Cognition and adherence are self-management factors predicting the quality of life of adults living with a left ventricular assist device

Interventions for increasing medication adherence in heart failure patients: A narrative review

Heart failure is one of the critical and most costly medical challenges of the 21st century. It is a chronic debilitating condition and adherence to medication, a precondition for successful treatment is often poor. There are various interventions for improving the adherence. Depending on the goal of the intervention, these are roughly patient centric, healthcare provider centric and system centric. We provide an overview of these interventions with a focus on effectiveness and appropriateness in different clinical situations. Their use can lead to improved patient outcomes and reduced economic burden of the disease.

Professional Employment in Patients on Ventricular Assist Device Support-A National Multicenter Survey Study

This study aimed to assess patients of working age returning to professional employment as a surrogate marker for functional recovery and psychosocial reintegration after ventricular assist device (VAD) implantation. A national, multicenter study considered professional employment and its relationship to sociodemographic, psychosocial, and clinical adverse outcomes in outpatients on VAD support. Patient-reported outcome measures were administered. The survey had a 72.7% response rate. Mean age of 375 subjects was 58 ± 11 years, 53 (14%) were female. Thirty-five patients (15.15%; 95% confidence interval [CI] = 10.9-20.6) were employed, and the majority of them (n = 29, 82.9%) were bridged to transplantation. A regression model after variable selection revealed younger age (odds ratio [OR] = 0.95; 95% CI = 0.91-0.98; p < 0.005), and higher education (OR = 3.05; 95% CI = 1.72-5.41; p < 0.001) associated with professional employment. Employed patients reported higher health-related quality of life (HRQoL) (Kansas City Cardiomyopathy Questionnaire [KCCQ] overall sum-score, OR = 1.04; 95% CI = 0.92-1.07; p < 0.007), the OR for those employed was 2.18 (95% CI = 0.89-5.41; p < 0.08) indicating no significant relation for employment and a history of adverse events. In this sample, professional employment was rather small; the likelihood of adverse events was not significantly different between groups. Those employed perceived better overall HRQoL, which may encourage clinicians to support professional employment for selected patients on VAD support.

Cognitive Impairment in Heart Failure: A Heart Failure Society of America Scientific Statement

Cognitive impairment is common among adults with heart failure (HF), as both diseases are strongly related to advancing age and multimorbidity (including both cardiovascular and noncardiovascular conditions). Moreover, HF itself can contribute to alterations in the brain. Cognition is critical for a myriad of self-care activities that are necessary to manage HF, and it also has a major impact on prognosis; consequently, cognitive impairment has important implications for self-care, medication management, function and independence, and life expectancy. Attuned clinicians caring for patients with HF can identify clinical clues present at medical encounters that suggest cognitive impairment. When present, screening tests such as the Mini-Cog, and consideration of referral for comprehensive neurocognitive testing may be indicated. Management of cognitive impairment should focus on treatment of underlying causes of and contributors to cognitive impairment, medication management/optimization, and accommodation of deficiencies in self-care. Given its implications on care, it is important to integrate cognitive impairment into clinical decision making. Although gaps in knowledge and challenges to implementation exist, this scientific statement is intended to guide clinicians in caring for and meeting the needs of an increasingly complex and growing subpopulation of patients with HF.

Multidisciplinary Care in Heart Failure Services

The American College of Cardiology/American Heart Association/Heart Failure Society of American 2022 guidelines for heart failure (HF) recommend a multidisciplinary team approach for patients with HF. The multidisciplinary HF team-based approach decreases the hospitalization rate for HF and health care costs and improves adherence to self-care and the use of guideline-directed medical therapy. This article proposes the optimal multidisciplinary team structure and each team member's delineated role to achieve institutional goals and metrics for HF care. The proposed HF-specific multidisciplinary team comprises cardiologists, surgeons, advanced practice providers, clinical pharmacists, specialty nurses, dieticians, physical therapists, psychologists, social workers, immunologists, and palliative care clinicians. A standardized multidisciplinary HF team-based approach should be incorporated to optimize the structure, minimize the redundancy of clinical responsibilities among team members, and improve clinical outcomes and patient satisfaction in their HF care.

HFSA Expert Consensus Statement on the Medical Management of Patients on Durable Mechanical Circulatory Support

The medical management of patients supported with durable continuous flow left ventricular assist device (LVAD) support encompasses pharmacologic therapies administered in the preoperative, intraoperative, postoperative and chronic LVAD support stages. As patients live longer on LVAD support, the risks of LVAD-related complications and progression of cardiovascular and other diseases increase. Using existing data from cohort studies, registries, randomized trials and expert opinion, this Heart Failure Society of America Consensus Document on the Medical Management of Patients on Durable Mechanical Circulatory Support offers best practices on the management of patients on durable MCS, focusing on pharmacological therapies administered to patients on continuous flow LVADs. While quality data in the LVAD population are few, the utilization of guideline directed heart failure medical therapies (GDMT) and the importance of blood pressure management, right ventricular preload and afterload optimization, and antiplatelet and anticoagulation regimens are discussed. Recommended pharmacologic regimens used to mitigate or treat common complications encountered during LVAD support, including arrhythmias, vasoplegia, mucocutaneous bleeding, and infectious complications are addressed. Finally, this document touches on important potential pharmacological interactions from anti-depressants, herbal and nutritional supplements of relevance to providers of patients on LVAD support.

Validity and reliability of the left ventricular assist device self-care behaviour scale

BACKGROUND

Adequate self-care behaviour is essential for patients with a left ventricular assist device (LVAD) to prevent complications, prolong life, and optimise quality of life. However, there were no valid and reliable measurements available to assess self-care behaviour among patients with LVAD. We have previously developed the 33-item LVAD self-care behaviour scale.

OBJECTIVES

To evaluate psychometric properties of the 33-item LVAD self-care behaviour scale.

METHODS AND RESULTS

Data on 127 patients with a LVAD in Israel, Japan, and the USA were analysed (mean age 51±14.3, 81% male). Exploratory factor analysis extracted three factors, and 13 items were excluded from the scale. Internal consistency assessed by Cronbach's alpha was acceptable for the total scale (α = 0.80) and the three subscales: Factor 1: Monitoring (α = 0.81), Factor 2: Heart failure self-care (α = 0.67), and Factor 3: LVAD self-care (α = 0.63). The 20-item version of the LVAD self-care behaviour scale had sufficient convergent validity with another scale that assessed self-care related to the driveline of LVAD (r = 0.47, p<0.001). Test-retest reliability was adequate (intraclass correlation coefficient = 0.58).

CONCLUSIONS

The 20-item version of the LVAD self-care behaviour scale showed adequate validity and reliability. The scale is ready for use in clinical practice and research. Additional testing might further optimise the scale.

Use of the Self- and Family Management Framework in quantitative studies

BACKGROUND

The Self- and Family Management Framework (SFMF) identifies factors and outcomes of patient and family management of chronic illness. In a previous citation analysis, we reported the frequency and nature of use of the SFMF.

PURPOSE

We conducted a sub-analysis of quantitative articles in the citation analysis to examine testing of relationships depicted in the SFMF.

METHODS

We analyzed study purposes, independent and dependent variables, study implications, and text that referred to the SFMF in 40 articles.

FINDINGS

The SFMF has been used largely to explore factors affecting SFM behaviors, focusing on patient versus family self-management. Independent variables included all categories of facilitators/barriers specified in the SFMF. Dependent variables included all SFMF components (Facilitators/Barriers, Processes, Proximal and Distal Outcomes). Racial/ethnic diversity was limited among study participants. Study implications pertained mostly to psychosocial outcomes. Most studies referred to the SFMF generally.

DISCUSSION

Findings will contribute to revision of the SFMF.

The History of Durable Left Ventricular Assist Devices and Comparison of Outcomes: HeartWare, HeartMate II, HeartMate 3, and the Future of Mechanical Circulatory Support

The utilization of left ventricular assist devices (LVADs) in end-stage heart failure has doubled in the past ten years and is bound to continue to increase. Since the first of these devices was approved in 1994, the technology has changed tremendously, and so has the medical and surgical management of these patients. In this review, we discuss the history of LVADs, evaluating survival and complications over time. We also aim to discuss practical aspects of the medical and surgical management of LVAD patients and future directions for outcome improvement in this population.

Recommendations for Psychosocial Evaluation of VAD candidates: Adoption, completion, and barriers to implementation

BACKGROUND

Recommendations exist to guide clinicians on a comprehensive psychosocial (PS) evaluation prior to Mechanical Circulatory Support (MCS) implantation.

OBJECTIVES

Assess adoption, beliefs, methodologies, and barriers to completion of the 2018 ISHLT/APM/AST/ICCAC/STSW Recommendations for Psychosocial evaluation of adult cardiothoracic transplant and long term mechanical circulatory support.

METHODS

Cross-sectional survey distributed to all 183 implanting LVAD centers in North America via mail and email.

RESULTS

Total of 58 Programs (35.6% response rate) representing 29 states and all regions of the United States responded. Respondents reported implanting 1,183 adults (range 0 - 85; mean = 21.5, SD = 18) in 2018. A majority (n = 55, 94.8%) reported that the 2018 Recommendations were consistent with their clinical practice and most (n = 51, 87.9%) had adopted the recommendations. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) (n = 25, 47.1%) was the most commonly cited assessment tool in the use, although 15 centers reported utilizing more than one tool during the assessment process. Most common barriers influencing completion of the PS evaluation include patient too ill (total responses = 104), lack of time (total responses = 89), patient poor candidate (total responses = 44), and lack of Insurance coverage/reimbursement (total responses = 41).

CONCLUSION

The 2018 ISHLT Recommendations for PS evaluation of LVAD Candidates are widely adopted by respondents in clinical practice, although barriers are still reported to their implementation. Additional research is needed to understand strategies to reduce barriers to implementation and maintenance of the recommendations in clinical practice.

A pilot clinical trial of a self-management intervention in patients with a left ventricular assist device

Self-management is a health behavior known to predict treatment outcomes in patients with multiple co-morbidities and/or chronic conditions. However, the self-management process and outcomes in the left-ventricular assist device (LVAD) population are understudied. This pilot randomized control trial (RCT) evaluated the feasibility of a novel "smartphone app-directed and nurse-supported self-management intervention" in patients implanted with durable LVADs. Assessments included behavioral (self-efficacy and adherence), clinical (complications), and healthcare utilization (unplanned clinic, emergency room (ER) visits, and re-hospitalization) outcomes, completed at baseline (pre-hospital discharge) and months 1, 3, and 6 post-hospital discharge. Intervention patients (n = 14) had favorable patterns/trends of results across study outcomes than control patients (n = 16). Notably, intervention patients had much lower complications and healthcare utilization rates than controls. For example, intervention patients had 2 (14.3%) driveline infections in 6 months while control patients had 3 (19.0%). Additionally, at month 3, intervention patients had 0% ER visits versus 36% of control patients. At month 6, the mean cumulative number of re-hospitalizations for the control group was higher (0.9 ± 0.93) than intervention (0.3 ± 0.61) group. Despite the small sample size and limitations of feasibility/pilot studies, our outcomes data appeared to favor the novel intervention. Lessons learned from this study suggest the intervention should be implemented for 6 months post-hospital discharge. Further research is needed including large and rigorous multi-center RCTs to generate knowledge explaining the mechanism of the effect of self-management on LVAD treatment outcomes.

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.

Use of the self- and family management framework and implications for further development

BACKGROUND

The Self- and Family Management Framework (SFMF) was created in 2006 and revised in 2015 to guide research on self- and family management of chronic conditions. There has been no review of use of the SFMF.

PURPOSE

We reviewed articles citing the SFMF to identify the frequency and nature of use.

METHOD

We conducted a citation analysis, searching Web of Science, Scopus, and Google Scholar databases and extracted key data from identified articles.

FINDINGS

Of 126 articles, 84(66%) cited the 2006 SFMF, 37(29%) cited the 2015 SFMF, and 6(5%) cited both. The SFMF was used most to inform study design. Users noted strengths (e.g., considers family context) and limitations (e.g., non-specification of patient- family caregiver synergies) of the framework.

DISCUSSION

The SFMF has been used broadly to guide research on self- and family management of chronic conditions. Findings will inform development of a third version of the SFMF.

Patient-Reported Issues Following Left Ventricular Assist Device Implantation Hospitalization

The purpose of this study was to explore the information reported by patients via a smartphone application (VAD Care App) used for left ventricular assist device (LVAD) self-care monitoring and reporting post hospital discharge. Specific aims were to examine the type and frequency of issues reported by patients through the app during months 1, 3, and 6 postdischarge. An exploratory-descriptive research design was used with 17 patients (12 males and 5 females) with durable LVADs, mean age of 48.6 ± 16 years. Data generated by the patients' daily smartphone app usage more than 6 months were extracted from the server. Data were coded and clustered according to issues reported by patients via the app and analyzed with descriptive statistics. Three clusters of issues were found: physiologic, behavioral (self-care), and signs and symptoms. LVAD flows and pulsatility indices, hypertension, driveline care, and heart failure symptoms were worse at month 1, and then appeared to improve at months 3-6. However, abnormal levels of the international normalization ratio were common at all assessment points. Further research is needed to understand the mechanism of the reported issues on treatment outcomes, then develop and test interventions to inform evidence-based practice and clinical guidelines for smartphone apps used in LVAD self-care monitoring.

Self-management for patients on ventricular assist device support: a national, multicentre study: protocol for a 3-phase study

INTRODUCTION

Self-management (SM) may facilitate patient participation and involvement to become active and knowledgeable partners in the care of complex chronic conditions such as ventricular assist device (VAD) therapy. The 'SM model for patients on VAD support' will serve to distinguish between SM components, and will guide the development, implementation and evaluation of an evidence-based curriculum.

METHODS AND ANALYSIS

This is a 3-phase, multicentre study. In phase 1, a prevalence study will be performed. Phase 2 aims to develop an evidence-based, interprofessional curriculum for SM support for VAD patients. In phase 3, a non-blinded block-randomised controlled trial (RCT), allocation ratio 1:1, intervention group superiority, with an unblinded multifacetted intervention with assessments before (T1) and after (T2) the intervention, and two follow-up assessments at three (T3), and 12 (T4) months after VAD implantation, will be performed. The curriculum guides the intervention in the RCT. Patient recruitment will consider centre-related volume: power analyses require 384 patients for phase 1, and 142 patients for phase 3.

ETHICS AND DISSEMINATION

Ethical considerations will be continuously taken into account and approved by the institutional review boards. Central ethical review board approval has been obtained by the Albert-Ludwigs University Freiburg. This study will be performed in concordance with the Declaration of Helsinki and the European data protection law. Publications will exclusively report aggregated data and will be distributed in the scientific community, and patient support groups. Report languages will be German and English.

TRIAL REGISTRATION NUMBERS

NCT04234230 and NCT04526964; Pre-results.

The Preimplantation Psychosocial Evaluation and Prediction of Clinical Outcomes During Mechanical Circulatory Support: What Information Is Most Prognostic?

BACKGROUND

Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects.

METHODS

A single-site retrospective analysis was performed for adults receiving MCS between April 2004 and December 2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT versus bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly defined adverse medical events (AEs).

RESULTS

In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (odds ratio, 1.76; P = 0.017); and postimplantation pump exchange and occurrence of AEs (hazard ratios [HRs] ≥ 1.25; P ≤ 0.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs ≥ 1.39; P ≤ 0.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (odds ratios and HRs ≥ 1.32; P ≤ 0.010).

CONCLUSIONS

The psychosocial evaluation predicts not only clinical decisions about MCS use (DT versus bridge) but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.

Flying after left ventricular assist device implantation

Literature on the air travel activities of patients supported by permanent mechanical assist devices is rare. To the best of our knowledge, no air travel guidelines or fitness prerequisites exist on whether and when ventricular assist device (VAD) patients are allowed to travel by plane after device implantation. In this study, we evaluated the topic of air travel after VAD implantation. This working group aimed to produce a report on air travel passengers supported by VADs, regarding their fitness to fly. Fifty left ventricular assist device (LVAD) patients were surveyed in a worldwide multicenter study. The single survey was performed with a multimethod design, including interviews conducted face-to-face, online, and on phone. Out of 50 patients, 97% described their traveling by aircraft as perfect and uneventful during the flight. Eighty-five percent of the study participants consulted their medical practitioner before the flight. No patient reported the occurrence of a severe condition associated with flying. LVAD alarms, especially low flow alarms, did not occur in any of the devices. Thirty-five percent of the surveyed patients, however, stated a major problem pertaining to the security check procedures at the airport. The results of this study suggest that commercial air travel is safe for stable patients on permanent VAD support and traveling can be resumed securely after VAD implantation. Conscientious preparation by packing necessary devices, fluids, medications, and careful preparation for the airport security check is recommended.

Psychological Spectrum Experienced by Heart Failure Patients After Left Ventricular Assist Device Implantation

Depression and anxiety disorders are prevalent in patients with heart failure. They are associated with adverse effects such as rapid disease progression, poor medication compliance, low quality of life and increased mortality rate. The current literature review aims to provide an overview of the overall rate of depression in patients who receive left ventricular assist device (LVAD) implantation and identify the psychological phases that these individuals experienced peri- and post-LVAD implantation. A PubMed search using regular and Medical Subject Headings (MeSH) keywords identified 239 articles. After applying inclusion/exclusion criteria, removal of duplicate studies, and careful review of articles, 40 studies provided relevant information on our primary end-point. These 40 studies selected include 13 paid articles with abstracts and 27 free full-text articles comprising eight prospective cohort studies, five retrospective cohort studies, six cross-sectional studies, one qualitative study, one randomized clinical trial, one systematic review, four literature reviews, and one practice guide. Our review shows that patients experienced different psychological phases after LVAD implantation. However, as the time from implantation progressed, these patients showed a significant improvement in depression, anxiety, and health-related quality of life.

Psychosocial dimensions of hand transplantation: lessons learned from solid organ transplantation

PURPOSE OF REVIEW

The present review examines psychosocial factors emerging as predictive of clinical outcomes among solid organ transplant (SOT) recipients, with possible extensions to vascular composite allograft (VCA) and hand transplantation, in particular. The Chauvet Workgroup report and International Society of Heart and Lung Transplantation consensus guidelines are used to delineate areas of commonality between SOT and VCA, as well as unique features contributing to post-VCA psychosocial risk.

RECENT FINDINGS

Increasing evidence suggests that depression, cognitive function, and other posttransplant psychosocial factors consistently associate with clinical risk in SOT. However, the mechanisms precipitating these psychosocial risk factors are likely diverse in their cause, with large individual differences across SOT and VCA. Transdiagnostic dimensions may serve as mechanistic factors, increasing the risk of adverse clinical outcomes and suggesting potential treatment strategies for risk mitigation. Psychosocial dimensions including psychological flexibility, self-efficacy, and posttraumatic growth are discussed as potential contributory factors.

SUMMARY

Psychosocial factors hold importance in predicting posttransplant clinical outcomes. Emerging transdiagnostic factors may provide insight into mechanisms and potential treatments.

Ready, Set, Go: How Patients and Caregivers Are Prepared for Self-Management of an Implantable Ventricular Assist Device

Since the first use of an implantable ventricular assist device (VAD) nearly 3 decades ago, many VAD Centers in the United States expect patients and caregivers to manage the device and related care following hospital discharge. Despite this customary practice and the rapid advancements in VAD technology, no research data about the patient and caregiver preparations exist for self-management of VAD. This study explored the process of preparing patients and caregivers for VAD care before hospital discharge along with their perceived experiences of the discharge process. Using an exploratory research design, we collected the data with self-administered demographics and VAD Hospital Discharge Survey questionnaires. We analyzed the data provided by 102 patients and 116 caregivers from different regions in the United States. Patients' mean age was 51.4 ± 13.8 years; they were predominantly White (78%); male (66%); and duration of device between 2 and 74 months. Caregivers were predominantly White (80%); female (81%); and had a mean of age 48.9 ± 12.7 years. Participants reported that their VAD care preparations, a crucial component of hospital discharge, were extensive and intensive processes comprising education, training, competency validation, and provision of resources for VAD self-management in home settings. Participants were satisfied with the process and felt prepared for discharge. Further research is needed to rectify the study limitations, advance the science of VAD self-management, and develop evidenced-based VAD self-management guidelines that are aimed at optimizing longevity of the VAD, patients' health, and quality of life.

Psychosocial Evaluation of Candidates for Heart Transplant and Ventricular Assist Devices: Beyond the Current Consensus

Advanced heart failure therapies, including heart transplantation and durable mechanical circulatory support, are available to a limited number of patients because of the scarcity of donors, expense, and large burden of care. The importance of psychological and social determinants of health, including cognitive status, health literacy, psychopathology, social support, medical adherence, and substance abuse, are emphasized in advanced heart failure and further amplified in the context of mechanical circulatory support and heart transplantation. The psychosocial assessment of advanced heart failure therapy candidates remains largely subjective, requiring a multidisciplinary evaluation, which may include psychiatrists, social workers, case managers, financial coordinators, pharmacists, and clinicians. Objective tools—including the Stanford Integrated Psychosocial Assessment for Transplantation, Psychosocial Assessment of Candidates for Transplantation, and Transplant Evaluation Rating Scale—were developed and validated in limited populations to help standardize the evaluation process. Small, retrospective studies have inconsistently shown that these tools may predict clinical outcomes in the transplant population, with higher-risk scores associated with readmissions, rejection episodes, and infections. However, it has been more difficult to show that these tools can predict mortality, and their applicability to the mechanical circulatory support population is less studied. The International Society for Heart and Lung Transplantation released a consensus statement in 2018 to promote consistency of psychosocial evaluation across advanced heart failure programs, but it lacks specific recommendations given the current state of evidence. This state-of-the-art review expands on the current consensus by critically reviewing current studies supporting available objective assessment tools, proposing a psychosocial evaluation framework that uses a multidisciplinary approach and offering future directions for research.

Outcomes of orthotopic heart transplantation and left ventricular assist device in patients aged 65 years or more with end-stage heart failure

Age has traditionally been a limiting factor for advanced heart failure (HF) therapies. Orthotopic heart transplantation (OHT) age guidelines have become less restrictive, and left ventricular assist devices (LVADs) are increasingly utilized as destination therapy for patients ≥65 years. Although indications differ, we assessed outcomes for both modalities in this older population. We reviewed charts of consecutive advanced HF therapy recipients aged ≥65 years at our center from 2012 to 2016. Of 118 patients evaluated, 46 (39%) received an LVAD and 72 (61%) received OHT. Gender, body mass index, and rate of prior sternotomy were similar between groups; OHT recipients were younger, less likely to have diabetes mellitus, and more likely to have HF due to ischemic etiology. Forty-six percent of patients receiving LVADs were urgent need (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] profile 1-2), compared to 29% of patients receiving OHT (United Network for Organ Sharing 1A criteria; P = 0.068). OHT recipients had shorter lengths of stay and better 1-year survival compared to LVAD recipients. Although many centers do not offer advanced HF therapy to patients aged ≥65 years, our results indicate that age alone should not be prohibitive for advanced HF therapy, particularly OHT.

Inpatient Cardiac Rehabilitation of LVAD Patients-Updated Recommendations from the Working Group of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases

Cardiac rehabilitation physicians are faced to an increasing number of heart failure patients supported by left ventricular assist devices (LVAD). Many of these patients have complex medical issues and prolonged hospitalizations and therefore need special cardiac rehabilitation strategies including psychological, social, and educational support which are actually poorly implemented.Cardiac rehabilitation with clear guidance and more evidence should be considered as an essential component of the patient care plan especially regarding the increasing number of destination patients and their long-term follow-up.In this article the working group for postimplant treatment and rehabilitation of LVAD patients of the German Society for Prevention and Rehabilitation of Cardiovascular Diseases has summarized and updated the recommendations for the cardiac rehabilitation of LVAD patients considering the latest literature.

Young adult patients' experience of living with mechanical circulatory support: A phenomenological hermeneutical study

AIM

To describe young adult patients' experiences of living with a mechanical circulatory support (MSC) as a bridge to heart transplantation and impact of self-efficacy.

DESIGN

A qualitative and explorative interview study.

METHODS

Eight interviews with adult participants were conducted and analysed using the phenomenological hermeneutical method.

RESULTS

An overall theme, "Navigating from helplessness to feeling strong in the new reality," and three themes were identified: "Feeling homeless in a changed reality" describes the experience of suddenly falling ill and the loneliness caused by the disease; "Finding my own inner resources" shows that the interviewees found the strength to fight for their lives and began to regain control of their situation; and "Adapting to my new reality" describes the importance of finding strength from others and being able to see MCS as a friend providing respite from the disease. Self-efficacy beliefs play a significant role in the process that the participants went through.

Development and Feasibility of Self-Management Application in Left-Ventricular Assist Devices

Despite major advancements in mechanical circulatory support, the self-management (SM) for patients with a left-ventricular assist device (LVAD) remains complex and challenging for patients and their caregivers. We have developed a mobile phone application (VAD Care App) to organize and simplify the LVAD SM process. This article describes the development and feasibility study of the app as an SM tool for LVAD patients and caregivers requiring support from ventricular assist device (VAD) coordinators. The specific aim was to evaluate the app's acceptability and usability and the users' competency. App features included an automated alert, data collection/reporting, and dynamic real-time interaction systems embedded in the LVAD SM process. Beta-testing of the prototype was completed by five adults. For the feasibility study, we employed a mixed-method descriptive research design involving nine patients and nine caregivers from two VAD centers in the Midwest. We asked them to use the app daily for more than 30 days and complete an app Evaluation Questionnaire and an interview. The questionnaire uses a five-point rating scale (1 = strongly disagree to 5 = strongly agree) evaluating usability, acceptability, and competency domains. Data generated from the questionnaires and interviews were analyzed with descriptive statistics and content analytic procedures. A total of 16 users (eight patients [all male] and eight caregivers [seven female]) aged 22 to 68 years completed the 30 day study. Median acceptability, usability, and competency scores were 4.6, 4.5, and 4.7, respectively. Based on the data, it is feasible for patients and caregivers to use an app as an LVAD SM tool warranting further research.

Patient "Activation" of Patients Referred for Advanced Heart Failure Therapy

Advanced heart failure (HF) is a devastating chronic illness requiring complex treatment regimens and patient engagement. Having the information, motivation, and skills to live with a medical condition are conceptualized by the term, "activation." Patients referred for advanced HF therapy and their unpaid family caregiver were invited to participate in this study by completing the 10-item patient activation measure (PAM) questionnaire. Anxiety and depression were assessed via the hospital anxiety and depression scale. We compared activation, anxiety, and depression between those selected versus not selected for advanced HF therapy (left ventricular assist device or heart transplantation). We analyzed those who subsequently underwent advanced HF therapy in regards to activation and 1-year survival. There were 133 (68%) patients selected for therapy. Neither depression nor anxiety differed by selection status, but PAM levels did (p = 0.02). Those not selected for therapy were approximately 4 times more likely to have lower activation than those who were selected (8% vs 2%). Of the 133 selected patients, 110 (84%) subsequently underwent advanced HF therapy and 15 (14%) of those died within 1 year. Survival was independent of baseline anxiety (p = 0.92) and depression (p = 0.70), as well as patient and caregiver PAM (p = 0.50 and 0.77, respectively). In conclusion, patients with higher activation were more likely to be selected for advanced HF therapy.

The Rehabilitation of Patients With Advanced Heart Failure After Left Ventricular Assist Device Placement: A Narrative Review

Because more patients with advanced heart failure are receiving a left ventricular assist device (LVAD) as destination therapy or a bridge to transplantation, there is increasing attention on functional outcomes and quality of life after LVAD implantation. Rehabilitation providers in the acute inpatient rehabilitation setting increasingly will treat patients with an LVAD and should understand the exercise physiology, medical management, rehabilitation considerations, and outcomes after rehabilitation for patients with an LVAD. The purpose of this article is to provide the physiatrist with a comprehensive understanding of the rehabilitation of patients with advanced heart failure and LVAD implantation. Changes in relevant organ system physiology and exercise physiology after LVAD are summarized. Safety of rehabilitation and program considerations for acute inpatient rehabilitation are reviewed. Recommendations for medical management and prevention of secondary complications seen in patients with an LVAD are outlined. A discussion of outcomes after acute inpatient rehabilitation, the dual diagnosis of stroke and LVAD placement, and long-term cognitive, functional, and quality-of-life outcomes after LVAD placement is presented.

Burnout and Quality of Work Life Among Nurse Practitioners in Ventricular Assist Device Programs in the United States

Background:

A mixed-method study of role stress and work intensity among nurse practitioners (NPs) in mechanical circulatory support (MCS) programs in the United States reported a qualitative data related to burnout. We empirically investigated this phenomenon by pursuing the following specific aims: (1) describe levels of personal burnout (PB), work-related (WB) burnout, and client-related burnout (CB) and quality of work life (QOWL) among MCS-NPs; (2) determine the relationship between burnout and QOWL variables; and (3) identify which type of burnout is a predictor of QOWL.

Methods:

We employed an exploratory correlational research design. Demographics, work characteristics, and psychometrically robust measures of burnout and QOWL were completed by 47 MCS-NPs from various regions of the United States. Data were analyzed with descriptive and inferential statistics.

Results:

Higher levels of burnout (PB, WB, and CB) were associated with lower levels of QOWL ( r = −.52 to −.64, P < .001). Of the 3 types of burnout, WB burnout showed a significant predictor of QOWL ( R2 = .44, P < .01). Multiple regression models showed that a 1 point increase in mean score of WB would decrease a mean QOWL score by 0.64 after controlling the effect of PB and CB. Some dimensions of QOWL were associated with work/hospital characteristics ( r > −.30, P values <.05).

Conclusion:

Work-related burnout is negatively associated with low QOWL among NPs. Hospital/work environment was contributing factors to high burnout and low QOWL. Further research is needed to confirm the findings including the effect of burnout and QOWL on patient and ventricular assist device program outcomes.

Telemonitoring of left-ventricular assist device patients-current status and future challenges

E-health, especially telemedicine, has undergone a remarkably dynamic development over the past few years. Most experience is currently in the field of telemedical care for heart failure (HF) patients. However, HF patients with an implanted left-ventricular assist device (LVAD) have been more or less excluded from consistent telemonitoring until now. And yet, continual monitoring would be very significant for this patient group because of the complexity of its aftercare, requiring steady control of various parameters (device-related parameters, vital parameters, coagulation parameters, etc.). With timely action, severe and costly complications like pump thromboses and driveline infections could be detected early on or even avoided completely. This paper describes the potential of telemonitoring in LVAD patients, as well as its first clinical implementation according to the available literature. It also describes the requirements for a complete telemonitoring of LVAD patients, facilitating the advancement of this form of continual monitoring to a clinical standard which would increase the quality of aftercare for this very special patient collective enormously.

The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support

The psychosocial evaluation is well-recognized as an important component of the multifaceted assessment process to determine candidacy for heart transplantation, lung transplantation, and long-term mechanical circulatory support (MCS). However, there is no consensus-based set of recommendations for either the full range of psychosocial domains to be assessed during the evaluation, or the set of processes and procedures to be used to conduct the evaluation, report its findings, and monitor patients' receipt of and response to interventions for any problems identified. This document provides recommendations on both evaluation content and process. It represents a collaborative effort of the International Society for Heart and Lung Transplantation (ISHLT) and the Academy of Psychosomatic Medicine, American Society of Transplantation, International Consortium of Circulatory Assist Clinicians, and Society for Transplant Social Workers. The Nursing, Health Science and Allied Health Council of the ISHLT organized a Writing Committee composed of international experts representing the ISHLT and the collaborating societies. This Committee synthesized expert opinion and conducted a comprehensive literature review to support the psychosocial evaluation content and process recommendations that were developed. The recommendations are intended to dovetail with current ISHLT guidelines and consensus statements for the selection of candidates for cardiothoracic transplantation and MCS implantation. Moreover, the recommendations are designed to promote consistency across programs in the performance of the psychosocial evaluation by proposing a core set of content domains and processes that can be expanded as needed to meet programs' unique needs and goals.