INTRODUCTION. Recently, the COVID-19 pandemic has caused postponements of elective cardiac surgery. We hypothesised that postponements due to the pandemic were associated with higher levels of psychological distress than prepandemic postponements.
METHODS. A prospective, observational cohort study was conducted among patients in whom elective cardiac surgery was postponed. Patients who received information regarding a new date of surgery prior to the pandemic were compared with patients postponed during the pandemic without information regarding a new date of surgery. Data were collected from patient records, validated questionnaires and interviews.
RESULTS. Out of 55 postponed patients, 21 experienced prepandemic postponement. No significant differences were observed between groups regarding the psychological measures before their rescheduled operation. However, patients in both groups reported high levels of anxiety and depression with > 60% indicative of potentially positive diagnoses. No differences were found in mortality across groups and no patients developed severe complications. Interviews showed that patients in the COVID-19 group felt immediate relief at postponement and engaged in a meaning-making process with respect to their ability to tolerate postponement in order to reassure themselves and their relatives.
CONCLUSIONS. No significant differences were found in psychological distress between the patients of the two groups. However, both groups experienced high levels of psychological distress. It remains unknown whether these results may be extrapolated to other surgical fields.
TRIAL REGISTRATION. not relevant.
Cancellations of planned cardiac surgery may be triggered for organisational, staff, or patient-related reasons [1, 2], and, most recently, also due to the COVID-19 pandemic. Studies have indicated that waiting time for surgery may increase levels of psychological distress [3-5]. Postponement of elective cardiac surgeries due to the COVID-19 pandemic may aggravate this situation, as psychological distress seems to be increased in the general population during the pandemic [6, 7].
A prospective, mixed methods cohort study among patients waiting for open cardiac surgery at Aalborg University Hospital (AAUH), Denmark, was initiated during the autumn of 2019 to evaluate psychological distress in patients experiencing postponement of planned cardiac surgery. As a lockdown was imposed in Denmark as from 11 March 2020 due to COVID-19, the hospital started experiencing a shortage of intensive care resources, and consequently a variety of elective surgeries were postponed. In the Department of Cardiothoracic Surgery, all elective, open cardiac surgeries, such as coronary artery bypass grafting and valve surgeries, were postponed, whereas all emergent and urgent cardiac surgeries continued. In contrast to the standard procedure, patients who had their surgeries postponed due to the pandemic received no information regarding a new date of surgery.
The aim of the study was to examine differences in patients’ psychological responses to postponement of elective cardiac surgery prior to and during the COVID-19 pandemic. In addition, the aim was to reveal patients’ psychological reactions to postponements during the pandemic. We hypothesised that postponement of elective cardiac surgery due to the COVID-19 pandemic was associated with higher levels of psychological distress than in the prepandemic setting.
This study formed part of a large prospective, ongoing observational cohort study in the Department of Cardiothoracic Surgery, AAUH, among patients who experienced postponement of elective open cardiac surgery after they had received their date of surgery. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline  and requirements from the Danish Data Protection Agency were met. The study protocol was approved by the Head of the Department and registered by the hospital (ID: 2019-128). Acceptance from the regional scientific committee was waived due to the observational character of the study.
Participants consisted of two groups of postponed patients. Patients in group 1 were recruited between 30 September 2019 and 10 March 2020. Patients in group 2 had their surgery postponed due to the COVID-19 lockdown and were recruited between 11 March and 6 July 2020. All patients scheduled for open, elective cardiac surgery were eligible for inclusion if their surgery was postponed after they had received their date of surgery. Pregnant patients, patients on a ventilator waiting for surgery and patients who had their surgery postponed more than once were excluded.
When surgeries were postponed for patients in group 1, the patients received information regarding a new date of surgery within a few days either in the hospital, by phone or by mail. Patients in group 2 were informed by phone or mail notifying them that their surgery needed to be postponed due to the pandemic. Patients in group 2 received no information regarding a new date of surgery. In both groups, the information given stated that the decision to postpone surgery was based on doctors’ evaluation to ensure that postponed patients were not in need of urgent surgery. Valve patients were informed that supplementary transthoracic echocardiography was planned during the waiting period to ensure that potential heart failure did not worsen.
Recruitment of patients was conducted by project nurses on the last working day prior to the day of actual surgery if the patients were conscious and able to read and understand Danish.
The study was based on both quantitative (survey and clinical) and qualitative (interview) data. The survey consisted of validated questionnaires regarding anxiety and depression (the Hospital Anxiety and Depression Scale (HADS)), quality of life (Short-form Health Survey, 36 items (SF-36)) and heart-focused anxiety (Cardiac Anxiety Questionnaire (CAQ)), questions on sociodemographic and clinical information, and ad hoc questions regarding the patient’s feelings when his or her surgery was postponed (Table 1).
To explore in-depth how patients experienced postponement of surgery due to the COVID-19 pandemic, personal interviews were conducted with all patients in the COVID-19 group 3-6 months after surgery. These interviews were held at the patients’ homes and were transcribed verbatim .
Prior to analyses, continuous variables were tested for normality using the Shapiro-Wilk test due to the small sample size; non-normal data were analysed accordingly. Subsequently, the two groups were compared on various sample characteristics using a t-test-, Mann-Whitney-, χ2- or Fisher’s exact test, as appropriate, to ascertain whether any pre-existing differences could account for differences in psychological distress. An α = 0.05 was considered statistically significant. We also calculated effects sizes as Cohen’s D, Cramer’s V or r to evaluate whether nonsignificant results may have been due to reduced power.
An inductive latent content analysis was performed using NVivo 12  to condense the meaning of the interviews. After familiarising ourselves with the text, the interviews were coded and divided into themes by three researchers (DN, HS and CBT), and the themes were discussed among all authors [13, 15].
Trial registration: not relevant.
A total of 177 cardiac surgeries were expected to be performed in the hospital between 1 October 2019 and 7 July 2020. Among these, 81 (46%) patients experienced postponement of their elective surgery (Figure 1), and a total of 55 patients were eligible for inclusion in this study. However, some patients experienced additional postponements, leaving 21 patients for evaluation in group 1 and 15 patients in group 2. All patients in group 2 participated in interviews conducted 118-186 days post-operatively, except one (287 days). The interviews produced 105 standard pages of transcribed interviews. Here, only findings regarding patients’ expressions of psychological distress when postponed during the COVID-19 pandemic are presented.
Patients in group 2 were older (p = 0.02), more likely to be informed of the postponement by phone (p = 0.01) and waited 9-10 times longer for their rescheduled surgery. In contrast, post-operative hospitalisation was significantly longer in group 1 (p = 0.01). No other preoperative sociodemographic or clinical differences between groups were identified (Table 2).
Comparing levels of psychological distress, we found no significant differences between groups with regards to anxiety and depression (HADS), quality of life (SF-36) or heart-focused anxiety (CAQ). However, patients in both groups reported high levels of anxiety and depression, indicating potentially positive diagnoses according to the HADS (Table 2). Responses to ad hoc questions also revealed that more patients in the COVID-19 group were anxious about their disease aggravating while waiting. However, no differences were found in mortality across groups and no patients developed severe complications while waiting, i.e. myocardial infraction, stroke or complications requiring urgent surgery.
Qualitative analysis revealed two themes focusing on psychological reactions: 1) feelings of relief followed by anxiety and distress, and 2) meaning-making of not being ill and able to tolerate postponement.
As part of theme 1, patients expressed immediate feelings of relief and being given “a breather”. Even so, the time after postponement was “the hardest to go through that I can remember” (Quotes 1 and 2, Table 3). Additionally, psychological distress caused by postponement was expressed as disappointment, uncertainty, sadness, confusion, loneliness and anxiety (quotes not included). Related to theme 2, psychological distress instigated a meaning-making process around the postponement. In this process, most of the patients created a narrative of not being ill and therefore being able to tolerate postponement (Quotes 3-4, Table 3). In addition, the patients’ expressions of how they understood and experienced the severity of cardiac disease seemed to influence the process of meaning-making around postponement.
Some expressed unawareness of critical symptoms of cardiac disease (Quote 3, Table 3), whereas those feeling more seriously ill had been told so by external cardiac experts or had the longest history of cardiac disease (Quote 5-6, Table 3). These patients expressed doubts relating to their postponement, and one did not find COVID-19 to be a more acceptable reason for postponement than any other reason (Quote 7, Table 3). For the rest of the patients, postponement due to COVID-19 was a circumstance they had to accept (Quote 8, Table 3), and it seemed reasonable as hospitalisation during the pandemic seemed unsafe.
In most patients, being defined as “being able to tolerate postponement” produced a feeling of not being at risk of exacerbation of their condition, morbidity or of dying from their cardiac disease while waiting. They relied on this feeling to reduce their own fear and anxiety and to decrease the worries expressed by their relatives and friends (Quote 9, Table 3).
Overall, no significant differences were reported by the two groups regarding anxiety, depression or impaired quality of life, although both groups experienced high levels of psychological distress on the day before their rescheduled operation. Postponement due to the pandemic that left patients with no date of rescheduled surgery did not seem to play a significant role compared with postponement for other reasons without a new date of surgery. This was surprising as COVID-19 seems to add extra psychological distress in the general population [6, 7], and some patients awaiting cardiac surgery would rather die of their known cardiac disease than being exposed to COVID-19 virus .
Patients awaiting cardiac surgery have previously been shown to experience psychological distress [3-5] and, compared with anxiety and depression determined at hospital discharge , the patients in the present study presented more than twice as high levels of anxiety and depression as determined by the HADS. This difference may represent a transformation in the patients’ psychological distress from the day before surgery to discharge.
The high number of postponed surgeries prior to the pandemic was primarily due to organisational and patient-related issues. Further investigation of the potential association between reasons for postponement and patient reactions is needed to fully understand ways of coping with postponements.
Previous research has shown that waiting for cardiac surgery is experienced as being beyond the individual’s control, and therefore accepting the waiting time is the only way to avoid frustration and maintain meaning in life . This corresponds to the findings of the present study, as immediate feelings of anxiety and other negative reactions to postponement seemed to subside as the patients accepted and complied with postponement and found meaning through the belief of “not being ill and being able to tolerate postponement”.
Theoretically, meaning making is an essential coping strategy when adjusting to stressful events . It refers to processes that align situational meaning (e.g., postponement of surgery) and global meaning (e.g., a full and healthy life) . In the present study, faith in surgeons’ assessments seemed to play a major role in meaning-making, as the patients’ narrative of “being able to tolerate postponement” seemed essential to their psychological response. However, the interviews indicated that some patients expressed alarming cardiac symptoms during the prolonged waiting period without contacting the hospital. This finding indicates that adequate patient information and follow-up may be essential if surgery is postponed, especially on a long-term basis.
The study sample is a subsample of a larger study on postponements. Hence, a priori power calculation was not possible as the pandemic determined the sample size in both groups. Consequently, the sample size is limited, and therefore we also used effect sizes (Table 2) to evaluate whether the lack of significant results may be due to a lack of power.
Although no differences between groups were found on standardized measures, the interviews revealed more information on psychological responses, suggesting that the use of both quantitative and qualitative data may be superior to either method alone. Of note, these data were collected on the day prior to surgery for all patients, which may have affected their reporting of psychological distress even though most questionnaires focused on the past week or month.
Finally, these data may not be generalisable to other populations or situations.
No significant differences were observed regarding anxiety, depression or quality of life among patients in whom open cardiac surgery was postponed during the pandemic compared with patients who experienced prepandemic postponement. However, patients generally reported high levels of anxiety and depression, indicating that waiting for cardiac surgery was associated with psychological distress. The patients in the COVID-19 group felt immediate relief and engaged in a meaning-making process to be able to tolerate postponement and reassure themselves and their relatives. It remains unknown whether these results may be extrapolated to other surgical fields.
Correspondence Charlotte Brun Thorup. E-mail: email@example.com
Accepted 27 October 2021
Conflicts of interest none. Disclosure forms provided by the authors are available with the article at ugeskriftet.dk/dmj
Acknowledgement Secretary Jeanett Sylvan Nielsen for transcribing all patient interviews.
References can be found with the article at ugeskriftet.dk/dmj
Cite this as Dan Med J 2022;69(1):A06210492
Fitzsimons MG, Dilley JD, Moser C et al. Analysis of 43 intraoperative cardiac surgery case cancellations. J Cardiothorac Vasc Anesth 2016;30:19-22.
Tagarakis GI, Karangelis D, Voucharas C et al. Why are heart operations postponed? J Cardiothorac Surg 2011;6:3-5.
McCormick KM, Naimark BJ, Tate RB. Uncertainty, symptom distress, anxiety, and functional status in patients awaiting coronary artery bypass surgery. Hear Lung J Acute Crit Care 2006;35:34-45.
Arthur HM, Daniels C, McKelvie R et al. Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery: a randomized, controlled trial. Ann Intern Med 2000;133:253-62.
Koivula M, Paunonen-Ilmonen M, Tarkka MT et al. Fear and anxiety in patients awaiting coronary artery bypass grafting. Hear Lung J Acute Crit Care 2001;30:302-11.
Ettman CK, Abdalla SM, Cohen GH et al. Prevalence of depression symptoms in US adults before and during the COVID-19 pandemic. JAMA Netw Open 2020;3:e2019686.
Salari N, Hosseinian-Far A, Jalali R et al. Prevalence of stress, anxiety, depression among the general population during the COVID-19 pandemic: a systematic review and meta-analysis. Global Health 2020;16:57.
von Elm E, Altman DG, Egger M et al. The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg 2014;12:1495-9.
Ware JE, Sherbourne CD. The MOS 36-Item Short-Form Health Survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30:473-83.
Bjelland I, Dahl AA, Tangen T et al. The validity of the Hospital Anxiety and Depression Scale An updated literature review. J Psychiatr Res 2002;52:69-77.
Eifert GH, Thompson RN, Zvolensky MJ et al. The Cardiac Anxiety Questionnaire: development and preliminary validity. Behav Res Ther 2000;38:1039-53.
Marker CD, Carmin CN, Ownby RL. Cardiac anxiety in people with and without coronary atherosclerosis. Depress Anxiety 2008;25:824-31.
Elo S, Kääriäinen M, Kanste O et al. Qualitative content analysis: a focus on trustworthiness. SAGE Open 2014;4:1-10.
Zamawe FC. The implication of using NVivo software in qualitative data analysis: evidence-based reflections. Malawi Med J 2015;27:13-5.
Vaismoradi M, Turunen H, Bondas T. Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study. Nurs Heal Sci 2013;15:398-405.
Byrnes ME, Brown CS, De Roo AC et al. Elective surgical delays due to COVID-19: the patient lived experiences. Med Care 2021;59:288-94.
Berg SK, Rasmussen TB, Thrysoee L et al. DenHeart: differences in physical and mental health across cardiac diagnoses at hospital discharge. J Psychosom Res 2017;94:1-9.
Carr T, Teucher U, Casson AG. Waiting for scheduled surgery: a complex patient experience. J Health Psychol 2017;22:290-301.
Park CL. Making sense of the meaning literature: an integrative review of meaning making and its effects on adjustment to stressful life events. Psychol Bull 2010;136:257-301.
Sacco SJ, Leahey TM, Park CL. Meaning-making and quality of life in heart failure interventions: a systematic review. Qual Life Res 2019;28:557-65.