HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sidney Chocron François Clement Kifah Alwan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chocron, S. Articles by Schipman, N. Search for Related Content PubMed PubMed Citation Articles by Chocron, S. Articles by Schipman, N.

Ann Thorac Surg 1996;61:153-157
© 1996 The Society of Thoracic Surgeons

---

Original Articles: Cardiovascular

Prospective Study of Quality of Life Before and After Open Heart Operations

Department of Thoracic and Cardiovascular Surgery and Department of Public Health, Biostatistics and Epidemiology Unit, Hôpital Saint-Jacques, Besançon, France

Accepted for publication September 15, 1995.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

 
Background. The aim of this prospective study, with completion of questionnaires before and 3 months after open heart operations, was to evaluate the improvement of quality of life brought about by these operations and the predictors of this improvement.

Methods. The Nottingham health profile questionnaire contains 38 subjective statements divided into six sections: energy, physical mobility, emotional reaction, pain, sleep, and social isolation. Factors influencing quality of life scores were determined by analysis of covariance. Factors influencing the status of the patients (improved or worsened) were determined by logistic regression.

Results. From January to July 1994, 215 consecutive patients underwent elective open heart operations. The comparison between mean preoperative and postoperative scores showed an improvement in all sections of quality of life. An average of 80% of patients were improved by their operations. Independent predictors of less improvement of quality of life scores were as follows: for the energy section, age over 70 and New York Heart Association functional class III or IV; for sleep, age over 70; for physical mobility, New York Heart Association functional class III or IV; for social isolation, female gender; and for pain, age over 70 and abnormal segmental wall motion. Independent predictors of patients worsened by operation were as follows: New York Heart Association functional class III or IV in the energy section (odds ratio = 3.7, 95% confidence interval 1.4 to 9.8) and in the physical mobility section (odds ratio = 2.4, 95% confidence interval 1.02 to 5.5), female gender in the social isolation section (odds ratio = 2.8, 95% confidence interval 1.03 to 7.7), and presence of at least one comorbid disease in the emotional reaction section (odds ratio = 2.5, 95% confidence interval 1.17 to 5.2).

Conclusions. Cardiac operations improve quality of life in patients. The improvement is similar for patients undergoing coronary artery bypass grafting versus valve replacement, and for patients with no postoperative events versus those with nonlethal postoperative complications. The strongest predictive factors for quality of life are age and New York Heart Association functional class.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

 
In cardiac operations, results are usually evaluated in terms of mortality, complications, or recurrence of symptoms. These criteria restrict the field of evaluation to cardiac symptoms. However, problems in sleeping or limitation of physical mobility that appear or worsen after surgery affect the quality of life (QOL) of the patients and are not taken into account in traditional evaluations of surgical results. Most of the studies on QOL in cardiac operations deal with coronary artery bypass grafting (CABG) [1–3]. We decided to study all patients undergoing elective open heart operations during a period of 6 months in terms of QOL and the factors influencing QOL status, particularly the influence of age and the type of operation. We chose the Nottingham health profile (NHP) questionnaire [4, 5], which has been applied to several areas of treatment, particularly to compare pre- and postoperative QOL [6, 7].

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

 
From January to July 1994, 215 patients underwent elective open heart operations requiring cardiopulmonary bypass in the Department of Thoracic and Cardiovascular Surgery of Besançon (France). The questionnaire was distributed to all patients before and 3 months after open heart operations.

The variables recorded were as follows: age, sex, occupation, heart disease, angina pectoris status according to Canadian classification, dyspnea class according to the New York Heart Association (NYHA) classification, comorbid diseases (previous heart operation, chronic obstructive pulmonary disease, renal failure, diabetes mellitus, cerebral or peripheral vascular disease), ejection fraction, left ventricular wall motion, surgical procedure, and operative complications.

The NHP questionnaire was written originally in English [4], then underwent rigorous translation into French, back-translation, and linguistic validation [8]. It contains 38 subjective statements divided into six sections: energy, physical mobility, emotional reaction, pain, sleep, and social isolation. The number of statements in each section varies, from three in the energy section to nine in the emotional reaction section. Within each section, an aggregation of responses is made possible by the use of item weights, determined on a general population sample using the Thurstone method of paired comparisons [8]. The questionnaire is included in the Appendix and has been reported previously [8].

One question (question 39) was added to the postoperative questionnaire to obtain the patient's overall perception of improvement due to the operation, namely, ``I feel better than before heart surgery.''

Statistical Analysis
The answer to each question was binary (yes or no). The score of each section was obtained by adding the weights of the questions to which the responses were positive. For example, the energy section is composed of three questions (see Appendix 1), each of which has a weight (39.20 for the first question, 36.80 for the second, and 24.00 for the third). A patient who answered no to the first question, and yes to the second and third, would have a score of [(0 x 39.20) + (1 x 36.80) + (1 x 24.00)] = 60.80 for the energy section. Thus, scores range from 0 to 100; a higher score indicates a higher level of dysfunction or distress.

FACTORS INFLUENCING QUALITY OF LIFE SCORES.
For the preoperative period, we evaluated the influence of each variable on each section of QOL using a Wilcoxon rank sum test. The preoperative and postoperative scores for each section of QOL were compared using a Wilcoxon matched-pairs rank test.

To determine the preoperative factors influencing the improvement of QOL scores, we analyzed each variable category in each section using analysis of covariance, with the changes in QOL measures as dependent variables. To determine independent predictors, factors with a level of significance less than or equal to 0.20 in univariate analysis were analyzed simultaneously by analysis of covariance, with the changes in QOL measures as dependent variables.

FACTORS INFLUENCING THE PROPORTION OF PATIENTS IMPROVED OR WORSENED BY OPERATION.
For each section of QOL, the preoperative and postoperative scores of each patient were compared to determine which patients improved and which patients worsened after operation. To determine the factors influencing the status of a patient, with the dependent variable being binary (improved or worsened), we performed logistic regression, first by univariate analysis and then by multivariate analysis. Variables with a level of significance less than or equal to 0.20 in the univariate analysis were included in the multivariate model, which was analyzed using a stepwise logistic regression. Occupational status was omitted from these analyses because the large number of categories made interpretation difficult.

All statistical analyses were performed with BMDP statistical software (BMDP, Los Angeles, CA).

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

 
Characteristics of the Study Population
Six patients did not fill in the questionnaire. Four did not speak French and 2 refused, resulting in 209 completed preoperative questionnaires.

The mean age was 65 ± 10 years, and the sex ratio (male to female) was 3:1 (Table 1). Eighty-one patients (39%) were less than 65 years of age, 39 (18%) were aged 65 to 70, 59 (29%) were 70 to 75, and 30 (14%) were older than 75.

Half of the patients suffered from coronary artery disease and 40% from heart valve disease. The predominant heart valve disease was calcified aortic stenosis (62 patients, 30%); 17 patients (8%) had a double-valve disease. The postoperative course was uneventful in 184 patients. Eight patients (3.7%) died postoperatively.

Factors Influencing Preoperative Quality of Life
Characteristics significantly associated with preoperative QOL are reported in Table 2. Compared with those undergoing an initial procedure, patients with previous cardiac operations had a significantly higher energy score (p < 0.01). The physical mobility score was higher in women (p < 0.01) and in patients suffering from cerebral or peripheral vascular disease (p < 0.05). The emotional reaction score was higher in women (p < 0.05), in patients with an ejection fraction less than 0.30 (p < 0.01), and in patients with NYHA functional class III or IV (p < 0.05).

The comparison between preoperative and postoperative scores showed an improvement in all sections of QOL (Fig 1). Independent predictors of less improvement of QOL scores were as follows: age over 70 and NYHA functional class III or IV for the energy section, age over 70 for the sleep section, NYHA functional class III or IV for the physical mobility section, female gender for the social isolation section, and age over 70 and abnormal segmental wall motion for the pain section (Table 3). Type of operation (CABG versus heart valve operation) (Fig 2) and nonlethal complications did not influence the improvement in QOL.

View larger version (29K): [in this window] [in a new window]   Fig 1. . Mean scores for each section of quality of life before and after operation (199 patients). The Wilcoxon matched-pairs rank test, comparing scores before and after operation for each section of quality of life, showed an improvement in all sections (**p < 0.01; *p < 0.05). Expected scores are based on reference scores for a ``normal'' population [10], applied to sex and age distribution in our series. Postoperative scores are similar to expected scores in all sections except the sleep section. (En = energy; ER = emotional reaction; PM = physical mobility; SI = social isolation.)

View larger version (39K): [in this window] [in a new window]   Fig 2. . Mean scores of the Nottingham Health Profile scale in patients before and after grafting and heart valve replacement. Preoperative scores and postoperative scores were similar in the two groups. In each group, preoperative scores were significantly higher than postoperative scores. (En = energy; ER = emotional reaction; PM = physical mobility; SI = social isolation.)

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

During the postoperative visit at month 3, patients often complain of noncardiac problems such as pain in the wound, arthritis, and others, which have been caused or worsened by operation. Even though a surgical intervention is successful, it may not improve the quality of life. For example, some troubles that patients perceived to be of minor importance before operation when compared with cardiac symptoms, or that they kept hidden because of fear of operation, may be of major importance after the operation. All of these disturbances, which can be found in a QOL evaluation, are omitted in traditional assessments of surgical outcome.

The NHP questionnaire is a generic scale and was not originally designed for patients undergoing cardiac operations. Thus, it is an adjunct to traditional clinical measures. It is not intended to be a measure of disease, but an indicator of limitations on health [7]. The NHP questionnaire explores different aspects of QOL, and the pre- and postoperative states can be easily compared. The questions are simple and the questionnaire is easy to complete. It has been used successfully in a number of treatment evaluations, including cardiac transplantation [6], heart-lung transplantation [7], cardiovascular strokes [9], and CABG [1–3]. Its translation, which has been certified as correct in several languages, allows comparisons between different cultures and populations.

The preoperative QOL scores were similar in patients older and younger than 70 years of age. This fact probably represents a selection in old patients to undergo cardiac operations. Scores for improvement of energy, sleep, and pain were lower for patients older than 70 than for those younger than 70, but the proportion of patients improved or worsened was not statistically different between the groups. This suggests that even if improved, older patients are more sensitive to side effects induced by operation. Improvement of QOL in all the sections of the NHP questionnaire confirmed the results of Caine and associates [2], which were restricted to male patients younger than 60 undergoing CABG. Our study extended these results to heart valve operations; the QOL improved similarly after CABG and heart valve operations.

Postoperative scores were similar to expected scores in all sections except the sleep section (see Fig 1). This tends to demonstrate that, with the exception of sleep, limitations on health are the same in patients after operation as in a ``normal'' population. The NYHA functional class is an important independent predictor of variations in QOL. It influences not only the level of improvement of energy and physical mobility scores, but also the proportion of patients improved in these two sections. Although the NHP is a generic scale, it is sensitive to this cardiac symptom.

Another important issue concerns postoperative complications, which, one can assume, would influence QOL 3 months after their occurrence. In fact, postoperative complications did not influence improvement of QOL. This might be because of the quality of rehabilitation in convalescent homes, the stay in which was longer for patients with postoperative complications.

One possible restriction should be mentioned concerning the interpretation of our results. Improvement may reflect either the effects of operation or the effects of factors linked to operation. Our patients undergo a rehabilitation program that lasts 3 to 6 weeks. During rehabilitation, patients take exercise, follow a healthful diet, and refrain from smoking. Conversely, their medications are generally reduced. We cannot confirm what part of the improvement is due to rehabilitation and what part to the surgical procedure. Another limitation concerns the patients' knowledge of their participation in a trial. This might lead to a bias in the results if patients exaggerated their assessment of improvement to please their doctors. However, as Caine and associates [2] stated, the improvements in the scores on the NHP were so overwhelming that the underlying improvements are probably real.

Even if statistically significant, score changes were marginal in the social isolation section (with an improvement of 2%) and in the pain section (with an improvement of 4%). It is clear that the better the baseline level (9 for social isolation, 17 for pain), the less the expected improvement.

Ninety-one percent of the patients felt that their lives had been improved by operation (answered yes to question 39), whereas analysis of the NHP questionnaire showed an improvement in only 80% of patients (p < 0.05). Although the NHP questionnaire explores a number of aspects of QOL, there is no method for combining the different sections to obtain an overall score; nor are all aspects of QOL included in this questionnaire.

We conclude that cardiac operations improve QOL in patients. This improvement is similar for patients undergoing CABG versus valve replacement, and for patients with no postoperative events versus those having nonlethal postoperative complications. The strongest predictors of improvement of QOL were age and preoperative NYHA functional class.

	Appendix 1. Nottingham Health Profile Questionnaire Classified According to Sections [8]

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

 

• Physical mobility
  

• I'm unable to walk at all.
  
• I can only walk about indoors.
  
• I need help to walk about outside.
  
• I find it hard to dress myself.
  
• I find it hard to stand for long.
  
• I have trouble getting up and down stairs or steps.
  
• I find it hard to bend.
  
• I find it hard to reach for things.
  

• Social isolation
  

• I feel I am a burden to people.
  
• I feel lonely.
  
• I feel there is nobody I am close to.
  
• I'm finding it hard to make contact with people.
  
• I'm finding it hard to get on with people.
  

• Emotional reactions
  

• I feel that life is not worth living.
  
• I've forgotten what it's like to enjoy myself.
  
• I feel as if I'm losing control.
  
• Things are getting me down.
  
• I wake up feeling depressed.
  
• Worry is keeping me awake at night.
  
• The days seem to drag.
  
• I'm feeling on edge.
  
• I lose my temper easily these days.
  

• Pain
  

• I'm in constant pain.
  
• I have unbearable pain.
  
• I have pain at night.
  
• I'm in pain when I walk.
  
• I'm in pain when going up/down stairs or steps.
  
• I'm in pain when I'm standing.
  
• I find it painful to change position.
  
• I'm in pain when I'm sitting.
  

• Sleep
  

• I take tablets to help me sleep.
  
• I lie awake most of the night.
  
• I sleep badly at night.
  
• It takes me a long time to get to sleep.
  
• I'm waking up in the early hours of the morning.
  

• Energy
  
• I'm tired all the time.
  
• Everything is an effort.
  
• I soon run out of energy.
  

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

 
Address reprint requests to Dr Chocron, Department of Thoracic and Cardiovascular Surgery, Hôpital Saint-Jacques, 25030 Besançon Cedex, France.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Appendix 1. Nottingham Health... References

 

1. Guadagnoli E, Ayanian JZ, Cleary PD. Comparison of patient-reported outcomes after elective coronary artery bypass grafting in patients aged and <65 years. Am J Cardiol 1992;70:60–4.[Medline]
2. Caine N, Harrison SCW, Sharples LD, Wallwork J. Prospective study of quality of life before and after coronary artery bypass grafting. BMJ 1991;302:511–6.
3. Folks DG, Blake DJ, Fleece L, Sokol RS, Freeman AM. Quality of life six months after coronary artery bypass surgery: a preliminary report. South Med J 1986;79:397–9.[Medline]
4. Hunt SM, McEwen J, McKenna SP. Measuring health status: a new tool for clinicians and epidemiologists. J R Coll Gen Pract 1985;35:185–8.[Medline]
5. Hunt SM, McKenna SP, McEwen J, Backett EM, Williams J, Papp E. A quantitative approach to perceived health status: a validation study. J Epidemiol Community Health 1980;34:281–6.[Abstract/Free Full Text]
6. Hunt SM. Quality of life considerations in cardiac transplantation. Qual Life Cardiovasc Care 1985;31:308–16.
7. O'Brien BJ, Banner NR, Gibson S, Yacoub MH. The Nottingham Health Profile as a measure of quality of life following combined heart and lung transplantation. J Epidemiol Community Health 1988;42:232–4.[Abstract/Free Full Text]
8. Bucquet D, Condon S, Ritchie K. The French version of the Nottingham Health Profile. A comparison of item weights with those of the source version. Soc Sci Med 1990;30:829–35.
9. Ebrahim S, Barer D, Nouri F. Use of the Nottingham Health Profile with patients after a stroke. J Epidemiol Community Health 1986;40:166–9.[Abstract/Free Full Text]
10. Hunt SM, McEwen J, McKenna SP. Perceived health: age and sex comparisons in community. J Epidemiol Community Health 1984;38:156–60.[Abstract/Free Full Text]

This article has been cited by other articles:

				K. L. Grady, R. Lee, H. Subacius, S. C. Malaisrie, E. C. McGee Jr, J. Kruse, J. J. Goldberger, and P. M. McCarthy Improvements in Health-Related Quality of Life Before and After Isolated Cardiac Operations Ann. Thorac. Surg., March 1, 2011; 91(3): 777 - 783. [Abstract] [Full Text] [PDF]

				T. Djarv, J. M. Blazeby, and P. Lagergren Predictors of Postoperative Quality of Life After Esophagectomy for Cancer J. Clin. Oncol., April 20, 2009; 27(12): 1963 - 1968. [Abstract] [Full Text] [PDF]

				A. Merkouris, E. Apostolakis, D. Pistolas, V. Papagiannaki, E. Diakomopoulou, and E. Patiraki Quality of Life after Coronary Artery Bypass Graft Surgery in the Elderly European Journal of Cardiovascular Nursing, March 1, 2009; 8(1): 74 - 81. [Abstract] [Full Text] [PDF]

				A. Aboud, M. Breuer, T. Bossert, and J. F Gummert Quality of Life After Mechanical vs. Biological Aortic Valve Replacement Asian Cardiovasc Thorac Ann, February 1, 2009; 17(1): 35 - 38. [Abstract] [Full Text] [PDF]

				K. Bruscia, C. Shultis, K. Dennery, and C. Dileo Predictors of Quality of Life in Hospitalized Cardiac Patients J Health Psychol, November 1, 2008; 13(8): 982 - 987. [Abstract] [PDF]

				C. Gorman Koch, F. Khandwala, and E. H. Blackstone Health-Related Quality of Life After Cardiac Surgery Seminars in Cardiothoracic and Vascular Anesthesia, September 1, 2008; 12(3): 203 - 217. [Abstract] [PDF]

				G. A. Lee Patients Reported Health-Related Quality of Life Five Years Post Coronary Artery Bypass Graft Surgery - A Methodological Study European Journal of Cardiovascular Nursing, March 1, 2008; 7(1): 67 - 72. [Abstract] [Full Text] [PDF]

				S. J. Durham and J. P. Gold Late Complications of Cardiac Surgery Card. Surg. Adult, January 1, 2008; 3(2008): 535 - 548. [Full Text]

				J. J. Jokinen, M. J. Hippelainen, O. A. Pitkanen, and J. E.K. Hartikainen Mitral Valve Replacement Versus Repair: Propensity-Adjusted Survival and Quality-of-Life Analysis Ann. Thorac. Surg., August 1, 2007; 84(2): 451 - 458. [Abstract] [Full Text] [PDF]

				P. Loponen, M. Luther, J.-O. Wistbacka, K. Korpilahti, J. Laurikka, H. Sintonen, H. Huhtala, and M. R. Tarkka Quality of life during 18 months after coronary artery bypass grafting Eur J Cardiothorac Surg, July 1, 2007; 32(1): 77 - 82. [Abstract] [Full Text] [PDF]

				C. G. Koch, F. Khandwala, L. Li, F. G. Estafanous, F. D. Loop, and E. H. Blackstone Persistent Effect of Red Cell Transfusion on Health-Related Quality of Life After Cardiac Surgery Ann. Thorac. Surg., July 1, 2006; 82(1): 13 - 20. [Abstract] [Full Text] [PDF]

				V. M. Peric, M. D. Borzanovic, R. V. Stolic, A. N. Jovanovic, and S. R. Sovtic Severity of Angina as a Predictor of Quality of Life Changes Six Months After Coronary Artery Bypass Surgery Ann. Thorac. Surg., June 1, 2006; 81(6): 2115 - 2120. [Abstract] [Full Text] [PDF]

				P. E. Falcoz, S. Chocron, F. Laluc, M. Puyraveau, D. Kaili, M. Mercier, and J. P. Etievent Gender analysis after elective open heart surgery: a two-year comparative study of quality of life. Ann. Thorac. Surg., May 1, 2006; 81(5): 1637 - 1643. [Abstract] [Full Text] [PDF]

				V. Peric, M. Borzanovic, A. Jovanovic, R. Stolic, S. Sovtic, and G. Trajkovic The relationship between EuroSCORE preoperative risk prediction and quality of life changes after coronary artery by-pass surgery Interact CardioVasc Thorac Surg, December 1, 2005; 4(6): 622 - 626. [Abstract] [Full Text] [PDF]

				T. M. Goyal, E. L. Idler, T. J. Krause, and R. J. Contrada Quality of Life Following Cardiac Surgery: Impact of the Severity and Course of Depressive Symptoms Psychosom Med, September 1, 2005; 67(5): 759 - 765. [Abstract] [Full Text] [PDF]

				I Florath, A Albert, U Rosendahl, T Alexander, I C Ennker, and J Ennker Mid term outcome and quality of life after aortic valve replacement in elderly people: mechanical versus stentless biological valves Heart, August 1, 2005; 91(8): 1023 - 1029. [Abstract] [Full Text] [PDF]

				C. G. Koch, F. Khandwala, F. G. Estafanous, F. D. Loop, and E. H. Blackstone Impact of Prosthesis-Patient Size on Functional Recovery After Aortic Valve Replacement Circulation, June 21, 2005; 111(24): 3221 - 3229. [Abstract] [Full Text] [PDF]

				J. S. Rumsfeld, P. M. Ho, D. J. Magid, M. McCarthy Jr, A. L. W. Shroyer, S. MaWhinney, F. L. Grover, and K. E. Hammermeister Predictors of health-related quality of life after coronary artery bypass surgery Ann. Thorac. Surg., May 1, 2004; 77(5): 1508 - 1513. [Abstract] [Full Text] [PDF]

				P.-E. Falcoz, S. Chocron, L. Stoica, D. Kaili, M. Puyraveau, M. Mercier, and J.-P. Etievent Open heart surgery: one-year self-assessment of quality of life and functional outcome Ann. Thorac. Surg., November 1, 2003; 76(5): 1598 - 1604. [Abstract] [Full Text] [PDF]

				A. Sedrakyan, V. Vaccarino, A. D. Paltiel, J. A. Elefteriades, J. A. Mattera, S. A. Roumanis, Z. Lin, and H. M. Krumholz Age does not limit quality of life improvement in cardiac valve surgery J. Am. Coll. Cardiol., October 1, 2003; 42(7): 1208 - 1214. [Abstract] [Full Text] [PDF]

				J. Bucerius, S. Metz, T. Walther, V. Falk, N. Doll, F. Noack, D. Holzhey, A. Diegeler, and F. W. Mohr Endoscopic internal thoracic artery dissection leads to significant reduction of pain after minimally invasive direct coronary artery bypass graft surgery Ann. Thorac. Surg., April 1, 2002; 73(4): 1180 - 1184. [Abstract] [Full Text] [PDF]

				P. E. Falcoz, S. Chocron, M. Mercier, M. Puyraveau, and J. P. Etievent Comparison of the Nottingham Health Profile and the 36-item health survey questionnaires in cardiac surgery Ann. Thorac. Surg., April 1, 2002; 73(4): 1222 - 1228. [Abstract] [Full Text] [PDF]

				J. S. Rumsfeld, D. J. Magid, M. O'Brien, M. McCarthy Jr, S. MaWhinney, A. L. W. Shroyer, T. E. Moritz, W. G. Henderson, G. K. Sethi, F. L. Grover, et al. Changes in health-related quality of life following coronary artery bypass graft surgery Ann. Thorac. Surg., December 1, 2001; 72(6): 2026 - 2032. [Abstract] [Full Text] [PDF]

				I. R. A. Goldsmith, G. Y. H. Lip, and R. L. Patel A prospective study of changes in the quality of life of patients following mitral valve repair and replacement Eur J Cardiothorac Surg, November 1, 2001; 20(5): 949 - 955. [Abstract] [Full Text] [PDF]

				E. Simchen, N. Galai, D. Braun, Y. Zitser-Gurevich, E. Shabtai, and I. Naveh Sociodemographic and clinical factors associated with low quality of life one year after coronary bypass operations: The Israeli Coronary Artery Bypass Study (ISCAB) J. Thorac. Cardiovasc. Surg., May 1, 2001; 121(5): 909 - 919. [Abstract] [Full Text] [PDF]

				J. Bucerius, S. Metz, T. Walther, N. Doll, V. Falk, A. Diegeler, R. Autschbach, and F. W. Mohr Pain is significantly reduced by cryoablation therapy in patients with lateral minithoracotomy Ann. Thorac. Surg., September 1, 2000; 70(3): 1100 - 1104. [Abstract] [Full Text] [PDF]

				S. Chocron, J.-P. Etievent, J.-F. Viel, A. Dussaucy, F. Clement, D. Kaili, and Y. Yan Preoperative quality of life as a predictive factor of 3-year survival after open heart operations Ann. Thorac. Surg., March 1, 2000; 69(3): 722 - 727. [Abstract] [Full Text] [PDF]

				Ann. Thorac. Surg., January 1, 2000; 69(1): 165 - 170.

				K. L. Yun, C. F. Sintek, A. D. Fletcher, T. A. Pfeffer, G. S. Kochamba, P. R. Mahrer, and S. Khonsari Time related quality of life after elective cardiac operation Ann. Thorac. Surg., October 1, 1999; 68(4): 1314 - 1320. [Abstract] [Full Text] [PDF]

				T. Walther, V. Falk, S. Metz, A. Diegeler, R. Battellini, R. Autschbach, and F. W. Mohr Pain and quality of life after minimally invasive versus conventional cardiac surgery Ann. Thorac. Surg., June 1, 1999; 67(6): 1643 - 1647. [Abstract] [Full Text] [PDF]

				T. H. Marwick, C. Zuchowski, M. S. Lauer, M.-A. Secknus, M. J. Williams, and B. W. Lytle Functional status and quality of life in patients with heart failure undergoing coronary bypass surgery after assessment of myocardial viability J. Am. Coll. Cardiol., March 1, 1999; 33(3): 750 - 758. [Abstract] [Full Text] [PDF]

				C. R. Cartwright and C. M. Mangano Quality of Life After Coronary Artery Bypass Surgery: Past Progress and Future Directions Seminars in Cardiothoracic and Vascular Anesthesia, November 1, 1998; 2(4): 302 - 310. [Abstract] [PDF]

				R. Autschbach, T. Walther, V. Falk, A. Diegeler, S. Metz, and F. W. Mohr S-shaped in comparison to L-shaped partial sternotomy for less invasive aortic valve replacement Eur J Cardiothorac Surg, October 1, 1998; 14(Supplement_1): S117 - S121. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sidney Chocron François Clement Kifah Alwan Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Chocron, S. Articles by Schipman, N. Search for Related Content PubMed PubMed Citation Articles by Chocron, S. Articles by Schipman, N.