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Abstract

Purpose: Acute type A aortic dissection is a life-altering event that profoundly impacts one's subsequent daily existence. Limited research has explored these patients’ perspectives in their daily lives after aortic dissection. The purpose was to explore the perception of rehabilitation in survivors of acute type A aortic dissection.

Material and method: Six semi-structured interviews were conducted and analyzed using Systematic Text Condensation by Kristi Malterud.

Result and conclusion: Five code groups emerged: Relatives; The hospital course; How do I move forward?; The body's reaction; and Future. Twelve subgroups illustrate the diversity within the code groups. The complexity of acute type A aortic dissection is characterized by various physical and psychosocial challenges during rehabilitation. Our findings indicate that health-related quality of life depends on adequate information, psychosocial support, required restrictions, and participation in cardiac rehabilitation including bicycle testing. Furthermore, patients emphasise the significance of support from both relatives and peers.

Following major surgery, a prolonged recovery process is required for patients to attain a tolerable life, including work and daily tasks, as a crucial part of their identity. They perceived their bodies to remain attentive and prone to being easily alarmed. However, time fosters healing and hope in future patients.

Keywords

dissection-thoracic-aorta, health-related quality of life, perception, qualitative research, rehabilitation

 

Introduction

Acute aortic dissection is a life-threatening disease. The estimated incidence of aortic dissection, encompassing both type A and type B, is five-30 cases per one million people per year [1]. A study from the International Registry of acute aortic dissection indicates that Acute Type A Aortic Dissection (ATAAD) is the most prevalent aortic dissection [2]. The incidence of aortic dissection is higher in men than women, with the risk increasing with age [3-5].

Survivors of ATAAD undergo a chronic, intensive, long-term, life-altering process [6]. International guidelines on diagnosing and treating aortic diseases underscore that surviving acute aortic dissection ultimately evolves into a chronic condition. Patients require ongoing clinical follow-up and must adhere to lifelong restrictions, including physical activity, management of Blood Pressure (BP), and vigilance for abdominal and chest pain [3,4,7].

ATAAD necessitates thoracic surgery. Health care professionals are extensively involved in the care of ATAAD survivors, spanning both the acute phase and the subsequent rehabilitation period. There is limited evidence for recommending Cardiac Rehabilitation (CR) for ATAAD [7-9]. Recommendations regarding physical exercise and psychosocial follow-up for patients with ATAAD remain unclear [3,4,7,10-12].

CR seems to improve ATAAD’s hemodynamic response to exercise compared to other cardiac patients to improve both mental and physical Health-Related Quality Of Life (HRQOL) [7,11,13]. Patient-reported HRQOL has become more important because patients are worried about returning to work, pain, activity guidelines, and neurological complications [7].

Qualitative studies, based on interviews, reveal that patients with acute aortic dissection mostly including type B grapple with an intense fear of death [14-16] and a sense of loss of control [16,17]. Their restrictions have a significant impact on the patient’s social activities and their overall job prospects [6,15-17]. Following their diagnosis, patients with aortic dissection often struggle with giving up important activities [6,15,16]. Patients experience mental crises, such as feelings of isolation [6,15], and difficulties in coping [14,16,17]. Some patients contend with depression, stress, and fear [17]. Fatigue and pain symptoms from the chest and back exacerbate emotional distress and increase their awareness of bodily signals, resulting in considerable uncertainty [6,14,16]. Coping mechanisms include acceptance of their health condition, the use of humour, and seeking social support [6,17]. Quantitative studies support these statements [17-21].

A questionnaire-based study by Adam et al. [18], indicated that patients with ATAAD experienced reduced mental and physical health. Their mental condition may manifest as post-traumatic stress disorder, anxiety, and depression [15]. It is also described that patients with aortic dissection often carry the burden of advocating for their own care planning [15,22].

When considering patients' perspectives, there has been a notable gap in research encompassing the entire care continuum, spanning from the initial onset of ATAAD symptoms to cardiac thoracic surgery, long-term management of their chronic condition, rehabilitation and their reintegration into daily life [14,15]. Furthermore, no other qualitative study has focused solely on ATAAD patients' HRQOL. In a study by Jönsson et al. [14], only one of 10 patients had ATAAD. As a result, our understanding of the struggles and requirements of ATAAD patients following their acute condition, cardiac surgery, and re-entry into daily life is incomplete. Consequently, health care professionals face challenges in providing adequate support and assisting patients in coping with their debilitating condition. This study aimed to investigate the perception of HRQOL and the impact of rehabilitation in ATAAD survivors.

Materials and methods

Design

We used Systematic Text Condensation (STC) by Kirsti Malterud as an analytical strategy. Malterud is inspired by a psychological phenomenological approach [23,24]. The COREQ checklist was used to ensure comprehensive reporting [25].

Data Collection

Cardiac rehabilitation staff assisted in patient recruitment during the patients’ cardiac rehabilitation at Aarhus University Hospital, Denmark. To minimize selection bias, we included patients of varying genders and ages. Additionally, Aarhus University Hospital is one of two centers in Denmark with highly specialized expertise in the treatment, care and rehabilitation of ATAAD [26]. The inclusion criteria were ATAAD, age ≥  18 years, and Danish speaking. Six adults with ATAAD from Aarhus University Hospital, Denmark were interviewed.

We used a pilot-tested semi-structured interview guide provided by the second author. The interviews were conducted between March 2021 and October 2022. Data were collected between three months and one year after hospital discharge. Patients were contacted during CR. None of the patients declined participation. Four were interviewed at the hospital, and two at home.

We explored the aspects of patients considered most significant in their daily lives following post-surgical ATAAD. The interviewer (JFS) had no prior relationship with the patients. She informed the patients that the purpose of the study was to enhance the entire trajectory of living with ATAAD.

The duration of the interviews was approximately one hour. The interviews were digitally recorded and transcribed verbatim by the first author. Field notes were not used. The patients did not have the opportunity to comment on the transcribed interviews. Supervision was provided between the interviews to ensure the quality of data collection.

Analysis

The analysis employs the qualitative method of Systematic Text Condensation (STC) [23], developed by Professor Kristi Malterud, chosen for its ability to condense complex and nuanced data while preserving the original meanings and contexts of the interview material. This structured and versatile approach is applicable across various qualitative studies and is particularly suitable for novice researchers. The analysis, conducted by both authors without the use of software, follows Malterud's four-step process: (1) Total impression-from chaos to themes; (2) Identifying and sorting meaning units-from themes to codes; (3) Condensation-from code to meaning; and (4) Synthesizing-from condensation to descriptions and concepts. Additionally, authentic illustrative quotations were identified and applied as outlined by Malterud [23].

Patients

Four men aged 44-51 years and two women aged 62-63 years participated in this study. Before the diagnosis, all patients worked full-time and were fully functional with an active daily life.

Findings

The analysis process is illustrated in Figure 1 and contains themes, code groups, and subgroups.

Figure 1. Overview of the analysis process from themes to code groups and belonging subgroups according to Malterud's Systematic Text Condensation

Relatives

The code group comprised statements regarding the role of family members in the process. The subgroups included the patients' perception of family members as invaluable support, the patients' worries for my loved ones, and the significance of having a relative as one who listens to me.

Invaluable support

Patients had difficulty remembering information from health care professionals. Thus, relatives have become important in helping patients remember their healthcare information. “So, I have always had my wife on the sideline, as she has managed all that information because there has been an abundance of information.” (Patient 5).

Those without relatives were at a risk of losing control over their treatment course. “(...) because I can’t remember what is being said (...) because when you are so frustrated you are not paying attention (...) but there is no one who can come with me." (Patient 1).

Worries for my loved ones

Most patients were concerned that their loved ones would be burdened by the course of events, as they had been on the sideline during the acute phase when patients were unconscious. “It has definitely been worse for them than it has been for me because I’ve just been away (…) they didn't know anything about how he is when he wakes up." (Patient 4).

Some worried that they would impose tasks on their relatives, such as practical responsibilities that patients themselves cannot perform. However, they were mindful that relatives often took on these responsibilities not only to prevent physical burden on the patients, but also to protect them. “So it shouldn't become too great a burden for her, and well, that was... all that planning, how do I approach my everyday life when my ability to walk is limited, you know.” (Patient 3).

One who listens to me

Patients experienced relatives as emotionally supportive, particularly when it came to their thoughts and concerns. "(...) then I just became aware that my entire nervous system calms down when I talk about it." (Patient 3).

A problem occurred when there was no one to talk to. They became unhappy. “(…) I haven’t spoken to anyone at all. The only thing was that I called The Heart Association when I was completely unhappy." (Patient 1).

The hospital course

This code group describes patients’ experiences of hospitalisation. It includes a subgroup of stressful hospital routines and addresses how patients perceive hospital admission and discharges. In another subgroup, if the information succeeds, its significance is unfolded.

Stressful hospital routines

Patients experienced prolonged and challenging hospitalisations. Several disruptions occurred in daily routines, such as nighttime examinations and treatments.  "It was annoying if, for instance, there was that one time when I had to reinsert this tube. They did it in the middle of the night at 12:00 am. Or between 12:00 and 2:00 am. I had to go for an X-ray and a scan, and then you have it inserted. So, it was kind of tough, I thought”. (Patient 6).

Some patients experienced noise from staff activities, which created stressful conditions, especially at night. “(...) there is simply no peace. And it's actually a place where you need peace (...) at night, there is a bit more noise (...).” (Patient 4).

If the information succeeds

All the patients conveyed that they carried a multitude of questions for which they sought answers. Thus, there was profound relief when the health care professionals took the time to address these inquiries. Receiving information regarding the treatment course was a source of reassurance.  “You just have to think that they might have saved up a lot of questions and are carrying some thoughts, so it can be truly liberating if someone takes the time to answer (…) it can almost be like you get tears in your eyes afterward (…) you don't find peace until you get an answer." (Patient 2).

How do I move forward?

This code group included subgroups cardiac rehabilitation and bicycle test, containing the significance and sense of security during exercise-based CR. The subgroup importance of my peers underscores the importance of communicating with someone who shares the same medical condition.

Cardiac rehabilitation

The nurse contributed to beneficial knowledge during CR, which gave patients a greater understanding of their illness. "...the nurse has provided some valuable insights and such, so I find that really valuable, actually.” (Patient 3).

CR helped to understand the extent to which they must adhere to BP restrictions. For some, this insight gave them confidence in exercising at home. "So, it was a matter of figuring out... well, the maximum blood pressure should be 160 during activity and needs to be below 130 at rest (...) And what does that correspond to? You found out when you started THAT rehabilitation program." (Patient 2)

Bicycle test

Completing a bicycle test was significant to the patients because it granted them access to initiate CR and provided a sense of security. The test helped determine the extent to which they could resume their daily lives without causing harm. "(...) it is worth noting, for I have been walking very gently. I have simply taken a consistent route every day, twice a day, and dared not to strain it or... kept it completely calm and steady. (...) And then I get on that cursed bicycle, and then I realise that it does not break." (Patient 4).

Importance of my peers

The presence of fellow patients during CR was important for well-being and life with illness. "That we could sit and have a little laugh, you know, that there were others who had the same thoughts, or that we thought it was quite strange, that it's so rigid. I mean, that's why I was so excited to join that group, because there are others who have been to the Cardiothoracic Department." (Patient 1).

Engaging in conversations with peers who live with the same medical condition was valuable, emphasising the importance of identifying with fellow patients in age and illness type.” Some of them were quite elderly (…) But later in the group, some younger individuals joined. It's not that I was happier about it, but (…) at least there was something I could relate to (…)" (Patient 2).

The body’s reaction

The subgroups “fatigue” and “my body is in alert” contain descriptions of how fatigue was debilitating, and how the body is in a constant state of alarm continually stressing the patients.

Fatigue

Fatigue forced patients to rest during the day and after work, whereas others needed a few days off to regain energy. The energy level had to be adjusted to reduce the strain on the body. “I still need to take a little rest during the day. Sometimes, I fall asleep, and it takes an hour and a half (...) That thing where you just 'reset' yourself, it's... it's good." (Patient 2).

Some experienced fatigue, which prevented them from performing strenuous tasks or forced them to divide tasks into subtasks. “Then you must speak up, I mean, if something is too heavy. Or if you get tired. Then you must speak up and say: Now I need to take a break” (Patient 5).

My body is in alert

Patients who had experienced their bodies remained in a state of watchfulness long after discharge and were easily alarmed. "The body remains on alert for an extended period. The nerve endings are constantly active. I believe it will persist for quite some time." (Patient 2).

Most patients experienced symptoms, such as dizziness and back pain, resulting in fear and anxiety. Several patients also contemplated future complications such as the risk of new dissection. Some patients became more aware of their heart activity. They felt this externally through their clothing, palate, or ear canal, raising concerns about whether everything was as it should be. “Well, it was also all that anxiety about certain things (…) the anxiety that it didn’t heal properly (…) You're so 'alert,' right? (…) I… feel my heart beating. I could also before, but now I FEEL it. I can feel it against my shirt (…) You have all those thoughts that come with it. Is it supposed to be like that? (…) If you had pain in your stomach, back, or chest again (…) 'Ah, now I have pain there – what’s that?”. (Patient 6).

Future

This code group pertains to patients' thoughts on how the disease may affect them in the future. They worry about my future work-life and how the disease affects my daily activities.

My future work-life

Some patients envisioned a future in which restrictions would affect their work-life. This was challenging to accept as work constituted a crucial part of life. This included accepting that work tasks must be reduced to maintain employability. “So, I’m going to start working full-time again at my job in a month. Then I’ll gradually ramp it up. If I were to find it too much, well, I would reduce my hours, and that would just be how it is. But I was determined not to end up as someone who needed some kind of financial support or something like that (…) it was too early for that." (Patient 2).

The disease affects my daily activities

ATAAD significantly affected patients' self-perceptions. Several daily activities were associated with this disease. Patients were unable to manage the same tasks as before, which could be challenging to accept. This constituted a significant upheaval and was the outcome of the constraints and limitations imposed by the disease. “So, it’s like a process, I would say, to discover what I can’t…. when I’m out weeding, where I really had that; now I just need to do that. And I shouldn’t do that either because then I must use my abdominal press. So, I must figure out other ways to do that, right? So, it’s kind of a long journey to adjust that functionality, but well... I’ve stopped fighting with the reality of it." (Patient 3).

The extent to which these restrictions affected patients' daily lives was individual and depended on their former physical activity. Missing activities, such as being a badminton coach upset. However, some came to terms with this reality and were largely trying to accept it or to think of alternative solutions. "Of course, I can’t expect to run a marathon, or... Well, I CAN, but it just must be done at a much slower pace. I might not be able to play badminton matches like I used to, or tennis (…) I just must keep an eye on it. There are limitations, of course (…) they are quite minor in the grand scheme of things, so they shouldn’t have much significance. At the very least, they shouldn’t ruin anything. Not being able to lift over 25 kg and not being allowed to, well, how often do you even do that?”. (Patient 2).

Results and discussion

To our knowledge, this qualitative study is the first to address ATAAD patients’ perceptions of their HRQOL after the hospital course and upon their return to daily life. Despite this, some of the findings are consistent with articles concerning patients with B-dissections.

HRQOL is a multidimensional concept that addresses various aspects of an individual's well-being and delineates how their health status influences their overall quality of life. Several factors contribute to the definition of HRQOL [27,28]. It encompasses physical, mental, and social well-being with a focus on the repercussions of illness and, specifically, the impact of the treatment on quality of life [28]. Gill and Feinstein (29) illustrate that psychosocial elements such as job, family, friends, and other life circumstances are components of HRQOL. Our study demonstrated all aspects of HRQOL, as described above.

Physical health

It is well known that HRQOL deteriorates following ATAAD [7,29,30). However, it has been shown that CR significantly increases peak oxygen uptake, maximal workload, and HRQOL after exercise-based CR [8,9, 11,30]. In addition, Chadda et al. [20], and Fuglsang et al. [11], described how systolic BP is significantly reduced by exercise-based CR. The patients in our study described how CR provided them with knowledge and confidence regarding what they were allowed to do with their systolic BP. This gave them courage and assurance to engage in more exercise and activities in their daily lives, as described in the studies above [11,20].

When not offered CR, qualitative studies delineated how patients were more inclined to seek information regarding permissible daily activities and exercise [14,15,31]. They described feeling inhibited in their daily lives because they were afraid of doing something that could worsen their dissection [6,14,19]. The patients in our study experienced the same emotions and concerns; however, the CR process contributed to a greater understanding of their physical capabilities within the constraints and provided them with mental tranquillity.

The bicycle test was important for our patients. It provided a sense of reassurance regarding the appropriate intensity of physical exercise during and after CR and fostered an understanding that daily activity was no longer perceived as a challenge. In two studies, it was secure to perform an incremental exercise bicycle test owing to hemodynamic responses. No adverse events were observed during these tests [8,10,11,32]. Several positive outcomes of physical exercise were observed in patients with ATAAD. This includes reduction in systolic BP, resumption of daily activities, and the realisation that activities are safe, thereby contributing to enhanced physical and mental HRQOL. It is disconcerting that there is little evidence for physical exercise and maximal incremental tests in patients with ATAAD. In the ECS guidelines [3,4], it is surprising that neither exercise tests nor physical CR are mentioned as gaps in the evidence concerning ATAAD. However, despite limited data, the American guidelines by Isselbacher et al. [7], recommend CR as safe and to promote cardiovascular health. They pointed out that further studies are needed to clarify the level of resistance activity and the intensity of aerobic exercise [7]. This is also described in a scoping review by Jepsen et al. [9].

We found that psychological uncertainty and fear of further deterioration of the dissection resulted in the patients imposing physical restrictions on themselves. This was manifested in their reluctance to engage in activities, such as being a badminton coach or abstaining entirely from physical exertion. This is also described in a phenomenological study where patients i.e. avoid lifting heavy things [6]. A follow-up study of exercise-based CR including ATAAD patients, showed improved peak oxygen uptake, maximal workload, and improved HRQOL [10,11]. This indicated that patients with ATAAD were allowed to maintain their physical activity level. Jönsson et al. [14], described how patients are afraid of exercising, gardening, and picking up their grandchildren. However, our patients accepted these restrictions by reducing the intensity of their daily activities or exercise. They were more likely to perform the same activity at a moderate pace. In a combined qualitative and quantitative study by Connors et al. [17], patients with aortic disorders described how they negotiated their restrictions. Some adapted restrictions as ‘just a part of life,' while others resisted restrictions, striving to maintain a sense of normalcy. When living in a restricted life, they feel differentiated from their peers, family, and society [17,22].

A recent qualitative study presents findings like our findings, including the significant impact of rehabilitation on self-confidence and improved HRQOL in patients with type B dissections. The study also found that fatigue and physical symptoms contribute to a perceived loss of control over their bodies [16].

Furthermore, three interview-based studies reported fatigue as total exhaustion from daily life activities [6,14,16]. Some individuals felt drained of energy and struggled to cope with grocery shopping, cooking, and cleaning [6]. Others found it necessary to break down daily tasks into small increments to accomplish them [14]. In our study, we also found that patients needed to divide tasks into subtasks. However, some patients experience fatigue, which forces them to rest during the day to regain energy.

Psychosocial health

The presence of relatives was of paramount importance to patients. They serve as substantial support during communication with the hospital staff, aiding in the retention of information. Relatives provided emotional support to address their thoughts and concerns. Having a relative to talk to bring about a sense of calm. However, patients were concerned about potentially overloading their relatives by assigning practical responsibilities that they struggled to manage. These concerns regarding overloading are identical to those reported in another study [6,22].

Some patients did not receive support from their relatives, resulting in a sense of sadness. However, it was a great redemption to be part of the CR, where they met peers who had experienced the same. These experiences have also been described in studies on aortic dissection [6,15].

In our study, hospitalisation was arduous because of the presence of stressful routines, unfamiliar sounds, and noise in the environment. A Danish study elucidated that vigilant monitoring by health care professionals impeded the maintenance of their integrity, despite acknowledging the necessity of hospitalisation for their well-being [14]. Patients in our study also experienced environmental stressors, despite expressing a level of acceptance.

This study shows that successful information can serve as a profound source of relief. However, lack of information from professionals leads to worries and feelings of neglect. Others have described that patients actively pursue information concerning their postoperative trajectory as well as their physical and psychological well-being. Thus, lack of information results in feelings of insecurity [6,19,22]. The absence of adequate information poses a challenge in both short and long terms. Consequently, certain patients sought information from the Internet to address these gaps; however, their health literacy seemed insufficient for comprehension [15,22].

We found that obtaining an ATAAD led to future existential reflections. Studies including type B dissections, have described patients' thoughts regarding their conditions and future lives. They must live with a new identity, and their work and social lives change [6,14,16,33]. However, patients in our study were more likely to remain in their jobs by finding alternative work tasks. Some studies have reported that many individuals found themselves compelled to reconsider their employment situation due to imposed restrictions [15,20]. Engaging in employment challenged these restrictions and complicated their occupational circumstances. Research indicates that a varying percentage (3%-21%) successfully retained the same job [19,20]. Some studies highlight a sense of isolation arising from the impact of restrictions on social and daily life [15,31], although this aspect of isolation was not specified in our study.

Our patients described their bodies as easily alerted. They remained vigilant and their nerve endings were consistently active. They reported dizziness and back pain-induced fear. Most of them were cognisant of their heartbeat and sensed it externally through their clothing. The same pattern has been described in other studies [14–17,31]. They elucidated how patients perceived a loss of bodily control, and some individuals encountered a lack of integration between their bodies and selves [17,22]. They were constantly on guard, watchful, and easily startled after ATAAD (23). This culminated in a fear of dying and their whole life got destabilised (19). Fear of death can impact the risk of PTSD [15,21,31], anxiety [22], and depression [15,17,19,20,31,33]. However, PTSD and depression was not found among our patients.

Our patients revealed that their identities were threatened by professional and social activities. Patients grappled with the ambivalence of accepting or rejecting the imposed restrictions on their social lives. Other studies have also confirmed these findings [6,17,19,22,33).

One study suggested that patients gradually come to terms with living with ATAAD by adopting a less physically challenging life over time [6]. While our study lacks a long-term follow-up to substantiate these findings, there is optimism that individuals with ATAAD are progressively embracing their condition. This occurs in a composing manner, enabling them to gradually participate in a broader range of activities.

Some studies have delineated coping strategies, including acceptance, utilisation of humour, and pursuit of social support including rehabilitation [6,16,17,19). Our patients are closer to a transition towards these coping strategies because they addressed accepting their condition and sought support from their loved ones.

The above-described results highlight the need for a more targeted adjustment of cardiac rehabilitation programs for ATAAD patients. Due to the lack of clinical guidelines both internationally and nationally for ATAAD patients, they end up participating in general cardiac rehabilitation. To improve support for these patients, clinical practices should consider including specific guidelines that address the physical and psychosocial rehabilitation of ATAAD patients. In the long term, this could lead to changes in policies that support better and more qualified rehabilitation, as well as closer follow-up for these patients. It should therefore be considered whether the lack of guidelines could benefit from incorporating elements from current international and national cardiac rehabilitation programs, as these programs currently include physical exercise including bicycle test, patient education, psychosocial interventions, screening for anxiety and depression, dietary advice, and a focus on how to return to work [34,35], areas that address the general issues the patients in our study are seeking.

Strength and limitations

We used the COREQ Checklist (27) to ensure that the criteria for reporting qualitative research were met. One-third of the patients were women, while two-thirds were men, and women exhibited an older age profile than men, as outlined in the ECS guidelines and other relevant studies [3,5,36,37]. This strengthens transferability.

Six patients were included in this study, rendering it uncertain whether additional participants could enhance the transferability. To reduce selection bias, we included patients of different genders and age groups. The larger number of patients may have contributed to a more extensive array of descriptions and experiences. On the other hand, the aim of qualitative research is not to interrogate as many individuals as possible but rather to obtain detailed descriptions as feasible. In accordance with Malterud [24], it is unknown whether data saturation has been achieved. However, most of our findings agree with those of the previous studies including patients with type B dissection.

Despite the interviewer’s limited experience, training and supervision enhanced the data collection during the interviews. We followed Malterud systematically [23]. We endeavoured to work phenomenologically and strived to set aside our preconceptions.

Conclusion

Our findings indicate that the rehabilitation of patients’ with ATAAD depends on sufficient information, psychosocial support, imposed restrictions, and the quality of CR, including bicycle testing. Patients highlighted the significance of CR, familial relationships and the value of peer support. ATAAD is characterised by its complexity and presents patients with various physical and psychosocial challenges. This imposes substantial demand on health care professionals. Moreover, to adhere to an elevated standard of treatment and care, health care professionals require more explicit guidelines. When developing guidelines for ATAAD patients, it may be advisable to integrate components from existing international and national cardiac rehabilitation programs, since these guidelines encompass key concerns of the patients in this study. Patients undergoing CR, including the bicycle test, experienced a restoration of resilience and courage for life. CR alleviated identity crises and mitigated physical inactivity.

There is a need for increased comparative research specific to exercise care and cardiac rehabilitation to standardize treatment, care, and CR. This will promote consistent information and communication with ATAAD patients. It should be noted that after major surgery, a protracted recovery process is required for patients to return to a tolerable HRQOL. Nevertheless, there are indications that time also plays a role in healing, instilling hope in future ATAAD patients. Additional qualitative investigations are warranted to examine both short- and long-term perceptions of HRQOL in patients with ATAAD. The study involved a small sample size of just six participants. This limited number may not fully represent the diversity of experiences among all survivors of acute type A aortic dissection.

Conflicts of interest

The authors report there are no competing interests to declare.

Financial support and sponsoring

No funding was received.

Acknowledgments

Special gratitude to Malene Arensbach Ahlmann (RN), Department of Cardiothoracic Surgery, and Maria Lund (physical therapist), Department of Occupational and Physical Therapy for their assistance in patient recruitment during the patients´ cardiac rehabilitation at Aarhus University Hospital.

Ethical approval and consent

According to the Helsinki Declaration [38], all patients were provided with verbal and written information and consent. According to Danish law, qualitative research needs no approval from the Danish Research Ethics Committees (Danish Legislation-LBKnr.1338, 2020) [39]. The head of the Department of Cardiothoracic Surgery approved the study.

Author contribution

Both authors planned the study, performed the analysis, wrote the first draft of the manuscript and revised the manuscript critically and have given their final approval for the version to be published.

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