Recipient selection and management before cardiac transplantation

Psychosocial and behavioural factors in heart transplant candidates – an overview

Mortality among heart transplant (HTX) candidates remains high. This review of the literature shows that psychosocial characteristics like depression, social isolation and coping strategies contribute to morbidity and mortality in heart failure (HF) patients, and may also be relevant to the prognosis of HTX candidates. Based on the research to date, physical activity favourably affects subjective and objective parameters not only in HF patients, but also in HTX candidates. Depression is prevalent among HTX candidates, especially in ischaemic patients, and seems to be related to earlier transplantation. Findings on the effects of depression on pretransplant mortality are conflicting. Not much is known concerning social isolation, coping, nutrition, or weight loss in this patient group. Identification of modifiable psychosocial and behavioural variables related to clinical status in this patient group is clearly needed and will aid the development of behavioural interventions to supplement medical therapies.

Psychosoziale Aspekte und Gesundheitsverhalten bei Herzinsuffizienz

Zusammenfassung. Für die steigende Zahl von Patienten mit Herzinsuffizienz stehen verschiedene medizinische Behandlungsansätze zur Verfügung, darunter als letzte Option die Herztransplantation (HTX). Ergänzende psychosoziale und behaviorale Interventionen erscheinen aus verschiedenen Gründen auch für Patienten auf der HTX-Warteliste sinnvoll. Unser Literaturüberblick zeigt, dass bekannte psychosoziale koronare Risikofaktoren wie Depressivität und soziale Isolation auch bei Herzinsuffizienz Morbidität und Mortalität erhöhen. Körperliche Aktivität wirkt sich dagegen günstig auf subjektive und objektive Parameter aus. Diese Faktoren stellen erste Ansatzpunkte für verhaltensorientierte Interventionen dar. Welche Rolle andere koronare Risikofaktoren (z.B. Feindseligkeit, Ärger, Ernährung und Gewichtsreduktion) spielen, ist bislang ungeklärt. Ausblickend werden einige viel versprechende Forschungsansätze skizziert.

Cardiac Transplantation

Heart transplantation is a treatment option available to patients with end-stage heart failure who meet standardized selection criteria for transplant. Through a rigorous evaluation process, professionals set out to establish the patient's severity of heart failure, screen for comorbidities that may negatively affect survival, and assess psychosocial variables necessary for successful outcomes following transplantation. Because of a limited donor organ supply, each of these factors must be examined carefully to assure that this scarce resource is used to its greatest potential benefit.

Benefits of cardiac resynchronization therapy in outpatients with indicators for heart transplantation

BACKGROUND

Despite several new advances in the treatment of end-stage congestive heart failure (CHF) the number of patients moving onto the heart transplant list continues to rise. Recently, cardiac resynchronization therapy (CRT) has become a Food and Drug Administration (FDA)-approved therapy for advanced CHF. Currently, there are no available data on CRT in cardiac transplant candidates.

METHODS

To determine the effects of CRT on potential transplant candidates we retrospectively reviewed patients (n = 34) enrolled in resynchronization trials at our center who met accepted criteria for transplantation. Ventricular function, oxygen uptake and New York Heart Association (NYHA) class were compared at baseline and after 6 months of active therapy for each patient.

RESULTS

CRT reduced QRS duration from 178 +/- 29 to 143 +/- 17 msec (p < 0.0001) and NYHA class from 3.1 +/- 0.3 to 1.8 +/- 0.7 (p < 0.0001). Ejection fraction (EF) increased from 18.4 +/- 5.1 to 25.1 +/- 8.4% (p < 0.0001) and maximum VO(2) increased from 11.9 +/- 1.8 to 15.3 +/- 3 ml/kg/min (p < 0.0001). Only 2 of the initial 34 patients still met the criteria for transplantation at 6 months.

CONCLUSIONS

CRT improves ventricular function, oxygen uptake and NYHA class in ambulatory patients who have a QRS of >130 msec and might be considered candidates for cardiac transplantation. Transplantation can be prevented or deferred in the majority of patients. Outpatients with chronic CHF and a widened QRS should be evaluated for CRT before being listed for cardiac transplantation.

Use of behavioral contingency contracting with heart transplant candidates

For many years, behavioral contingency contracting has been useful in increasing compliance in a variety of patient populations. More recently, this type of contracting has been used to facilitate communication and motivate behavioral change among patients referred for transplantation. This article discusses the theoretical basis of behavioral contingency contracting and describes the development and implementation of a multipurpose behavioral contract for patients receiving heart transplants. The scarcity of donor organs and the stringent posttransplant regimen mandates that psychosocial as well as medical variables be considered during the transplant evaluation process. Behavioral contingency contracting is useful in identifying those individuals with the potential to maintain a transplanted organ capably.

Advances in the treatment of congestive heart failure: new approaches for an old disease

Heart failure is a symptom complex of varied etiology associated with substantial mortality. Approximately 5 million Americans have the disease, with 400,000 new cases diagnosed each year. Despite better understanding of its pathophysiology, therapeutic options remain suboptimal and the syndrome remains associated with high rates of hospitalization and loss of economic productivity. Management traditionally included vasodilators, diuretics, and digoxin, with a focus on controlling symptoms and improving ejection fraction and exercise capacity. Drug therapy now is focused on improving survival, with a reduction in health care costs related to hospitalizations. Drugs with a proven benefit in reducing morbidity and mortality are angiotensin-converting enzyme inhibitors, beta-blockers, and the combination of hydralazine plus a nitrate. Diuretics, digoxin, dihydropyridine calcium channel blockers, phosphodiesterase inhibitors, catecholamine infusions, amiodarone, left ventricular assist devices, and transplantation are also options.