Patterns and predictors of quality of life at 5 to 10 years after heart transplantation

Symptom Distress Before and After Heart Transplantation - A Longitudinal 5-Year Follow-Up

INTRODUCTION

Symptom distress after heart transplantation (HTx) is a significant problem causing uncertainty, low self-efficacy, and psychological distress. Few studies have addressed self-reported symptoms. The aim was to explore self-reported symptom distress from time on the waiting list to 5 years after HTx and its association with self-reported psychological well-being, chronic pain, and fatigue in order to identify possible predictors of psychological or transplant specific well-being.

METHODS

This multicenter, longitudinal cohort study includes 48 heart recipients (HTRs), 12 women, and 36 men, with a median age of 57 years followed from pretransplant to 5 years post-transplant. Symptom distress was explored by means of four instruments measuring psychological general wellbeing, transplant specific wellbeing, pain, and fatigue.

RESULTS

Transplant specific well-being for the whole improved in a stepwise manner during the first 5 years compared to pretransplant. Heart transplant recipients with poor psychological wellbeing were significantly more burdened by symptom distress, in particular sleep problems and fatigue, for up to 5 years after HTx, and their transplant-specific well-being never improved compared to baseline. The prevalence of pain varied from 40% to 60% and explained a significant proportion of the variance in transplant-specific well-being, while psychological general well-being was mainly predicted by overall symptom distress.

CONCLUSION

The presence of distressing symptoms explains a significant proportion of poor psychological wellbeing both among HTRs reporting chronic pain and those without pain.

Diagnostic accuracy of brain natriuretic peptide and N-terminal-pro brain natriuretic peptide to detect complications of cardiac transplantation in adults: A systematic review and meta-analysis

BACKGROUND

We aimed to evaluate the utility of BNP and NT-proBNP in identifying adverse recipient outcomes following cardiac transplantation.

METHODS

We searched MEDLINE (Ovid), Embase (Ovid), and the Cochrane Library from inception to February 2023. We included studies reporting associations between BNP or NT-proBNP and adverse outcomes following cardiac transplantation in adults. We calculated standardised mean differences (SMD) with 95% confidence intervals (CI); or confusion matrices with sensitivities and specificities. Where meta-analysis was inappropriate, studies were analysed descriptively.

RESULTS

Thirty-two studies involving 2,297 cardiac transplantation recipients were included. We report no significant association between BNP or NT-proBNP and significant acute cellular rejection of grade 3A or higher (SMD 0.40, 95% CI -0.06-0.86) as defined by the latest 2004 International Society for Heart and Lung Transplantation Guidelines. We also report no strong associations between BNP or NT-proBNP and cardiac allograft vasculopathy or antibody mediated rejection.

CONCLUSION

In isolation, serum BNP and NT-proBNP lack sufficient sensitivity and specificity to reliably predict adverse outcomes following cardiac transplantation.

Quality of life and lifetime achievement in adult survivors of pediatric heart transplant

BACKGROUND

Survival in pediatric heart transplantation has improved since the first successful transplant over 35 years ago leading to increasing numbers of patients entering adulthood. We sought to examine quality of life and various lifetime achievements in our institutional population of long-term adult survivors of pediatric heart transplant.

METHODS

Participants ≥18 years of age who received a heart transplant as a pediatric patient (<18 years old), and who have survived ≥10 years post-transplant, completed two self-report surveys: (1) Ferrans and Powers QLI cardiac version which reports a measure of life satisfaction with a range of 0 (very dissatisfied) to 1 (very satisfied); and (2) CHONY Pediatric Heart Transplant Life Achievement Survey to examine lifetime achievement.

RESULTS

Sixty-two and sixty-five participants completed the Ferrans and Powers QLI cardiac version and CHONY Pediatric Heart Transplant Life Achievement Survey. The mean overall QLI was 0.75 ± 0.14 with the most satisfaction in the family domain. QLI scores were analyzed by age at initial transplant, gender, indication for transplant, and whether patients currently followed by pediatric or adult providers, with no statistically significant differences noted. Seventy-two percent of participants demonstrated stable employment or schooling. Around thirty percent of participants showed the ability to reach academic milestones including college and post-graduate education and ten percent to start their own families.

CONCLUSIONS

Our cohort of long-term adult survivors of pediatric heart transplant report a quality of life with scores thought to be reflective of a satisfactory quality of life, and many demonstrate achievement of major life milestones.

Baseline Quality-of-Life of Caregivers of Patients With Heart Failure Prior to Advanced Therapies: Findings From the Sustaining Quality of Life of the Aged: Transplant or Mechanical Support (SUSTAIN-IT) Study

BACKGROUND

We compared health-related quality of life (HRQOL), depressive symptoms, anxiety, and burden in caregivers of older patients with heart failure based on the intended therapy goal of the patient: awaiting heart transplantation (HT) with or without mechanical circulatory support (MCS) or prior to long-term MCS; and we identified factors associated with HRQOL.

METHODS

Caregivers (n = 281) recruited from 13 HT and MCS programs in the United States completed measures of HRQOL (EQ-5D-3L), depressive symptoms (PHQ-8), anxiety (STAI-state), and burden (Oberst Caregiving Burden Scale). Analyses included ANOVA, Kruskal-Wallis tests, χ² tests, and linear regression.

RESULTS

The majority of caregivers were female, white spouses with ≤ 2 comorbidities, median [Q1,Q3] age = 62 [57.8, 67.0] years. Caregivers (HT with MCS = 87, HT without MCS = 98, long-term MCS = 96) reported similarly high baseline HRQOL (EQ-5D-3L visual analog scale median score = 90; P = 0.67 for all groups) and low levels of depressive symptoms. STAI-state median scores were higher in the long-term MCS group vs the HT groups with and without MCS, (38 vs 32 vs 31; P < 0.001), respectively. Burden (task: time spent/difficulty) differed significantly among groups. Caregiver factors (number of comorbidities, diabetes and higher anxiety levels) were significantly associated with worse caregiver HRQOL, R² = 26%.

CONCLUSIONS

Recognizing caregiver-specific factors, including comorbidities and anxiety, associated with the HRQOL of caregivers of these older patients with advanced HF may guide support strategies.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Factors Associated With Health-Related Quality of Life 2 Years After Left Ventricular Assist Device Implantation: Insights From INTERMACS

Background

Factors related to health‐related quality of life (HRQOL) 2 years after left ventricular assist device (LVAD) implantation are unknown. We sought to determine whether preimplant intended goal of LVAD therapy (heart transplant candidate [short‐term group], uncertain heart transplant candidate [uncertain group], and heart transplant ineligible [long‐term group]) and other variables were related to HRQOL 2 years after LVAD implantation.

Methods and Results

Our LVAD sample (n=1620) was from INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support). Using the EuroQol‐5 Dimension Questionnaire (EQ‐5D‐3L), a generic HRQOL measure, and the Kansas City Cardiomyopathy Questionnaire (KCCQ‐12), a heart failure–specific HRQOL measure, multivariable linear regression modeling was conducted with the EQ‐5D‐3L Visual Analog Scale (VAS) score and KCCQ‐12 overall summary score (OSS) as separate dependent variables. Two years after LVAD implant, the short‐term group had a significantly higher mean VAS score versus the uncertain and long‐term groups (short‐term: 75.18 [SD, 20.62]; uncertain: 72.27 [SD, 20.33]; long‐term: 70.87 [SD, 22.09], P=0.01); differences were not clinically meaningful. Two‐year mean scores did not differ by group for the KCCQ‐12 OSS (short‐term, 67.85 [SD, 20.61]; uncertain, 67.79 [SD, 19.31]; long‐term, 67.08 [SD, 21.49], P=0.80). Factors associated with a worse VAS score 2 years postoperatively (n=1205) included not working; not having a short‐term LVAD; and postoperative neurological dysfunction, greater health‐related stress, coping poorly, less VAD self‐care confidence, and less satisfaction with VAD surgery, explaining 28% of variance (P<0.001). Factors associated with a worse KCCQ‐12 OSS 2 years postoperatively (n=1250) included not working; history of high body mass index and diabetes mellitus; and postoperative renal dysfunction, greater health‐related stress, coping poorly, less VAD self‐care confidence, less satisfaction with VAD surgery, and regret regarding VAD implantation, accounting for 36% of variance (P<0.001).

Conclusions

Factors related to HRQOL 2 years after LVAD implantation include demographic, clinical, and psychological variables.

Assessing palliative care need in left ventricular assist device patients and heart transplant recipients

OBJECTIVES

Palliative care (PC) has gained rising attention in a holistic treatment approach to chronic heart failure (HF). It is unclear whether there is a need for PC in left ventricular assist device (LVAD) patients or heart transplant recipients.

METHODS

In a cross-sectional explorative pilot study, outpatients after heart transplantation (HTx, n = 69) or LVAD implantation (n = 21) underwent screening for palliative care (PC) need and evaluation of symptom burden and psychological distress using tools that emanated from palliative cancer care.

RESULTS

The 'Palliative Care Screening Tool for Heart Failure Patients' revealed scores of 4.3 ± 2.2 in HTx and 6.0 ± 2.1 in LVAD patients (max. 12 points, P = 0.003), indicating the need for PC (≥5 points) in 32% of HTx and 67% of LVAD patients. Symptom burden, as assessed by MIDOS ('Minimal Documentation System for Palliative Care') scores was substantial in both groups (4.9 ± 4.7 in HTx vs 6.6 ± 5.3 in LVAD, max. 30 points, P = 0.181). 'Fatigue', 'weakness' and 'pain' were the most frequent symptoms. Using the 'Distress-Thermometer', 'clinically relevant' distress was detected in 57% of HTx and 47% of LVAD patients (P = 0.445). In the PHQ-4 ('4-Item Patient Health Questionnaire'), 45% of LVAD patients, compared to only 10% of HTx patients, reported mild symptoms of anxiety and depression.

CONCLUSIONS

Findings reveal substantial need for PC in LVAD patients and, to a lesser extent, in heart transplant recipients, suggesting that multi-disciplinary PC should be introduced into routine aftercare.

Postoperative Psychological Disorders Among Heart Transplant Recipients: A Meta-Analysis and Meta-Regression

OBJECTIVE

This meta-analysis evaluates the pooled prevalence of depression, anxiety, adjustment disorder, and posttraumatic stress disorder (PTSD) among heart transplant recipients globally and determines underlying moderators.

METHODS

The authors searched PubMed, Embase, PsychINFO, BIOSIS, Science Direct, and Cochrane CENTRAL databases from inception to March 1, 2019, and 1321 records and 42 full-text articles were selected and reviewed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We calculated the pooled prevalence proportion of depression, anxiety, adjustment disorder, and PTSD using random-effects models. Meta-regression was performed to identify important moderators that contribute to heterogeneity.

RESULTS

Twenty studies met the inclusion criteria and comprised 2169 patients. The pooled prevalence of depression was 21.6% (95% confidence interval [CI] = 16.8%-27.3%), anxiety 11.1% (95% CI = 3.8%-28.5%), adjustment disorder 11.0% (95% CI = 3.1%-32.1%), and PTSD 13.5% (95% CI = 8%-21.8%). There was significant heterogeneity. Meta-regression was conducted to account for the heterogeneity of the prevalence proportion. Predisposing factors, for example, New York Heart Association classes II and III/IV, steroid treatment, and acute rejection of transplant (<3 months), were associated with high prevalence of depression. Protective factors, for example, age and higher ejection fraction after transplant of patients, were associated with low prevalence of depression. Female sex, single status, and number of months since transplant were associated with high prevalence of anxiety. Single status was associated with high prevalence of both adjustment disorder and transplant-related PTSD.

CONCLUSIONS

The prevalence of psychiatric conditions, particularly depression, is high in heart transplant recipients. The identified protective and risk factors may guide psychological interventions in heart transplant recipients.

A comparison of quality of life and psychological distress in heart transplantation patients at adult and pediatric ages

BACKGROUND

The aim of the current study was to evaluate and compare the quality of life (QOL) and psychological status of adult patients who underwent heart transplant (HTx) at pediatric or adult ages.

METHODS

The population consisted of two groups: patients who received HTx after 18 years old and pediatrics who received HTx between the age of 1 and 18 years. At the time of the study, all patients were over 18 years old. QOL data were collected from patients using 36-item Short-Form Health Survey (SF-36) and psychological distress by the Symptom checklist 90-revised questionnaire (SCL-90-R).

RESULTS

A total of 232 HTx patients were evaluated; 217 were transplanted at an adult age and 15 at a pediatric one. QOL improved significantly in pediatrics patients in the general health perceptions subscale and physical pain subscale than adult patients. The Global Index of the psychological distress did not differ in the two groups, but the pediatric patients registered statistically significant higher scores on the interpersonal sensitivity symptom subscale (adult group 36 ± 0.42 vs pediatric group 81 ± 0.79), the hostility subscale (adult group m 39 ± 0.44 vs pediatric group 73 ± 0.76) and the paranoid ideation subscale (adult group 46 ± 0.46 vs pediatric group 96 ± 1.02).

CONCLUSION

The pediatric heart recipients showed better quality of life, but they show marked sensitivity, hostility and paranoid ideation which increases the risk of mental distress and therefore their adherence to medical treatment.

Self-efficacy, recovery and psychological wellbeing one to five years after heart transplantation: a Swedish cross-sectional study

BACKGROUND

Self-efficacy refers to a person´s confidence in carrying out treatment-related activities and constitutes the foundation of self-management as well as long-term follow-up after heart transplantation. Exploring the heart recipients´ experiences by means of self-report instruments provides healthcare professionals with valuable information on how to supply self-management support after heart transplantation.

AIMS

The aim was to explore self-efficacy in relation to the self-reported level of recovery and psychological wellbeing, among adult heart recipients, one to 5 years after transplantation.

METHODS

This cross-sectional study includes 79 heart recipients, due for follow-up one to 5 years after transplantation. Three different self-assessment instruments were employed: the self-efficacy for managing chronic disease 6-item scale; the postoperative recovery profile; and the psychological general wellbeing instrument.

RESULTS

The reported level of self-efficacy was high (median 8.3, maximum score 10). Significantly higher self-efficacy was seen among those who had returned to work (P = 0.003) and those without pre-transplant mechanical circulatory support (P = 0.033). In total, 65.5% (n = 52) reported being reasonably recovered, while 18.8% (n = 12) were not recovered. The median total psychological general wellbeing score was 108 (P25 = 24, P75 = 117), suggesting overall good psychological wellbeing in the whole group of heart recipients.

CONCLUSION

The heart transplant recipients in our study had an overall high level of self-efficacy. Low self-efficacy was found among those with a low self-reported level of recovery, pre-transplant treatment with mechanical circulatory support or who had not returned to work. This is important information for transplant professionals when helping heart recipients to balance their expectations about recovery.

Cost-utility of venoarterial extracorporeal membrane oxygenation in cardiogenic shock and cardiac arrest

BACKGROUND

The use of venoarterial extracorporeal membrane oxygenation in cardiogenic shock keeps increasing, but its cost-utility is unknown.

METHODS

We studied retrospectively the cost-utility of venoarterial extracorporeal membrane oxygenation in a five-year cohort of consequent patients treated due to refractory cardiogenic shock or cardiac arrest in a transplant centre in 2013-2017. In our centre, venoarterial extracorporeal membrane oxygenation is considered for all cardiogenic shock patients potentially eligible for heart transplantation, and for selected postcardiotomy patients. We assessed the costs of the index hospitalization and of the one-year hospital costs, and the patients' health-related quality of life (response rate 71.7%). Based on the data and the population-based life expectancies, we calculated the amount and the costs of quality-adjusted life years gained both without discount and with an annual discount of 3.5%.

RESULTS

The cohort included 102 patients (78 cardiogenic shock; 24 cardiac arrest) of whom 67 (65.7%) survived to discharge and 66 (64.7%) to one year. The effective costs per one hospital survivor were 242,303€. Median in-hospital costs of the index hospitalization per patient were 129,967€ (interquartile range 150,340€). Mean predicted number of quality-adjusted life years gained by the treatment was 20.9 (standard deviation 9.7) without discount, and the median cost per quality-adjusted life year was 7474€ (interquartile range 10,973€). With the annual discount of 3.5%, 13.0 (standard deviation 4.8) quality-adjusted life years were gained with the cost of 12,642€ per quality-adjusted life year (interquartile range 15,059€).

CONCLUSIONS

We found the use of venoarterial extracorporeal membrane oxygenation in refractory cardiogenic shock and cardiac arrest justified from the cost-utility point of view in a transplant centre setting.

Contemporary Treatment of Heart Failure

Heart failure (HF) affects 2.4% of the adult population in the United States and is associated with high health care costs. Medical and device therapy delay disease progression and improve survival in HF with reduced ejection fraction. Stage D HF is characterized by significant functional limitation, frequent HF hospitalization for decompensation, intolerance of medical therapy, use of inotropes, and high diuretic requirement. Advanced therapies with left ventricular assist devices and cardiac transplantation reduce mortality and improve quality of life, and early referral to specialized centers is imperative for patient selection and success with these therapies.

Importance of physical capacity and the effects of exercise in heart transplant recipients

One of the most important prognostic factors in heart failure patients is physical capacity. Patients with very poor physical performance and otherwise eligible, may be listed as candidates for heart transplantation (HTx). After such surgery, life-long immunosuppression therapy is needed to prevent rejection of the new heart. The dark side of immunosuppression is the increased risk of infections, kidney failure, cancer and advanced atherosclerosis (cardiac allograft vasculopathy), with the two latter conditions as the main causes of later mortality. In a worldwide perspective, 50% of the HTx patients survive past 10 years. Poor aerobic capacity prior to graft deterioration is not only limited to the failing heart, but also caused by peripheral factors, such as limited function in the skeletal muscles and in the blood vessels walls. Exercise rehabilitation after HTx is of major importance in order to improve physical capacity and prognosis. Effects of high-intensity interval training (HIT) in HTx recipients is a growing field of research attracting worldwide focus and interest. Accumulating evidence has shown that HIT is safe and efficient in maintenance HTx recipients; with superior effects on physical capacity compared to conventional moderate exercise. This article generates further evidence to the field by summarizing results from a decade of research performed at our center supported by a broad, but not strict formal, literature review. In short, this article demonstrates a strong association between physical capacity measured after HTx and long-term survival. It describes the possible “HIT-effect” with increased levels of inflammatory mediators of angiogenesis. It also describes long-term effects of HIT; showing a positive effect in development of anxiety symptoms despite that the improved physical capacity was not sustained, due to downregulation of exercise and intensity. Finally, our results are linked to the ongoing HITTS study, which investigates safety and efficiency of HIT in de novo HTx recipients. Together with previous results, this study may have the potential to change existing guidelines and contribute to a better prognosis for the HTx population as a whole.

Improvements in exercise capacity following cardiac transplantation in a patient born with double inlet left ventricle

A 32-year-old man born with double inlet left ventricle (DILV) and other significant cardiac abnormalities underwent surgical palliation at 1 day, 2 years and 20 years, before receiving a donor heart at 29 years. To our knowledge, there are no case reports or cohort studies of the effect of exercise training on exercise capacity and peak oxygen uptake (VO2peak) following heart transplantation (HTx) for individuals born with DILV. The patient accessed our clinical exercise physiology service for assessment, advice and support for exercise training over a 7-year period spanning pre-HTx and post-HTx. An individualised exercise plan, together with careful assessment and monitoring, and the patient's own motivation have contributed to him achieving an outstanding post-HTx doubling of VO2peak and exercise capacity.

Effects of Older Donor Age and Cold Ischemic Time on Long-Term Outcomes of Heart Transplantation

Using older donor hearts in cardiac transplantation may lead to inferior outcomes: older donors have more comorbidities that reduce graft quality, including coronary artery disease, hypertension, diabetes mellitus, and dyslipidemia. Shorter cold ischemic times might overcome the detrimental effect of older donor age. We examined the relationship between donor allograft age and cold ischemic time on the long-term outcomes of heart transplant recipients. rom 1994 through 2010, surgeons at our hospital performed 745 heart transplantations. We retrospectively classified these cases by donor ages of <50 years (younger) and ≥50 years (older), then by cold ischemic times of <120 min (short), 120 to 240 min (intermediate), and >240 min (long). Endpoints included recipient and graft survival, and freedom from cardiac allograft vasculopathy, nonfatal major adverse cardiac events, and rejection. For intermediate ischemic times, the 5-year recipient survival rate was lower when donors were older (70% vs 82.6%; P=0.02). This was also true for long ischemic times (69.8% vs 87.6%; P=0.09). For short ischemic times, we found no difference in 5-year recipient or graft survival rates (80% older vs 85.6% younger; P=0.79), in freedom from nonfatal major adverse cardiac events (83.3% vs 91.5%; P=0.46), or in freedom from cardiac allograft vasculopathy (50% vs 70.6%; P=0.66). Rejection rates were mostly similar. Long-term graft survival in heart transplantation patients with older donor allografts may improve when cold ischemic times are shorter.

Honoring 50 Years of Clinical Heart Transplantation in Circulation

Heart transplantation has become a standard therapy option for advanced heart failure. The translation of heart transplantation from innovative experiments to long-term clinical success has married prescient insights with discipline and organization in the domains of surgical techniques, organ preservation, immunosuppression, organ donation and transplantation logistics, infection control, and long-term graft surveillance. This review explores the key milestones of the past 50 years of heart transplantation and discusses current challenges and promising innovations on the clinical horizon.

Symptom Experience, Self-Care Adherence, and Quality of Life Among Heart Transplant Recipients in South Korea

Among heart transplant recipients, the perceived quality of life (QOL) is a key indicator of successful transplantation. QOL is affected by posttransplant treatments, including immunosuppressive therapy or self-care. However, few studies have evaluated QOL after heart transplantation in South Korea. This study aimed to investigate posttransplant symptoms associated with immunosuppressant, self-care adherence, and QOL in 105 heart transplant recipients in South Korea. Educational status (β = −1.05, p = .013), symptoms (β = −3.98, p = .004), and diet (β = 0.38, p < .001) were found to affect subjects’ overall QOL. In addition to these factors, caregivers and the duration of heart disease (years) were found to be influencing factors, depending on the individual QOL subdimension. These findings highlight the importance of controlling symptoms and managing medications as well as of self-care (particularly dietary compliance). Educational programs targeting beneficial changes in lifestyle, including diet, are needed.

Appraisal of transplant-related stressors, coping strategies, and psychosocial adjustment following kidney transplantation

This study examined the relations between appraisal of transplant-related stressors, coping, and adjustment dimensions following kidney transplantation (KT). Two models were tested: (1) the main effects model proposing that stress appraisal and coping strategies are directly associated with adjustment dimensions; and (2) the moderating model of stress proposing that each coping strategy interacts with stress appraisal. Importantly, there is a lack of research examining the two models simultaneously among recipients of solid organ transplantation. A total of 174 KT recipients completed the questionnaires. Predictors of post-transplant adjustment included appraisal of transplant-related stressors and coping strategies (task-, emotion-, and avoidance-focused). Adjustment dimensions were psychological distress, worries about the transplant, feelings of guilt, fear of disclosure of transplant, adherence, and responsibility for the functioning of the new organ. The main and moderating effects were tested with regression analyses. Appraisal of transplant-related stressors and emotion-oriented coping were related to all adjustment dimensions, except of adherence and responsibility. Task-oriented coping was positively related to responsibility. Avoidance-oriented coping was negatively correlated with adherence. Only 1 out of 18 hypothesized interactive terms was significant, yielding a synergistic interaction between appraisal of transplant-related stressors and emotion-oriented coping on the sense of guilt. The findings have the potential to inform interventions promoting psychosocial adjustment among KT recipients.

Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

Predictors of employment participation following lung transplant

BACKGROUND/AIM

Limited information about return to productive activities after lung transplantation has been published. The purpose of our study was to identify issues relating to occupational engagement in employment after surgery.

METHOD

We conducted a cross-sectional study of surviving lung transplant recipients from one transplant service in Australia. We used descriptive statistics, chi-square tests and Cox regression to analyse the data.

RESULTS

A total of 100 lung transplant recipients completed the assessment (83.3% of 120 eligible surviving recipients). The mean age of respondents was 50 ± 13 years; 45% of the sample were men. Cystic fibrosis and chronic obstructive pulmonary disease were the most frequent pre-transplant diagnoses. Fifty-five percent of participants identified employment or alternate occupational engagement prior to transplant. Of those respondents who had not retired from work prior to transplant, 44.2% identified engagement in paid employment after transplantation. Participants who obtained paid employment post-transplantation were more likely to have completed high school (P = 0.05) or worked as managers (P < 0.0001).

CONCLUSION

Occupational therapists should be actively involved in pre- and post-transplantation goal setting and intervention to support return to work. Pre-transplant, participation in any amount of voluntary or paid employment or study will maintain networks, skills, and confidence. Post-transplant, while physician encouragement is known as a key predictor of return to work, occupational therapist support can address function and activity components of work participation.

Age and gender differences and factors related to change in health-related quality of life from before to 6 months after left ventricular assist device implantation: Findings from Interagency Registry for Mechanically Assisted Circulatory Support

BACKGROUND

Gaps in the literature exist regarding health-related quality of life (HRQOL) early after left ventricular assist device (LVAD) surgery. The purposes of our study were to describe HRQOL over time, by age and gender, and identify risk factors for poor HRQOL early after LVAD implant.

METHODS

Patients (n = 7,353) from the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database received a continuous-flow LVAD as a primary implant at 133 United States hospitals. Of these, 5,640 patients had pre-LVAD HRQOL data, 3,353 patients had 6-month post-LVAD HRQOL data, and 2,748 patients had data at both times. HRQOL was measured using the EQ-5D-3L (Euro-Qol) instrument. Data were collected pre-implant and 3 and 6 months post-operatively. Statistical analyses included chi-square test, t-test, Pearson correlation coefficients, and multiple regression analysis.

RESULTS

Overall HRQOL and dimensions of HRQOL improved from before to 6 months after device implant when examined by age and gender. However, younger patients and women reported significantly more problems regarding all dimensions before implant and significantly more problems regarding pain/discomfort and anxiety/depression at 3 and 6 months after implant. An increase in overall HRQOL from before to 6 months after implant was related to pre-implant INTERMACS Level 1. Factors related to a decrease in HRQOL from before to 6 months after implant were listed for heart transplant before surgery, comorbidities, better preoperative HRQOL, adverse events within 6 months after implant, bridge to transplant moderately likely and unlikely, and New York Heart Association Functional Classification IV at 6 months after LVAD (R(2) = 41%).

CONCLUSIONS

Overall HRQOL and dimensions of HRQOL improve in sub-groups of patients from before to 6 months after surgery, although differences in improvement exist. Adverse events are risk factors for decreased HRQOL across time and support the ongoing need to improve device technology with the aim of reducing adverse events.

Gender differences in appraisal of stress and coping 5 years after heart transplantation

OBJECTIVES

We examined whether gender differences exist regarding stress, symptom distress, coping, adherence, and social support 5 years after heart transplantation.

BACKGROUND

Differences exist in health-related quality of life outcomes by gender after heart transplantation; women report poorer outcomes.

METHODS

Patients (n = 210, female = 42), were from a prospective, multi-site, study of health-related quality of life long-term after heart transplantation. Patients completed self-report instruments 5 years after heart transplantation (mean = 4.98 ± 0.17 years after transplant). Statistical analyses included two-sample t-tests, Chi-square or Fisher's exact test, and multivariable modeling.

RESULTS

Women did not report more overall stress or symptom distress, but reported more difficulty adhering to the transplant regimen, yet more actual adherence than men. Women reported using more negative coping styles, but reported more satisfaction with social support.

CONCLUSIONS

Gender differences exist regarding appraisal of stress, coping styles, and coping resources long-term after heart transplantation. These differences may guide tailoring therapy regarding stress, poor coping, and lack of resources.

Peak oxygen uptake and self-reported physical health are strong predictors of long-term survival after heart transplantation

BACKGROUND

Peak oxygen uptake (VO2peak ) is known as the gold standard measure of cardiopulmonary fitness. We therefore hypothesized that measures of physical health would predict long-term survival in heart transplant recipients (HTx).

METHODS

This retrospective study investigated survival in two HTx populations; the cardiopulmonary exercise test (CPET) cohort comprised 178 HTx patients who completed a VO2peak test during their annual follow-up (1990-2003), and the SF-36 cohort comprised 133 patients who completed a quality of life questionnaire, SF-36v1 (1998-2000).

RESULTS

Mean (SD) age in the CPET cohort was 52 (12) yr and 54 (11) yr in the SF-36 cohort. Mean observation time was, respectively, 11 and 10 yr. Mean (SD) VO2peak was 19.6 (5.3) mL/kg/min, and median (IR) physical function (PF) score was 90 (30). VO2peak and PF scores were both significant predictors in univariate Cox regression. Multiple Cox regression analyses adjusted for other potential predictors showed that VO2peak , age, and cardiac allograft vasculopathy (CAV) were the most important predictors in the CPET cohort, whereas age, PF score, smoking, and CAV were the most important predictors in the SF-36 cohort. In Kaplan-Meier analysis, VO2peak and PF scores above the median value were related to significant longer survival time.

CONCLUSION

Peak oxygen uptake and self-reported physical health are strong predictors for long-term survival in HTx recipients. VO2peak is a crucial measurement and should be more frequently used after HTx.

Life experiences in heart transplant recipients

INTRODUCTION

Heart transplantation is considered as a golden standard of treatment for advanced heart failure. After - transplantation health of patients is influenced by numerous issues which many of them are unknown to the treatment team including nurses. This research - with the aim of describing the life experiences of heart transplant patients - help us to get close to the patients private life and gain comprehensive and a general understanding of all aspects of their life.

METHODS

This study applied qualitative approach using phenomenology method. The purposive sampling was conducted and continued with 9 participants until information reached saturation point. The participants are the heart transplant recipients who had surgery in Esfahan's Heart Surgery Center of Shahid Chamran.

RESULTS

The extracted interviews were analyzed through Colaizzi method: The eleven extracted main concepts were included: Belief, tendencies of the recipient and family of donor, bewilderment, moment of facing with transplantation, satisfaction, vital organ, support, temperament, physical effects of transplantation, mental changes, paradox of life and death.

CONCLUSION

In heart transplant patients, being in touch with peers and family support have an important role in putting up with the transplantation issue. Lack of social situation and social support were among the patients distresses. Lack of the necessary information about transplantation made patients dissatisfied with the heart transplantation. Regarding the research findings, training received by patients would not be suffice and lack of information has been made them face with problems; therefore, the nurse team of transplantation should play more an active role in training the patients.

Quality of life and metrics of achievement in long-term adult survivors of pediatric heart transplant

Many children who undergo heart transplantation will survive into adulthood. We sought to examine the QOL and capacity for achievement in long-term adult survivors of pediatric heart transplantation. Adults >18 yr of age who received transplants as children (≤18 yr old) and had survived for at least 10 yr post-transplant completed two self-report questionnaires: (i) Ferrans & Powers QLI, in which life satisfaction is reported as an overall score and in four subscale domains and is then indexed from 0 (very dissatisfied) to 1 (very satisfied); and (ii) a "Metrics of Life Achievement" questionnaire regarding income, education, relationships, housing status, and access to health care. A total of 20 subjects completed the survey. The overall mean QLI score was 0.77 ± 0.16. Subjects were most satisfied in the family domain (0.84 ± 0.21) and least satisfied in the psychological/spiritual domain (0.7 ± 0.28). Satisfaction in the domains of health/functioning and socioeconomic were intermediate at 0.78 and 0.76, respectively. Most respondents had graduated from high school, reported a median annual income >$50 000/yr, and lived independently. Adult survivors of pediatric heart transplant report a good QOL and demonstrate the ability to obtain an education, work, and live independently.

Organ transplants and education: experience of the Universidade Federal de Ciências da Saúde de Porto Alegre with subjects

INTRODUCTION

Today there is an insufficient number of donated organs in Brazil. This is particularly due to the general population's and health care professionals' lack of information. Therefore, with this project we intend to consolidate knowledge on organ donation to teach health care students of different areas so they are able to propagate such knowledge.

MATERIALS AND METHODS

In 2006, at Universidade Federal de Ciências da Saúde de Porto Alegre, an "Organ donation and transplants" subject was created, with the aim to educate health care students. In the next years, it was split in two subjects, named "Introduction to transplants" and "Donation and transplants." By enrolling, students get theoretical classes and practical experience in out- and inpatient facilities and in surgical environments at the Santa Casa Hospital Complex. Furthermore, they can participate in campaigns at parks, stadiums, and health care fairs that take place at several schools in Porto Alegre. To finish the subjects, students present a conclusion report.

RESULTS

Seven years after implementation of the subject, and with more than 400 students enrolled, several accomplishments can be highlighted. For example, the creation of the Organ Transplantation League, the implementation of a day to spread conception of the donation-transplant process (with the elaboration of a Web page on the subject), and the release of a book on the subject written by students and professors.

DISCUSSION AND CONCLUSION

Health care professionals' education is a central point in donation and transplant process. This is because they become, inevitably, educators, and this brings a long-term consequence, consisting of enhanced logistics skills on brain-death diagnosis and further transfer of information to the population (hopefully reducing denial by families at the time of the donation). We conclude that this is a project to be followed by other medical schools so that, effectively, the number of donors increases and, consequently, the transplantation of organs and tissues as well.

Anxiety, depression, and associated factors among inpatients waiting for heart transplantation

Background

Although heart transplants have become more common, little is known about the psychological status of patients waiting for a heart transplant.

Methods

Thirty-eight inpatients waiting for heart transplantation from October 2010 to December 2011 in a large general hospital in Shanghai were assessed by a psychiatrist using the Hamilton Depression Scale and the Hamilton Anxiety Scale at admission and weekly thereafter until the operation took place.

Results

The patients included 30 males and 8 females with a mean (sd) age of 44.7 (12.9) years who had been seriously limited due to their heart disease (i.e., Stage III heart disease) for a mean of 18.5 (24.0) months. Among them, 7.9% (3/38) were moderately or severely depressed and 47.4 % (18/38) had moderate or severe anxiety symptoms; only one (2.6%) had concurrent moderate to severe anxiety and depression. There was a slight but statistically significant increase in both anxiety and depressive symptoms during the first week of hospitalization. In the stepwise backward logistic regression, the reported level of anxiety was significantly associated with the duration of Stage III heart disease (less anxiety in those with longer Stage III disease), prior treatment in an intensive care unit (associated with less anxiety), age (anxiety increases with age), and prior emergency cardiac treatment (associated with greater anxiety). Multivariate linear regression analysis also found that longer duration of Stage III disease and higher educational status were associated with reporting less depressive symptoms, but a longer total duration of heart disease was associated with reports of more depressive symptoms.

Conclusion

Unlike reports from other countries, we found that anxiety symptoms are more prevalent and more severe than depressive symptoms among inpatients waiting for heart transplantation in Shanghai. There is an inverse relationship between duration of disabling illness and the preoperative self-reports of anxiety and depressive symptoms: those who had had Stage III disease for over a year reported less severe anxiety and depressive symptoms than those who had had Stage III disease for less than a year.

The relationships among satisfaction with social support, quality of life, and survival 5 to 10 years after heart transplantation

BACKGROUND

Despite the fact that social support has been found to be important to cardiovascular health, there is a paucity of information regarding the relationship between social support and outcomes long-term after heart transplantation (HT).

OBJECTIVES

Therefore, the purposes of our retrospective analyses of a prospective, longitudinal study were to examine (1) the relationship between satisfaction with social support and post-HT health-related quality of life (HRQOL) and survival and (2) whether 2 types of social support (emotional and tangible) were predictors of survival and HRQOL.

METHODS

Data were collected from 555 HT patients over a 5-year period (78% male, 88% white; mean age, 53.8 years at time of transplantation) at 4 US medical centers using the following instruments: Social Support Index, Quality of Life Index, Heart Transplant Stressor Scale, Jalowiec Coping Scale, and medical records review. Statistical analyses included t tests, correlations, Kaplan-Meier survival actuarials, and linear and multivariable regression.

RESULTS

Patients were very satisfied with overall social support from 5 to 10 years after HT (0 = very satisfied, 1 = very dissatisfied), which was stable across time (P = .74). Satisfaction with emotional social support (P = .53) and tangible social support (P = .61) also remained stable over time. When stratified into low, medium, and high levels of satisfaction, satisfaction with social support was not related to survival (P = .24). At 5 years, overall satisfaction with social support was a predictor of HRQOL (r = 0.59, P < .0001), and satisfaction with emotional social support was a predictor of HRQOL at 10 years after HT (r = 0.66, P < .0001).

CONCLUSIONS

Patients were very satisfied over time with emotional and tangible social support. While social support explained quality of life outcomes, it did not predict survival. Knowledge of relationships among social support, stress, and outcomes may assist clinicians to address social support needs and resources long-term after HT.

Exercise after heart transplantation: An overview

While life expectancy is greatly improved after a heart transplant, survival is still limited, and compared to the general population, the exercise capacity and health-related quality of life of heart transplant recipients are reduced. Increased exercise capacity is associated with a better prognosis. However, although several studies have documented positive effects of exercise after heart transplantation (HTx), little is known about the type, frequency and intensity of exercise that provides the greatest health benefits. Moreover, the long-term effects of exercise on co-morbidities and survival are also unclear. Exercise restrictions apply to patients with a denervated heart, and for decades, it was believed that the transplanted heart remained denervated. This has since been largely disproved, but despite the new knowledge, the exercise restrictions have largely remained, and up-to-date guidelines on exercise prescription after HTx do not exist. High-intensity, interval based aerobic exercise has repeatedly been documented to have superior positive effects and health benefits compared to moderate exercise. This applies to both healthy subjects as well as in several patient groups, such as patients with metabolic syndrome, coronary artery disease or heart failure. However, whether the effects of this type of exercise are also applicable to heart transplant populations has not yet been fully established. The purpose of this article is to give an overview of the current knowledge about the exercise capacity and effect of exercise among heart transplant recipients and to discuss future exercise strategies.

Factors associated with stress and coping at 5 and 10 years after heart transplantation

BACKGROUND

Heart transplant-related stressors and coping are related to poor outcomes early after transplant. The purposes of our study were to (1) identify the most frequent and bothersome stressors and most used and effective coping strategies and (2) compare the most frequent and bothersome stresses and most used and effective coping styles between patients at 5 and 10 years after heart transplantation. We also examined differences in coping styles by patient characteristics and factors associated with frequency and intensity of stress at 5 and 10 years after heart transplantation.

METHODS

This report is a secondary analysis of data from a prospective, multisite study of quality of life outcomes. Data are from separate cohorts of 199 patients at 5 years after transplant and 98 patients at 10 years. Patients completed the Heart Transplant Stressor Scale and Jalowiec Coping Scale. Statistical analyses included frequencies, measures of central tendency, t-tests, chi-square, and generalized linear models.

RESULTS

At 5 and 10 years after heart transplantation, the most bothersome stressors were regarding work, school, and financial issues. Patients who were 10 years after transplant reported less stress, similar stress intensity, and less use and perceived effectiveness of negative coping than patients who were 5 years after transplant. Long-term after transplant, demographic characteristics, psychologic problems, negative coping, and clinical factors were related to stress frequency and/or intensity.

CONCLUSIONS

Heart transplant-related stress occurs long-term after surgery. Types of transplant-related stress and factors related to stress confirm the importance of ongoing psychologic and clinical support after heart transplantation.