| Abstract |
Aims
The present study have multidominant aims due to the variety of scales used and the multi complex profile of cardio surgical patients and procedures. The first hypotheses that were assessed was “if the preoperative evaluation of mental health and health related quality of life, EuroSCORE II, Charlson Comorbidity index, frailty and feasibility, could foresee the presence of postoperative complications, in an attempt to improve postoperative health related quality of life.” In the process, the need to expand the research project became imperative, raising other questions, thus broadening the original purpose. Therefore, the second purpose of the present study was to identify risk factors for postoperative atrial fibrillation and to propose a multifactorial tool for assessing or even early prognosis of the risk of this complication. Another purpose was to identify preoperative, intraoperative and postoperative risk factors for postoperative delirium in cardiac surgery patients. Finally, to investigate whether the postoperative quality of life (1-12 months) was affected by preoperative stress and postoperative delirium, with the ultimate goal of highlighting ways to assess the outcome of a heart surgery, in the long run.
Methods
The study was conducted in three phases. The first phase took place from September 2018 to March 2020 at the cardiac surgery clinic of the University General Hospital of Heraklion, with a population of patients who were to undergo a scheduled cardiac surgery. In phase 2 each patient was approached 1 month after surgery and in phase 3, 12 months after.
The study involved patients over 18 years of age who were to undergo a scheduled cardiac surgery, using extracorporeal circulation, during the aforementioned time period. The study excluded patients who did not speak Greek, who suffered from mental deprivation (dementia), who underwent surgery as an emergency, and finally those who had already undergone surgery and were hospitalized due to complications.
Mental health (symptoms of anxiety and depression), health-related quality of life, frailty and functionality, perioperative risk index and multi-morbidity / mortality rate, were assessed preoperatively.
Anxiety symptoms were assessed using the State-Trait Anxiety Inventory (STAIX-1) self-assessment questionnaire. Depressive symptoms were assessed using the Beck Depression Inventory (BDI) questionnaire. The health-related quality of life was assessed using the “Short Form for Physical and Mental Health and Quality of life” questionnaire (SF36). Frailty was assessed using the Frail Non-Disabled tool (FiND) and the Clinical Frailty Scale (CFS). Patients' functionality was assessed using the Barhtel Index Score (BIS). Perioperative mortality was assessed using the "European System for Cardiac Operative Risk Evaluation II" (EuroSCORE II). The Charlson Comorbidity Index (CCI) was used to assess co-morbidity and 10-year survival.
The extracorporeal circulation time and aortic convergence time were recorded intraoperatively. Postoperatively, the complications were evaluated and recorded. More specifically, the diagnosis of delirium was made between the 1st and 7th postoperative day using the CAM-ICU scale and the postoperative atrial fibrillation was defined as atrial fibrillation 1-5 postoperative day, detected by monitoring or telemetry, is confirmed by electrocardiogram and lasts up to or more than 5 minutes. Also, the intubation time, the mechanical ventilation time and the use of non-invasive mechanical ventilation were recorded. Furthermore, quality control indicators of the provided nursing care in the intensive care unit were evaluated.
In the 2nd phase the quality of life and the anxiety were evaluated and in the 3rd phase the quality of life, the anxiety and the depression.
Multivariable analysis was assessed to identify predictors of postoperative atrial fibrillation.
Results
Mean value of anxiety(ST) was 53.1 ± 6.8, personality stress (TR) 45.9 ± 6.8, depression (BDI) 10.3 ± 6.7, health-related quality of life (SF36 ) ranged from 41.4 ± 37.1 physical limitations (RLP), to 70.1 ± 31.2 pain (P). In terms of frailty, the mean value in the FiND questionnaire was 1.4 ± 1.2, in CFS was 2.8 ± 0.5 and for functionality (BIS) it was 96.0 ± 4.7. The mean value of the perioperative mortality index (EuroSCORE II) was 2.9 ± 2.3, the multi-disease mortality index (CCI score) 4.2 ± 1.7 and the 10-year survival rate 48.8 ± 30.3. The mean extracorporeal circulation (min) was 142.6 ± 40.7, aortic convergence time (min) 88.1 ± 31.8, mechanical ventilation (hours) 26.4 ± 23.6, extubation days (days) 1 , 4 ± 0.9.
The most common complications were postoperative atrial fibrillation 48.4% (n = 44) and postoperative delirium 19.8% (n = 18). Regarding postoperative atrial fibrillation, comparing the two groups with each other, in the univariate analysis, the patients who developed postoperative atrial fibrillation were 66-75 years old and had an OR of 5.78 (CI1.37-24.34, p = 0.017) result statistically significant. In addition, they had increased hours of mechanical ventilation compared to those who did not (OR 1.03, CI 1.00-1.06, p = 0.047). Also, statistically significant differences were observed between the two groups, in terms of CCI score (3.7 ± 1.4 vs 4.6 ± 1.8, p = 0.012) OR 1.42 (CI: 1.07-1, 89) and 10-year survival (55.1 ± 29.0 vs 42.2 ± 30.7, p = 0.042) OR 1.01 (CI 1.00-1.03). In the multifactorial analysis, the CCI score seems to be an independent risk factor for the occurrence of postoperative atrial fibrillation (exp: 1,412, CI 1,017-1,961, p = 0.0039). Regarding postoperative delirium, in the univariate analysis, patients who experienced postoperative delirium had moderate (OR 5.27, CI 1.1-25.2, p = 0.037) or severe (OR 7.5, CI). 1.02-55.0, p = 0.047) renal impairment, poor mobility (OR 7.1, CI 1.09-46.25, p = 0.040) results statistically significant. Regarding the assessed scales, differentiation was observed between the two groups, in terms of preoperatively estimated depression (OR 1,083 CI 1,0-1,17, p = 0.039), energy / vitality (EV) (OR 0,94, CI 0.91-0.98, p = 0.003) and perioperative risk (EuroSCORE II) (OR 1.285, CI 1.041-1.585, p = 0.020). Also, patients with increased hours of mechanical ventilation, delayed extubation and more days of stay in the ICU, were more likely to experience postoperative delirium (OR1.07, CI1.03-1.11, p <0.001, OR 2.44, CI 1.19-5.01, p = 0.015, OR2.49, CI 1.45-4.29, p = 0.001). Also, the group, which was not included in non invasive ventilation, seemed to have an increased probability of delirium (OR 4.01, CI 1.26-12.78, p = 0.014). Finally, a difference was observed between the two groups, in terms of postoperative atrial fibrillation (OR 3.5, CI 1.1-10.9, p = 0.034). In the multifactorial analysis diabetes mellitus (exp: 4,342, CI 1,060-17,781, p = 0.041), mechanical ventilation time (exp: 1,069, CI1,023-1,118, p = 0,003) and energy-vitality (EF) (exp : 0.950, CI 0.911-0.990, p = 0.015) were independent risk factors, for the occurrence of postoperative delirium.
At 30 days the state of anxiety showed a reduction and statistically significant difference from the preoperative (52.45 ± 4.7, 53.1. 6.8, p <0.001). The health-related quality of life ranged from 36.0 ± 36.5 for physical limitations (RLP), aggravated from preoperative (41.4 ± 37.1) to 72.5 ± 40.4 for emotional restrictions (RLE) improved by preoperative (64.4 ± 39.7), results statistically significant (p <0.001, p <0.001). At 12 months, the state of anxiety showed a decrease and a statistically significant difference from the preoperative one (49.8 ± 11,5,53,1 ± 6,8, p <0,001). Depression (BDI) decreased significantly compared to preoperatively, a statistically significant result (6.2 ± 5.5, 10.3 ± 6.7, p <0.001). The health-related quality of life ranged from 69.2 ± 24.3 physical function (PF), improved compared to the preoperative (51.4 ± 26.6) but also with the 30 days (39.0 ± 22.9, p <0.001), reached 89.4 ± 19.4 (p <0.001) for social functionality (SF), statistically significant results. Comparing the two groups (with / without postoperative delirium) at two different times (preoperatively-30 days after surgery), there was a statistically significant difference in physical function (PF) and general health (GH) [Effect(time)F(1.61) = 4.230, p = 0.044, Effect (time) F (1.64) = 9.545, p=0.003] and in physical limitations (RLP) and vitality (EF)[Trait(time x delirium) F(1.64)= 7.809, p = 0.007, effect (time x delirium) F (1, 61) = 5,261p = 0.025].
Conclusion
The scales, assessed preoperatively (mental state, health-related quality of life, frailty, functionality, perioperative mortality, comorbidities), were mildly affected. They were associated both with each other and with postoperative assessments, as well as with postoperative atrial fibrillation and delirium. Future research may aim at implementing and evaluating protocols-guidelines, with the aim of preventing postoperative complications and improving the postoperative quality of life of cardiac surgery patients.
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