Long-term quality of life in adult survivors after the arterial switch operation

Long-term quality of life in adult survivors after the arterial switch operation Abstract OBJECTIVES We sought to determine the quality of life after the arterial switch operation (ASO) using the Short Form 36 questionnaire in adult survivors. METHODS All patients (n = 107) who underwent the ASO and were 18 years of age or older living in the Australian state of Victoria with a contact telephone number were identified from the hospital database. Fifty-one (48%) patients were 18–24 years old and 56 (52%) patients were 25–34 years old. Patients completed the Short Form 36 quality of life questionnaire via telephone. The results of the 8 domains of the Short Form 36 questionnaire and the derived health state summary score (Short Form 6-Dimension) were compared against mean scores from age-matched Australian population data. RESULTS Compared with the Australian population age-matched data, 18- to 24-year-old ASO patients ranked their health higher in 3 of the 8 domains (P < 0.01). The 25–34 age group ranked their health higher in 4 of the 8 domains (P < 0.01). No statistically significant differences in the mean Short Form 6-Dimension scores were observed in the 18–24 age group (0.769 for ASO patients vs 0.772 for Australian population, P = 0.85) or the 25–34 age group (0.795 for ASO patients vs 0.780 for Australian population, P = 0.33). CONCLUSIONS Young adult survivors of the ASO have similar outcomes to age-matched controls in quality of life measured by Short Form 6-Dimension. Arterial switch operation, Transposition of the great arteries, Quality of life INTRODUCTION Current outcomes after the arterial switch operation (ASO) are excellent as survivors reach adolescence and young adulthood, with an overall low incidence of late mortality and reoperation [1–9]. Limited data exist on quality of life after the ASO in those patients who reach adulthood [10, 11]. Therefore, we sought to describe health-related quality of life in adult survivors after the ASO using the Short Form 36 (SF-36) questionnaire. MATERIALS AND METHODS Patients This study was approved by the Royal Children’s Hospital Human Research Ethics Committee. Patients (n = 127) who underwent the ASO and were 18 years of age or older living in the Australian state of Victoria with a contact telephone number were identified from the hospital database. Of the 127 patients, 19 (15%) patients were unable to be contacted using hospital record contact details and 1 (0.8%) patient declined to participate in the study. This resulted in 107 patients included for this study. The clinical characteristics of the group in this study are presented in Table 1. Fifty-one (48%) patients were 18–24 years old and 56 (52%) patients were 25–34 years old. Patients were contacted via telephone and completed the SF-36 quality of life questionnaire at this time over the telephone from May 2016 to September 2016. Table 1: Patient clinical characteristics No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) AAO: aortic arch obstruction; ASO: arterial switch operation; AXCL: aortic cross-clamp; CA: circulatory arrest; CPB: cardiopulmonary bypass; IQR: interquartile range; No.: number of patients; TBA: Taussig–Bing anomaly; TGA-IVS: transposition of the great arteries with intact interventricular septum; TGA-VSD: transposition of the great arteries with ventricular septal defect. Table 1: Patient clinical characteristics No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) AAO: aortic arch obstruction; ASO: arterial switch operation; AXCL: aortic cross-clamp; CA: circulatory arrest; CPB: cardiopulmonary bypass; IQR: interquartile range; No.: number of patients; TBA: Taussig–Bing anomaly; TGA-IVS: transposition of the great arteries with intact interventricular septum; TGA-VSD: transposition of the great arteries with ventricular septal defect. Definitions The SF-36 is a validated health-related quality of life questionnaire that contains 36 questions across 8 mental and physical health domains. These domains include physical functioning (impact of health of physical activities), role limitations caused by physical health problems (impact of physical health on vocational and avocational activities), general health, bodily pain (frequency and impact of pain on activities), role limitations caused by emotional problems (impact of emotional problems on vocational and avocational activities), social functioning (impact of physical or emotional problems on social activities), vitality (perception of energy and fatigue) and mental health [12]. Responses to the 36 questions indicate the presence or absence of limitations and are scored and averaged so that a higher score in a domain indicates more favourably ranked quality of life. The SF-36 can be converted to a summary score, the Short Form 6-Dimension (SF-6D) score, to present a generic single-index health state that is comparable across different disease areas and the general population. The SF-6D has interval scale property, i.e. a difference between 0.2 and 0.4 is equally valued as a difference between 0.6 and 0.8, and thus is easily interpretable. The Australian population-representative scores are estimated from the Household, Income and Labour Dynamics in Australia (HILDA) survey [13]. Statistical analysis Data were imported into Stata version 12 (Stata Corp, College Station, TX, USA). Results of the SF-36 and the SF-6D were compared against age-matched Australian population data derived from the HILDA survey [13]. The HILDA survey is an Australian government-funded longitudinal survey of more than 17 000 Australians. A 2-sample t-test was used to determine any statistical significant difference between the SF-36 domains and the SF-6D scores. RESULTS The mean scores of the study group in the 8 domains and the SF-6D compared with the general age-matched Australian population are presented in Table 2. Compared with the age-matched Australian population data, 18- to 24-year-old ASO patients ranked their health significantly higher in 3 of the 8 domains. The 25- to 34-year-old ASO patients ranked their health higher in 4 of 8 domains. There were no significant differences in the mean SF-6D scores in the 18–24 age group (0.769 for ASO patients vs 0.772 for the Australian population, P = 0.85) or the 25–34 age group (0.795 for ASO patients vs 0.780 for the Australian population, P = 0.33). Table 2: SF-36 domain and SF6D scores Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Aus: Australian; 95% CI: 95% confidence interval; EW: emotional well-being; GH: general health; PF: physical functioning; RLEP: role limitations due to emotional problems; RLPH: role limitations due to physical health; SD: standard deviation; SF: social functioning; SF-36: Short Form 36; SF6D: Short Form 6-Dimension; Vit: vitality. Table 2: SF-36 domain and SF6D scores Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Aus: Australian; 95% CI: 95% confidence interval; EW: emotional well-being; GH: general health; PF: physical functioning; RLEP: role limitations due to emotional problems; RLPH: role limitations due to physical health; SD: standard deviation; SF: social functioning; SF-36: Short Form 36; SF6D: Short Form 6-Dimension; Vit: vitality. DISCUSSION We have previously reported excellent long-term clinical outcomes in patients who underwent the ASO at our institution [1–7]. The hospital mortality for the ASO at Royal Children’s Hospital has been reported to be 2.8% for patients operated between 1983 and 2009 and this has not changed significantly with time [2]. Late mortality is an uncommon event with a 96% survival at 15 years postoperatively [2]. This has resulted in an ever-growing number of ASO survivors reaching adulthood in recent years. Although similar results have been reported by others [8, 9], quality of life in adult survivors of the ASO has not been as well described. As these patients begin to reach adulthood, seemingly with good outcomes in the majority of patients, focus is now placed on the general health of these individuals. Investigating health-related quality-of-life outcomes in patients with repaired congenital heart disease informs our understanding of the overall effect the condition has on survivors reaching adulthood and may help to develop therapeutic interventions to address physical and psycho-social issues. To the best of our knowledge, our study represents the largest cohort of adult ASO survivors to have quality of life examined and compared with the general age-matched population. Recently, Kalfa et al. [10] investigated quality-of-life outcomes in 67 adult ASO survivors aged 18–31 years using the SF-36. They found that patients overall had a satisfying quality of life but that their cohort had poorer results in the physical domains of the SF-36 and the summary SF-6D health state was not available. Ruys et al. [11] reported superior results in all 8 domains of SF-36 in 30 adult ASO survivors, and the health state summary of SF-6D was not reported. Görler et al. [14] compared SF-36 results from 24 ASO survivors above the age of 14 with 74 atrial switch survivors as well as the general population. No statistically significant differences were found between the SF-36 domains and the SF-6D scores were not reported. Our results as summarized by the SF-6D demonstrated that adult ASO survivors have similar overall quality of life when compared with the general age-matched population. The SF-6D, derived from the SF-36 questionnaire, is a widely-used generic measure of health that can be used to describe more than 18 000 health states and generate quality-adjusted life years. It is used by health regulatory agencies around the world to compare the overall impact of interventions across disease areas to facilitate funding decisions. Although the SF-36 questionnaire is typically a written survey, telephone administration has been shown to be equivalent to the written form [15]. Absolute differences in the SF-36 domains between our ASO patients and the general population are difficult to interpret; however, ASO survivors did have similar scores in the majority of the domains and noticeably higher scores in the 2 domains of vitality and emotional well-being. Furthermore, there were no statistically significant differences in the SF-6D scores in the 2 ASO age groups compared with the Australian population. Therefore, it is reasonable to conclude that the quality of life of ASO survivors is comparable with the general public in this sample. Limitations One limitation of this study is that patients without a valid contact telephone number were unable to be investigated. As there could be various reasons as to why an adult ASO patient would have a contact number different from that on the hospital record, and given the excellent survival of 96% at 15 years postoperatively for this patient group [3], we believe that this would have a limited impact on our conclusion. Also, the results of our study come from a single institution and thus may not be generalizable for ASO survivors worldwide. CONCLUSION Young adult survivors of the ASO have similar quality-of-life outcomes to age-matched controls measured by the SF-6D. Funding Tyson Fricke is supported by a National Health and Medical Research Council Medical Research Postgraduate Scholarship and an Australian Government Research Training Program Scholarship (1134203). Yves d’Udekem is Practitioner Fellow of the National Health and Medical Research Council of Australia (1082186). Conflict of interest: none declared. REFERENCES 1 Fricke TA , d’Udekem Y , Richardson M , Thuys C , Dronavalli M , Ramsay JM. Outcomes of the arterial switch operation for transposition of the great arteries: 25 years of experience . Ann Thorac Surg 2012 ; 94 : 139 – 45 . Google Scholar CrossRef Search ADS PubMed 2 Soszyn N , Fricke TA , Wheaton GR , Ramsay JM , d’Udekem Y , Brizard CP et al. Outcomes of the arterial switch operation in patients with Taussig-Bing anomaly . Ann Thorac Surg 2011 ; 92 : 673 – 9 . Google Scholar CrossRef Search ADS PubMed 3 Fricke TA , Bulstra AE , Naimo PS , Bullock A , Robertson T , d’Udekem Y et al. Excellent long-term outcomes of the arterial switch operation in patients with intramural coronary arteries . Ann Thorac Surg 2016 ; 101 : 725. Google Scholar CrossRef Search ADS PubMed 4 Fricke TA , Brizard CP , d’Udekem Y , Konstantinov IE. Aortic root and valve surgery after arterial switch operation . J Thorac Cardiovasc Surg 2012 ; 144 : 1269. Google Scholar CrossRef Search ADS PubMed 5 Fricke TA , Brizard C , d’Udekem Y , Konstantinov IE. 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Google Scholar CrossRef Search ADS PubMed 9 Khairy P , Clair M , Fernandes SM , Blume ED , Powell AJ , Newburger JW et al. Cardiovascular outcomes after the arterial switch operation for d-transposition of the great arteries . Circulation 2013 ; 127 : 331 – 9 . Google Scholar CrossRef Search ADS PubMed 10 Kalfa D , Kasmi L , Geronikola N , Calderon J , Lambert V , Belli E et al. Cognitive outcomes and health-related quality of life in adults two decades after the arterial switch operation for transposition of the great arteries . J Thorac Cardiovasc Surg 2017 ; 154 : 1028 – 35 . Google Scholar CrossRef Search ADS PubMed 11 Ruys TP , van der Bosch AE , Cuypers JA , Witsenburg M , Helbing WA , Bogers AJ et al. Long-term outcome and quality of life after arterial switch operation: a prospective study with a historical comparison . Congenit Heart Dis 2013 ; 8 : 203 – 10 . Google Scholar CrossRef Search ADS PubMed 12 Ware JE Jr , Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection . Med Care 1992 ; 30 : 473 – 83 . Google Scholar CrossRef Search ADS PubMed 13 Wilkins R. The household, income and labour dynamics in Australia survey: Selected findings from waves 1 to 14. Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, 2016 . 14 Görler H , Ono M , Thies A , Lunkewitz E , Westhoff-Bleck M , Haverich A et al. Long-term morbidity and quality of life after surgical repair of transposition of the great arteries: atrial versus arterial switch operation . Interact CardioVasc Thorac Surg 2011 ; 12 : 569 – 74 . Google Scholar CrossRef Search ADS PubMed 15 García M , Rohlfs I , Vila J , Sala J , Pena A , Masiá R et al. Comparison between telephone and self-administration of short form health survey questionnaire (SF-36) . Gac Sanit 2005 ; 19 : 433 – 9 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Journal of Cardio-Thoracic Surgery Oxford University Press

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Abstract

Abstract OBJECTIVES We sought to determine the quality of life after the arterial switch operation (ASO) using the Short Form 36 questionnaire in adult survivors. METHODS All patients (n = 107) who underwent the ASO and were 18 years of age or older living in the Australian state of Victoria with a contact telephone number were identified from the hospital database. Fifty-one (48%) patients were 18–24 years old and 56 (52%) patients were 25–34 years old. Patients completed the Short Form 36 quality of life questionnaire via telephone. The results of the 8 domains of the Short Form 36 questionnaire and the derived health state summary score (Short Form 6-Dimension) were compared against mean scores from age-matched Australian population data. RESULTS Compared with the Australian population age-matched data, 18- to 24-year-old ASO patients ranked their health higher in 3 of the 8 domains (P < 0.01). The 25–34 age group ranked their health higher in 4 of the 8 domains (P < 0.01). No statistically significant differences in the mean Short Form 6-Dimension scores were observed in the 18–24 age group (0.769 for ASO patients vs 0.772 for Australian population, P = 0.85) or the 25–34 age group (0.795 for ASO patients vs 0.780 for Australian population, P = 0.33). CONCLUSIONS Young adult survivors of the ASO have similar outcomes to age-matched controls in quality of life measured by Short Form 6-Dimension. Arterial switch operation, Transposition of the great arteries, Quality of life INTRODUCTION Current outcomes after the arterial switch operation (ASO) are excellent as survivors reach adolescence and young adulthood, with an overall low incidence of late mortality and reoperation [1–9]. Limited data exist on quality of life after the ASO in those patients who reach adulthood [10, 11]. Therefore, we sought to describe health-related quality of life in adult survivors after the ASO using the Short Form 36 (SF-36) questionnaire. MATERIALS AND METHODS Patients This study was approved by the Royal Children’s Hospital Human Research Ethics Committee. Patients (n = 127) who underwent the ASO and were 18 years of age or older living in the Australian state of Victoria with a contact telephone number were identified from the hospital database. Of the 127 patients, 19 (15%) patients were unable to be contacted using hospital record contact details and 1 (0.8%) patient declined to participate in the study. This resulted in 107 patients included for this study. The clinical characteristics of the group in this study are presented in Table 1. Fifty-one (48%) patients were 18–24 years old and 56 (52%) patients were 25–34 years old. Patients were contacted via telephone and completed the SF-36 quality of life questionnaire at this time over the telephone from May 2016 to September 2016. Table 1: Patient clinical characteristics No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) AAO: aortic arch obstruction; ASO: arterial switch operation; AXCL: aortic cross-clamp; CA: circulatory arrest; CPB: cardiopulmonary bypass; IQR: interquartile range; No.: number of patients; TBA: Taussig–Bing anomaly; TGA-IVS: transposition of the great arteries with intact interventricular septum; TGA-VSD: transposition of the great arteries with ventricular septal defect. Table 1: Patient clinical characteristics No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) No. TGA, n (%) 97 (91) No. TGA-IVS, n (%) 64 (60) No. TGA-VSD, n (%) 33 (31) No. TBA, n (%) 10 (9) No. AAO, n (%) 13 (12) Age at ASO (days), median (IQR) 11 (21) Weight at ASO (kg), median (IQR) 3.5 (0.8) No. <2.5kg at ASO, n (%) 2 (2) CPB time (min), median (IQR) 130 (50) AXCL time (min), median (IQR) 71 (28) No. CA used, n (%) 75 (70) Duration CA (min), median (IQR) 6 (16) No. reoperation, n (%) 19 (18) AAO: aortic arch obstruction; ASO: arterial switch operation; AXCL: aortic cross-clamp; CA: circulatory arrest; CPB: cardiopulmonary bypass; IQR: interquartile range; No.: number of patients; TBA: Taussig–Bing anomaly; TGA-IVS: transposition of the great arteries with intact interventricular septum; TGA-VSD: transposition of the great arteries with ventricular septal defect. Definitions The SF-36 is a validated health-related quality of life questionnaire that contains 36 questions across 8 mental and physical health domains. These domains include physical functioning (impact of health of physical activities), role limitations caused by physical health problems (impact of physical health on vocational and avocational activities), general health, bodily pain (frequency and impact of pain on activities), role limitations caused by emotional problems (impact of emotional problems on vocational and avocational activities), social functioning (impact of physical or emotional problems on social activities), vitality (perception of energy and fatigue) and mental health [12]. Responses to the 36 questions indicate the presence or absence of limitations and are scored and averaged so that a higher score in a domain indicates more favourably ranked quality of life. The SF-36 can be converted to a summary score, the Short Form 6-Dimension (SF-6D) score, to present a generic single-index health state that is comparable across different disease areas and the general population. The SF-6D has interval scale property, i.e. a difference between 0.2 and 0.4 is equally valued as a difference between 0.6 and 0.8, and thus is easily interpretable. The Australian population-representative scores are estimated from the Household, Income and Labour Dynamics in Australia (HILDA) survey [13]. Statistical analysis Data were imported into Stata version 12 (Stata Corp, College Station, TX, USA). Results of the SF-36 and the SF-6D were compared against age-matched Australian population data derived from the HILDA survey [13]. The HILDA survey is an Australian government-funded longitudinal survey of more than 17 000 Australians. A 2-sample t-test was used to determine any statistical significant difference between the SF-36 domains and the SF-6D scores. RESULTS The mean scores of the study group in the 8 domains and the SF-6D compared with the general age-matched Australian population are presented in Table 2. Compared with the age-matched Australian population data, 18- to 24-year-old ASO patients ranked their health significantly higher in 3 of the 8 domains. The 25- to 34-year-old ASO patients ranked their health higher in 4 of 8 domains. There were no significant differences in the mean SF-6D scores in the 18–24 age group (0.769 for ASO patients vs 0.772 for the Australian population, P = 0.85) or the 25–34 age group (0.795 for ASO patients vs 0.780 for the Australian population, P = 0.33). Table 2: SF-36 domain and SF6D scores Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Aus: Australian; 95% CI: 95% confidence interval; EW: emotional well-being; GH: general health; PF: physical functioning; RLEP: role limitations due to emotional problems; RLPH: role limitations due to physical health; SD: standard deviation; SF: social functioning; SF-36: Short Form 36; SF6D: Short Form 6-Dimension; Vit: vitality. Table 2: SF-36 domain and SF6D scores Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Domain Mean 18–24 score with SD Mean 18–24 Aus population score with SD P-value Mean 25–34 score with SD Mean 25–34 Aus population score with SD P-value PF 92.5 ± 10.1 (95% CI 89.6–95.3) 91.1 ± 20.3 (95% CI 90.1–92.0) 0.63 92.9 ± 12.1 (95% CI 89.6–96.1) 91.6 ± 18.3 (95% CI 90.9–92.3) 0.6 RLPH 87.3 ± 27.1 (95% CI 79.6–94.9) 88.8 ± 26.4 (95% CI 87.5–90.0) 0.69 92.4 ± 20.7 (95% CI 86.9–98.0) 88.2 ± 27.7 (95% CI 87.1–89.2) 0.25 RLEP 83.0 ± 30.1 (95% CI 74.5–91.5) 82.6 ± 32.3 (95% CI 81.1.–84.0) 0.92 92.8 ± 24.4 (95% CI 86.3–99.4) 84.6 ± 31.5 (95% CI 83.4–85.7) 0.049 Vit 69.7 ± 14.7 (95% CI 65.6–73.8) 59.8 ± 19.1 (95% CI 58.6–60.4) <0.01 68.0 ± 18.8 (95% CI 63.0–73.1) 58.3 ± 19.0 (95% CI 57.6–59.0) <0.01 EW 81.3 ± 16.6 (95% CI 76.7–85.6) 70.4 ± 18.3 (95% CI 69.6–71.3) <0.01 83.5 ± 14.7 (95% CI 79.6–87.4) 72.1 ± 17.0 (95% CI 71.4–72.7) <0.01 SF 84.6 ± 21.0 (95% CI 78.7–90.5) 83.2 ± 22.2 (95% CI 82.1–84.2) 0.65 90.0 ± 18.1 (95% CI 85.1–94.8) 84.6 ± 21.4 (95% CI 83.8–85.4) 0.06 Pain 88.7 ± 17.7 (95% CI 83.7–93.7) 81.1 ± 20.5 (95% CI 80.1–82.0) <0.01 85.2 ± 20.8 (95% CI 79.7–90.8) 78.8 ± 21.0 (95% CI 78.0–79.6) 0.02 GH 69.7 ± 18.5 (95% CI 64.5–74.9) 70.3 ± 19.6 (95% CI 69.4–71.2) 0.84 69.4 ± 18.5 (95% CI 64.4–74.3) 70.9 ± 19.0 (95% CI 70.2–71.6) 0.56 SF6D 0.769 ± 0.098 0.772 ± 0.121 0.85 0.795 ± 0.102 0.78 ± 0.116 0.33 Aus: Australian; 95% CI: 95% confidence interval; EW: emotional well-being; GH: general health; PF: physical functioning; RLEP: role limitations due to emotional problems; RLPH: role limitations due to physical health; SD: standard deviation; SF: social functioning; SF-36: Short Form 36; SF6D: Short Form 6-Dimension; Vit: vitality. DISCUSSION We have previously reported excellent long-term clinical outcomes in patients who underwent the ASO at our institution [1–7]. The hospital mortality for the ASO at Royal Children’s Hospital has been reported to be 2.8% for patients operated between 1983 and 2009 and this has not changed significantly with time [2]. Late mortality is an uncommon event with a 96% survival at 15 years postoperatively [2]. This has resulted in an ever-growing number of ASO survivors reaching adulthood in recent years. Although similar results have been reported by others [8, 9], quality of life in adult survivors of the ASO has not been as well described. As these patients begin to reach adulthood, seemingly with good outcomes in the majority of patients, focus is now placed on the general health of these individuals. Investigating health-related quality-of-life outcomes in patients with repaired congenital heart disease informs our understanding of the overall effect the condition has on survivors reaching adulthood and may help to develop therapeutic interventions to address physical and psycho-social issues. To the best of our knowledge, our study represents the largest cohort of adult ASO survivors to have quality of life examined and compared with the general age-matched population. Recently, Kalfa et al. [10] investigated quality-of-life outcomes in 67 adult ASO survivors aged 18–31 years using the SF-36. They found that patients overall had a satisfying quality of life but that their cohort had poorer results in the physical domains of the SF-36 and the summary SF-6D health state was not available. Ruys et al. [11] reported superior results in all 8 domains of SF-36 in 30 adult ASO survivors, and the health state summary of SF-6D was not reported. Görler et al. [14] compared SF-36 results from 24 ASO survivors above the age of 14 with 74 atrial switch survivors as well as the general population. No statistically significant differences were found between the SF-36 domains and the SF-6D scores were not reported. Our results as summarized by the SF-6D demonstrated that adult ASO survivors have similar overall quality of life when compared with the general age-matched population. The SF-6D, derived from the SF-36 questionnaire, is a widely-used generic measure of health that can be used to describe more than 18 000 health states and generate quality-adjusted life years. It is used by health regulatory agencies around the world to compare the overall impact of interventions across disease areas to facilitate funding decisions. Although the SF-36 questionnaire is typically a written survey, telephone administration has been shown to be equivalent to the written form [15]. Absolute differences in the SF-36 domains between our ASO patients and the general population are difficult to interpret; however, ASO survivors did have similar scores in the majority of the domains and noticeably higher scores in the 2 domains of vitality and emotional well-being. Furthermore, there were no statistically significant differences in the SF-6D scores in the 2 ASO age groups compared with the Australian population. Therefore, it is reasonable to conclude that the quality of life of ASO survivors is comparable with the general public in this sample. Limitations One limitation of this study is that patients without a valid contact telephone number were unable to be investigated. As there could be various reasons as to why an adult ASO patient would have a contact number different from that on the hospital record, and given the excellent survival of 96% at 15 years postoperatively for this patient group [3], we believe that this would have a limited impact on our conclusion. Also, the results of our study come from a single institution and thus may not be generalizable for ASO survivors worldwide. CONCLUSION Young adult survivors of the ASO have similar quality-of-life outcomes to age-matched controls measured by the SF-6D. Funding Tyson Fricke is supported by a National Health and Medical Research Council Medical Research Postgraduate Scholarship and an Australian Government Research Training Program Scholarship (1134203). Yves d’Udekem is Practitioner Fellow of the National Health and Medical Research Council of Australia (1082186). Conflict of interest: none declared. REFERENCES 1 Fricke TA , d’Udekem Y , Richardson M , Thuys C , Dronavalli M , Ramsay JM. Outcomes of the arterial switch operation for transposition of the great arteries: 25 years of experience . Ann Thorac Surg 2012 ; 94 : 139 – 45 . Google Scholar CrossRef Search ADS PubMed 2 Soszyn N , Fricke TA , Wheaton GR , Ramsay JM , d’Udekem Y , Brizard CP et al. Outcomes of the arterial switch operation in patients with Taussig-Bing anomaly . Ann Thorac Surg 2011 ; 92 : 673 – 9 . Google Scholar CrossRef Search ADS PubMed 3 Fricke TA , Bulstra AE , Naimo PS , Bullock A , Robertson T , d’Udekem Y et al. Excellent long-term outcomes of the arterial switch operation in patients with intramural coronary arteries . Ann Thorac Surg 2016 ; 101 : 725. Google Scholar CrossRef Search ADS PubMed 4 Fricke TA , Brizard CP , d’Udekem Y , Konstantinov IE. Aortic root and valve surgery after arterial switch operation . J Thorac Cardiovasc Surg 2012 ; 144 : 1269. Google Scholar CrossRef Search ADS PubMed 5 Fricke TA , Brizard C , d’Udekem Y , Konstantinov IE. 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Google Scholar CrossRef Search ADS PubMed 9 Khairy P , Clair M , Fernandes SM , Blume ED , Powell AJ , Newburger JW et al. Cardiovascular outcomes after the arterial switch operation for d-transposition of the great arteries . Circulation 2013 ; 127 : 331 – 9 . Google Scholar CrossRef Search ADS PubMed 10 Kalfa D , Kasmi L , Geronikola N , Calderon J , Lambert V , Belli E et al. Cognitive outcomes and health-related quality of life in adults two decades after the arterial switch operation for transposition of the great arteries . J Thorac Cardiovasc Surg 2017 ; 154 : 1028 – 35 . Google Scholar CrossRef Search ADS PubMed 11 Ruys TP , van der Bosch AE , Cuypers JA , Witsenburg M , Helbing WA , Bogers AJ et al. Long-term outcome and quality of life after arterial switch operation: a prospective study with a historical comparison . Congenit Heart Dis 2013 ; 8 : 203 – 10 . Google Scholar CrossRef Search ADS PubMed 12 Ware JE Jr , Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection . Med Care 1992 ; 30 : 473 – 83 . Google Scholar CrossRef Search ADS PubMed 13 Wilkins R. The household, income and labour dynamics in Australia survey: Selected findings from waves 1 to 14. Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, 2016 . 14 Görler H , Ono M , Thies A , Lunkewitz E , Westhoff-Bleck M , Haverich A et al. Long-term morbidity and quality of life after surgical repair of transposition of the great arteries: atrial versus arterial switch operation . Interact CardioVasc Thorac Surg 2011 ; 12 : 569 – 74 . Google Scholar CrossRef Search ADS PubMed 15 García M , Rohlfs I , Vila J , Sala J , Pena A , Masiá R et al. Comparison between telephone and self-administration of short form health survey questionnaire (SF-36) . Gac Sanit 2005 ; 19 : 433 – 9 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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European Journal of Cardio-Thoracic SurgeryOxford University Press

Published: May 10, 2018

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