Quality of life after open-heart surgery in patients over 75 years old

Age and Ageing,  Jan, 1996  by Sidney Chocron,  Nathalie Rude,  Alain Dussaucy,  Alain Leplege,  Francois Clement,  Kifah Alwan,  Jean-Francois Viel,  Joseph-Philippe Etievent

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Introduction

The efficacy of surgical procedures is usually assessed from objective and easily measurable criteria such as survival rates, recurrence of symptoms and complications. We felt it would be of interest to describe the quality of life (QOL) of patients over 75 years of age after cardiac surgery.

Cardiac surgery is now being performed on more and more elderly patients. Survival results for patients over 75 years of age and even 80, have been previously reported [1, 2], but there have been no evaluations of the QOL of these patients. We performed a postal survey of survivors of open-heart surgery using the Nottingham Health Profile (NHP) questionnaire.

Patients and Methods

For this retrospective study, the questionnaire was sent to all surviving patients who had been over 75 years of age when open-heart surgery was performed. From January 1984 to October 1993, there had been 146 such patients in the Department of Thoracic and Cardiovascular Surgery of St Jacques Hospital, Besangon, France. Eleven patients (7.5%) had died in the post-operative course. A questionnaire was sent to the 135 patients who had been discharged alive from hospital. The pathologies represented were as follows: calcified aortic stenosis (CAS) (51%), coronary artery disease (CAD) (23%), associated GAS-CAD (12%), aortic regurgitation (2%), mitral pathology (10%) and others (2%). The surgical procedures were as follows: isolated aortic valvular replacement (AVR) (53%), coronary artery bypass grafting (CABG) (23%), associated AVR-CABG (12%), mitral valve replacement (10%).

The NHP is a questionnaire written originally in English [3], which underwent rigorous translation into French, back translation and linguistic validation [4]. `The NHP is a questionnaire designed to measure social and personal effects of illness, to capture self-reported morbidity.... It contains 38 subjective statements, drawn from a pool of over 2000 commonly-used expressions of health problems, gathered from members of the public. These statements form six sections relating to the following areas: sleep, energy, pain, physical mobility, social isolation and emotional reactions. The number of statements in each section varies, from three in the energy section to nine in the emotional reactions section. Within each section an aggregation of responses is made possible by the use of item weights determined on a general population sample using the Thurstone method of paired comparisons' [4]. We have not included it. We added nine questions (Table I).

Table I. Nine questions added to NHP questionnaire

Statements                                  Yes %   No %
I feel better than before cardiac surgery   87.5    12.5
Je  me sens mieux qu'avant l'intervention
chirurgicale sur le coeur
I drive my car                              62.5    37.5
Je conduis ma voiture
I watch television                          85.6    14.4
Je regarde la television
I listen to the ratio                       78.8    21.2
J'ecoute la radio
I read books or magazines                   74.0    26.0
Je lis des livres ou des revues
I go out alone                              76.0    24.0
Je sors seul de chez moi
I live in an old people's home               4.8    95.2
Je vis en maison de retraite
I regularly go for a walk                   55.8    44.2
Je fads de la marche regulierement
I filled in this questionnaire myself       81.7    18.3
J'ai rempli moi-meme ce questionnaire

Does the improvement in surgical techniques lengthen the life expectancy of patients who will be bedridden and demented, or does it mean patients who, despite their age and reduced activity, will have a social life with satisfactory autonomy?

A successful operation may worsen the QOL, especially in elderly patients, because their systems cannot cope with the operative shock. The decision to operate takes into account not only the usual objective criteria for a specific pathology, but also the patients' will to live. Besides this subjective criterion, our results showed that surgery was particularly beneficial for men under 80 years old who drove their own car and lived in their own home.

Studies using the Nottingham l Health Profile questionnaire have been carried out on heart transplant patients [6], heart-lung transplant patients [7] and patients suffering from a cardiovascular stroke [8]. Comparing our results with previously reported data is rather difficult since there are very few similar series. Hunt et al. [3] have evaluated the QOL of patients suffering from arthritis, elderly patients suffering from a chronic disease, patients with peripheral vascular disease and of `fit' elderly subjects (Table II). Our patients had a similar profile to that of patients suffering from a chronic disease (Table II). The comparison of our results with those of younger patients operated on in our institution revealed better scores in all sections of QOL. It was not surprising that energy, pain and physical mobility were significantly better in the younger patients. Alterations in emotional reactions and sleep were similar in both groups. Even in this younger population, the scores were worse than the scores of `fit elderly' [3] (Table II).