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Health-Related Quality of Life After Extensive Aortic Replacement

      To assess and compare patient-reported long-term health-related quality of life (HRQoL) after combined proximal aortic (arch ± ascending, root) and distal aortic (descending thoracic ± abdominal) replacement using open vs multimodal/endovascular (hybrid) approaches. From 2010 to 2016, 146 adults underwent single- or multi-stage aortic arch plus descending thoracic aorta replacement, 31 open and 115 hybrid. The 2 surgical approach groups had similar preoperative characteristics and extent of surgery. Cross-sectional follow-up revealed 49 deaths (7 open, 42 hybrid). Of the 97 survivors, 72 (74%) responded to the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 survey (18 open, 54 hybrid) a median 6.2 years (15th, 85th percentiles: 3.1, 7.9) after their last aortic surgery. Predictors of HRQoL scores were identified by random forest regression. Overall physical HRQoL T-score was lower than that of population norms (46 vs 50, P < 0.0001); mental HRQoL T-score was similar (50 vs 50, P > 0.9). Neither T-score was significantly different according to surgical approach (P ≥ 0.3). Greater number of postoperative complications and history of chronic obstructive pulmonary disease were the most important predictors of lower physical HRQoL, and prior myocardial infarction was the most important predictor of lower mental HRQoL. Although extensive aortic replacement had a small long-term effect on patient-reported physical HRQoL, both physical and mental HRQoL can be preserved in survivors with both surgical approaches. Surgeons should recommend the approach they believe will yield the best long-term survival, but lifelong follow-up is crucial, and patients should understand that they may require multiple operations.

      Keywords

      Abbreviations:

      CI (Confidence interval), COPD (chronic obstructive pulmonary disease), HL (Hodges-Lehmann), HRQoL (health-related quality of life), IRB (Institutional Review Board), MI (myocardial infarction), PROMIS (Patient-Reported Outcomes Measurement Information System), randomForestsSRC (Fast Unified Random Forests for Survival, Regression, and Classification), SD (standard deviation)
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          In this edition of the Journal, Smolock et al. compare long-term health-related quality of life (HRQoL) between open and hybrid thoracic aortic operations.1 We commend the authors for their work examining meaningful and long-term outcomes. While 30-day and 1-year mortality have long been used as a benchmarks for outcomes, long-term HRQoL measures provide additional insight into patient outcomes. In one series of patients who underwent elective thoracoabdominal aortic aneurysm repair, only 63% survived to live ambulatory at home one year after surgery.
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          With advancements in cerebral perfusion, spinal cord protection, and endovascular technology, outcomes of thoracic aortic replacement have improved considerably over the past decades.1,2 Nevertheless, such operations can still carry substantial morbidity when extensive aortic reconstruction is performed. The impact of postoperative complications on quality of life (QoL) is becoming increasingly important in surgical decision-making as less invasive strategies are taking center stage. A recent systematic review analyzing health-related quality of life (HRQoL) following interventions on the thoracic aorta found that QoL was acceptable among the majority of studies, including in the elderly and in emergent situations.
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