Quality of Life after Type A Aortic Dissection Surgery in the United Kingdom: The QUADS Study

Abstract

Background Acute Type A aortic dissection (TAAD) is a life-threatening condition that carries significant mortality and morbidity; a proportion of the survivors might require further aortic procedures in the mid-/long-term follow-up. Quality of life (QoL) after TAAD is not well studied. Quality of life after Type A Aortic Dissection Surgery (QUADS) is the first multicentre study to assess QoL in survivors of surgically treated TAAD.

Methods A tailored questionnaire for survivors of TAAD was designed with patient and public involvement. Patients who underwent surgery from 2018 to 2022 in eight United Kingdom centres were invited to participate. Preoperative, intraoperative, and postoperative prospectively collected data were collated and analyzed retrospectively. The data were analyzed with SPSS v29. Patient's questionnaire was validated with a Cronbach's alpha analysis, exploratory factor analysis, and AMOS confirmatory factor analysis. Three groups were created according to QoL (Good, Fair, Poor).

Results A total of 162 patients were recruited. Majority were male with a mean age of 63 years (24–92). Surgical procedures for TAAD were root and ascending aorta replacement (n = 61, 38%), ascending (n = 81, 50%), and/or arch replacement (n = 20, 12%). Eleven patients (7%) required later intervention. Patient's answers regarding overall QoL were good (n = 67, 41%), fair (n = 89, 55%), and poor (n = 6, 4%). Neurological complications, circulatory arrest duration, reoperation for bleeding, postoperative myocardial infraction, arrhythmias, wound infection, and patient destination at discharge have been identified as main variables impacting on QoL after TAAD surgery across different domains of this questionnaire.

Conclusion QUADS questionnaire is the first tailored and validated questionnaire for TAAD survivors. Results in the United Kingdom population suggest that it is a useful tool to assess QoL after TAAD surgery.

Keywords

Type A aortic dissection - quality of life - aortic surgery - reintervention - multicenter study

Introduction

Acute Type A aortic dissection (ATAAD) is a life-threatening condition that carries a high mortality without surgical treatment. Mortality and morbidity after ATAAD repair are still significant. The International Acute Aortic Dissection Registry reported 18 to 20% mortality after surgery. Associated morbidity such as neurological complications, renal failure, and long in-hospital stay have strong impact on patients' recovery.[1]

In the United Kingdom in 2020, there were 4,106 deaths registered as aortic aneurysm and dissection, which in an island of nearly 60 million residents in England and Wales, is equivalent to 7 per 100,000 population. Mean age was over 60 years, and the majority were male. Therefore, with an average population of 2 million per region in United Kingdom, roughly 140 people are expected to die annually from this disease.[2]

Reintervention rate following proximal aortic repair for ATAAD is 20 to 40%, with 5-year mortality reported as 15 to 30% and 10-year mortality as 40 to 50%.[3]

Immediate postoperative results as well as mid and long-term survival after ATAAD repair have been extensively reported in the literature. Quality of life (QoL) following ATAAD repair has been reported less extensively using systematic reviews applying generic QoL questionnaires.[4] QoL with a specific tool designed for ATAAD survivors is yet to be investigated in detail.

Patients and Methods

Selection Criteria

Invitation to participate was sent to the Aortic Surgery leads in all Cardiothoracic Surgery units in the country but only eight centres consented to participate.

Once the centre accepted to participate, the patients who underwent ATAAD in that institution within the last 5 years were identified and those who were alive and contactable were invited to participate.

We limited the study to 5 years to facilitate clinical data collection and to maximize recollection of events and experiences pre- and postsurgery. It was mandatory that both the patient and the clinical questionnaire was completed for each patient. Quesionnaires were sent and collected between 2021 and 2022. Mean period since ATAAD surgery was 2.4 (0–5) years.

Exclusion criteria were patients who died before the start date of the study, <18 years old, or unable to give consent for any reason.

Systematic Literature Review

We conducted a systematic literature review prior to the study. The search included all studies on the QoL in cardiac and aortic surgery published on Embase, Medline, and the Cochrane Library from January 2002 to January 2022, including the terms “Type A Aortic Dissection,” “Quality of Life,” “re-intervention,” “multicentre study,” and “survivorship” in English, Spanish, German, and French manuscripts were analyzed for review. Meta-analysis was not conducted due to the lack of similarities between studies; however, observational studies and case series studies were included. Study quality and risk of bias and disagreements were assessed using the Agency for Healthcare Research and Quality methodology checklist and the Cochrane collaboration tool. The inclusion criteria followed the P.I.C.O. model. Primary outcomes (eligibility criteria): (1) identify QoL tools currently used in clinical practice, (2) determine QoL in ATAAD population, (3) report the key survivorship domains evaluated by these tools. Results are summarized in [Fig. 1].

Fig. 1 Timeline of the systematic literature review for studies about quality of life in aortic dissection survivors. From a total of 1,421 studies identified initially, only 24 were fully reviewed after applying the eligibility criteria explained in the methods. Details of the type of studies are provided on the table. AD, aortic dissection; QoL, quality of life; TAAD, Type A aortic dissection; TBAD, Type B aortic dissection; TEVAR, thoracic endovascular aortic repair.

Study Design

The questionnaire was tested and refined with a relevant patient public involvement group from the UK Aortic Dissection Awareness survivors' group. Ethical approval from IRAS (Integrated Application System) was obtained in 2021(REC reference: 21/WM/0071).

Data were collected via two methods: (1) QoL questionnaire for the patient and (2) database for the local clinical team providing demographics, surgical details, and complications for each patient enrolled. Each local Principal Investigator allocated a single patient link code anonymising identifiable data to the national database. The Chief Investigator ensured that the pseudoanonymized databases and questionnaires were analyzed and kept securely and performed the final analysis.

Patient Questionnaires: Domains and Definitiions

The five QoL domains explored were:

1. Physical and emotional health: the patient was asked how they would describe their own health before and after surgery.

2. Impact on physical activities: compared fitness of the patient before and after surgery. They were asked to describe how many regular activities involving physical efforts (i.e., running, cycling, weightlifting, sexual activities, walking, team sports), they could confidently perform. This section included a description of the activity they were doing when they experienced the ATAAD symptoms.

3. Impact on regular activities: impact of surgery on patient's daily physical activities, focusing on any difficulties with daily physical independence due to deterioration postsurgery, goals, and accomplishments compared with baseline. They were asked to describe how independent they were in specific tasks such as housework, groceries, or independent mobilization. This section included a detailed description of current pain and any long-term complications related to the ATAAD.

4. Impact of aortic dissection on capabilities: this section targeted the burden of the aortic dissection in the patient's everyday work–life and any adjustments required after the surgery.

5. Impact on social and emotional well-being: how the patient was feeling overall after surgery, any interferences with social activities including private and family life, travelling, and social interaction. This was not intended to be a formal assessment of mental health but an analysis of the emotional burden of the ATAAD as chronic disease.

Full questionnaires can be found in [Supplementary Appendix S1] (available in online version only).

Data Availability Statement

The data underlying the analysis of this article will be shared on reasonable request to the corresponding author. Questionnaire answers cannot be shared publicly to protect the privacy of the individuals that participated in the study.

Statistical Analysis

The expected minimum or clinically meaningful effect size sought was n = 100, based on sample calculations (QuestionPro software) on the estimated number of survivors, the volume of patients operated in each participating centre and the final number of patients recruited. We recognize that as a small sample with unavailable pilot data to use, our statistical methods were limited to our own sample size. Statistical analyses were performed using SPSS v 30.

Continuous variables were presented as mean (standard deviation, SD; range), and categorical data using frequency and percentage. The Saphiro–Wilk test for normality was applied as p < 0.05.

Two-sided chi-squared or Fisher's exact text were used to compare categorical variables among groups as appropriate. The baseline differences for demographic and clinical variables across each group were analyzed with the nonparametric test of Kruskal–Wallis and/or chi-squared as appropriate.

Validation and Correlation of the Questionnaire with the Variables Studied

The validation of the questionnaire followed a stepwise approach:

• Step 1. Cronbach alpha analysis to assess scale reliability (Cronbach alpha = 0.84, good)

• Step 2. Exploratory factor analysis to assess how many domains our questionnaire can assess. Each domain contains a group of questions ranked to score evaluated under the Kaiser/Meyer/Olkin of Sampling adequacy (=0.743, significative >0.6) and Bartlett's test of Sphericity (=0.000, significant <0.05). A total of five domains were identified by the validation process: each domain obtained a score, and its summative gave the total QoL assessment score ([Fig 2]). The questionnaire was ranked by different punctuation in each question by the clinician, with a range 0 to 60 total points (the more points scored, the worse the QoL). Minimum punctuation was 8 points.

Fig. 2 Summary of the steps followed for the statistical validation of the patient's questionnaire. CFI, Compariative fit index; RMSEA, root mean square error of approximation.

This allowed to identify three groups of QoL (Good: < 25 points, Fair: 24–45 points, and Poor: 45–60 points), which then were analyzed from the Investigator's questionnaire, and the significative variable assessed to ascertain which domains of the QoL were affected ([Fig. 3]).

Fig. 3 Combination of bar charts displaying the results of the patient questionnaire's, according the three different groups (Good, Fair, and Poor) based on the scoring for overall quality of life and the five different domains assessed.

• Step 3. An AMOS confirmatory factor analysis was performed to confirm the validation of the questionnaire with a positive result with root mean square error of approximation (=0.038, significative from 0.03 to 0.46) and comparative fit index (CFI = 0.912 (0.902–0.928)).

• Step 4. Correlation of the variables from the clinical database and the three QoL groups identified was performed using either correlation coefficient for numerical data or chi-square test for categorical data ([Fig. 3]).

Results

Patient Demographics

A total of 162 patients who underwent ATAAD repair over the period (2018–2022) were recruited among eight centres across the United Kingdom that agreed to participate in the multicenter study.

Patients were predominantly male (n = 104 [64.2%]) with a mean age of 63 (12; 24–92) years.

Patient's Questionnaire Results

The total score of each patient from the five domains of questions, provided the overall QoL Score of Good 67 (41%), Fair 89 (55%), Poor 6 (4%).

The areas of QoL that were less impacted by the TAAD were regular activities and social and emotional well-being, with the majority of the patients scoring Good on those categories (89 and 77%, respectively).

Conversely, physical activities was the area where more patients scored Fair (42%) and/or Poor (38%) QoL. The impact on physical and emotional heath (which compared their overall perception when comparing themselves pre- and postsurgery) also showed predominant Fair (51%) and Poor (11%) QoL scores. Finally, the impact on their work–life (capabilities) was balanced between Good (50%) and Fair/Poor (50%; [Fig. 3]).

Time Elapsed between Surgery and Survivor's Answers

The questionnaires assessed QoL at two different points in time: ATAAD repair and when the questionnaire was received. A subgroup analysis was perfomed taking account of the age at these two time points. Mean age of participants at the time of surgery with respect to the oveall QoL scores was: Good (mean 60 years), Fair (mean: 62 years), and Poor (mean: 53 years). Mean current age of survivors when answering the questionnaire was: Good (mean: 62 years), Fair (mean: 64 years), and Poor (mean: 56 years). There was no statistical difference between groups (p = 0.408).

Overall QoL scores were also analyzed with respect of time from surgery, and no statistical diference was found among groups (p = 0.275). A total of 43 patients answered the questionnaire during the first year after surgery (POY1) reporting a QoL: Good 20 (12.3%), Fair (13.6%), and Poor 1 (0.6%). A total of 21 patients completed the questionnaire during the 2nd year after surgery (POY2) with Good 8 (4.9%), Fair 10 (6.2%), and Poor 3 (1.9%) overall QoL scores. A total of 24 patients at POY3 reported Good 12 (50%) and Fair 12 (50%) overall QoL scores. The largest group was on POY4 (n = 69) and reported Good 25 (15.4%), Fair 42 (25.9%), and Poor 2 (1.2%) overall QoL. Only five patients at POY5 reportinged Good 2 (1.2%) and Fair 3 (1.9%) QoL scores.

Investigator's Questionnaire Results

Comorbidities such as hypertension, smoking history, previous myocardial infarction (MI) and peripheral vascular disease were significantly predominant in groups who score Poor QoL (p < 0.05). Preoperative comorbidities and risk factors are described in [Table 1].

Table 1 Demographics, risk factors, and preoperative comorbidities according to the three different quality of life scoring groups

	Good n = 67	Fair n = 89	Poor n = 6	p
Age, mean years (SD, range) At present time At time of surgery	62 (10; 40–82) 60 (11; 36–80)	64 (13; 24–92) 62 (14;20–87)	56 (12; 40–71) 53 (12; 37–68)	0.549 0.175
Sex Male Female	42 (63%) 25 (37%)	59 (66%) 30 (34%)	3 (50%) 3 (50%)	0.660
Status at time of referral Unstable Stable	32 (48%) 35 (52%)	51 (57%) 38 (43%)	5 (83%) 1 (17%)	0.163
Presentation with syncope	6 (9%)	5 (6%)	0	0.149
Presence of pericardial effusion	6 (9%)	12 (13%)	1 (17%)	0.804
Hypertension	45 (67%)	63 (71%)	5 (83%)	0.016
Diabetes	5 (7%)	9 (10%)	1 (17%)	0.707
Hypercholesterolemia	18 (27%)	25 (28%)	4 (67%)	0.334
Smoking history Current smoker Ex-smoker Nonsmoker	10 (15%) 23 (34%) 34 (51%)	11 (12%) 33 (37%) 45 (51%)	1 (17%) 3 (50%) 2 (33%)	0.035
Chronic pulmonary disease	10 (15%)	11 (12%)	1 (17%)	0.292
Previous MI One Two or more	8 (12%) 2 (3%)	14 (16%) 0	1 (17%) 0	0.007
History of neurological disease TIA or RIND CVA with full recovery CVA with residual deficit	8 (12%) 6 (9%) 1 (2%)	4 (5%) 0 3 (3%)	0 0 0	0.033
Peripheral valvular disease	25 (37%)	27 (30%)	3 (50%)	0.025
Preoperative heart rhythm SR AF	51 (76%) 16 (24%)	64 (72%) 26 (29%)	5 (83%) 1 (17%)	0.476
Previous cardiac surgery	13 (20%)	11 (16%)	2 (33%)	0.863
Creatinine, mean mmol/L (SD, range)	100.7 (31; 43–187)	102 (46; 44–322)	88.7 (19; 71–119)	0.058

Abbreviations: AF, atrial fibrillation; CVA, cerebrovascular accident; DVT, deep venous thrombosis; MI, myocardial infarct; PCI, percutaneous coronary intervention; PVD, peripheral vascular disease; RIND, reversible ischemic neurological defect; SD, standard deviation; SR, sinus rhythm; TIA, transient ischemic attack.

Index surgeries performed for the ATAAD repair root and ascending aorta replacement (61, 38%), ascending aorta replacement (81, 50%) aortic arch replacement (including elephant trunk techniques, [20, 12%]; [Table 2]).

Table 2 Surgical procedures used for the initial Type A aortic dissection repair

Surgical procedures offered for the aortic dissection repair	n (%)[a]
Root + ascending aorta replacement	61 (38%)
Ascending aorta replacement	81 (50%)
Aortic arch replacement	20 (12%)

^a Concomitant aortic valve replacement, n = 11 (7% of total).

Regarding the impact of different surgical procedures in QoL, only patients who underwent arch replacement showed a significant overall QoL score difference among groups (p = 0.016, Good 7 (35%), Fair 10 (50%), and Poor 3 (15%)).

Length of surgery (including cardiopulmonary bypass [CPB], cross-clamp and systemic circulatory arrest) was significantly longer in those who scored Poor QoL questionnaires. Intraoperative data are described in [Table 3].

Table 3 Intraoperative data, including surgical times and cerebral protection strategies according to the three different quality of life scoring groups

	Good n = 67	Fair n = 89	Poor n = 6	p
Ejection fraction Normal/mildly impaired (>40%) Impaired (<40%)	55 (82%) 12 (18%)	75 (83%) 14 (11%)	6 (100%) 0	0.655
Severity of aortic regurgitation Nil Mild Moderate Severe Unknown	20 (30%) 6 (9%) 8 (12%) 4 (65) 29 (43%)	19 (21%) 5 (6%) 20 (22%) 10 (11%) 35 (39%)	0 1 (17%) 2 (34%) 0 3 (50%)	0.165
CPB time, mean min (SD, range)	223.83 (82; 62–447)	236.58 (84; 92–506)	342.33 (131; 223–575)	0.041
Cross clamp time, mean min (SD, range)	133.38 (64; 29–348)	131 (61; 29–346)	180 (96; 86–349)	0.077
Systemic circulatory arrest time, mean min (SD, range)	47.66 (43; 0–180)	58.19 (64; 0–344)	98.50 (78; 134–349)	0.007
Core temperature, mean °C (SD, range)	21.95 (3; 18–35)	22.14 (4; 18–36)	20.33 (2; 18–24)	0.719
Cerebral protection time, mean min (SD, range)	33.46 (26; 0–131)	38.80 (28; 0–249)	48.33 (30; 16–101)	0.335
Cerebral protection strategy None Antegrade Retrograde	17 (25%) 48 (72%) 2 (3%)	9 (10%) 68 (76%) 12 (13%)	0 6 (100%) 0	0.366
Arterial cannulation site Femoral Central Axillary Innominate	33 (49%) 21 (31%) 8 (12%) 5 (8%)	40 (45%) 37 (42%) 10 (11%) 2 (2%)	3 (50%) 3 (50%) 0 0	0.291

Abbreviations: CPB, cardiopulmonary bypass; SD, standard deviation.

A correlation analysis confirmed the duration of systemic circulatory arrest to have negative impact on the regular activities (R 0.411, Sig 0.000); however, duration of CPB, cross clamp, and cerebral protection did now show further correlation with the QoL scores.

Complications such as reoperation for bleeding, sternal wound infection, and any neurological impairment were significantly predominant in the group who reported Poor QoL. Those who suffered TIA or cerebrovascular accident (CVA) with full recovery reported an overall Good QoL score, whereas those who had a CVA with a residual deficit (n = 9) scored predominantly a Fair QoL score. Those who required transfer to another hospital also reported predominantly a Poor QoL. Postoperative complications are summarized in [Table 4].

Table 4 Postoperative complications according to the three different quality of life scoring groups

	Good n = 67	Fair n = 89	Poor n = 6	p
Postoperative MI	0	3 (3%)	0	0.033
Reoperation for bleeding	12 (18%)	7 (8%)	3 (50%)	0.005
Postoperative arrhythmias	25 (37%)	41 (46%)	1 (17%)	0.271
Sternal wound infection	3 (5%)	4 (4.5%)	2 (34%)	0.010
Pulmonary complications Chest infection/HAP Atelectasis Pneumothorax Pulmonary oedema NIV/BiPAP/CPAP ARDS Tracheostomy	14 (21%) 4 (6%) 0 1 (1.5%) 0 ( 5 (7.5%) 2 (3%)	11 (12%) 12 (13%) 1 (1%) 5 (6%) 3 (3%) 10 (11%) 2 (2%)	0 0 0 1 (17%) 0 1 (17%) 0	0.986
Permanent pacemaker	5 (7.5%)	8 (9%)	0	0.642
Postoperative hemofiltration	14 (21%)	16 (18%)	0	0.437
Gastrointestinal complications	9 (13%)	22 (25%)	0	0.106
Sepsis	6 (9%)	6 (7%)	2 (34%)	0.235
Neurological complications Postoperative delirium Transient stroke Permanent stroke Paraplegia	6 (9%) 9 (13%) 1 (1.5%) 0	11 (12%) 24 (27%) 3 (3%) 0	1 (17%) 3 (50%) 1 (17%) 1 (17%)	0.001
Length of hospital stay, mean days (SD, range)	22 (14)	19 (15)	25 (16)	0.170
Destination at discharge Home Other hospital Specialised care facility	61 (91%) 6 (9%) 0 (0)	78 (88%) 10 (11%) 1 (1%)	5 (83%) 1 (17%) 0	0.040
Residual proximal aortic disease	9 (13%)	12 (13%)	0	0.631
Residual distal aortic disease	29 (43%)	47 (53%)	3 (50%)	0.539
Reintervention during the follow-up	5 (7.5%)	6 (7%)	0	0.783

Abbreviations: ARDS, acute respiratory distress syndrome; HAP, hospital-acquired pneumonia; MI, myocardial infarction; SD, standard deviation.

Postoperative neurological complications showed significant impact on three domains: overall QoL (p = 0.039), impact on regular activities (p = 0.012), and impact on physical activities (p = 0.052). Reopening for bleeding and wound infection also affected overall QoL (p = 0.005 and 0.010), and wound infection specifically impacted on physical and emotional health (p = 0.004). Postoperative MI showed impact on social and emotional well-being (p = 0.033), whereas postoperative arrhythmias showed impact on capabilities (p = 0.020). Destination at discharge showed impact on regular activities (p = 0.040; [Table 5]).

Table 5 Summary of the statistically significant results showing correlation between clinical variables and quality domains affected

Quality of life
Variable	Domain	p-Value
Neurological complications	Overall quality of life Impact on regular activities Impact on physical activities	0.039 0.012 0.052
Time (min) circulatory arrest	Impact on regular activities	R 0.411 Sig 0.000
Reopening for bleeding Postoperative MI Postoperative arrhythmias	Overall quality of life Impact on social an emotional well-being Impact of aortic dissection on capabilities	0.005 0.033 0.020
Wound infection	Overall quality of life Physical and emotional health	0.010 0.004
Status at discharge	Impact on regular activities	0.040

Abbreviation: MI, myocardial infraction.

Mean period since ATAAD was 2.4 (0–5) years. Eleven patients (7%) have already undergone an aortic reintervention during that period, whereas 21 patients (13%) have a degree of proximal disease (root aneurysm and/or residual dissection) and 79 patients (49%) are on surveillance for residual distal aortic disease (residual arch and/or thoracoabdominal dissection).

Discussion

QoL after cardiac surgery has been identified as number one at Top 10 research priorities by the National Cardiac Surgery Clinical Trials Initiative in the United Kingdom. However, the QoL tools used are often too generic and do not capture the challenges survivors of TAAD have to face during their recovery. None of these tools were tailored for TAAD survivors, had input from patients and surgeons, or had been statistically validated for this cohort of patients.

Previous reports of QoL in TAAD survivors have used different tools, including the SF-36, SF-12, EQ-5D: Bartell Index, WHO performance scale, and/or PROMIS. There are previous reports demonstrating a general QoL decline following TAAD, especially lower physical and general health scores in ATAAD survivors when compared with the normal population.[5] [6] [7] [8] [9] [10]

Other series, however, reported the majority of survivors of ATAAD are able to regain physically active lives,[9] with comparable QoL to healthy subjects after the first postoperative year[11] and comparable physical and mental scores at 10 years.[11] [12] [13]

Limitations of these questionnaires are not being able to discriminate between regular and physical activities and not considering baseline physical condition and patient's goals postsurgery.

Hence, QUADS designed different domains to assess QoL after ATAAD from a consensus between patients and surgeons.

Our study has proven that the overall QoL after TAAD is excellent, with only 4% of the patients scoring Poor in the overall QoL category. We proved that QoL in TAAD survivors is not affected significantly in their daily regular activities and working life; however, they are less likely to be able to perfom intense physical activities compared with their basline prior the dissection.

Preoperative comorbidities suchas as hypertension, smoking history, previous MI, and peripheral vascular disease were predominant in the Poor QoL scores, not surprisingly due to the chronic effects they cause in individuals health and physical capacity.

We also identified a significant lower QoL scores for those who underwent arch surgery, whereas the other surgical procedures offered did not show siginifcant differences in the QoL scores reported. We also found a significant longer surgical times for those who reported Poor QoL. Further correlation analysis demonstrated the duration of circulatory arrest as main risk factor for lower QoL scores. We observe in our group of survivors that those who underwent a longer systemic circulatory arrest (such arch replacement when compared with other repair techniques limited to the ascending aorta and/or aortic root) reported worse QoL scores and presented higher rate of postoperative complications, especially neurological.

We found that developing postoperative neurological complications impacted overall QoL scores but specifically physical and regular activities, even considering the lower number of patients with CVA and residual deficit in our cohort.

Not surprisingly, other postoperative complications such as reoperation for bleeding, sternal wound infection, and development of arrhythmias also impacted several domains of the QoL, likely related to the prolonged hospital length of stay that these complications associate. The fact that those who were discharged to another hospital facility rather than home also reported lower QoL reflects the likely complex postoperative period that they suffered that required extra time for hospitalization and/or rehabilitation.

QUADS study could not discriminate the responses according to age decades and specifically in elderly patients due to the sample size. There are conflicting findings in the literature, where some studies showed significantly lower PCS in subjects > 70 years;[14] [15] [16] [17] while others did not demonstrate significant differences between young and elderly patient groups.[18] [19]

QUADS study does not have a formal mental health component as we consider this sphere complex enough to produce its own study. Across the literature, younger patients scored worse when compared with elderly patients, with increased posttraumatic stress disorder, sexual dysfunction, and travelling phobia.[17] [20] Although QUADS study recognizes significant levels of anxiety across the responses and overall comments of the patients, we could not find sexual dysfunction in our sample in any group age.

ATAAD survivors demonstrated an interest in understanding the cause of the dissection, the surgical details, and any subsequent problems that might occur. Most of the patients reported that they have not had significant physical effects on daily life but would have appreciated extra reassurance and specific guidance in areas such exercise, diet, and how to manage long-term care. A significant number of patients reported the lack of follow-up in their local area, mostly being followed up once a year.

Our study has significant limitations, including the selection bias limited to both patient and unit willingness to participate in the study, especially the former might have contributed to an overestimated QoL. We also aknowledge the limitation to account for mortality and/or postoperative complications that cause a significant disability, as we can only include survivors and individuals with capacity to consent. Also, the time elapsed since surgery has not been considered as modifying variable; hence, those who had more time to recovery from surgery might have score higher in several domains. However, being a multicenter study with representation from different United Kingdom nations and regions adds into consideration the geographical diversity and ethnical influence in the recovery.

Future reseach implications that might arise after the creation of the QUADS questionnaire include a prospective application for patients prior to hospital discharge and at agreed intervals as well as a wider distribution including larger populations and wider geographical and demographical areas to eliminate the selection bias.

Conclusion

QUADS is the first validated tool to assess QoL after ATAAD Surgery. Patient's answers showed a predominantly overall Good QoL after ATAAD surgery in the United Kingdom. Neurological complications, duration of circulatory arrest, reoperation for bleeding, postoperative MI and arrhythmias, wound infection, and destination at discharge were identified as main variables impacting QoL after ATAAD surgery across different domains of this questionnaire.

Conflict of Interest

None declared.

Acknowledgment

We would like to thank the Aortic Dissection Awareness UK and Ireland who helped in the design and/or participated in this study as survivors. And special thank you to Mr Gareth Owens and Dr Gordon McManus, from Aortic Dissection Awareness UK and Ireland for their constant support and feedback link with the biggest association of survivors after ATAAD in Great Britain, and the research nurse who assisted in the data collection process for the London group, Ms Flores Garcia.

Authors' Contribution

B.R.: chief investigator, data and statistical analysis, manuscript writing. W.E., M.L., A.Y.O., A.L.M.: project supervision, data interpretation, manuscript edition. A.O., S.K., A.S., M.C., S.A., M.K., I.M., S.C., I.D., W.E., J.H., N.N., N.A., A.C.: local principal investigator and data collectors.

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Publikationsverlauf

Eingereicht: 07. Mai 2024

Angenommen: 06. November 2024

Artikel online veröffentlicht:
25. Februar 2025