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Ann Thorac Surg 2006;82:1167-1168
© 2006 The Society of Thoracic Surgeons
a Center for Health Services and Nursing Research, Katholieke Universiteit Leuven, Kapucijnenvoer 35/4, B-3000 Leuven, Belgium
b University Hospitals of Leuven, Herestraat 49, B-3000 Leuven, Belgium
(Email: philip.moons{at}med.kuleuven.be).
In their outcome study on the Ross operation, Luciani and coworkers [1] have used the New York Heart Association (NYHA) classification, school grade, employment, and regular and strenuous physical activities as indicators of quality of life. In addition, others have used these variables to draw conclusions in terms of quality of life. In a review of 70 quality-of-life studies in congenital heart disease [2], it was found that 27% of the studies used the NYHA system to estimate patients' quality of life, making it the most frequently used tool to assess quality of life in these patients. However, we recently reported that the correlation between quality of life and the NYHA functional class in a large sample of adults with congenital heart disease was only -0.20 [3]. This suggests that functional class and quality of life are interrelated but cannot be used interchangeably.
At the outpatient clinic of our Adult Congenital Heart Disease Program, we recruited 396 consecutive patients who have previously undergone congenital cardiac surgery (63% males and 37% females; median age, 25 years). Tetralogy of Fallot (27%) and coarctation of the aorta (21%) were the most prevalent heart defects. We simply asked the patients to grade how they perceive their quality of life, using a 10-cm, vertical, graded scale, ranging from 0 to 100 (linear analogue scale). The score of 0 corresponded to the worst imaginable quality of life and 100 to the best imaginable quality of life. In addition, data needed to determine the NYHA functional class, employment status, and physical activities were collected during patient interviews. The interviewer was blind to the quality-of-life scores of the patients.
Patients' functional status was classified as good according to the NYHA system, with 80% falling into class I, 17% in class II, 2.5% in class III, and 0.5% in class IV. Overall, 93% of the patients were actively employed or attended school regularly. Only 4% were unemployed and 3% were disabled. Of this sample, 47% were engaged in sports on a regular basis. The patients reported having a good quality of life as reflected by a median linear analogue scale score of 80.
Univariately, a better functional status, having a job, and participation in sports was associated with a better quality of life. However, using multiple linear regression analysis, the explained variance by these three covariates was only 10.8% (adjusted R2). This indicates that NYHA classification, employment, and physical activities are poor indicators of quality of life after congenital cardiac surgery.
Several years ago, Ganiats and colleagues [4] indicated that the NYHA classification is not a sensitive measure of quality of life. Although the NYHA provides insights in patients' functional status, it may result in misleading findings as to quality of life. Therefore, we agree with Luciani and colleagues [1] that the results of the Ross operation are excellent in terms of functional status and having an active lifestyle, but this does not permit drawing conclusions in terms of quality of life at large. To measure quality of life, more appropriate instruments should be used [5].
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  G. B. Luciani and A. Mazzucco Reply. Ann. Thorac. Surg., September 1, 2006; 82(3): 1168 - 1168. [Full Text] [PDF]
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