IJCS | Volume 33, Nº1, January / February 2019

40 Molero Junior et al. Valve prosthesis: assessment of quality of life Int J Cardiovasc Sci. 2020;33(1):36-42 Original Article Discussion The results of the present study indicate that the patients undergoing heart valve replacement reported a satisfactory QoL according to the scores achieved in most of the SF-36 domains. Similar findings were reported by Grady et al. 11 that evaluated 2,524 patients undergoing several cardiac surgeries and showed that the QoL of patients undergoing replacement of heart valve improved from baseline to six months after surgery and remained relatively stable through 3 years. This result demonstrates that the QoL of these patients markedly improves after valve replacement surgery comparedwith the preoperative period. Except for the SF-36 domains functional capacity, physical functioning and mental health, the SF-36 scores of our population were similar to the mean scores obtained from residents of Sao Paulo city, previously published. 12 This is in agreement with another study showing that patients undergoing cardiac operations reported comparable or even higher SF-36 scores comparedwith the general population of the same area. 11 In the analysis of the type of heart valve implanted (biological versus mechanical), we found a statistically significant difference only for the emotional functioning domain (p = 0.0084). Vicchio et al., 13 also concluded in a study about the QoL of octogenarians who had undergone heart valve replacement that the type of the valve had no influence on their QoL. In addition, our results were similar to those reported in a study that evaluated the QoL of 136 patients assessed two years after aortic valve replacement. The authors compared the QoL of patients with bioprostheses and patients with mechanical prostheses and found no statistically significant difference. 14 Compared with this study, our group reported higher mean scores for all SF- 36 domains, except for mental health and pain. In the mental health domain, which encompasses depression and anxiety, we found low scores, with a mean of 54.44. These data seemtodiffer fromthe results ofAboud et al., 14 who observedhigher scores in a studywith a similar sample (mean of 69.6). However, our results seem to be not that different considering the mean age of our sample, 51 years and 6 months old, and considering that most of our sample had a bioprosthesis, since the mean score in the mental health domain in the equivalent group was 56. According to Ruo et al., 15 depression and anxiety were found in 20%of the patients with coronary artery disease. The authors suggested that efforts should be made in the treatment of depression and anxiety in cardiac patients. Although we studied a different population, heart valve replacement surgery can also have a negative impact on the perception of health and performance of physical exercise, leading to worsening physical impairment and QoL, similarly to what was reported by Ruo et al. 15 The low score in health perception may be explained by the fact that many patients feel frustrated for not performing all the activities they wished to do, since expectations in the postoperative period may be high. Góis et al., 16 support this theory in the study about QoL in the pre and postoperative periods of myocardial revascularization to explain the deterioration in social functioning and mental health. These low scores can also be explained by the lack of physical activity, as 58.3% of the patients were physically inactive, which can have a negative impact on the QoL, on emotional status and on health. The positive impact of physical activity was well demonstrated in our study, as we found a statistically significant difference in three of the eight domains of the SF-36 questionnaire. Physically active individuals had better scores compared with physically inactive ones. Exercise increases work capacity and improves the QoL. 17 Araújo et al., 18 showed that physical activity has a positive effect on emotional health. Veigas &Gonçalves, 19 in a study on 207 individuals, reported the impact of physical activity on anxiety and stress in younger individuals and on depression in older individuals. The incidence of these conditions was lower in physically active than inactive ones. In addition, a considerable number of patients reported to be unsatisfied with the fact that they did not return to work and to feel insecure to perform activities that require greater effort. These findings are in accordance with another study 20 on acute myocardial infarction patients which reported that an inability to return or be fit for work had a negative influence on QoL. 20 The present study has some limitations including the different periods of time from the surgery between the patients and lack of information of ventricular function, which may have had some influence on the QoL. Also, the sample size was small due to the low adherence to the treatment by the patients during the study period. In the present study, patients undergoing aortic valve replacement showed better scores in functional