Perioperative Factors Associated With Postoperative Delirium in Patients Undergoing Noncardiac Surgery: An Individual Patient Data Meta-Analysis.

Importance: Postoperative delirium (POD) is a common and serious complication after surgery. Various predisposing factors are associated with POD, but their magnitude and importance using an individual patient data (IPD) meta-analysis have not been assessed. Objective: To identify perioperative factors associated with POD and assess their relative prognostic value among adults undergoing noncardiac surgery. Data Sources: MEDLINE, EMBASE, and CINAHL from inception to May 2020. Study Selection: Studies were included that (1) enrolled adult patients undergoing noncardiac surgery, (2) assessed perioperative risk factors for POD, and (3) measured the incidence of delirium (measured using a validated approach). Data were analyzed in 2020. Data Extraction and Synthesis: Individual patient data were pooled from 21 studies and 1-stage meta-analysis was performed using multilevel mixed-effects logistic regression after a multivariable imputation via chained equations model to impute missing data. Main Outcomes and Measures: The end point of interest was POD diagnosed up to 10 days after a procedure. A wide range of perioperative risk factors was considered as potentially associated with POD. Results: A total of 192 studies met the eligibility criteria, and IPD were acquired from 21 studies that enrolled 8382 patients. Almost 1 in 5 patients developed POD (18%), and an increased risk of POD was associated with American Society of Anesthesiologists (ASA) status 4 (odds ratio [OR], 2.43; 95% CI, 1.42-4.14), older age (OR for 65-85 years, 2.67; 95% CI, 2.16-3.29; OR for >85 years, 6.24; 95% CI, 4.65-8.37), low body mass index (OR for body mass index <18.5, 2.25; 95% CI, 1.64-3.09), history of delirium (OR, 3.9; 95% CI, 2.69-5.66), preoperative cognitive impairment (OR, 3.99; 95% CI, 2.94-5.43), and preoperative C-reactive protein levels (OR for 5-10 mg/dL, 2.35; 95% CI, 1.59-3.50; OR for >10 mg/dL, 3.56; 95% CI, 2.46-5.17). Completing a college degree or higher was associated with a decreased likelihood of developing POD (OR 0.45; 95% CI, 0.28-0.72). Conclusions and Relevance: In this systematic review and meta-analysis of individual patient data, several important factors associated with POD were found that may help identify patients at high risk and may have utility in clinical practice to inform patients and caregivers about the expected risk of developing delirium after surgery. Future studies should explore strategies to reduce delirium after surgery.

The power in being together for young adults who have heart disease - the photoshoot experience.

OBJECTIVES: The study aimed to determine perceived motivations and benefits of photoshoot participation for young adults who have heart disease. BACKGROUND: Feeling isolated and different can have lifelong affects on quality of life in heart disease survivors. Photoshoots, where people create a photographic image of themselves, promote positive interpretation of their cardiac illness experience, but participant experiences remain under-investigated. METHODS: Young adult heart disease support group members completing a photoshoot were interviewed and data were thematically analyzed. RESULTS: Seven females and one male aged 20-47 years participated. The main theme, People Like Me, emphasized feelings of being different, isolated and uncertain due to the heart disease. Other themes related to support gained from people who were not like them, gaining and providing support to their peers. The photoshoot enabled a highly valued collective feeling. CONCLUSIONS: For young adult heart disease survivors, the photoshoot provides a fun, social opportunity to reduce isolation and share experiences.

Predictors of warfarin non-adherence in younger adults after valve replacement surgery in the South Pacific.

OBJECTIVES: Globally, mechanical valves are predominant as replacements for adolescents and younger adults with rheumatic heart disease (RHD). Mechanical valve implantation necessitates lifelong antithrombotic management (warfarin) and associated lifestyle modification, with event-free survival largely dependent on international normalised therapeutic ratios (INRs) remaining within the target therapeutic range. There is limited information on factors that may influence warfarin adherence among younger people or those in resource-limited settings. This study sought to identify predictors of warfarin adherence after valve replacement surgery for RHD in Fiji (n=127). METHODS: A cross-sectional study design was used. RESULTS: The sample had a mean age of 31.23 years (SD 13.34) and a mean time-since-surgery of 3.72 years (SD 3.95). Just over half were women (n=71, 56%) and almost two-thirds were indigenous (I-taukei, n=78, 61%). Most had an isolated valve procedure (n=94, 74%) and at the time of survey, they were in New York Heart Association Class I (n=97, 76%). A quarter (n=33, 26%) reported poor adherence with anticoagulation therapy and 13.38% (n=17) reported complete warfarin cessation. While younger age was significantly associated with non-adherence to warfarin therapy (p=0.008), the independent predictors of people who discontinue warfarin completely were those not understanding why warfarin was needed (OR=9.97, p=0.006); a history of forgetting to take warfarin (OR=8.64, p=0.0013) and travel time to heart clinic >1 hour (OR=5.80, p=0.039). CONCLUSIONS: While medication adherence is complex and multifactorial, the consequences of warfarin non-adherence are potentially catastrophic. These results provide an important first step towards the development of country-specific and disease-specific strategies to improve warfarin adherence.

Health-related quality of life of patients after mechanical valve replacement surgery: an integrative review.

BACKGROUND: Heart valve replacement surgery is undertaken to improve cardiac function and health-related quality of life (HRQoL). Mechanical valves are typically used for younger people (aged <65 years). Implantation of these valves comes with life-long health self-management requirements which potentially impact on HRQoL. AIMS: The purpose of this study was to identify the short and long-term impact on HRQoL after mechanical valve replacement surgery. METHODS: Multiple electronic databases were searched for peer-reviewed studies published between 2000-2013, which focused on patients who had mechanical valve replacement, aged <65 years, and used a valid measure of HRQoL. RESULTS: Eight papers were included, all of which used the Short-Form 36 Health Survey (SF-36). Preoperatively, HRQoL was impaired, particularly in the SF-36 health domains of role-physical, physical-functioning, vitality and role-emotional. Postoperatively, most people had positive and sustained HRQoL improvement. In the early postoperative period all data showed significant improvement in at least four of eight health domains (physical function, role-physical, vitality, social function). Two-thirds of people also had significant improvement in an additional two health domains (general and mental-health). Whilst most people sustained HRQoL over time, one-third of younger adults (age <24 years) showed impairment in three domains (physical-function, mental-health and general-health). CONCLUSIONS: Mechanical valve replacement surgery results in important and sustained improvements in HRQoL. Future research should include investigation of HRQoL outcomes after mechanical valve replacement for specific groups such as younger adults and people in developing countries, and include evaluations of the potential impact of valve-specific factors and health self-management requirements.

Short- and long-term outcomes after valve replacement surgery for rheumatic heart disease in the South Pacific, conducted by a fly-in/fly-out humanitarian surgical team: a 20-year retrospective study for the years 1991 to 2011.

OBJECTIVES: Fiji has one of the highest rates of rheumatic heart disease in the world. Humanitarian fly-in/fly-out surgical teams, including Open Heart International, have been conducting valve replacement surgery in Fiji since 1991. We sought to determine the short- and long-term outcomes of valve replacement for rheumatic heart disease. METHODS: The Open Heart International team performed surgery on 167 patients from 1991 to 2011. Complete follow-up data to death or last evaluation on 149 patients (89.2%) and morbidity data for 152 patients (91%) were extracted from medical records. RESULTS: Patients' average age at the time of surgery was 26.1 years, with the majority being female (63.5%). Valves replaced were isolated mitral valves (52%), isolated aortic valves (19%), and multiple valves (29%). The cumulative mortality rate at 30, 60, and 90 days and at 1, 5, and 10 years was 2.4%, 6.0%, 8.4%, 12.0%, 19.8%, and 23.9%, respectively. Major adverse valve-related events-free survival was 10.1 years (95% confidence interval [CI], 8.32-11.94). After adjusting for confounders, female patients were 3.03 times more likely to die postoperatively than male patients (odds ratio [OR], 3.03; 95% CI, 1.23-7.69). Patients undergoing isolated valve replacement were less likely to have a morbidity event than those undergoing multiple valve replacement (isolated mitral 67% less likely [OR, 0.33; 95% CI, 0.12-0.93] and isolated aortic 76% less likely [OR, 0.34; 95% CI, 0.06-0.96]). CONCLUSIONS: The majority of people undergoing valve replacement for rheumatic heart disease have good outcomes. Mortality and morbidity rates at 1 and 5 years, particularly for female patients, are cause for concern and indicate a need for evaluation of resources toward systematic long-term postoperative surveillance and medical management.

Health-related quality of life of patients after mechanical valve replacement surgery for rheumatic heart disease in a developing country.

OBJECTIVE: To evaluate the health-related quality of life (HRQoL) of people in Fiji (n=128) undergoing heart valve replacement (VR) surgery for rheumatic heart disease (RHD), conducted by Open Heart International. METHODS: Patients who had undergone surgery from 1991 to 2009 (n=72) and patients undergoing surgery for the years 2010-2012 (n=56) were surveyed prospectively, preoperatively and/or postoperatively (the mean follow-up time 5.9 years) using the standard recall Short-Form 36, V.2 (SF-36v2) HRQoL Survey. RESULTS: The sample had a mean age of 26.7 years and 56% (n=72) were women. Preoperative HRQoL is impaired but by early postoperative (1 year) there is significant improvement across all domains (p<0.05) apart from mental health (p=0.081). At mid-term (2 years), HRQoL remained substantially improved from preoperative measurement with mental health now significantly better (p=0.028). However, compared with the early follow-up outcomes, at mid-term physical function (p=0.001), role-physical (p=0.002) and role-emotional (p=0.042) domains significantly declined. By late follow-up (>2 years), all HRQoL domains, except for mental health, were significantly better than preoperative (p=0.066 ). Predictors of less improved HRQoL included having an isolated mitral valve replacement (MVR) (for six of eight health domains, p<0.05), older age (three domains; role-physical, vitality and bodily pain, p<0.05) and male gender (in the role-emotional domain, p<0.05). CONCLUSIONS: This first investigation of the HRQoL of people in a developing country after VR surgery for RHD found significant improvement from surgery with this improvement generally sustained. The lack of improvement in mental health requires further exploration as does the influence of an isolated MVR, age and gender.