Background: Cardiac surgery, even when planned, has the potential for adverse outcomes, such that several factors are taken into consideration to help surgeons and their patients discuss the potential risks weighed against the expected recovery. Preoperative functional status and its influence on cardiac surgery, if any, have not been adequately evaluated to date. This study aimed to examine the relationship between preoperative functional status and postoperative mortality and morbidity in elective open heart patients. Methods: Preoperative baseline data (n = 43 subjects) were obtained to calculate Society of Thoracic Surgeons (STS) mortality and morbidity risk scores and preoperative functional status was measured using the Late-Life Function and Disability Instrument (LLFDI). Follow-up data were abstracted at one year postoperative to calculate actual mortality and morbidity events. Ordinary least squares and negative binomial regression analyses were conducted to assess the relationship between the LLFDI preoperative score to the STS mortality and morbidity risk scores. Results: Mortality risk was significant, F (1, 39) = 4.75, p = 0.035, with an adjusted R2 = 0.086, and Function Total (measured by LLFDI) yielded a significant negative association with mortality risk, β = − 0.329. Morbidity was found to be significant, F (1, 40) = 4.89, p = 0.033, with an adjusted R2 = 0.087 and Function Total yielded a significant negative association with morbidity risk, β = − 0.328, as well. Estimation of the counts for postoperative complications as estimated by Function Total failed to reach significance (Wald χ2 = 0.34, p = 0.56), which provided a pseudo R2 = 0.009. Probabilities for frequencies of adverse events (major complications), therefore, could not be reliably calculated. Conclusion: Preoperative diminished functional status, as measured by the LLFDI, is associated with an increased risk of mortality and morbidity in patients undergoing elective cardiac surgery. The risks and benefits of cardiac surgery should be weighed carefully and include a patient's preoperative functional status, especially in the case of an elective procedure.
KeywordsFunctional StatusElective Cardiac SurgeryMortality and Morbidity
Shahian, D.M., O’Brien, S.M., Filardo, G., Ferraris, V.A., Haan, C.K., Rich, J.B., Anderson, R.P., et al. (2009) The Society of Thoracic Surgeons 2008 Cardiac Surgery risk Models: Introduction and Part 1—Coronary Artery Bypass Grafting Surgery. Annals of Thoracic Surgery, 88, S1-S22. https://doi.org/10.1016/j.athoracsur.2009.05.053
Hillis, L., Smith, P.K., Anderson, J.L., Bittl, J.A., Bridges, C.R., Byrne, J.G., Winniford, M.D., et al. (2011) 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery: Executive Summary. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. Journal of American College of Cardiology, 58, 2584-2614. https://doi.org/10.1016/j.jacc.2011.08.008
Roger, V.L., Go, A.S., Lloyd-Jones, D.M., Adams, R.J., Berry, J.D., Brown, T.M., Wylie-Rosett, J., et al. (2011) American Heart Association. Heart Disease and Stroke Statistics 2011 Update: A Report from the American Heart Association. Circulation, 123, e18-e209. https://doi.org/10.1161/CIR.0b013e3182009701
Holmes, D.R., Mack, M.J., Kaul, S., Agnihotri, A., Alexander, K.P., Bailey, S.R., Thomas, J.D., et al. (2012) ACCF/AATS/SCAI/STS Expert Consensus Document on Transcatheter Aortic Valve Replacement. Journal of American College of Cardiology, 59, 1200-1254. https://doi.org/10.1016/j.jacc.2012.01.001
Society of Thoracic Surgeons (2015) STS Adult Cardiac Surgery Database. About the STS Risk Calculator (Version 2.81). Updated 2015. http://riskcalc.sts.org/stswebriskcalc/#/support.
van Straten, A.H.M., Bramer, S., Soliman Hamad, M.A., van Zundert, A.A.J., Martens, E.J., Schonberger, J.P.A.M. and de Wolf, A.M. (2010) Effect of Body Mass Index on Early and Late Mortality after Coronary Artery Bypass Grafting. Annals of Thoracic Surgery, 89, 30-37. https://doi.org/10.1016/j.athoracsur.2009.09.050
Bakaeen, F.G., Chu, D., Huh, J. and Carabello, B.A. (2010) Is an Age of 80 Years or Greater an Important Predictor of Short-Term Outcomes of Isolated Aortic Valve Replacement in Veterans? Annals of Thoracic Surgery, 90, 769-774. https://doi.org/10.1016/j.athoracsur.2010.04.066
Afilalo, J., Eisenberg, M.J., Morin, J.F., Bergman, H., Monette, J., Noiseux, N., Boivin, J-F., et al. (2010) Gait Speed as an Incremental Predictor of Mortality and Major Morbidity in Elderly Patients Undergoing Cardiac Surgery. Journal of American College of Cardiology, 56, 1668-1676. https://doi.org/10.1016/j.jacc.2010.06.039
Cervera, R., Bakaeen, F.G., Cornwell, L.D., Wang, X.L., Coselli, J.S., Le Maire, S.A. and Chu, D. (2012) Impact of Functional Status on Survival after Coronary Artery Bypass Grafting in a Veteran Population. Annals of Thoracic Surgery, 93, 1950-1955. https://doi.org/10.1016/j.athoracsur.2012.02.071
Lee, D.H., Buth, K.J., Martin, B.J., Yip, A.M. and Hirsch, G.M. (2010) Frail Patients Are at Increased Risk for Mortality and Prolonged Institutional Care after Cardiac Surgery. Circulation, 121, 973-978. https://doi.org/10.1161/CIRCULATIONAHA.108.841437
Sündermann, S.H., Dademasch, A., Praetorius, J., Kempfert, J., Dewey, T., Folk, V., Walther, T., et al. (2011) Comprehensive Assessment of Frailty for Elderly High-Risk Patients Undergoing Cardiac Surgery. European Journal of Cardio-Thoracic Surgery, 39, 33-37. https://doi.org/10.1016/j.ejcts.2010.04.013
Sündermann, S.H., Dademasch, A., Seifert, B., Biefer, H.R.C., Emmert, M.Y., Walther, T., Starck, C.T., et al. (2014) Frailty Is a Predictor of Short- and Mid-Term Mortality after Elective Cardiac Surgery Independently of Age. Interactive Cardiovascular and Thoracic Surgery, 18, 580-585. https://doi.org/10.1093/icvts/ivu006
Narain, P., Rubenstein, L.Z., Wieland, G.D., Rosbrook, B., Strome, L.S., Pietruszka, F. and Morley, J.E. (1988) Predictors of Immediate and 6-Month Outcomes in Hospitalized Elderly Patients. The Importance of Functional Status. Journal of the American Geriatrics Society, 36, 775-783. https://doi.org/10.1111/j.1532-5415.1988.tb04259.x
Inouye, S.K., Peduzzi, P.N., Robison, J.T., Hughes, J.S., Horwitz, R.I. and Concato, J. (1998) Importance of Functional Measures in Predicting Mortality among Older Hospitalized Patients. Journal of American Medical Association, 279, 1187-1193. https://doi.org/10.1001/jama.279.15.1187
Purser, J.L., Kuchibhatla, M.N., Fillenbaum, G.G., Harding, T., Peterson, E.D. and Alexander, K.P. (2006) Identifying Frailty in Hospitalized Older Adults with Significant Coronary Artery Disease. Journal of the American Geriatrics Society, 54, 1674-1681. https://doi.org/10.1111/j.1532-5415.2006.00914.x
Granton, J. and Cheng, D. (2008) Risk Stratification Models for Cardiac Surgery. Seminars in Cardiothoracic and Vascular Anesthesia, 12, 167-174. https://doi.org/10.1177/1089253208323681
Geissler, H.J., Holzl, P., Marohl, S., Kuhn-Régnier, F., Mehlhorn, U., Südkamp, M. and de Vivie, E.R. (2000) Risk Stratification in Heart Surgery: Comparison of Six Score Systems. European Journal of Cardio-Thoracic Surgery, 17, 400-406. https://doi.org/10.1016/S1010-7940(00)00385-7
Society of Thoracic Surgeons (2015) Using Gait Speed to Measure Frailty. https://www.sts.org/sites/default/files/documents/ACSD_SpecUpgradeChange SummaryV2_81.pdf
Wilson, C.M., Kostsuca, S.R. and Boura, J.A. (2013) Utilization of a 5-Meter Walk Test in Evaluating Self-Selected Gait Speed during Preoperative Screening of Patients Scheduled for Cardiac Surgery. Cardiopulmonary Physical Therapy Journal, 24, 36-43.
Enright, P.L. (2003) The Six Minute Walk Test. Respiratory Care, 48, 783-785.
LaPier, T.K. and Mizner, R. (2009) Outcome Measures in Cardiopulmonary Physical Therapy: Focus on the Late Life Function and Disability Instrument (LLFDI). Cardiopulmonary Physical Therapy Journal, 20, 32-35.
Jette, A.M., Haley, S.M. and Kooyoomjian, J.T. (2002) Late Life Function and Disability Instrument. Trustees of Boston University, Boston, MA.
Jette, A.M., Haley, S.M., Coster, W.J., Kooyoomjian, J.T., Levenson, S., Heeren, T. and Ashba, J. (2002) Late Life Function and Disability Instrument: I. Development and Evaluation of the Disability Component. The Journals of Gerontology: Series A, 57, M209-M216. https://doi.org/10.1093/gerona/57.4.M209
Haley, S.M., Jette, A.M., Coster, W.J., Kooyoomjian, J.T., Levenson, S., Heeren, T. and Ashba, J. (2002) Late Life Function and Disability Instrument: II. Development and Evaluation of the Function Component. The Journals of Gerontology: Series A, 57, M217-M222. https://doi.org/10.1093/gerona/57.4.M217
LaPier, T.K. and Waitt, M. (2007) Using the Late Life Function and Disability Instrument as a Self-Report Outcome Measure in Patients with Cardiovascular Disease. Journal of Cardiopulmonary Rehabilitation and Prevention, 27, 331. https://doi.org/10.1097/01.HCR.0000291340.61795.48
LaPier, T.K. (2012) Utility of the Late Life Function and Disability Instrument as an Outcome Measure in Patients Participating in Outpatient Cardiac Rehabilitation: A Preliminary Study. Physiotherapy Canada, 64, 53-62. https://doi.org/10.3138/ptc.2010-30
Sayers, S.P., Jette, A.M., Haley, S.M., Heeren, T.C., Guralnik, J.M. and Fielding, R.A. (2004) Validation of the Late-Life Function and Disability Instrument. Journal of the American Geriatrics Society, 52, 1554-1559. https://doi.org/10.1111/j.1532-5415.2004.52422.x
Denkinger, M.D., Igl, W., Coll-Planas, L., Bleicher, J., Nikolaus, T. and Jamour, M. (2009) Evaluation of the Short Form of the Late-Life Function and Disability Instrument in Geriatric Inpatients: Validity, Responsiveness, and Sensitivity to Change. Journal of the American Geriatrics Society, 57, 309-314. https://doi.org/10.1111/j.1532-5415.2008.02095.x
Dubuc, N., Haley, S.M., Ni, P., Kooyoomjian, J.T. and Jette, A.M. (2004) Function and Disability in Late Life: Comparison of the Late-Life Function and Disability Instrument to the Short-Form-36 and the London Handicap Scale. Disability and Rehabilitation, 26, 362-370. https://doi.org/10.1080/09638280410001658667
Beauchamp, M.K., Schmidt, C.T., Pedersen, M.M., Bean, J.F. and Jette, A.M. (2014) Psychometric Properties of the Late-Life Function and Disability Instrument: A Systematic Review. BMC Geriatrics, 29, 12.
Bennett, J.A., Riegel, B., Bittner, V. and Nichols, J. (2002) Validity and Reliability of the NYHA Classes Measuring Research Outcomes in Patients with Cardiac Disease. Heart & Lung, 31, 262-270. https://doi.org/10.1067/mhl.2002.124554
LaPier, T.K. and Howell, D. (2002) Functional Status Deficits in Patients Recovering from Coronary Artery Bypass: An Application of Evidence-Based Practice. Cardiopulmonary Physical Therapy Journal, 13, 12-19.