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Main ndings related to

HRQOL

instrument used

Follow-up

completion rate

HRQOL

functioning and general

health domain scores

were signicantly

(%)

SF-36 Median SF-36 physical

73%

higher in recipients of

autograft aortic root

replacement than in

those given homograft

aortic root replacement

in all of the SF-36

domains (apart from

bodily pain and social

function) for composite

group compared to the

David group

SF-36 Signicantly impaired

76%

Composite graft group

signicantly more

compromised by

prosthetic valve noise

and signicantly more

reported feeling

moderately or severely

M. K. H. Tan et al.

disturbed by this noise

Pre-op

HRQOL

3.2)

assessment Follow-up period

No 10.2years (±

Mean age (years): 39 (19–68) in

homograft group, 38 (19–66) in

autograft group

No signicant difference in

comorbidities between patient

groups.

Royal

Brompton and

Hareeld

Hospitals,

London, UK

least 6months

after the

operation was

performed’

No Measured ‘at

Mean age (years): 58±14in David

group and 56±in composite group

No signicant difference in

co-morbidity between patient

groups, although the composite

group had a signicantly higher

proportion of bicuspid aortic valves

and aortic arch aneurysm

University of

Cologne,

Germany

Author, year of

Table 4.2 (continued)

Patients <69years of age

requiring AVR were

randomly assigned to

etal. 2010 [11]

1994–2001

receive an autograft

Prospective

Study intent and number of

patients Surgical centre Patient characteristics

publication, study

El-Hamamsy

period and study

type

(n=108) or homograft

aortic root replacement

(n=108). Outcomes and

HRQOL were measured

Children and those with

Marfan syndrome were

excluded.

randomized

controlled trial

Comparison in QoL

between the David

operation (aortic valve

re-implantation, n=76)

with that of aortic

composite root

Franke etal.

2010 [12]

1999–2005

Retrospective

cohort study

replacement using a

mechanical prosthesis

(n=67)

4 Thoracic Aortic Surgery

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Main ndings related to

HRQOL

instrument used

Follow-up

completion rate

Pre-op

HRQOL

Sound pressures at

peak were lower for the

ATS than for the St.

Jude and Sorin

(%)

‘Valve

disturbance’

questionnaire

and loudness of

months after

surgery

assessment Follow-up period

No At three and six

composite grafts but

this did not reach

signicance

However, subjective

valve sounds

recorded.

100%

disturbance with the

ATS valves was

signicantly lower than

the St. Jude and Sorin

composite grafts

SF-36 SF-36 scores were

No 64 (6–90)

comparable between

the two groups at

follow-up

95%

months

General and disease-

specic HRQoL scores

were not signicantly

different between

groups

SAD

HADS

62.7%

No 40months EQ-5D

(continued)

No signicant difference in

baseline characteristics between

patients including BMI

University

Hospital

Berne,

Comparison of the closing

sounds of thirty patients

Study intent and number of

patients Surgical centre Patient characteristics

Author, year of

publication, study

period and study

type

receiving three different

Golczyk etal.

2010 [13]

Data collection

Switzerland

mechanical composite

aortic root prostheses

(Sorin, St. Jude and ATS)

period not

reported

Randomised

prospective

cohort study

Pre-operative characteristics

matched for age, gender, HCA-time

and year of surgery

Hannover

Medical

School,

Germany

Comparison of elective

composite root

replacement (n=23 of

which 13 mechanical) vs.

David operation (n=23)

Khaladj etal.

2009 [14]

1999–2006

Retrospective

cohort study

Patients in the biological group

were signicantly older than the

The University

of Alberta,

in patients requiring aortic

arch surgery using HCA

and ACP with the focus

on post-operative

neurological outcome and

QoL

Early and midterm results

analysis in patients

Lehr etal. 2011

[15]

patients in the mechanical group

(60.9±13.9 vs. 47.7±14.1years)

The mechanical group contained a

higher proportion of males (94.1%

vs. 66.7%)

The biological group contained a

signicantly higher number of

patients with hyperlipidemia,

previous cardiac surgery, coronary

Canada

undergoing aortic root

replacement (Bentall): 51

mechanical and 93

biological valve conduits

1998–2007

Retrospective

cohort study

artery disease and chronic

obstructive pulmonary disease

Main ndings related to

HRQOL

instrument used

Follow-up

completion rate

HRQOL

(%)

signicantly lower at

follow-up when

compared to an age-

and gender-matched

89%

control group in the

PCS or MCS

In contrast, patients had

signicantly inferior

results in four of the

eight subscales:

role-physical, general

health, vitality, and

mental health

minimally invasive

hemisternotomy

showed non-

statistically

91%

signicantly higher

scores in the

subcategories for

physical and mental

health

M. K. H. Tan et al.

Pre-op

HRQOL

assessment Follow-up period

No 37±11months SF-36 HRQoL not

Mean age of 57±15years and

77% were male

University of

Gothenburg,

Sweden

Quality of life outcomes

in patients undergoing

aortic root replacement

Study intent and number of

patients Surgical centre Patient characteristics

with homograft for

infective endocarditis

(n=62)

31 of these patients had

infective prosthetic valve

endocarditis and 31 had

native valve endocarditis

with root abscess

No 31±18months SF-36 Patients undergoing

Patients with the minimally

invasive hemisternotomy were

signicantly younger (56.5±13.6

vs. 64.8±11.6) and had a higher

proportion of males (81.2% vs.

69.3%)

No signicant differences in

co-morbidities between groups

Robert Bosch

Hospital,

Stuttgart,

Germany

Comparing outcomes in

patients having a David

procedure between

minimally invasive

hemisternotomy (n=117)

and conventional midline

sternotomy (n=75)

Author, year of

Table 4.2 (continued)

Perrotta etal.

type

2010 [16]

publication, study

period and study

1997–2008

Retrospective

cohort study

Wachter etal.

2017 [17]

2007–2012

Prospective

cohort study

4 Thoracic Aortic Surgery

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Main ndings related to

HRQOL

instrument used

Follow-up

completion rate

Pre-op

HRQOL

Based on the SF-36,

younger patients

undergoing valve-

sparing procedures and

(%)

SF-36

Valve-specic

questionnaire

97%

26.9months

(range

6–73months)

assessment Follow-up period

No Median

patients undergoing

Ross procedures scored

signicantly better on

all physical subscales

and two mental

subscales (vitality,

social functioning)

compared to older

patients undergoing

valve-sparing

procedures and

mechanical aortic valve

replacements

Patients undergoing

valve-sparing

procedures and the

Ross procedures

showed greater

freedom from

valve-related lifestyle

limitations when

compared to the

mechanical aortic valve

replacement patients

(e.g. follow-up care,

frequent doctor visits,

blood tests,

complications from

implanted valve)

Valve-sparing <50years old:

• Mean age 36.3±6.1years old

• 78% male

Valve-sparing >50years old:

• Mean age 59.2±7.7years old

• 70% male

Ross procedure:

• Mean age 37.8±11.9years old

• 83% male

Mechanical aortic valve

replacement:

• Mean age 39.7±7.3years old

• 69% male

Charles

University in

Prague,

Faculty of

Medicine and

Faculty

Hospital,

Czech

Republic

Study intent and number of

patients Surgical centre Patient characteristics

Determining the QoL in

patients undergoing aortic

valve-sparing procedures

<50years old (n=36),

aortic valve-sparing

procedure >50years old

(n=52), the Ross

procedure (n=22), and

mechanical aortic valve

replacement (n=29)

Author, year of

publication, study

period and study

type

Zacek etal.

2016 [18]

2006–2012

Cross- sectional

study

M. K. H. Tan et al.

tic root replacements, Zacek etal. showed both younger patients undergoing valve-sparing aortic root replacements and patients undergoing the Ross procedure to have better HRQoL than older patients undergoing valve-sparing procedures and patients undergoing mechanical aortic valve replacements. In this same study, a valve-specic questionnaire was used and showed patients undergoing mechanical aortic valve replacements to have less freedom from valve-related lifestyle limitations (e.g. frequent follow-ups, blood tests etc.) [18]. In the only analysis on HRQoL outcomes following homograft replacements for endocarditis, Perrotta et al. showed follow-up HRQoL to be comparable to an ageand gender- matched population, despite more than half of their patient population experiencing prosthetic valve endocarditis with root abscess, suggesting that aggressive treatment might still be justied even in high-risk subgroups [16]. In the only study in the literature examining outcomes after minimal access root surgery, Wachter etal. examed HRQoL differences between a minimally invasive ministernotomy versus the conventional midline sternotomy for the David procedure. This analysis showed that patients undergoing minimally invasive approach showed a higher HRQoL for both physical and mental health compared to those having a median sternotomy, although this was not statistically signicant at mid-term follow-up of around 3years [17].

Other Proximal Aortic Operations

Besides aortic root replacements, HRQoL outcomes after various proximal aortic operations are also reported in six studies identied from the literature [19–24]. These procedures also resulted in generally acceptable post-operative HRQoL (Table 4.3 adapted from Jarral et al. [4]), but emergency surgery was found to be predictive of impaired long-term HRQoL and need for reoperation in patients with Marfan syndrome [22]. The use of DHCA to be predictive of impaired physical role functioning in long-term follow-up [23].

Lohse etal. (134 patients with ascending aortic aneurysms) [20] and Stalder et al. (244 patients undergoing ascending aortic operations) [23] showed that post-operative HRQoL was comparable to that of an age- and sex-matched reference population. Older age and prolonged hospital stay were also found to be risk factors for reduced physical functioning [20, 23]. Abe et al. also showed that in patients undergoing ascending aorta wrapping or graft replacement during aortic valve replacement, post-operative HRQoL was not statistically different from that of a general population as well, but this was in a small population of 40 patients only [19]. In an older study by Olsson and Thelin, patients undergoing thoracic aortic repair with either a straight Dacron graft or composite root replacement over 20 years ago had signicantly lower HRQoL than a matched population [21]. This was limited by the small patient population (81 patients) and the fact that 82% of patients actually felt that their HRQoL was improved or preserved in this study, with 91% considering the operation a success. Another study by Olsson and FrancoCereceda showed that HRQoL scores were not affected by type of proximal aortic procedure performed but was instead predicted by current symptoms and conditions experienced by patients [24]. Finally, Song etal. was the only study that observed HRQoL in patients with Marfan’s syndrome, studying 194 survivors who underwent elective and emergency proximal aortic operations [22]. Emergency surgery was found to be associated with a higher incidence of chronic dissection, reoperation rate, dilated distal aorta and impaired HRQoL—the authors concluded the underlying need for early diagnosis and elective surgery based on these outcomes.

Type ADissection Repair

Type A dissection is a surgical emergency which carries a high mortality rate in the absence of prompt surgical treatment [25]. HRQoL outcomes are reported in six studies in the current literature [26–31], results of which are found in Table4.4 (adapted from Jarral etal. [4]).

4 Thoracic Aortic Surgery

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Main ndings related to HRQOL

of the subcategories on the SF-36

HRQoL in patients is not statistically

SF-36 No differences between groups for any

HRQOL

instrument used

Follow-up

91.6%

completion rate

(%)

different from the general population

physical function results signicantly

lower than the reference population in

patients between 70–79years of age

Prolonged hospital stay (>20days) was

identied as a risk factor for a

SF-36 Post-operative HRQoL revealed

98.7%

signicantly reduced PCS

PCS or MCS, although median scores

for subgroups including physical

functioning, general health, and mental

health were signicantly lower

No signicant differences between

scores for patients undergoing surgery

Not reported

for aneurysms vs. dissection, between

valve-sparing vs. mechanical/biological

valve-replacements, or between types

(continued)

of valve replacements

Exertional dyspnoea was predictive for

changes in MCS and PCS, while age,

exertional calf pain, and myocardial

infarction only predicted for changes

in PCS

Pre-op

HRQOL

Patient

(0.6–11.4)

assessment Follow-up period

No 4.9years

characteristics

No signicant

difference in age

(59.2±2.3 vs.

Nagoya

University

Graduate School

No 36.4±15.5

64.5±2.2years) or

gender distribution

(70% male vs. 60%

male) between

groups

Mean age of

of Medicine,

Nagoya, Japan

University of

months

survivors was

61.7±11years and

63.4% were men

Munich,

Germany

No Not reported SF-36 No signicant differences in median

Median age 57

(IQR 12)

70% male

Karolinska

Institutet,

Stockholm,

Sweden

Outcomes in 40 consecutive

patients undergoing either

wrapping (n=20) or ascending

aorta replacement (n=20) for

dilated ascending aorta

Author, year of

publication, study

period and study

type Study intent and number of patients Surgical centre

Abe etal. 2017

[19]

2000–2013

Prospective

Table 4.3 Studies observing other proximal aortic operations

cohort

Quality of life assessment in 134

consecutive patients with true

aneurysms undergoing ascending

aorta surgery: procedures consisted

of interposition graft (35.9%),

interposition+AVR (35.9%),

David (11.2%), Bentall (9%) and

Cabrol procedure in 2.2%

Investigating QoL after surgical

repair of the proximal aorta,

comparing it to a reference

Lohse etal. 2009

[20]

1999–2003

Retrospective

cohort

Olsson and

Franco- Cereceda

2013 [24]

population and identifying

predictors of QoL in 207 patients

Data collection

period not

reported

Retrospective

cohort study

HRQOL

instrument used

Follow-up

completion rate

Main ndings related to HRQOL

66% stated general health perception

improvement post-operatively and 82%

felt HRQoL improved or was

preserved

91% considered the operation

successful

Overall quality of life in this

population was signicantly lower than

in a matched population except for

bodily pain

SF-36

General health

perception

questionnaire

(%)

94%

(7–76)

Patients in the elective group had

signicantly higher reported activity

scores on the SF-36

SF-36 and

Karnofsky

Performance

Status score

emergency

group and

6.34years in

100%

elective group

M. K. H. Tan et al.

to an age- and sex-matched population

Patients who underwent DHCA had a

signicant decit in physical role

functioning compared with patients of

the same group operated on without

DHCA

SF-36 HRQoL in all groups was comparable

76.9%

months

Pre-op

HRQOL

Patient

assessment Follow-up period

characteristics

No 26months

Mean age of 59 of

whom 70% were

male

Uppsala

University

Hospital,

Sweden

Assessment of QoL in survivors

(n=81) of thoracic aortic surgery

In respondents: a straight Dacron

vascular graft was used in 64

(81%), 12 had a composite root

replacement and 3 received AVR

and interposition graft. DHCA was

used in 52% of cases

No 4.73years in

No signicant

difference in age

between emergency

& elective group

(34.9 vs. 38.0), of

whom 66% were

male

Multi-

institutional,

USA

Analysis of the long-term clinical

courses of patients with Marfan

syndrome who are survivors from

emergency (type A dissection) vs.

elective proximal aortic surgery

A total of 194 patients underwent

surgery of which 47 were

emergencies and 147 elective

operations

Patients in the emergency group

were more likely to have

No 26.6±8.8

Mean age was

60.6±14.6years

and 75% were male

61.9% had true

aortic aneurysm

University

Hospital Berne,

Switzerland

The impact different aortic surgical

procedures (n=244) on outcome

and QoL

76 patients (31.2%) underwent

incomplete proximal aortic

resection: 83% included root

replacement compared with 95%

of elective procedures

interposition graft to the ascending

(>5cm) and 30.7%

had acute type A

dissection. 58.2%

underwent a

procedure using

DHCA

aorta, 42 (17.2%) received separate

AVR and supracoronary

replacement of the aorta, 86

(35.2%) received a mechanical

composite graft, and 40 (16.4%)

received a biologic composite graft

Author, year of

Table 4.3 (continued)

publication, study

period and study

type Study intent and number of patients Surgical centre

Olsson and

Thelin 1999 [21]

1990–1995

Retrospective

cohort

Song etal. 2012

[22]

Marfan patients

enrolled in

GeneTAC

registry as of

March 2011

Retrospective

cohort

Stalder etal.

2007 [23]

2001–2003

Retrospective

cohort

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Main ndings related to

HRQOL

Only 188 patients

lled up the SF-12in

HRQOL

instrument used

Follow-up

completion rate

(%)

Post- traumatic

Pre-op

HRQOL

assessment Follow-up period

No 51±27.8months SF-12

full

Lower mean PCS and

MCS scores were seen

compared to the

population norm

PCS continually

Diagnostic

Scale (PDS)

Post- traumatic

Stress Scale 14

(PTSS-14)

declined with

increasing age of

patients

65 patients (31.5%)

53%

possibly had PTSD

according to the

PTSS-14, and 43

patients (27%) were at

risk of PTSD based on

the PDS criteria

Trend towards more

females, younger

patients,

unemployment and

disability increasing

(continued)

risk of PTSD after

operations

Author, year of

Table 4.4 Studies observing operations for type A dissection

Mean age

59.1±12.3years

62.9% male

4 patients had Marfan’s

syndrome

Deutsches

Herzzentrum

Berlin, Berlin,

Germany

Study intent and number of

patients Surgical centre Patient characteristics

Determine HRQoL outcomes

of 393 patients undergoing

repair for type A aortic

dissection

Deep hypothermia used in

publication,

study period

and study type

Adam etal.

2018 [26]

2006–2010

Retrospective

cohort

84%, with retrograde (75%)

or antegrade (6%) cerebral

perfusion applied

2 main procedures:

• Aortic valve reconstruction

(40.5%)

• Aortic valve replacement

with bioprosthesis (5.7%) or

mechanical prosthesis (24%)

Main ndings related to

HRQOL

instrument used

Follow-up

completion rate

Pre-op

HRQOL

had reasonable

long-term survival and

(%)

EQ-5D Discharged patients

69%

26.6months

assessment Follow-up period

No Mean of

good HRQoL

90% reported minimal

limitation on

functional scores

48% recorded full

health with an overall

mean index of 0.854

(where the best

possible score is 1)

using the US

preference weighted

index score

“Some” problems in

only one category of

the EQ-5D

questionnaire was

reported by 10.34%

and 6.89% reported

some problems in two