Quality of life outcomes after heart transplantation in individuals bridged to transplant with ventricular assist devices

ACLP Best Practice Guidance: Evaluation and Treatment of Depression in Solid Organ Transplant Recipients

We present Academy of Consultation Liaison Psychiatry best practice guidance on depression in solid organ transplant (SOT) recipients, which resulted from the collaboration of Academy of Consultation Liaison Psychiatry's transplant psychiatry special interest group and Guidelines and Evidence-Based Medicine Subcommittee. Depression (which in the transplant setting may designate depressive symptoms or depressive disorders) is a frequent problem among SOT recipients. Following a structured literature review and consensus process, the Academy of Consultation Liaison Psychiatry transplant psychiatry special interest group proposes recommendations for practice: all organ transplant recipients should be screened routinely for depression. When applicable, positive screening should prompt communication with the mental health treating provider or a clinical evaluation. If the evaluation leads to a diagnosis of depressive disorder, treatment should be recommended and offered. The recommendation for psychotherapy should consider the physical and cognitive ability of the patient to maximize benefit. The first-line antidepressants of choice are escitalopram, sertraline, and mirtazapine. Treating depressive disorders prior to transplantation is recommended to prevent posttransplant depression. Future research should address the mechanism by which transplant patients develop depressive disorders, the efficacy and feasibility of treatment interventions (both pharmacological and psychotherapeutic, in person and via telemedicine), and the resources available to transplant patients for mental health care.

Depression in transplantation

PURPOSE OF REVIEW

To review and summarize the literature published between 1 January 2020 and 30 June 2022, on the prevalence, risk factors and impact of depression in transplant population.

RECENT FINDINGS

Depression is common in transplantation candidates and recipients, with a prevalence up to 85.8% in kidney recipients. Multiple studies have indicated after transplantation depression correlates with increased mortality and with higher healthcare utilization. Social risk factors for posttransplant depression include financial difficulties and unemployment, while less is understood about the biological substrate of depression in this population. There is evidence that dynamic psychotherapy is effective for depression in organ transplant recipients, while cognitive behavioral therapy or supportive therapy did not lead to improvement of depression in transplant recipients. For living organ donors, the rates of depression are similar to the general population, with financial factors and the clinical status of the recipient playing a significant role.

SUMMARY

Depression is a common finding in transplant population. More research is needed to understand the biological substrate and risk factors and to develop effective treatment interventions.

Health-related quality of life in left ventricular assist device-supported patients

Aims

This study aimed to evaluate the different health‐related quality of life (HR‐QoL) aspects in patients with both short‐term and long‐term duration LVAD support at pre‐specified time intervals.

Methods and results

We performed a single‐centre HR‐QoL analysis of short‐term and long‐term LVAD‐supported patients using the short version of the Kansas City Cardiomyopathy Questionnaire (KCCQ‐12) and the Changes in Sexual Functioning Questionnaire along with a survey to evaluate patients' social and driving routines. Data were collected at baseline and at 6 or 12 month follow‐up. Included were 46 patients with a median time from LVAD implantation of 1.1 [inter‐quartile range (IQR) 0.5, 2.6] years. The median KCCQ‐12 summary score was 56 (IQR 29, 74) with most favourable scores in the symptom frequency domain [75 (IQR 50, 92)] and worse scores in the physical limitation [42 (IQR 25, 75)] and QoL [44 (IQR 25, 75)] domains. No significant changes were apparent during study follow‐up [KCCQ‐12 summary score 56 (IQR 35, 80)], and no significant correlation between the KCCQ‐12 summary score and ventricular assist device‐support duration was detected (r = −0.036, P = 0.812). Sexual dysfunction was noted across all domains with a cumulative score of 31 (IQR 22, 42). Seventy‐six per cent of patients resumed driving after LVAD implantation, and 43% of patients reported they socialize with family and friends more frequently since surgery.

Conclusions

Short‐term and long‐term LVAD‐supported patients had impaired HR‐QoL and sexual function at baseline and at follow‐up yet reported an improvement in social interactions and independency. A broader spectrum of patient's reported HR‐QoL measures should be integrated into the pre‐LVAD implantation assessment and preparation.

Posttraumatic stress disorder prevalence in medical populations: A systematic review and meta-analysis

OBJECTIVE

PTSD is increasingly recognized following medical traumas although is highly heterogeneous. It is difficult to judge which medical contexts have the most traumatic potential and where to concentrate further research and clinical attention for prevention, early detection and treatment. The objective of this study was to compare PTSD prevalence in different medical populations.

METHODS

A systematic review of the literature on PTSD following medical traumas was conducted as well as a meta-analysis with final pooled result and 95% confidence intervals presented. A meta-regression was used to investigate the impact of potential effect modifiers (PTSD severity, age, sex, timeline) on study effect size between prevalence studies.

RESULTS

From 3278 abstracts, the authors extracted 292 studies reporting prevalence. Using clinician-administered reports, the highest 24 month or longer PTSD prevalence was found for intraoperative awareness (18.5% [95% CI=5.1%-36.6%]) and the lowest was found for epilepsy (4.5% [95% CI=0.2%-12.6%]). In the overall effect of the meta-regression, only medical events or procedures emerged as significant (p = 0.006) CONCLUSION: This review provides clinicians with greater awareness of medical contexts most associated with PTSD, which may assist them in the decision to engage in more frequent, earlier screening and referral to mental health services.

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.

Psychiatric Aspects of Organ Transplantation in Critical Care: An Update

Transplant patients face challenging medical journeys, with many detours to the intensive care unit. Before and after transplantation, they have significant psychological and cognitive comorbidities, which decrease their quality of life and potentially compromise their medical outcomes. Critical care staff are essential in these journeys. Being cognizant of relevant psychosocial and mental health aspects of transplant patients' experiences can help critical care personnel take comprehensive care of these patients. This knowledge can empower them to understand their patients' psychological journeys, recognize patients' mental health needs, provide initial interventions, and recognize need for expert consultations.

Cognitive function after heart transplantation: Comparing everolimus-based and calcineurin inhibitor-based regimens

BACKGROUND

Studies have shown conflicting results concerning the occurrence of cognitive impairment after successful heart transplantation (HTx). Another unresolved issue is the possible differential impact of immunosuppressants on cognitive function. In this study, we describe cognitive function in a cohort of HTx recipients and subsequently compare cognitive function between subjects on either everolimus- or calcineurin inhibitor (CNI)-based immunosuppression.

METHODS

Cognitive function, covering attention, processing speed, executive functions, memory, and language functions, was assessed with a neuropsychological test battery. Thirty-seven subjects were included (everolimus group: n=20; CNI group: n=17). The extent of cerebrovascular pathology was assessed with magnetic resonance imaging.

RESULTS

About 40% of subjects had cognitive impairment, defined as performance at least 1.5 standard deviations below normative mean in one or several cognitive domains. Cerebrovascular pathology was present in 33.3%. There were no statistically significant differences between treatment groups across cognitive domains.

CONCLUSIONS

Given the high prevalence of cognitive impairment in the sample, plus the known negative impact of cognitive impairment on clinical outcome, our results indicate that cognitive assessment should be an integrated part of routine clinical follow-up after HTx. However, everolimus- and CNI-based immunosuppressive regimens did not show differential impacts on cognitive function.

Mental health status of patients with mechanical aortic valves, with ventricular assist devices and after heart transplantation

OBJECTIVES

Mental health is a complex construct, in which emotional aspects and quality of life are central. It has been assessed in patients after heart transplantation (HTX) and occasionally in those with ventricular assist devices (VADs). However, there are no studies that compare patients with primary HTX with those with HTX ending VAD support. Evidence for patients with mechanical aortic valve replacement is also limited. We compared mental outcome for these four groups for the first time. We also focused on the question of an artificial device, i.e. VAD or mechanical aortic valve, as distinct from a biological graft, i.e. HTX.

METHODS

Two questionnaires were applied: The Hospital Anxiety and Depression Scale, the German version consists of two subscales for anxiety and for depression, and the 12-item Short Form Health Survey, the German version contains two subscales for physical and for mental performance measuring quality of life. We included 46 patients with mechanical aortic valve replacement, 55 after HTX and 22 on support by a long-term VAD. The HTX group consisted of 38 patients with primary HTX and 17 recipients who were on VAD support before transplantation. The index operation was at least 6 months ago.

RESULTS

HTX patients suffered less from anxiety and depression than patients with mechanical aortic valve replacement or those on VAD. HTX patients had higher scores on the physical scale but not on the mental component scale of the 12-item Short Form Health Survey compared with VAD patients. Conversely, patients with mechanical aortic valve replacement did worse with regard to mental but not physical performance compared with HTX patients. VAD and mechanical aortic valve replacement patients differed only with regard to physical condition, but not with regard to anxiety, depression and mental status. HTX patients with and without VAD support before transplantation achieved similar values on all scales. Mental scales did not correlate with age or time after surgery.

CONCLUSIONS

HTX patients had the best outcome compared with the other groups with respect to mental health. Mechanical aortic valve replacement patients did not differ from VAD patients with respect to anxiety, depression and mental quality of life scores. Mechanical aortic valve replacement patients might be more in need of psychological support than expected. Further, VAD patients who undergo HTX reach similar mental and physical results when compared with patients with primary HTX, i.e. they seem to cope well in the long run.

Quality of life of advanced chronic heart failure: medical care, mechanical circulatory support and transplantation

OBJECTIVES

Advanced chronic heart failure (ACHF) is progressive with poor prognosis and quality of life (QoL). Heart transplantation (HTx) is an effective treatment for ACHF, but is limited by scarcity of donor hearts. Left ventricular assist device (LVAD) support is a useful bridging therapy, and short- and medium-term outcomes have improved. We investigated QoL in patients assessed for HTx, awaiting HTx and after HTx.

METHODS

We carried out a cross-sectional survey across four groups: Group 1-patients assessed for HTx, Group 2-patients listed for HTx on medical therapy, Group 3-patients supported with LVAD and Group 4-patients after HTx. Two questionnaires, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQol dimensions (EQ-5D), were administered in all adult HTx centres in the UK. Scores calculated for the KCCQ and EQ-5D were compared.

RESULTS

Three hundred and eighty-six patients completed questionnaires: 194 in Group 1, 28 in Group 2, 82 in Group 3 and 82 in Group 4. Patients after HTx reported the best QoL [KCCQ overall summary score: mean 73.0 (SD 27.2)]; patients with LVAD reported better QoL than those being assessed for HTx and those listed for HTx on medical therapy [overall summary score; LVAD: 52.6 (22.0), Listed on medical therapy: 33.3 (21.1), ASSESSMENT: 35.5 (21.5)]. Similarly, EQ-5D scores were highest in patients after HTx [HTx: mean 0.74 (0.27); LVAD: 0.58 (0.26), Listed on medical therapy: 0.44 (0.27), ASSESSMENT: 0.50 (SD 0.30)].

CONCLUSIONS

Patients supported with LVAD had a significantly better QoL than those awaiting HTx without LVAD support, although HTx patients reported the best QoL.

PTSD in solid organ transplant recipients: Current understanding and future implications

PTSS are quite prevalent in transplant recipients, although full-scale PTSD may not be that common. Those symptoms have been linked to poor transplant outcomes, perhaps owing to non-adherence to medications and other recommendations, brought about by the avoidance dimension of the PTSD/PTSS construct (patients may avoid taking their medications because they serve as reminder of the emotionally traumatic event--the transplant). It is possible to treat PTSD via specific psychotherapeutic techniques, and the treatment has been shown to be safe and likely effective in other populations. Therefore, practitioners who treat transplant recipients should be familiar with the presentation and treatment of those symptoms. This manuscript provides a systematic literature review of the PTSD/PTSS presentation in the pediatric transplant setting, a synthesis of available research findings, and suggestions for current care and future research.

Background and design of the profiling biobehavioral responses to mechanical support in advanced heart failure study

BACKGROUND

Unexplained heterogeneity in response to ventricular assist device (VAD) implantation for the management of advanced heart failure impedes our ability to predict favorable outcomes, provide adequate patient and family education, and personalize monitoring and symptom management strategies. The purpose of this article was to describe the background and the design of a study entitled "Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure" (PREMISE).

STUDY DESIGN AND METHODS

PREMISE is a prospective cohort study designed to (1) identify common and distinct trajectories of change in physical and psychological symptom burden; (2) characterize common trajectories of change in serum biomarkers of myocardial stress, systemic inflammation, and endothelial dysfunction; and (3) quantify associations between symptoms and biomarkers of pathogenesis in adults undergoing VAD implantation. Latent growth mixture modeling, including parallel process and cross-classification modeling, will be used to address the study aims and will entail identifying trajectories, quantifying associations between trajectories and both clinical and quality-of-life outcomes, and identifying predictors of favorable symptom and biomarker responses to VAD implantation.

CONCLUSIONS

Research findings from the PREMISE study will be used to enhance shared patient and provider decision making and to shape a much-needed new breed of interventions and clinical management strategies that are tailored to differential symptom and pathogenic responses to VAD implantation.

Social function after solid organ transplantation: An integrative review

The way organ transplant recipients depend on social interactions to develop and experience social health and well-being is similar to that of the general population. A transplant may result in a close to full recovery of health status, but the physical and social problems can persist in some patients. The focus on improving the recipients’ social participation has therefore become an important issue. The purpose of this integrative literature review was study social function after solid organ transplantation, that is, kidney, liver, lung or heart. An integrative review was performed on studies that matched the selection criteria and published in peer-reviewed journals from January 2000 to December 2014. The information from the text was extracted and patterns of social function were categorized into different subgroups that were further looked at, and five categories emerged: 1) work, 2) education, 3) daily activities and leisure, 4) social adaption and 5) barriers. The key aspects of social functioning involve five vital domains, that is, work, education, daily activities and leisure, social adaption and barriers. Returning to work appears to be the most important for the recipients independently of the transplanted organ.

Incidence and predictors of cognitive decline in patients with left ventricular assist devices

BACKGROUND

After left ventricular assist device (LVAD) placement for advanced heart failure, increased cerebral perfusion should result in improved cognitive function. However, stroke (a well-known LVAD complication) and subclinical cerebral ischemia may result in transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool.

METHODS AND RESULTS

Among 4419 patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent LVAD implantation between May 2012 and December 2013, cognitive function was assessed in 1173 patients with the Trail Making B Test before LVAD and at 3, 6, and 12 months. The test detects several forms of cognitive impairment, including subclinical stroke. Cognitive decline was defined as a clinically important increase during follow-up using a moderate Cohen d effect size of 0.5×baseline SD (32 s). The cumulative incidence of cognitive decline in the year after LVAD implantation, treating death and transplantation as competing risks, was 29.2%. In adjusted analysis, older age (≥70 versus <50 years; hazard ratio, 2.24; 95% confidence interval 1.46-3.44; P(trend)<0.001) and destination therapy (hazard ratio, 1.42; 95% confidence interval, 1.05-1.92) were significantly associated with greater risk of cognitive decline.

CONCLUSIONS

Cognitive decline occurs commonly in patients in the year after LVAD and is associated with older age and destination therapy. These results could have important implications for patient selection and improved communication of risks before LVAD implantation. Additional studies are needed to explore the association between cognitive decline and subsequent stroke, health status, and mortality in patients after LVAD.

Posttraumatic stress disorder in organ transplant recipients: a systematic review

OBJECTIVE

To summarize and critically review the existing literature on the prevalence of posttraumatic stress disorder (PTSD) following organ transplantation, risk factors for posttransplantation PTSD and the relationship of posttransplant PTSD to other clinical outcomes including health-related quality of life (HRQOL) and mortality.

METHODS

We conducted a systematic literature review using PubMed, CINAHL Plus, the Cochrane Library and PsycInfo and a search of the online contents of 18 journals.

RESULTS

Twenty-three studies were included. Posttransplant, the point prevalence of clinician-ascertained PTSD ranged from 1% to 16% (n=738), the point prevalence of questionnaire-assessed substantial PTSD symptoms ranged from 0% to 46% (n=1024) and the cumulative incidence of clinician-ascertained transplant-specific PTSD ranged from 10% to 17% (n=482). Consistent predictors of posttransplant PTSD included history of psychiatric illness prior to transplantation and poor social support posttransplantation. Posttransplant PTSD was consistently associated with worse mental HRQOL and potentially associated with worse physical HRQOL.

CONCLUSIONS

PTSD may impact a substantial proportion of organ transplant recipients. Future studies should focus on transplant-specific PTSD and clarify potential risk factors for, and adverse outcomes related to, posttransplant PTSD.

Ethical dilemmas surrounding the use of ventricular assist devices in supporting patients with end-stage organ dysfunction

Successful practice of cardiovascular medicine requires familiarity with the complex ethical issues that accompany therapeutic innovation and diffusion. Even as technologies transition from experimental to standard care, challenges remain. Mechanical circulatory support devices, for instance, are increasingly conceptualized as conventional therapies. Despite this, or perhaps because of it, the ethical issues surrounding the use of these devices in patients with end-stage organ dysfunction are becoming increasingly apparent. In this paper, we provide an introduction to ethical considerations related to the use of ventricular assist devices (VADs) in end-stage organ failure, focusing on three stages or decision points: initiation, continued use, and deactivation. Our goal is not to exhaustively resolve these dilemmas but to illustrate how ethical considerations relate to decision making.

Posttraumatic stress symptoms after solid-organ transplantation: preoperative risk factors and the impact on health-related quality of life and life satisfaction

Background

Solid-organ transplantations (SOT) are usually life-saving high-tech medical procedures. The transplantation itself and the intensive care unit stay could be traumatic stressors triggering posttraumatic stress symptoms (PTSS). Our retrospective follow-up study aimed to explore preoperative risk factors of PTSS in a cohort of SOT recipients, and we investigated how PTSS are associated with health-related quality of life (HRQOL) and life satisfaction.

Methods

126 SOT recipients were enrolled in this investigation. Psychiatric examination of all SOT candidates based on the Transplant Evaluation Rating Scale was carried out before SOT, and after SOT, recipients completed the PTSS-10, the SF-36 and the FLZ.

Results

After the surgical intervention 19 (15.1%) SOT recipients had clinical significant PTSS. Preoperative risk factors for developing postoperative PTSS were: 1.) preexisting psychiatric morbidity, 2.) history of retransplantation, 3.) chronic benzodiazepine consumption, 4.) age, and 5.) type of transplantation.

SOT-related PTSS were associated with maximal decrements in HRQOL and life satisfaction. The following HRQOL and life satisfaction domains were affected: Physical Functioning, Role Physical, Pain, General Health, Vitality, Social Functioning, Role Emotional, Mental Health, Occupation/Work and Character/Own Skills.

Conclusion

SOT recipients may face a major risk of transplantation- and treatment-related PTSS and the development of impairments to HRQOL and life satisfaction.

Overall mental distress and health-related quality of life after solid-organ transplantation: results from a retrospective follow-up study

Background

Our retrospective follow-up study aimed to explore the degree of overall mental distress in a cohort of solid-organ transplantation (SOT) recipients after liver, heart or lung transplantation. Furthermore, we investigated how overall mental distress is linked to health-related quality of life.

Methods

123 SOT patients treated during the study period were enrolled in this investigation at a mean of 24.6 months (SD=11.6) after transplantation. Before transplantation, the Transplant Evaluation Rating Scale (TERS) was used to classify the level of adjustment in psychosocial functioning among transplantation candidates. After transplantation, recipients completed a research battery, which included the SCL-90-R, and the SF-36.

Results

39 (31.7%) transplantation recipients had clinically significant overall mental distress as measured on the Global Severity Index of the SCL-90-R. Obsessive-compulsive symptoms (92.3%), somatization symptoms (87.2%), anxiety symptoms (84.6%), depression symptoms (82.1%) and phobic anxiety symptoms (69.2%) were a frequent finding.

Transplantation recipients with overall mental distress had significant lower levels of adjustment in psychosocial functioning before transaplantation than those without overall mental distress as measured in the TERS. Transplantation-related overall mental distress symptomatology was associated with maximal decrements in health-related quality of life.

Conclusion

Transplantation recipients may face major transplantation- and treatment-related overall mental distress and impairments to their health-related quality of life. Further, overall mental distress is a high-risk factor in intensifying impairments to patients’ overall quality of life.

Depression and anxiety levels of the mothers of children and adolescents with left ventricular assist devices

VADs have been used to provide treatment for end-stage heart failure. Parents may feel overwhelmed with the VAD regimes responsibility and be affected from this process beside children. In this study, we aimed to evaluate the depressive and anxiety symptoms of mothers of the first eight children equipped with a VAD in Turkey. The mothers of eight pediatric patients living with VADs were filled BDI and STAI at first month of VAD implantation (E.I) and secondly six months after their first evaluation (E.II). In E.I, the BDI mean score of mothers was 20.87, in E.II 14.37. STAI-S mean score was 53.37 in E.I and 43.62 in E.II. The Wilcoxon nonparametric-paired t-test revealed significant difference between baseline and end-point STAI-S scores (Z: -2.035; p: 0.042), and for BDI scores (Z, -1.965; p, 0.049). Prolonged usage of VAD may increase distress in parents. Psychiatric evaluation and support of the primary caregiver is important for the well-being of the pediatric patients.

Psychiatric evaluation of children and adolescents with left ventricular assist devices

OBJECTIVES

To evaluate the psychiatric symptoms of children equipped with a ventricular assist device (VAD) and follow them up for 6 months. With the shortage of donor hearts available for the treatment of end-stage heart failure, VADs have been used to provide temporary treatment until a heart becomes available. VADs provide external sources of power for mechanical circulatory support and are capable of sustaining life over weeks and months. This study provides preliminary details about the psychiatric symptoms and disorders of the first eight children equipped with a VAD in Turkey.

METHODS

Eight pediatric patients who recently underwent VAD implantation, aged 1 to 16 years, were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia, Child Behavior Checklist, Children's Depression Inventory, Beck Depression Inventory, and State-Trait Anxiety Inventory for Children and followed up for 6 months.

RESULTS

In the first evaluation, five participants had a psychiatric disorder diagnosis. Two patients had adjustment disorder with depressive and anxiety symptoms; one had anxiety disorder, not otherwise specified; and two had major depressive disorder. The anxiety and depressive symptom levels in questionnaires were consistent with psychiatric diagnoses. Two patients had heart transplantation during the follow-up period.

CONCLUSIONS

To determine and treat psychiatric symptoms and disorders at an earlier stage, it is important for children and adolescents with a VAD and those who have undergone heart transplantation to be evaluated by a multidisciplinary consultation liaison team including psychiatrists, psychologists, consultant nurses, and counselors.

Health-related quality of life and exercise tolerance in recipients of heart transplants and left ventricular assist devices: a prospective, comparative study

BACKGROUND

The aim of this study was to evaluate and compare health-related quality of life (HRQoL) and physical exercise tolerance in patients after heart transplantation (HTx) or implantation of a left ventricular assist device (LVAD).

METHODS

A prospective, comparative design was used to characterize changes over time in HRQoL (SF-36) and exercise tolerance in patients after HTx (n = 54) and during LVAD support (n = 36). Nine LVAD patients were lost for follow-up. The majority of patients in both groups were male (97%); the LVAD cohort tended to be younger (p = 0.06).

RESULTS

HRQoL improved significantly in HTx patients in the SF-36 physical (p = 0.02), but not in the psychosocial (p = 0.27) component score during follow-up. In the LVAD group, HRQoL showed improvements for both the SF-36 physical and psychosocial component scores (both p = 0.04). Between-group comparisons revealed better HRQoL for the HTx cohort than the LVAD cohort for 2 of 8 SF-36 subscales. Age-, gender- and body mass index (BMI)-adjusted exercise tolerance (workload; VO(2max)) showed significant improvements for both HTx (p = 0.01) and LVAD (p = 0.01) patients. Adjusted maximum oxygen consumption was higher for HTx patients (p = 0.05) relative to LVAD patients at 8 ± 1 months after implant.

CONCLUSION

HRQoL and exercise capacity increased in both groups over the time-course of the study. After adjusting for relevant variables, HTx patients showed a higher exercise tolerance compared with the LVAD group during follow-up. Thus, future large-scale intervention studies should emphasize the specific needs of these patient cohorts.

Nursing Education and Implications for Left Ventricular Assist Device Destination Therapy

The HeartMate VE Left Ventricular Assist Device (vented electric abdominally positioned pulsatile blood pump; Thoratec Corp., Pleasanton, CA), approved as a permanent support, or destination therapy, by the US Food and Drug Administration in 2002 and Medicare in 2003, is now a potential therapy for numerous patients. Postimplantation nursing care is crucial to the success of left ventricular support device therapy and long-term recipient outcome. Nurses also contribute to cost containment, making this a viable treatment for the facility and the patient. Consequently, nurses must be educated about left ventricular assist device concepts and challenges, the benefits of device placement, intensive care unit and postintensive care unit daily care requirements, and outpatient preparation. This knowledge will enable nurses to provide necessary care and to educate recipients, families, and community health care providers on how to give appropriate posthospital care.

Psychiatric aspects of organ transplantation in critical care

Intensive care unit teams are a critical part of the solid organ transplant process. The psychosocial issues involved during critical periods of transplantation are important for intensive care physicians and clinicians to understand to provide comprehensive care to transplant patients. This article provides a brief overview of transplant epidemiology, followed by a review of the psychosocial issues relevant to the phases of the transplant process. Considered are the pretransplant evaluation phase, psychiatric disorders in transplant patients, and cognitive impairments and delirium with additional issues specific to particular organs. Also covered are the side effects of immunosuppressive medications and special issues arising with living donors.

Quality of life and psychological well-being during and after left ventricular assist device support

BACKGROUND

Left ventricular assist devices (LVAD) are increasingly being used to treat patients in end-stage heart failure to facilitate survival to cardiac transplant or as a bridge to myocardial recovery. The technical innovation of the LVAD has a significant benefit on the patients' physical functioning. However, within the United Kingdom, there has been no systematic evaluation of the psychological adjustment and quality of life (QoL) of patients currently living with an LVAD, or of the differences in QoL for patients who are either explanted or transplanted.

AIM

To assess the differences in QoL and psychological adjustment for current LVAD patients, patients who have been transplanted from an LVAD and patients in whom the device has been explanted.

METHODS

Twenty-two patients involved in an LVAD programme were recruited (18 men and four women; age range 18-60). Eight patients had an LVAD in situ, six patients had the LVAD explanted and eight had undergone transplantation. QoL and psychological functioning were assessed using previously validated measures.

RESULTS

Although there were no significant differences between the three groups, there was a trend for the LVAD patients to have higher levels of anxiety and depression and a lower QoL compared with transplanted or explanted patients.

CONCLUSIONS

For patients with an LVAD in situ, there was a trend for QoL and psychological functioning to be poorer than for transplanted and explanted patients. Larger studies will be needed to confirm these findings, but psychological assessment and interventions to reduce psychological morbidity and improve QoL will be important in these patients, particularly in view of the increasing numbers of LVADs being implanted and the possibility of their use for long-term "destination" therapy.

Symptomatic Relief: Left Ventricular Assist Devices Versus Resynchronization Therapy

In patients who have end-stage heart failure, medical therapy is of limited use, and heart transplantation is frequently not an option because of the shortage of donor hearts. Two new treatment options, left ventricular assist devices (LVADs) and implantable cardiac resynchronization therapy (CRT) devices, can improve survival and quality of life in patients who have heart failure. Both types of devices are easy to implant. However, LVADs carry the risk of infection and mechanical failure, and CRT is ineffective in a substantial proportion of patients who have heart failure. Therefore, methods must be devised to identify patients who have heart failure who are likely to benefit from these devices. Data suggest that early LVAD implantation, before end-stage heart failure develops, is critical to slowing or reversing disease progression. Similarly, in indicated patients who have less advanced disease, CRT may be particularly beneficial.

Mechanical Circulatory Support as a Bridge to Heart Transplantation: What Remains? Long-term Emotional Sequelae in Patients and Spouses

BACKGROUND

Implantation of a ventricular assist device (VAD) reduces short-term mortality and morbidity and provides patients with reasonable quality of life even though it may also be a long-lasting emotional burden. This study was conducted to analyze the long-time emotional consequences of VAD implantation, followed by heart transplantation in patients and spouses.

METHODS

This cross-sectional study used the Impact of Event Scale-Revised (IES-R) Version, recording avoidance, intrusion, and hyperarousal, to investigate symptoms of post-traumatic stress disorder (PTSD), and VAD-related fears and concerns. The study cohort comprised 38 patients (36 men, 2 women) and 27 spouses (26 women, 1 man), 6 to 135 months post-operatively.

RESULTS

Seven (26%) of the 27 spouses but none of the patients met the criteria for PTSD. Patients who were operated at the early stage of our VAD program (82.0 +/- 31.4 months between implantation and evaluation) were significantly more likely to have a spouse with PTSD syndromes than those whose operation took place later on (42.1 +/- 31.1 months, p = 0.007). Patients with higher avoidance scores and a higher level of hyperarousal were significantly more often affiliated with a PTSD spouse than those with lower avoidance (p = 0.008) and hyperarousal scores (p = 0.001). Spouses displayed significantly higher scores in all IES-R dimensions, and they worried more about device-related problems (malfunctioning, pain, infection, and stroke) than the patients themselves. The noise of the device system was not a crucial issue.

CONCLUSION

Our study found that implantation of a VAD, followed by transplantation, does not lead to PTSD in patients but it does in their spouses in the long run. Their emotional well being deserves much closer attention.

Evaluation of the clinical effectiveness of the Ventricular Assist Device Program in the United Kingdom (EVAD UK)

BACKGROUND

The UK Government funds ventricular assist device (VAD) implantation as bridge to transplantation (BTT) at three centers. Results from this program have not been published.

METHODS

All 70 VAD implants for BTT, 71 inotrope-dependent and 179 non-VAD transplant candidates, accepted for transplantation between April 2002 and December 2004, were prospectively monitored for survival to transplantation, survival overall and quality of life.

RESULTS

Of the 70 VAD patients, 31 (44%) survived to heart transplantation, 4 (6%) were bridged to recovery and 5 remained on support at the end of the study. Thirty patients (43%) died while on support. Overall survival from VAD implant was 52% at 1 year. Ten percent of non-VAD inotrope-dependent patients and 9% of routine transplant candidates died while on the waiting list. For transplant recipients, 12-month post-operative survival was 84%, 85% and 84%, respectively, for VAD, inotrope-dependent and routine transplant candidates. VAD and non-VAD patients had similar post-transplant adverse event rates.

CONCLUSIONS

There was a role for VAD bridge to transplant for selected patients in the UK, despite the availability of an effective urgent transplant list. VAD patients who underwent transplantation had survival rates similar to other transplant candidates.

Psychosocial Issues for Patients with Ventricular Assist Devices: A Qualitative Pilot Study

• Background Surgical implantation of a ventricular assist device is being used increasingly in patients in the United Kingdom, yet few studies have focused on patients’ experiences from a phenomenological (psychological) perspective.

• Objective To explore, through a pilot study, the impact of implantation of a ventricular assist device on patients’ bodies and lives.

• Methods This qualitative retrospective study included 6 patients (4 men and 2 women) and 3 of these patients’ relatives. Patients were from 17 to 50 years old and had used Thoratec, Heartmate, or VentrAssist devices.

• Results The participants’ accounts clustered around a number of themes, 2 of which are reported here: (1) body and self and (2) trust. Each theme comprised several subthemes: body and self had sub-themes of shock, restrictions, scarring, and infection; trust had subthemes of keeping me alive, device failure, and confidence.

• Conclusions The ventricular assist device has a considerable effect on a patient’s body and sense of self. This effect is often accommodated without much difficulty, but some patients and their families need additional psychological support during and after use of a ventricular assist device. Assessment before implantation of such a device can sometimes reveal this need, but such assessment may not be possible in emergency procedures. Trusting the new heart or the native recovered heart may be difficult for some patients. Further research is needed to understand this phenomenon.

Cognitive impairment in heart failure: a systematic review of the literature

BACKGROUND

Heart failure (HF) and cognitive impairment are common medical conditions that are becoming increasingly prevalent in the aging Western population. They are associated with frequent hospitalisation and increased mortality, particularly when they occur simultaneously. Evidence from a number of studies suggests that HF is independently associated with impairment in various cognitive domains.

AIMS

This systematic literature review evaluates the relation between cognitive deterioration and heart failure.

METHODS

We searched electronic databases from 1966 to May 2006 for studies that investigated cognitive function in HF patients. Twenty-two controlled studies that met the inclusion criteria were selected for analysis. Study characteristics and data on global cognitive performance, memory scores, psychomotor speed and depression scores were extracted and analysed using the Cochrane Review Manager software.

RESULTS

Pooled analysis shows diminished neuropsychological performance in HF patients, as compared to control subjects. In a pooled sample of 2937 heart-failure patients and 14,848 control subjects, the odds ratio for cognitive impairment was 1.62 (95% confidence interval:1.48-1.79, p<0.0001) among subjects with HF.

CONCLUSION

This review confirms the relationship between HF and cognitive impairment, but it also stresses the need for additional systematic neuropsychological data and adequate neuro-imaging from representative populations of HF patients.

Trajectories of change in quality of life in 12-month survivors of lung or heart transplant

Survival and functional outcomes for lung transplant recipients continue to lag behind those for heart recipients. Whether these poorer physical outcomes translate into poorer quality of life (QOL) for lung recipients relative to heart recipients is unknown. Lung versus heart transplant recipients' perceptions of QOL were longitudinally compared at three time-points across the first year posttransplant. Additionally, potentially important predictors of patient QOL were examined. Adult transplant recipients (N = 199) participated in semi-structured interviews that included measures of QOL, optimism, mastery, social support, religiosity and coping. Temporal patterns of QOL change were compared between lung and heart recipients who survived until 1 year posttransplant using mixed-model, hierarchical analysis of variance (ANOVA). Demographic and psychosocial predictors were examined with multiple regression analysis to identify the unique effects of each variable on QOL 1 year posttransplant. While heart recipients' QOL across several domains was higher shortly after transplant, lung patients' QOL improved and was equivalent to that of heart recipients by 1 year posttransplant. Greater optimism and support from friends predicted better QOL in physical, psychological and social domains. Conversely, avoidant coping strategies predicted poorer physical functioning. Thus, while clinical interventions designed to improve QOL posttransplant should be tailored to transplant recipients' initial psychosocial assets and liabilities, they need not be distinguished by transplant type.

Cognitive Dysfunction in Advanced Heart Failure and Prospective Cardiac Assist Device Patients

BACKGROUND

Extended periods of hypoperfusion in an advanced heart failure (HF) places patients at high risk for neurobehavioral compromise, which has not been studied systematically. It is also not clear how intravenous inotropic therapy and mechanical cardiac assist devices (MCAD) affect cognitive function.

METHODS

This prospective cross-sectional cognitive preliminary study evaluated 252 potential heart transplant candidates assessing functions in memory, motor, and processing speed. Patients were divided into three HF groups based on severity of disease: group 1 outpatients (n = 113), group 2 in-patients requiring inotropic infusion (n = 83), and group 3 inpatients likely requiring MCAD support (n = 56). Aggregate z-scores for memory, motor, and processing speed and independent samples t tests assessed intergroup differences on 13 cognitive measures.

RESULTS

A broad pattern of cognitive impairment was observed within the advanced HF group; fewer deficits were found in group 1 outpatients and more severe deficits in group 3 MCAD subjects. A difference in motor functions was observed as the earliest abnormality, with group 3 showing significant changes compared with group 1. The most dramatic changes were seen in domain mental processing speed along with specific verbal and visual memory functions, which were slower in group 3 compared with groups 1 and 2.

CONCLUSIONS

Cognitive deficits are common in advanced HF and worsen with increasing severity of HF. Appropriately designed and randomized studies will be needed to demonstrate if earlier MCAD implantation is warranted to arrest cognitive dysfunction and better postimplantation adaptation.

Executive cognitive dysfunction without stroke after long-term mechanical circulatory support

Among patients who receive heart transplantation (HTx) after long-term mechanical circulatory support (MCS), some show executive cognitive dysfunction without a history of stroke. Fifty HTx patients (19 patients on MCS for longer than 3 months before HTx and 31 patients without MCS as control group) were enrolled in the study. All subjects were men aged between 20 and 59 years without a history of stroke. Patients with MCS were divided into two groups: the AH-Thr group (n = 11), in which thrombus was detected in the left ventricular assist device (LVAD) and quickly removed (mean 3.3 times); and the AH group (n = 8), in which there was no detectable thrombus in the LVAD. The Trail Making Test (TMT) and the Wisconsin Card Sorting Test (WCST) were administered. The AH-Thr group showed poorer cognitive performance both in the TMT part B, with longer completion time (p < 0.05 versus the other two groups), and in the WCST, with more perseverative errors (p < 0.001 versus the other two groups). These data indicate that patients in the AH-Thr group showed executive cognitive dysfunction in set-shifting ability, suggesting frontal lobe damage. The conditions that facilitate thrombus formation in the LVAD may induce executive cognitive dysfunction without stroke.

Mild cognitive impairment after adjuvant chemotherapy in breast cancer patients--evaluation of appropriate research design and methodology to measure symptoms

The development of new chemotherapeutic agents and regimens has contributed to reduced risk of cancer recurrence and prolonged patient survival. However, mild cognitive impairment (MCI), also known as ''chemofog'' or ''chemobrain'' following adjuvant chemotherapy for breast cancer has been reported since the late 1980s. Unfortunately, little is known about it's mechanism, type, severity, and episode length. This article reviewed related studies on the subject, and found that chemotherapy-induced MCI appears to occur in 10-40% of patients, and memory loss and lack of concentration are the most frequent symptoms. The symptoms are apparently transient, but take at least several years to disappear. Reviewed studies show a lack of clear understanding of what causes MCI directly. There is also a lack of consistency in symptom measurement. We point to the need to conduct well-designed studies which begin with a proper hypothesis. Future research needs to be randomized and longitudinal with a base measurement point before the chemotherapy cycle starts. Future studies must adopt an effective and sensitive method to measure MCI. The latest imaging technique, positron emission tomography (PET) may be a powerful tool. Also, all confounding factors, such as age, education, intelligence quotient (IQ), fatigue and depression, hormonal therapy and other treatments should be controlled within the study design. It is hoped that the results of such future studies will allow medical professionals to contemplate effective prevention, treatment and rehabilitation for MCI.

Social adaptation after cardiothoracic transplantation: a review of the literature

From the earliest days of transplantation, research has contributed to our knowledge of the psychosocial sequelae associated with the outcomes of the procedure. The purpose of this review is to describe the social adaptation literature for heart, lung, and heart-lung recipients. Social adaptation refers to employment and performance of social roles and responsibilities. Employment research focused on vocational rehabilitation, physical health restoration, and return to work. Social roles and responsibilities research focused on social roles, family relationships, social support, and psychosocial adjustment. Predictors, interventions, and their associations with outcomes are discussed.

Cognitive function in adult cardiothoracic transplant candidates and recipients

Innovative surgical and medical techniques have prolonged the life span of cardiothoracic (CT) transplant recipients and made transplantation an option for many older patients. Cognitive function is a key determinant of the CT transplant recipient's ability to manage the complex treatment regimen and experience optimum benefit of the procedure. As the CT population ages, risk of cognitive dysfunction due to normal aging is compounded by the physical and mental changes associated with end-stage organ disease, comorbid conditions, and transplant-related complications. Cognitive abilities consist of (a) receptive functions (ability to select, acquire, classify, and integrate information); (b) memory and learning (ability to store and retrieve information); (c) thinking (ability to mentally organize and reorganize information; and (d) expressive functions (ability to communicate or act upon information). Although each of these functions represents a distinct type of behavior, they are interdependent. The purpose of this article is to (a) discuss the literature regarding cognitive function before and after adult heart, lung, and heart-lung transplantation; (b) identify methodological problems associated with the studies done to date; and (c) make recommendations for future research in this area.

Depression and quality of life in patients living 10 to 18 years beyond heart transplantation

BACKGROUND

The purpose of this study was to advance current understanding of factors that influence long-term quality-of-life (QoL) outcomes after heart transplantation, by addressing the influence of depression on perceived health status.

METHODS

Data were collected from all recipients (n = 137) still alive at >10 years after transplantation. They completed the Short Form Health Survey (SF-36) inventory and the Beck Depression Inventory (BDI) questionnaire, while objective measures of health status were retrieved from medical records. All instruments used had acceptable reliability and validity. Data were analyzed using descriptive statistics, general linear regression models and survival analysis.

RESULTS

We assessed 137 patients who received transplants between November 1985 and June 1994 in Pavia and have survived 10 to 18 years after transplantation (mean 13.64 years, SD 2.25). They rated their health as good and only the physical QoL (PCS) was impaired when compared with the general population. Thirty-two percent of patients experienced mood depressive symptoms in the long term after transplantation, indicating a low perceived QoL. Higher educational qualification (p = 0.049), being unemployed and receiving a disability pension (p = 0.001), high triglycerides levels (p = 0.020) and lack of physical activity (p < 0.001) were predictors of high BDI scores.

CONCLUSIONS

Assessment of depression levels and better understanding of risk factors for psychiatric disorders in the long term after transplantation could be of benefit in predicting negative outcomes and allowing future developments in patient management.

Posttraumatic stress disorder after implantation of a Mechanical Assist Device Followed by Heart Transplantation: Evaluation of Patients and Partners

AIM

We sought to investigate the prevalence of posttraumatic stress disorder, anxiety, and depression in patients and their partners after implantation of a mechanical assist device as a bridge to heart transplantation.

METHODS

This was a retrospective assessment of 41 patients (age 46.3 +/- 12.0 years; male-female ratio, 38:3; time since transplantation, 55.3 +/- 34.2 months [range, 7-122 months) and 27 partners (male-female ratio 2:25) by standardized instruments (Impact of Event Scale, Hospital Anxiety and Depression Scale), in 2 University Heart Transplant Centers (Vienna, Austria, Munster, Germany). The duration of the support systems (MicroMed DeBakey-VAD in 17 patients, Novacor in 10, Thoratec in 8, TCI HeartMate in 5, and Berlin Heart Incor in 1 patient) ranged from 28 to 711 (176 +/- 146) days.

RESULTS

None of the patients, but 23% of the partners (n = 6), met the criteria for posttraumatic stress disorder (Maercker cutoff >0). The Impact of Event Scale (IES) sum scales differed significantly between the 2 groups (21.2 +/- 15.1, mean +/- SD) for the patients versus 38.1 +/- 27.8 for the partners, respectively; P = .001). Two percent of the patients, but 19% of the partners, showed mild to moderate depression; 4% of patients, but 23% of their partners, reported mild to moderate anxiety. None of the results were significantly influenced by the time since transplantation, patient age, diagnoses, type of assist device, or indication for heart transplantation.

CONCLUSIONS

Despite patients being much closer to a life threat, their partners experience significantly more psychologic distress even in the long run. Our findings highlight the need for attention to the supporting persons.

State of the Science for Cardiovascular Nursing Outcomes

The incidence of heart failure is increasing because of the progressive aging of the population and improved survival from cardiovascular disease. This article synthesizes the state of the science of nurse sensitive outcomes in heart failure treated medically or surgically and provides recommendations for building the science. Outcomes studied include mortality, morbidity, resource use, quality of life, symptoms, physical function, return to work, and self-care and compliance behavior. Gaps in the literature are identified and recommendations for future research are provided.