (1) QoL questionnaire for the patient and (2)
database for the local clinical team providing demographics, surgical details, and
complications for each patient enrolled. Each local Principal Investigator allocated
a single patient link code anonymising identifiable data to the national database.
The Chief Investigator ensured that the pseudoanonymized databases and questionnaires
were analyzed and kept securely and performed the final analysis.
Patient Questionnaires: Domains and Definitiions
The five QoL domains explored were:
-
Physical and emotional health: the patient was asked how they would describe their
own health before and after surgery.
-
Impact on physical activities: compared fitness of the patient before and after surgery.
They were asked to describe how many regular activities involving physical efforts
(i.e., running, cycling, weightlifting, sexual activities, walking, team sports),
they could confidently perform. This section included a description of the activity
they were doing when they experienced the ATAAD symptoms.
-
Impact on regular activities: impact of surgery on patient's daily physical activities,
focusing on any difficulties with daily physical independence due to deterioration
postsurgery, goals, and accomplishments compared with baseline. They were asked to
describe how independent they were in specific tasks such as housework, groceries,
or independent mobilization. This section included a detailed description of current
pain and any long-term complications related to the ATAAD.
-
Impact of aortic dissection on capabilities: this section targeted the burden of the
aortic dissection in the patient's everyday work–life and any adjustments required
after the surgery.
-
Impact on social and emotional well-being: how the patient was feeling overall after
surgery, any interferences with social activities including private and family life,
travelling, and social interaction. This was not intended to be a formal assessment
of mental health but an analysis of the emotional burden of the ATAAD as chronic disease.
Full questionnaires can be found in [Supplementary Appendix S1] (available in online version only).
Data Availability Statement
The data underlying the analysis of this article will be shared on reasonable request
to the corresponding author. Questionnaire answers cannot be shared publicly to protect
the privacy of the individuals that participated in the study.
Statistical Analysis
The expected minimum or clinically meaningful effect size sought was n = 100, based on sample calculations (QuestionPro software) on the estimated number
of survivors, the volume of patients operated in each participating centre and the
final number of patients recruited. We recognize that as a small sample with unavailable
pilot data to use, our statistical methods were limited to our own sample size. Statistical
analyses were performed using SPSS v 30.
Continuous variables were presented as mean (standard deviation, SD; range), and categorical
data using frequency and percentage. The Saphiro–Wilk test for normality was applied
as p < 0.05.
Two-sided chi-squared or Fisher's exact text were used to compare categorical variables
among groups as appropriate. The baseline differences for demographic and clinical
variables across each group were analyzed with the nonparametric test of Kruskal–Wallis
and/or chi-squared as appropriate.
Validation and Correlation of the Questionnaire with the Variables Studied
The validation of the questionnaire followed a stepwise approach:
-
Step 1. Cronbach alpha analysis to assess scale reliability (Cronbach alpha = 0.84,
good)
-
Step 2. Exploratory factor analysis to assess how many domains our questionnaire can
assess. Each domain contains a group of questions ranked to score evaluated under
the Kaiser/Meyer/Olkin of Sampling adequacy (=0.743, significative >0.6) and Bartlett's
test of Sphericity (=0.000, significant <0.05). A total of five domains were identified
by the validation process: each domain obtained a score, and its summative gave the
total QoL assessment score ([Fig 2]). The questionnaire was ranked by different punctuation in each question by the
clinician, with a range 0 to 60 total points (the more points scored, the worse the
QoL). Minimum punctuation was 8 points.
Fig. 2 Summary of the steps followed for the statistical validation of the patient's questionnaire.
CFI, Compariative fit index; RMSEA, root mean square error of approximation.
This allowed to identify three groups of QoL (Good: < 25 points, Fair: 24–45 points,
and Poor: 45–60 points), which then were analyzed from the Investigator's questionnaire,
and the significative variable assessed to ascertain which domains of the QoL were
affected ([Fig. 3]).
Fig. 3 Combination of bar charts displaying the results of the patient questionnaire's,
according the three different groups (Good, Fair, and Poor) based on the scoring for
overall quality of life and the five different domains assessed.
-
Step 3. An AMOS confirmatory factor analysis was performed to confirm the validation
of the questionnaire with a positive result with root mean square error of approximation
(=0.038, significative from 0.03 to 0.46) and comparative fit index (CFI = 0.912 (0.902–0.928)).
-
Step 4. Correlation of the variables from the clinical database and the three QoL
groups identified was performed using either correlation coefficient for numerical
data or chi-square test for categorical data ([Fig. 3]).
Results
Patient Demographics
A total of 162 patients who underwent ATAAD repair over the period (2018–2022) were
recruited among eight centres across the United Kingdom that agreed to participate
in the multicenter study.
Patients were predominantly male (n = 104 [64.2%]) with a mean age of 63 (12; 24–92) years.
Patient's Questionnaire Results
The total score of each patient from the five domains of questions, provided the overall
QoL Score of Good 67 (41%), Fair 89 (55%), Poor 6 (4%).
The areas of QoL that were less impacted by the TAAD were regular activities and social
and emotional well-being, with the majority of the patients scoring Good on those
categories (89 and 77%, respectively).
Conversely, physical activities was the area where more patients scored Fair (42%)
and/or Poor (38%) QoL. The impact on physical and emotional heath (which compared
their overall perception when comparing themselves pre- and postsurgery) also showed
predominant Fair (51%) and Poor (11%) QoL scores. Finally, the impact on their work–life
(capabilities) was balanced between Good (50%) and Fair/Poor (50%; [Fig. 3]).
Time Elapsed between Surgery and Survivor's Answers
The questionnaires assessed QoL at two different points in time: ATAAD repair and
when the questionnaire was received. A subgroup analysis was perfomed taking account
of the age at these two time points. Mean age of participants at the time of surgery
with respect to the oveall QoL scores was: Good (mean 60 years), Fair (mean: 62 years),
and Poor (mean: 53 years). Mean current age of survivors when answering the questionnaire
was: Good (mean: 62 years), Fair (mean: 64 years), and Poor (mean: 56 years). There
was no statistical difference between groups (p = 0.408).
Overall QoL scores were also analyzed with respect of time from surgery, and no statistical
diference was found among groups (p = 0.275). A total of 43 patients answered the questionnaire during the first year
after surgery (POY1) reporting a QoL: Good 20 (12.3%), Fair (13.6%), and Poor 1 (0.6%).
A total of 21 patients completed the questionnaire during the 2nd year after surgery
(POY2) with Good 8 (4.9%), Fair 10 (6.2%), and Poor 3 (1.9%) overall QoL scores. A
total of 24 patients at POY3 reported Good 12 (50%) and Fair 12 (50%) overall QoL
scores. The largest group was on POY4 (n = 69) and reported Good 25 (15.4%), Fair 42 (25.9%), and Poor 2 (1.2%) overall QoL.
Only five patients at POY5 reportinged Good 2 (1.2%) and Fair 3 (1.9%) QoL scores.
Investigator's Questionnaire Results
Comorbidities such as hypertension, smoking history, previous myocardial infarction
(MI) and peripheral vascular disease were significantly predominant in groups who
score Poor QoL (p < 0.05). Preoperative comorbidities and risk factors are described in [Table 1].
Table 1
Demographics, risk factors, and preoperative comorbidities according to the three
different quality of life scoring groups
|
Good
n = 67
|
Fair
n = 89
|
Poor
n = 6
|
p
|
|
Age, mean years (SD, range)
At present time
At time of surgery
|
62
(10; 40–82)
60
(11; 36–80)
|
64
(13; 24–92)
62
(14;20–87)
|
56
(12; 40–71)
53
(12; 37–68)
|
0.549
0.175
|
|
Sex
Male
Female
|
42 (63%)
25 (37%)
|
59 (66%)
30 (34%)
|
3 (50%)
3 (50%)
|
0.660
|
|
Status at time of referral
Unstable
Stable
|
32 (48%)
35 (52%)
|
51 (57%)
38 (43%)
|
5 (83%)
1 (17%)
|
0.163
|
|
Presentation with syncope
|
6 (9%)
|
5 (6%)
|
0
|
0.149
|
|
Presence of pericardial effusion
|
6 (9%)
|
12 (13%)
|
1 (17%)
|
0.804
|
|
Hypertension
|
45 (67%)
|
63 (71%)
|
5 (83%)
|
0.016
|
|
Diabetes
|
5 (7%)
|
9 (10%)
|
1 (17%)
|
0.707
|
|
Hypercholesterolemia
|
18 (27%)
|
25 (28%)
|
4 (67%)
|
0.334
|
|
Smoking history
Current smoker
Ex-smoker
Nonsmoker
|
10 (15%)
23 (34%)
34 (51%)
|
11 (12%)
33 (37%)
45 (51%)
|
1 (17%)
3 (50%)
2 (33%)
|
0.035
|
|
Chronic pulmonary disease
|
10 (15%)
|
11 (12%)
|
1 (17%)
|
0.292
|
|
Previous MI
One
Two or more
|
8 (12%)
2 (3%)
|
14 (16%)
0
|
1 (17%)
0
|
0.007
|
|
History of neurological disease
TIA or RIND
CVA with full recovery
CVA with residual deficit
|
8 (12%)
6 (9%)
1 (2%)
|
4 (5%)
0
3 (3%)
|
0
0
0
|
0.033
|
|
Peripheral valvular disease
|
25 (37%)
|
27 (30%)
|
3 (50%)
|
0.025
|
|
Preoperative heart rhythm
SR
AF
|
51 (76%)
16 (24%)
|
64 (72%)
26 (29%)
|
5 (83%)
1 (17%)
|
0.476
|
|
Previous cardiac surgery
|
13 (20%)
|
11 (16%)
|
2 (33%)
|
0.863
|
|
Creatinine, mean mmol/L
(SD, range)
|
100.7
(31; 43–187)
|
102
(46; 44–322)
|
88.7
(19; 71–119)
|
0.058
|
Abbreviations: AF, atrial fibrillation; CVA, cerebrovascular accident; DVT, deep venous
thrombosis; MI, myocardial infarct; PCI, percutaneous coronary intervention; PVD,
peripheral vascular disease; RIND, reversible ischemic neurological defect; SD, standard
deviation; SR, sinus rhythm; TIA, transient ischemic attack.
Index surgeries performed for the ATAAD repair root and ascending aorta replacement
(61, 38%), ascending aorta replacement (81, 50%) aortic arch replacement (including
elephant trunk techniques, [20, 12%]; [Table 2]).
Table 2
Surgical procedures used for the initial Type A aortic dissection repair
|
Surgical procedures offered for the aortic dissection repair
|
n (%)[a]
|
|
Root + ascending aorta replacement
|
61 (38%)
|
|
Ascending aorta replacement
|
81 (50%)
|
|
Aortic arch replacement
|
20 (12%)
|
a Concomitant aortic valve replacement, n = 11 (7% of total).
Regarding the impact of different surgical procedures in QoL, only patients who underwent
arch replacement showed a significant overall QoL score difference among groups (p = 0.016, Good 7 (35%), Fair 10 (50%), and Poor 3 (15%)).
Length of surgery (including cardiopulmonary bypass [CPB], cross-clamp and systemic
circulatory arrest) was significantly longer in those who scored Poor QoL questionnaires.
Intraoperative data are described in [Table 3].
Table 3
Intraoperative data, including surgical times and cerebral protection strategies according
to the three different quality of life scoring groups
|
Good
n = 67
|
Fair
n = 89
|
Poor
n = 6
|
p
|
|
Ejection fraction
Normal/mildly impaired (>40%)
Impaired (<40%)
|
55 (82%)
12 (18%)
|
75 (83%)
14 (11%)
|
6 (100%)
0
|
0.655
|
|
Severity of aortic regurgitation
Nil
Mild
Moderate
Severe
Unknown
|
20 (30%)
6 (9%)
8 (12%)
4 (65)
29 (43%)
|
19 (21%)
5 (6%)
20 (22%)
10 (11%)
35 (39%)
|
0
1 (17%)
2 (34%)
0
3 (50%)
|
0.165
|
|
CPB time, mean min (SD, range)
|
223.83
(82; 62–447)
|
236.58
(84; 92–506)
|
342.33
(131; 223–575)
|
0.041
|
|
Cross clamp time, mean min (SD, range)
|
133.38
(64; 29–348)
|
131
(61; 29–346)
|
180
(96; 86–349)
|
0.077
|
|
Systemic circulatory arrest time, mean min (SD, range)
|
47.66
(43; 0–180)
|
58.19
(64; 0–344)
|
98.50
(78; 134–349)
|
0.007
|
|
Core temperature, mean °C (SD, range)
|
21.95
(3; 18–35)
|
22.14
(4; 18–36)
|
20.33
(2; 18–24)
|
0.719
|
|
Cerebral protection time, mean min (SD, range)
|
33.46
(26; 0–131)
|
38.80
(28; 0–249)
|
48.33
(30; 16–101)
|
0.335
|
|
Cerebral protection strategy
None
Antegrade
Retrograde
|
17 (25%)
48 (72%)
2 (3%)
|
9 (10%)
68 (76%)
12 (13%)
|
0
6 (100%)
0
|
0.366
|
|
Arterial cannulation site
Femoral
Central
Axillary
Innominate
|
33 (49%)
21 (31%)
8 (12%)
5 (8%)
|
40 (45%)
37 (42%)
10 (11%)
2 (2%)
|
3 (50%)
3 (50%)
0
0
|
0.291
|
Abbreviations: CPB, cardiopulmonary bypass; SD, standard deviation.
A correlation analysis confirmed the duration of systemic circulatory arrest to have
negative impact on the regular activities (R 0.411, Sig 0.000); however, duration
of CPB, cross clamp, and cerebral protection did now show further correlation with
the QoL scores.
Complications such as reoperation for bleeding, sternal wound infection, and any neurological
impairment were significantly predominant in the group who reported Poor QoL. Those
who suffered TIA or cerebrovascular accident (CVA) with full recovery reported an
overall Good QoL score, whereas those who had a CVA with a residual deficit (n = 9) scored predominantly a Fair QoL score. Those who required transfer to another
hospital also reported predominantly a Poor QoL. Postoperative complications are summarized
in [Table 4].
Table 4
Postoperative complications according to the three different quality of life scoring
groups
|
Good
n = 67
|
Fair
n = 89
|
Poor
n = 6
|
p
|
|
Postoperative MI
|
0
|
3 (3%)
|
0
|
0.033
|
|
Reoperation for bleeding
|
12 (18%)
|
7 (8%)
|
3 (50%)
|
0.005
|
|
Postoperative arrhythmias
|
25 (37%)
|
41 (46%)
|
1 (17%)
|
0.271
|
|
Sternal wound infection
|
3 (5%)
|
4 (4.5%)
|
2 (34%)
|
0.010
|
|
Pulmonary complications
Chest infection/HAP
Atelectasis
Pneumothorax
Pulmonary oedema
NIV/BiPAP/CPAP
ARDS
Tracheostomy
|
14 (21%)
4 (6%)
0
1 (1.5%)
0 (
5 (7.5%)
2 (3%)
|
11 (12%)
12 (13%)
1 (1%)
5 (6%)
3 (3%)
10 (11%)
2 (2%)
|
0
0
0
1 (17%)
0
1 (17%)
0
|
0.986
|
|
Permanent pacemaker
|
5 (7.5%)
|
8 (9%)
|
0
|
0.642
|
|
Postoperative hemofiltration
|
14 (21%)
|
16 (18%)
|
0
|
0.437
|
|
Gastrointestinal complications
|
9 (13%)
|
22 (25%)
|
0
|
0.106
|
|
Sepsis
|
6 (9%)
|
6 (7%)
|
2 (34%)
|
0.235
|
|
Neurological complications
Postoperative delirium
Transient stroke
Permanent stroke
Paraplegia
|
6 (9%)
9 (13%)
1 (1.5%)
0
|
11 (12%)
24 (27%)
3 (3%)
0
|
1 (17%)
3 (50%)
1 (17%)
1 (17%)
|
0.001
|
|
Length of hospital stay, mean days (SD, range)
|
22 (14)
|
19 (15)
|
25 (16)
|
0.170
|
|
Destination at discharge
Home
Other hospital
Specialised care facility
|
61 (91%)
6 (9%)
0 (0)
|
78 (88%)
10 (11%)
1 (1%)
|
5 (83%)
1 (17%)
0
|
0.040
|
|
Residual proximal aortic disease
|
9 (13%)
|
12 (13%)
|
0
|
0.631
|
|
Residual distal aortic disease
|
29 (43%)
|
47 (53%)
|
3 (50%)
|
0.539
|
|
Reintervention during the follow-up
|
5 (7.5%)
|
6 (7%)
|
0
|
0.783
|
Abbreviations: ARDS, acute respiratory distress syndrome; HAP, hospital-acquired pneumonia;
MI, myocardial infarction; SD, standard deviation.
Postoperative neurological complications showed significant impact on three domains:
overall QoL (p = 0.039), impact on regular activities (p = 0.012), and impact on physical activities (p = 0.052). Reopening for bleeding and wound infection also affected overall QoL (p = 0.005 and 0.010), and wound infection specifically impacted on physical and emotional
health (p = 0.004). Postoperative MI showed impact on social and emotional well-being (p = 0.033), whereas postoperative arrhythmias showed impact on capabilities (p = 0.020). Destination at discharge showed impact on regular activities (p = 0.040; [Table 5]).
Table 5
Summary of the statistically significant results showing correlation between clinical
variables and quality domains affected
|
Quality of life
|
|
Variable
|
Domain
|
p-Value
|
|
Neurological complications
|
Overall quality of life
Impact on regular activities
Impact on physical activities
|
0.039
0.012
0.052
|
|
Time (min) circulatory arrest
|
Impact on regular activities
|
R 0.411 Sig 0.000
|
|
Reopening for bleeding
Postoperative MI
Postoperative arrhythmias
|
Overall quality of life
Impact on social an emotional well-being
Impact of aortic dissection on capabilities
|
0.005
0.033
0.020
|
|
Wound infection
|
Overall quality of life
Physical and emotional health
|
0.010
0.004
|
|
Status at discharge
|
Impact on regular activities
|
0.040
|
Abbreviation: MI, myocardial infraction.
Mean period since ATAAD was 2.4 (0–5) years. Eleven patients (7%) have already undergone
an aortic reintervention during that period, whereas 21 patients (13%) have a degree
of proximal disease (root aneurysm and/or residual dissection) and 79 patients (49%)
are on surveillance for residual distal aortic disease (residual arch and/or thoracoabdominal
dissection).
Discussion
QoL after cardiac surgery has been identified as number one at Top 10 research priorities
by the National Cardiac Surgery Clinical Trials Initiative in the United Kingdom.
However, the QoL tools used are often too generic and do not capture the challenges
survivors of TAAD have to face during their recovery. None of these tools were tailored
for TAAD survivors, had input from patients and surgeons, or had been statistically
validated for this cohort of patients.
Previous reports of QoL in TAAD survivors have used different tools, including the
SF-36, SF-12, EQ-5D: Bartell Index, WHO performance scale, and/or PROMIS. There are
previous reports demonstrating a general QoL decline following TAAD, especially lower
physical and general health scores in ATAAD survivors when compared with the normal
population.[5]
[6]
[7]
[8]
[9]
[10]
Other series, however, reported the majority of survivors of ATAAD are able to regain
physically active lives,[9] with comparable QoL to healthy subjects after the first postoperative year[11] and comparable physical and mental scores at 10 years.[11]
[12]
[13]
Limitations of these questionnaires are not being able to discriminate between regular
and physical activities and not considering baseline physical condition and patient's
goals postsurgery.
Hence, QUADS designed different domains to assess QoL after ATAAD from a consensus
between patients and surgeons.
Our study has proven that the overall QoL after TAAD is excellent, with only 4% of
the patients scoring Poor in the overall QoL category. We proved that QoL in TAAD
survivors is not affected significantly in their daily regular activities and working
life; however, they are less likely to be able to perfom intense physical activities
compared with their basline prior the dissection.
Preoperative comorbidities suchas as hypertension, smoking history, previous MI, and
peripheral vascular disease were predominant in the Poor QoL scores, not surprisingly
due to the chronic effects they cause in individuals health and physical capacity.
We also identified a significant lower QoL scores for those who underwent arch surgery,
whereas the other surgical procedures offered did not show siginifcant differences
in the QoL scores reported. We also found a significant longer surgical times for
those who reported Poor QoL. Further correlation analysis demonstrated the duration
of circulatory arrest as main risk factor for lower QoL scores. We observe in our
group of survivors that those who underwent a longer systemic circulatory arrest (such
arch replacement when compared with other repair techniques limited to the ascending
aorta and/or aortic root) reported worse QoL scores and presented higher rate of postoperative
complications, especially neurological.
We found that developing postoperative neurological complications impacted overall
QoL scores but specifically physical and regular activities, even considering the
lower number of patients with CVA and residual deficit in our cohort.
Not surprisingly, other postoperative complications such as reoperation for bleeding,
sternal wound infection, and development of arrhythmias also impacted several domains
of the QoL, likely related to the prolonged hospital length of stay that these complications
associate. The fact that those who were discharged to another hospital facility rather
than home also reported lower QoL reflects the likely complex postoperative period
that they suffered that required extra time for hospitalization and/or rehabilitation.
QUADS study could not discriminate the responses according to age decades and specifically
in elderly patients due to the sample size. There are conflicting findings in the
literature, where some studies showed significantly lower PCS in subjects > 70 years;[14]
[15]
[16]
[17] while others did not demonstrate significant differences between young and elderly
patient groups.[18]
[19]
QUADS study does not have a formal mental health component as we consider this sphere
complex enough to produce its own study. Across the literature, younger patients scored
worse when compared with elderly patients, with increased posttraumatic stress disorder,
sexual dysfunction, and travelling phobia.[17]
[20] Although QUADS study recognizes significant levels of anxiety across the responses
and overall comments of the patients, we could not find sexual dysfunction in our
sample in any group age.
ATAAD survivors demonstrated an interest in understanding the cause of the dissection,
the surgical details, and any subsequent problems that might occur. Most of the patients
reported that they have not had significant physical effects on daily life but would
have appreciated extra reassurance and specific guidance in areas such exercise, diet,
and how to manage long-term care. A significant number of patients reported the lack
of follow-up in their local area, mostly being followed up once a year.
Our study has significant limitations, including the selection bias limited to both
patient and unit willingness to participate in the study, especially the former might
have contributed to an overestimated QoL. We also aknowledge the limitation to account
for mortality and/or postoperative complications that cause a significant disability,
as we can only include survivors and individuals with capacity to consent. Also, the
time elapsed since surgery has not been considered as modifying variable; hence, those
who had more time to recovery from surgery might have score higher in several domains.
However, being a multicenter study with representation from different United Kingdom
nations and regions adds into consideration the geographical diversity and ethnical
influence in the recovery.
Future reseach implications that might arise after the creation of the QUADS questionnaire
include a prospective application for patients prior to hospital discharge and at
agreed intervals as well as a wider distribution including larger populations and
wider geographical and demographical areas to eliminate the selection bias.
Conclusion
QUADS is the first validated tool to assess QoL after ATAAD Surgery. Patient's answers
showed a predominantly overall Good QoL after ATAAD surgery in the United Kingdom.
Neurological complications, duration of circulatory arrest, reoperation for bleeding,
postoperative MI and arrhythmias, wound infection, and destination at discharge were
identified as main variables impacting QoL after ATAAD surgery across different domains
of this questionnaire.
