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De Rui, Marina (2018) Aortic valve replacement in elderly subjects: effects on physical performance, cognitive function and quality of life. [Ph.D. thesis]

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Abstract (italian or english)

Background: aortic valve stenosis (AVS) is becoming more and more common in the elderly population, involving around 13.2% of subjects older than 75 years. In addition to worsening quality of life, untreated severe AVS has been associated with high short term mortality rate. However, these adverse outcomes could be modified by aortic valve replacement (AVR). In recent years, in particular, newer surgery procedures and anesthesiological techniques have allowed also older and frailer patients access to AVR procedures. Previous studies have evaluated the effectiveness of AVR in older subjects in terms of peri- and post-operative mortality, but its impact on frail patients’ global health has been scarcely investigated.
Aim of the study: the aim of our study was to evaluate the impact of AVR procedure on older patients’ physical performance, cognitive status and quality of life at 45 days, three and six months after surgery.
Subjects and methods: this prospective study included 46 patients over 70 years, enrolled in collaboration with the Department of Cardiac Surgery of the University of Padova. All subjects were affected by AVS, and were recommended to undergo AVR. Study participants were evaluated with a multidimensional geriatric assessment before AVR (T0) and 45 days (T1), three (T2) and six months (T3) after surgery. In particular, for each participant we collected data on clinical examination, self-sufficiency (using the Activites of Daily Living and Instrumental Activites of Daily Living scales), cognitive status (using the Mini Mental State Examination and the Montreal Cognitive Assessment), presence of depressive symptom (through the Geriatric Depression Scale), quality of life (using the Short-Form 36 items Health Survey) and physical performance (through the Short Physical Performance Battery, gait speed, 6-minute walking test, and measurements of upper and lower limbs strength).
Results: of the initial sample of 46 patients, 22 reached the 6-month follow-up and were included in the study. Compared with the pre-operative evaluation, at T1 we observed a significant decline in nutritional status (BMI, arm circumference, MNA score) and in physical performance (SPPB, handgrip strength, lower limb flexion-extension and isometric strength). At T3, MMSE, MoCA, MNA and SPPB scores improved significantly from baseline. Upper and lower limbs strength at 6-month follow up was not significantly different from baseline. Quality of life remained nearly stable at T1, but improved significantly at T2 and T3.
Considering the variation in gait speed from baseline to 6-month follow up, subjects that showed an improvement in this item compared to worsening subjects, at baseline had lower values of handgrip and limbs strength, gait speed and 6-MWT distance.
Conclusions: our results show that in older AVS patients, AVR have a positive impact on nutrition, physical performance, cognitive functioning, mood and quality of life, whereas it does not have any significant impact on limbs muscle strength.

Abstract (a different language)

Premessa: la stenosi valvolare aortica (AVS) sta diventando sempre più frequente nella popolazione anziana, coinvolgendo circa il 13.2% dei soggetti sopra i 75 anni. Oltre a compromettere la qualità della vita, la AVS di grado severo non trattata porta alla morte in un tempo relativamente breve. La storia naturale della AVS può essere modificata dalla sostituzione della valvola aortica (AVR). I progressi nelle tecniche operatorie e anestesiologiche hanno ampliato negli ultimi anni l’accesso all’intervento chirurgico a pazienti sempre più anziani e sempre più fragili. In letteratura gli studi hanno finora valutato l’efficacia della AVR nel paziente anziano in termini di mortalità peri- e post-operatoria, mentre mancano dati circa l’esito dell’intervento sulla salute globale del paziente fragile a medio termine.
Scopo dello studio: lo scopo del nostro studio era valutare nel soggetto anziano l’impatto dell’intervento di AVR sulla performance fisica, sullo stato cognitivo e sulla qualità di vita a distanza di 45 giorni, tre e sei mesi dall’intervento chirurgico.
Soggetti e metodi: in collaborazione con l’U.O. Cardiochirurgia, secondo un disegno osservazionale longitudinale sono stati studiati 46 pazienti di età > 70 anni affetti da AVS per i quali era stata posta indicazione all’AVR. I soggetti sono stati valutati prima dell’intervento chirurgico (T0) e dopo l’intervento chirurgico a 45 giorni (T1), a tre mesi (T2) e a 6 mesi (T3). In tutte le visite i soggetti sono stati sottoposti a una valutazione geriatrica multidimensionale, comprensiva di esame clinico, valutazione dell’autonomia funzionale (Activites of Daily Living e Instrumental Activites of Daily Living Scales), dello stato cognitivo (Mini Mental State Examination, Montreal Cognitive Assessment), del tono dell’umore (Geriatric Depression Scale), della qualità di vita (Short-Form 36 items Health Survey, SF-36) e della performance fisica (Short Physical Performance Battery, Gait Speed, Six minute Walking Test, misurazione della forza massimale degli arti superiori e inferiori).
Risultati: dei 46 pazienti inclusi nello studio in questo lavoro sono stati considerati solo i 22 soggetti che hanno completato il follow-up a 6 mesi. Rispetto alla valutazione preoperatoria, al follow-up dei 45 giorni era evidente un significativo peggioramento nei parametri nutrizionali (BMI,circonferenza del braccio, punteggio MNA) e dei test di performance fisica (forza massimale di prensione della mano, forza di flesso-estensione degli arti inferiori e test isometrico della forza degli arti inferiori). Al follow-up dei 6 mesi MNA, MMSE, MoCA, SPPB miglioravano significativamente, raggiungendo valori superiori a quelli basali. La forza degli arti superiori e inferiori non si modificava significativamente 6 mesi dopo l’intervento rispetto al basale. Per ciò che concerne la qualità di vita, i punteggi all’SF-36 rimanevano pressoché stabili a 45 giorni mentre miglioravano significativamente al controllo a 3 e a 6 mesi.
Considerando la variazione della velocità del passo tra la valutazione basale e quella a 6 mesi, i soggetti che presentavano un miglioramento nel follow up, rispetto agli altri soggetti al basale presentavano valori più bassi di forza degli arti superiori e inferiori, di velocità del passo e percorrevano una distanza significativamente inferiore al 6-MWT.
Conclusioni: i dati di questo studio evidenziano che nei pazienti anziani affetti da AVS, la sostituzione valvolare aortica migliora lo stato nutrizionale, le facoltà cognitive, il tono dell’umore, la performance fisica e la qualità di vita. La forza degli arti inferiori e superiori invece mantiene a 6 mesi valori non diversi da quelli pre-operatori. I soggetti che sembrano beneficiare maggiormente dal punto di vista funzionale della AVR sono quelli più compromessi a basale dal punto di vista della performance fisica.

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EPrint type:Ph.D. thesis
Tutor:Manzato, Enzo
Supervisor:Sergi, Giuseppe
Ph.D. course:Ciclo 31 > Corsi 31 > SCIENZE CLINICHE E SPERIMENTALI
Data di deposito della tesi:15 November 2018
Anno di Pubblicazione:02 November 2018
Key Words:aortic valve stenosis, elderly, physical performance
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/09 Medicina interna
Struttura di riferimento:Dipartimenti > Dipartimento di Medicina
Codice ID:11332
Depositato il:08 Nov 2019 11:41
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