The impact of anxiety experienced by patients undergoing surgical aortic valve replacement on perceived pain, self-efficacy, and body esteem in the perioperative period

Introduction

A surgical aortic valve replacement (SAVR) is currently one of the most commonly performed cardiac surgical procedures in Poland. According to the Polish National Registry of Cardiovascular Surgeries, 7671 such procedures were performed in 2022 [1].

SAVR remains the “method of choice” in the treatment of severe aortic valve disease. It is performed with access through median sternotomy, upper ministernotomy, or right minithoracotomy with the use of extracorporeal circulation. A mechanical or biological prosthetic valve is implanted in place of the native aortic valve after its removal. The use of a mechanical valve requires constant anticoagulant therapy, but its major advantage is durability, unlike a bioprosthesis, which undergoes gradual degradation. In patients > 75 years old or younger with very high perioperative risk who have severe aortic valve stenosis, the less invasive transcatheter aortic valve implantation (TAVI) technique is recommended. The biological valve prosthesis is then implanted inside the degenerated native aortic valve using (usually) a transfemoral approach on the beating heart [2].

This operation, aimed at saving and prolonging life and improving its quality, undoubtedly constitutes a tremendous source of physiological and psychological stress for the individual undergoing it [3–5].

To ensure that the postoperative period is as minimally stressful as possible for the patient and to be associated with a minimal and short-term deterioration in their quality of life, regardless of the type of cardiac surgery performed, it is extremely important for them to have a good preoperative psychological state [6–13].

The available literature in the field of psychology concerning cardiac surgical patients addresses the functioning of patients undergoing aortic valve procedures, comparing SAVR with TAVI [5, 14, 15], valve repair [6], or heart transplantation [16]. Publications mainly focus on the relationship between the severity of pre- and postoperative depressive and/or anxiety symptoms experienced by patients and their quality of life [6, 7, 14–16].

In-depth exploration of how patients perceive their own physical condition or attractiveness, as well as their emotional attitudes towards various aspects of their body, including those related to postoperative scars, following isolated classical aortic valve replacement procedures, has not been undertaken so far. However, these aspects play a significant role in evaluating the outcomes of the surgery for the patients undergoing it and impact their perceived quality of life [17].

Similar to patients undergoing coronary artery bypass grafting (CABG) [18] or other cardiac surgical procedures, these issues likely influence their attitude towards the length of postoperative hospitalization and the timing of transfer to further rehabilitation in a health resort hospital or a cardiac rehabilitation ward.

Our studies on patients undergoing CABG [18] identified relationships between variables such as perceived self-efficacy or body esteem and the level of perioperative anxiety and pain experienced. They also raised questions about their occurrence in patients undergoing the second most common type of cardiac surgical operation – SAVR. We decided to analyze these issues as well.

Based on the available literature regarding patients after SAVR [5, 6, 14–16] (hypotheses A1–A4), other operations [9, 13] (hypothesis A5), and in reference to the results of our studies on patients after CABG [18] (hypotheses B), the following hypotheses were adopted:

Hypothesis A1: The level of preoperative state anxiety experienced by patients awaiting SAVR is positively correlated with their age (the higher the patient’s age undergoing the surgery, the higher the level of state anxiety experienced by them).

Hypothesis A2: The intensity of state anxiety experienced before the operation is higher in women.

Hypothesis A3: Patients undergoing SAVR who participated in a prehabilitation clinic visit exhibit lower levels of state anxiety in the perioperative period.

Hypothesis A4: The intensity of state anxiety experienced by patients undergoing SAVR in the postoperative period (5–6 days) is similar to that experienced before the operation.

Hypothesis A5: The level of state anxiety experienced preoperatively is positively correlated with the intensity of postoperative pain experienced (the higher the level of preoperative state anxiety experienced by the patient, the greater the intensity of pain experienced after the operation).

Hypothesis B1: The level of trait anxiety perceived pre- and postoperatively correlates with the intensity of postoperative pain experienced.

Hypothesis B2: The level of postoperative state anxiety correlates with perceived self-efficacy.

Hypothesis B3: The intensity of postoperative pain correlates with perceived self-efficacy at that time.

Hypothesis B4: The intensity of pre- and postoperative pain correlates with the body esteem at that time (in terms of physical condition and body strength).

Hypothesis B5: The level of postoperative state anxiety correlates with the body esteem at that time (in terms of physical condition and body strength).

Aim

The aim of this questionnaire-based study was to examine the relationships between the level of perioperative anxiety and the postoperative levels of pain, perceived self-efficacy, and body esteem and to determine their direction.

Material and methods

The questionnaire-based study was conducted from mid-January 2022 to the end of February 2024 at the Clinical Department of Heart, Vascular, and Transplantation Surgery in the St John Paul II Hospital in Krakow, Poland. They consisted of two parts. The first part was administered to patients on the day before surgery, and the second part was administered on the fifth or sixth day after surgery, before transferring the patients to a cardiology rehabilitation facility. In the first part, 66 patients undergoing SAVR participated. However, complete questionnaire results (from both parts) were ultimately obtained from only 56 patients, representing the subject of analysis in this study. The research group was predominantly male, aged 26 to 71 years, with 41 individuals (73%). There were 15 females aged 32 to 71 years (27%). The mean age of the participants was 57.2 years (55.9 years among males and 60.8 years among females).

Inclusion criteria for the study comprised: undergoing SAVR on an urgent or elective basis, providing written, informed, and voluntary consent to participate in the study, and having the cognitive ability to understand the content of the questionnaires (instructions, questions) and independently respond to them by marking the appropriate options provided.

Exclusion from participation in the study was determined by undergoing surgery “due to life-threatening indications on an emergency basis,” having a previously diagnosed mental disorder or psychiatric or neurological treatment, suffering from other serious somatic diseases (including oncological, endocrinological, and rheumatological diseases), and lacking the ability to independently complete the questionnaires.

Additionally, patients who experienced complications during the postoperative period (such as sudden cardiac arrest, stroke, or significantly prolonged stay in the Intensive Care Unit – over 5 days) were excluded from participating in the second part of the study among those who participated in the first part.

The assessment of situational anxiety (state anxiety) and trait anxiety (a general tendency to react with anxiety or worry) was conducted using the State-Trait Anxiety Inventory (STAI). This is the most commonly used tool for measuring these variables, providing the opportunity to compare the obtained results with those presented in the literature [7–9, 13]. Each of its two parts consists of twenty statements regarding one’s well-being. The respondent rates the truthfulness of these statements on a four-point scale. The overall score is the sum of the given ratings. It is then converted, taking into account gender and age, into standard scales – sten (from 1 to 10) and percentile [19].

To measure the intensity of pain experienced by patients, the Visual Analog Scale (VAS) was used. This is a numerical scale in graphical form – a 10 cm line with endpoints. The number “0” indicates no pain, while “10” represents the most intense pain experienced so far. The participant indicates on the line the current intensity of pain experienced. This scale allows for a simple and quick assessment of subjective characteristics or attitudes that may have continuous values and are not subject to precise measurement using available devices [8]. It is commonly used in healthcare facilities as well as in scientific research [7–9, 13].

The Self-Efficacy Gauge used in the study was created and primarily used by occupational therapists. It was designed to help them assess how seniors perceive their abilities to perform various activities. It consists of 27 activity items with varying levels of effort. On a 10-point scale, the patient indicates how independently they perceive their ability to perform each of these activities at the moment. The overall score obtained is referred to as the Self-Efficacy Gauge [20].

The Body Esteem Scale by Franzoi and Shields, in the Polish adaptation by Lipowska and Lipowski, provides information regarding individuals’ attitudes toward their own bodies. It consists of a list of 35 body parts or physiological aspects, to which individuals rate their feelings using a five-point Likert scale (strongly/moderately negative, neutral, strongly/moderately positive). The final outcome comprises scores in three subscales unique to each gender. For women, these are Sexual Attractiveness, Weight Concern and Physical Condition, while for men, they are Physical Attractiveness, Upper Body Strength and Physical Condition [21].

The collected patient data were encoded numerically and then subjected to specialized statistical computations in the R environment.

First, the Shapiro-Wilk test was used to examine the compatibility of the distributions of individual variables with the normal distribution. The obtained p-values of the test are presented in the corresponding columns of Table I (labeled: Shapiro test p-value).

For comparison of the distribution of individual indicators’ values between the preoperative and postoperative periods, the following were used:

The presence of a monotonic relationship between selected variables was examined using the Spearman rank correlation coefficient (Table II).

P-values of the applied tests were reported in the study with a precision of 0.001.

Results

In the form of tables, the obtained results of the statistical analyses conducted on the collected data are presented.

Table I presents the basic descriptive statistics of individual indicators as well as results of comparing the distributions of their values using the t-test or Mann-Whitney U test, along with an assessment of the statistical significance of differences, between the pre- and postoperative periods. The table includes the means, medians, and standard deviations of the indicators obtained in both compared groups, as well as p-values (with a precision of 0.001) of the Shapiro-Wilk normality test. Depending on the results of this test, the last column of Table I presents the p-values of the t-test (for comparing normal distributions) or the U test (for distributions that do not follow normality).

For data meeting the assumption of normal distribution, the parametric t-test for equality of means was used. In cases where the data did not meet this assumption, its nonparametric counterpart, the Mann-Whitney U ^1.2 test, was used. P-values less than the accepted significance level of 0.05 are highlighted in bold.

The results indicated the following relationships:

The presence of a monotonic relationship between selected variables was examined using the Spearman rank correlation coefficient. The obtained values of the coefficient and the p-values of the test, indicating its significance, are summarized in Table II.

They indicate the presence of the following relationships:

The relationship between postoperative pain intensity and self-efficacy just before discharge showed a Spearman correlation of –0.254 (p = 0.059), indicating a marginal negative association that did not reach the conventional significance level of α = 0.05.

Table III summarizes the descriptive statistics of STAI-state scores in different patient subgroups assessed before and after surgery. The group names are presented in the second column together with their sample sizes in parentheses. The term prehab patients refers to patients who participated in the prehabilitation program prior to surgery, while non-prehab patients are those who did not undergo prehabilitation. For each group, the mean, median, and standard deviation are reported. The Shapiro-Wilk test was applied to verify the normality of distributions. Depending on the outcome of this test, between-group comparisons were performed using either Student’s t-test (when both groups demonstrated normal distribution) or the non-parametric Mann-Whitney U test (when at least one of the groups deviated from normality).

The results revealed a statistically significant difference between the preoperative assessment of state anxiety in patients scheduled for surgical aortic valve replacement and their gender (U test, p = 0.022). This implies that females (mean = 46.933) exhibited a statistically significantly higher level of state anxiety before surgery compared to males (mean = 41.415).

Discussion

We found that patients undergoing SAVR experienced a similar level of state anxiety on the day before the surgery and at 5–6 days postoperatively (there was no significant difference between the mean scores at these time points). This is consistent with the findings regarding the pre- and postoperative anxiety levels reported by Petersen et al. [6]. In their study, in patients undergoing classical surgical aortic valve replacement, the baseline preoperative level of anxiety was significantly lower postoperatively only after 2–3 weeks from the surgery. However, it should be noted that the timing (1 week before and after the surgery, and then monthly for up to 6 months) and methods (anxiety subscale from the Hospital Anxiety and Depression Scale) used in our study differed from those used by Petersen et al.

The topic of perioperative pain experience and self-perceived physical functionality among patients undergoing SAVR has not been a particular focus of research interest thus far. We examined this among patients scheduled for CABG, both on the day before the operation and on the average fifth–sixth day postoperatively [18]. Similar to our findings, the intensity of preoperative pain before aortic valve replacement surgery was statistically significantly lower compared to postoperative pain, and patients perceived higher physical functionality before surgery than after. This observation is considered appropriate given the acquired surgical wound and the early postoperative days, which represent only the beginning of a several-month-long recovery process.

Similarly to the patients were examined by us after CABG, the assessment of trait anxiety in individuals undergoing classical surgical aortic valve replacement does not vary between the pre- and postoperative periods [18]. The anticipation of this type of cardiac surgical procedure did not distort their assessment of their general tendency to react with anxiety and apprehension [19] – a variable perceived as relatively stable due to personality traits.

The evaluation of body image by individuals undergoing SAVR revealed statistically significant differences between pre- and postoperative comparisons in specific areas for men – body strength and physical condition – and for women in terms of sexual attractiveness. Emotional attitudes towards parts of their own bodies and physiological aspects related to these specific aspects were significantly less positive in the early postoperative days among the participants.

Unfortunately, there are no other studies available for these patients in this area. The most similar study group may be patients after coronary artery bypass grafting. However, our identical procedural studies of individuals after CABG did not reveal statistically significant differences in emotional attitudes towards specific parts of their own bodies and physiological aspects between the day before surgery and the early postoperative days (5–6 days) [18]. It is possible that this was influenced by the small sample size, especially of women (n = 7). Nevertheless, in each of the gender-specific areas considered (subscales – women: Sexual Attractiveness, Weight Control, and Physical Condition; men: Physical Attractiveness, Upper Body Strength, Physical Condition), emotional attitudes in the early postoperative days were less positive than before the surgery.

The available studies on body image in patients undergoing CABG differ significantly in methodology. Adib-Hajbaghery et al. [22] examined individuals (n = 140) using the Multidimensional Body-Self Relations Questionnaire (MBSRQ – Brown et al., 1990) 1 day before the procedure and 4 weeks after it. The results showed statistically significant differences (p ≤ 0.001) in body image before and after the operation in Overall Score (139 ±13.21 vs. 160.25 ±7.75) and subscales such as Appearance Evaluation (21.85 ±2.97 vs. 24.27 ±2.41) and Fitness Evaluation (7.86 ±1.69 vs. 10.12 ±1.49). It is possible that with increasing time since the surgery, the attitudes of patients after other cardiac procedures – such as SAVR – will improve. Primarily, this change is expected in the area of body strength and physical condition, as postoperative wounds are inevitable, and their image, although changing, progresses much more slowly (wound healing, “smoothing” of scars).

A very strong positive monotonic relationship was found between levels of trait anxiety before and after SAVR. It showed that patients who experienced higher trait anxiety preoperatively also experienced higher anxiety postoperatively. This relationship is predictable due to the nature of the variable under study – as a personality trait, something enduring and persistent. It is therefore not surprising that individuals who reacted with greater anxiety to everyday events before the operation also reacted similarly after it.

Previous studies on the relationship between the intensity of preoperative anxiety and postoperative pain mainly focused on measuring the latter and the use of analgesia on the first day after surgery [9]. They indicated a statistically significant positive relationship between these variables.

Greszta and Siemińska extensively investigated the relationship between the level of state anxiety and various aspects of pain experiences in the first week after cardiac surgery, although their study focused on patients after myocardial revascularization [13]. Therefore, it is relevant to mention their findings here. Their results revealed a significant negative correlation between the intensity of perceived state anxiety and the degree of postoperative pain relief (p < 0.01). However, the authors did not find statistically significant differences between the level of situational anxiety and the average intensity of pain after surgery. Regarding trait anxiety, a relationship was found between its experience and the degree of postoperative wound pain relief after administration of analgesic medications (p < 0.001), as well as the intensity of extreme postoperative wound pain (p < 0.01) [14; p.158]. However, no significant relationship was found between the level of trait anxiety and the average intensity of postoperative pain.

It is difficult to compare the study by Poole et al. [12] with our study. Apart from the difference in the type of cardiac surgery undergone by the study group (CABG), there were important differences in procedural aspects and measurement methods. Hence we have refrained from making such a comparison here.

However, in their study focusing on the assessment of preoperative anxiety, Zemła et al. hypothesized that the postoperative period preceded by intensified anxiety is usually associated with higher levels of experienced pain [10; p.67]. This hypothesis was confirmed by the results of our analysis conducted on patients undergoing SAVR. It revealed a statistically significant relationship between the level of preoperative state anxiety and the intensity of postoperative pain experienced. However, this relationship was not evident in our identical, procedurally comparable study on patients after CABG [18]. Nonetheless, our study on valve replacement patients did not show any significant positive relationships between both pre- and postoperative trait anxiety ratings and postoperative pain experience, as observed in individuals after coronary artery bypass grafting.

The comparison of the experienced postoperative state anxiety and the perceived self-efficacy among individuals undergoing SAVR revealed a statistically significant negative relationship between these variables. The higher the postoperative state anxiety experienced by the patient, the lower they rated their self-efficacy. This finding aligns with the assumptions made by Zemła et al. [10].

In the study, a result suggesting the possibility of a negative relationship between the intensity of pain experienced by patients after SAVR just before leaving the hospital (typically on the fifth–sixth postoperative day) and their perceived self-efficacy at that time was also obtained. However, further research involving a larger group of patients would be required to confirm this relationship.

Its potential existence is consistent with the conclusions of Zemła et al. regarding the effectiveness of postoperative rehabilitation and the subjective assessment of treatment effectiveness from the patient’s perspective [10]. It suggests that the higher the patient’s perception of pain after surgery, the lower is their postoperative self-assessment of efficacy. The presence of such a statistically significant relationship at the 0.05 level was confirmed in our study involving individuals after CABG [18].

Unlike the findings of research conducted by Misiewicz et al. [5] on individuals after SAVR, our study did not reveal a statistically significant relationship between the level of state anxiety experienced by those awaiting the specific type of cardiac surgery and their age. Similarly, we found no such relationship in our study of patients before CABG [18], contrary to the findings of Pawlak et al. [11]. However, our analyses indicated a statistically significant relationship between preoperative trait anxiety ratings and age. The older the patients were, the higher was their level of trait anxiety before classical aortic valve replacement surgery. Our results, both regarding preoperative state anxiety and trait anxiety, are consistent with research on patients awaiting various surgical procedures conducted by Robaszkiewicz-Bouakaz et al. [23]. Unfortunately, their study did not include patients awaiting cardiac surgery. Contrary to expectations, similar results were found in the studies of Pawlak et al. [11] and our own research on patients after coronary artery bypass grafting [18]. We found a statistically significant negative relationship between postoperative state anxiety and the participants’ current evaluation of their body in terms of physical condition and body strength after SAVR. The stronger the anxiety experienced, the less positive was their emotional attitude towards parts of their own body and physiological aspects related to physical condition and body strength. This finding aligns with expectations based on the studies of Adib-Hajbaghery et al. [22] concerning individuals after CABG. The expected relationship between the intensity of pre- and postoperative pain and the assessment of the body in terms of physical condition and body strength at specific times turned out to be statistically significant and negative only among men in the early days after SAVR. The higher the perception of pain after the operation, the less positively the participants emotionally related to their body in terms of strength and physical condition. Considering that the study included only 15 female participants, it is necessary to replicate these analyses in a larger cohort to ensure that the findings are representative of the female population. It is worth noting that the study used the Body Esteem Scale (BES), in which the Upper Body Strength subscale is only distinguished for men [21].

Our statistical analyses revealed a statistically significant relationship between preoperative assessment of state anxiety and gender. Anxiety related to the anticipation of SAVR was higher in women. This is consistent with expectations based, among others, on the findings of Misiewicz et al. [5] regarding individuals specifically after surgical aortic valve replacement, as well as studies of patients awaiting other surgical procedures [23]. However, the small sample of women after SAVR participating in our study, coupled with the substantial imbalance compared to the male cohort, necessitates repeating these analyses on a larger group to ensure their representativeness.

The anticipated significant relationship between intensity perioperative anxiety and participation in a prehabilitation clinic visit was not confirmed. The perceived intensity of state anxiety before and after surgical aortic valve replacement in individuals who attended a meeting with specialists (cardiac surgeon, cardiologist, anesthesiologist, physiotherapist, and psychologist) at the clinic was lower, but not statistically significant. Perhaps the small sample size (n = 12) of patients who visited the preoperative clinic influenced these results. It would be necessary to repeat the study with a larger sample size.

As indicated by available literature [7, 24], the presence of the patient in the preoperative clinic, through the opportunity to obtain all necessary information from various specialists in an individualized manner, should result in lower perioperative anxiety intensity compared to those who are absent. Studies by Prado-Olivares and Chover-Sierra revealed a statistically significant inversely proportional relationship between received information and the level of anxiety in patients undergoing cardiac procedures [7]. Applied psychological interventions tailored to specific patients allow for predicting the reinforcement of this effect [24, 25]. Among preoperative psychological interventions, techniques such as cognitive-behavioral therapy (including working with dysfunctional beliefs about the disease and surgery, relaxation techniques, and setting individual achievable activity goals) have been particularly effective in reducing pre-procedural anxiety and improving postoperative functioning in patients undergoing CABG [24, 25]. Increasing application of them by psychologists and CBT therapists in prehabilitation would likely lead to a stronger desired effect on their psycho-physical state around the time of surgery than currently achieved. It is also important to consider the possibility of differences in the need for specific psychological interventions or their intensity among patients undergoing different types of cardiac procedures (SAVR vs. CABG), such as in the case of patients after surgical implantation of a mechanical aortic valve and heart transplantation [16].

Conclusions

In the conducted research on patients undergoing classical aortic valve replacement surgery in the perioperative period, the following hypotheses were confirmed:

Hypothesis A2: The intensity of state anxiety experienced before the operation is higher in women.

Hypothesis A4: The intensity of state anxiety experienced by patients undergoing SAVR in the postoperative period (5–6 days) is similar to that experienced before the operation.

Hypothesis A5: The level of state anxiety experienced preoperatively is positively correlated with the intensity of postoperative pain experienced (the higher the level of preoperative state anxiety experienced by the patient, the greater the intensity of pain experienced after surgery).

Hypothesis B2: The level of postoperative state anxiety is negatively correlated with perceived self-efficacy.

Hypothesis B4: In men, the intensity of postoperative pain is negatively associated with body esteem in terms of physical condition and body strength.

Hypothesis B5: The level of postoperative state anxiety is negatively correlated with the body esteem at that time in terms of physical condition and body strength.

Future study plans

Our psychological study of patients after surgical aortic valve replacement and prior coronary artery bypass grafting [23] provided numerous insights into factors influencing their quality of life and functioning in the immediate postoperative period. In our next publication, we will compare both types of cardiac surgical procedures to determine whether there are significant differences in the patient’s functional status and potentially in their needs and opportunities for effective psychological interventions.

So far, the current operative guidelines in cardiac surgery, risk prediction models (e.g., EUROSCORE), and daily practices have proven to be suboptimal in incorporating highly significant psychosocial aspects, suggesting that a change is warranted.