Long-Term Survivors of Aortic Replacement Report Good Health-Related Quality of Life

Life is good, say long-term survivors of extensive replacement of the aorta for severe pathologies such as aneurysmal disease. In a survey of patients who underwent this surgery at Cleveland Clinic, physical quality of life was only slightly worse than that in the general population, and mental quality of life was about the same. Results were comparable regardless of the surgical approach used (open surgery vs. a hybrid open-endovascular approach). The report was published online in Seminars in Thoracic and Cardiovascular Surgery.

“These findings indicate that physical and mental health-related quality of life in patients who undergo multistage operations and survive beyond three years is substantially similar to that of the general population,” says Francis Caputo, MD, Vascular Surgery Director of Cleveland Clinic’s Aorta Center. “This is important, as we previously had no information about the long-term effect of such extensive aortic replacement on quality of life.”

Patients and methods

From 2010 to 2016, 146 adult patients underwent combined replacement of the proximal and distal aorta at Cleveland Clinic. By the time of the survey, conducted in August and September 2018, 49 (34%) had died. “Historically, rates of early morbidity and mortality after extensive replacement of the proximal and distal thoracic aorta have been high,” says Dr. Caputo. “Advances in surgery and approaches — as well as the separation of therapies into various stages — have substantially lowered the mortality rate, but significant morbidity has endured.”

The patients who died were older and had more extensive aortic and peripheral arterial disease and chronic renal failure. Another 25 patients did not respond to the survey. Both nonresponders and those who died were more likely than responders to have experienced postoperative paralysis.

This left 72 patients who participated in the survey. Eighteen of them had undergone fully open surgery and 54 had undergone hybrid surgery. All but one of the patients had undergone at least two operations. The mean age was 59 in the open surgery group and 63 in the hybrid surgery group.

In telephone interviews conducted a median of 6.2 years after their last operation, the participants replied to the 10-item Patient-Reported Outcomes Measurement Information System (PROMIS Global-10) questionnaire. On a scale of 1 to 5, the questionnaire asks patients to rate their:

• General health
• Quality of life
• Physical health
• Mental health, including mood and ability to think
• Satisfaction with social activities and relationships
• How well they carry out their usual social activities and roles
• Ability to carry out everyday physical activities
• Frequency of being bothered by emotional problems
• Fatigue
• Pain (scale of 0 to 10)

The questionnaire yields separate scores for physical and mental health-related quality of life (HRQoL).

Results

The median T-score for physical HRQoL was 46 in the study patients compared with 50 (standard deviation, 10) in the general population (P < .0001); the median score was lower in the open surgery group than in the hybrid surgery group (44 and 48, respectively). The median T-score for mental HRQoL was 50 in both surgical groups, which was statistically indistinguishable from that in the general population (P > .9).

Factors that predicted a lower physical HRQoL were chronic obstructive pulmonary disease, greater number of complications, shorter interval between the most recent cardiovascular surgery and the survey follow-up and, to a lesser degree, lower weight at the time of the first surgery. Factors that predicted a lower mental HRQoL were myocardial infarction and, to a lesser degree, female sex, readmission to the hospital or intensive care unit, and chronic obstructive pulmonary disease.

Takeaways for practice and counseling patients

“To our knowledge, this is the first published study to explore long-term health-related quality of life in patients undergoing both proximal and distal aortic surgery,” says the study’s corresponding author, Michael Tong, MD, MBA, of Cleveland Clinic’s Department of Thoracic and Cardiovascular Surgery. “The fact that quality of life holds up so well in a population that requires such large, multistage operations is notable.”

He and his colleagues acknowledge that the study was limited by several factors that may have introduced bias, including its relatively small size and single-center design, as well as the fact that HRQoL data could be gathered only from survivors. Nevertheless, they conclude, it demonstrates that long-term survivors of extensive aortic replacement for severe atherosclerotic thoracic aortic disease tend to enjoy a preserved mental quality of life and an acceptable — albeit slightly decreased — physical quality of life.

“These findings were independent of the surgical approach used, which suggests that surgeons should recommend the method they deem likeliest to maximize survival,” Dr. Tong observes. “Regardless of surgical approach, lifelong follow-up is essential, and patients should understand that they may require multiple operations.”