Patient-Reported Outcomes in Left Ventricular Assist Device Therapy

Development of a quality of life measure for left ventricular assist device recipients using a mixed methods approach

BACKGROUND

Left ventricular assist device (LVAD) recipients report symptom improvement but find adjusting to life with the LVAD challenging. These challenges are unique, and existing patient-reported outcome measures (PROMs) do not reflect their experiences. This study aimed to develop a culturally relevant quality of life PROM for use with LVAD recipients in future research, design evolutions and clinical practice.

METHODS

A three-stage mixed-methods approach was used to develop a PROM: stage 1 included group concept mapping (GCM); stage 2 semi-structured qualitative interviews were conducted with 11 LVAD recipients and 10 clinicians, and a questionnaire was developed using a conceptual framework; and stage 3 used exploratory psychometric analysis of the PROM data using Rasch measurement theory. This paper presents stages 2 and 3.

RESULTS

The conceptual framework consisted of four key concepts, including general health, life with the LVAD, equipment and clothing and emotional impact. Statements from interviews and GCM were used to create items for the LVAD quality of life (LVAD-QoL). Cognitive interviews tested face validity and participant comprehension. Forty-nine participants were recruited from three UK transplant centres. PROM data were collected and analysed using Rasch analysis. Four items displayed misfit; dependency between item sets was the biggest issue (57/485 pairwise differences). After restructuring and dealing with item misfit, the LVAD-QoL conformed to the Rasch model, supporting the psychometric properties and quality of the LVAD-QoL.

CONCLUSIONS

Using a mixed-methods approach ensured the development of a robust and psychometrically sound tool for research, design evolution and clinical practice with LVAD recipients.

Shared care for patients with a left ventricular assist device: a scoping review

Left ventricular assist devices (LVADs) are increasingly implanted in patients with advanced heart failure. Currently, LVAD care is predominantly concentrated at specialized tertiary care hospitals. However, the increasing workload and logistical burden for implanting centres pose significant challenges to accessing care for individual patients in remote areas. An emerging approach to LVAD patient management is the use of a shared care model (SCM), which facilitates collaboration between implanting centres and local non-implanting hospitals. This scoping review explores and synthesizes the current scientific evidence on the use of SCMs in LVAD care management. Eligible studies were identified in EMBASE, PubMed MEDLINE, Web of Science, Cochrane and Google Scholar. Findings were synthesized in accordance with PRISMA-ScR guidelines. Of the 950 records screened, five articles met the inclusion criteria. Four review articles focused on the proposed benefits and challenges of using SCMs. Main benefits included improved patient satisfaction and continuity of care. Important challenges were initial education of non-implanting centre staff and maintaining competency. One prospective study showed that absence of LVAD-specific care was associated with impaired survival and higher rates of pump thrombosis and LVAD-related infections. The use of SCMs is a promising approach in the long-term management of LVAD patients. However, sufficient evidence about the impact of SCMs on patients and the healthcare system is not currently available. Standardized protocols based on prospective studies are needed to develop safe and effective shared care for LVAD patients.

Recognition of psychological comorbidity and psychotherapeutic treatment status of ventricular assist device patients

BACKGROUND

Due to its high impact on quality of life and mental health, close monitoring and often psychotherapy is recommended for patients with a ventricular assist device (VAD). This study investigates the psychological comorbidity and the corresponding psychotherapeutic treatment situation of VAD patients. Special attention is also given to the professional perspective VAD team (assistant and senior cardiologists and specialized nurses).

METHODS

We conducted a cross-sectional observational study. Data from 50 VAD patients (mean age = 53.52, standard deviation = 13.82 years, 84.0% male) and their VAD team were analyzed. The presence of a psychological disorder was evaluated by structured clinical interviews for DSM-IV (SCID-I-Interviews). Patients answered a questionnaire regarding their current psychotherapeutic treatment status and their attitude towards psychotherapy. The VAD team answered a questionnaire about the patients' needs for psychotherapy and indicated whether they addressed this topic with the patient. Data were analyzed descriptively, by analysis of variance and t-test.

RESULTS

A total of 58% of VAD patients suffered from at least one significant psychological disorder, 79.3% of those were not in psychotherapy. The VAD team could not identify the patients who suffered from a psychological disorder (F = 1.90; p = 0.18). They perceived more need for psychotherapy than they addressed with their patients (T = 3.39; p < 0.001).

CONCLUSIONS

While there is a high psychological morbidity among VAD patients, only few receive psychotherapy. Psychological comorbidity is not easily detected by the VAD team. Standardized psychosocial care could be implemented by regular psychological assessments and further information of patients and their VAD teams.

Mental Health and Substance Use Disorders in Transplant Waitlist, VAD, and Heart Transplant Patients: A TriNetX Database Analysis

Background/Objectives: Mental health and substance use disorders (MHDs and SUDs) affect cardiac allograft and VAD recipients and impact their quality of life and compliance. Limited research currently exists on MHDs and SUDs in this population. Methods: This study compares the incidence of MHDs and SUDs in the transplant list, VAD, and post-transplant patients with that in heart failure patients. Study cohorts were derived from the TriNetX database using ICD-10 codes. Differences in incidence were examined using the log-rank test. Adults with MHDs and SUDs before the window of time were excluded. All comparisons were made between propensity-matched cohorts. Statistical significance was set at p < 0.05. Results: Transplant waitlist patients showed a significant increase in the incidence of anxiety, depression, panic, adjustment, mood, alcohol use, and eating disorders. Post-transplant patients showed a significant increase in depression and opioid use. VAD patients showed a significant increase in depression and a decrease in panic disorder and anxiety. These results allow for further investigations on prevention and coping strategies. Conclusions: The deterioration of mental health can significantly impact medication compliance, survival, and quality of life. Opioid use for pain management in the early postoperative period should be further investigated to assess its impact on long-term substance use and addiction.

Association of Psychosocial Risk Factors With Quality of Life and Readmissions 1 Year After LVAD Implantation

BACKGROUND

Among patients with advanced heart failure (HF), treatment with a left ventricular assist device (LVAD) improves health-related quality of life (HRQOL). We investigated the association between psychosocial risk factors, HRQOL and outcomes after LVAD implantation.

METHODS

A retrospective cohort (n = 9832) of adults aged ≥ 19 years who received durable LVADs between 2008 and 2017 was identified by using the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Patients were considered to have psychosocial risk factors if ≥ 1 of the following were present: (1) substance abuse; (2) limited social support; (3) limited cognitive understanding; (4) repeated nonadherence; and (5) major psychiatric disease. Multivariable logistic and linear regression models were used to evaluate the association between psychosocial risk factors and change in Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 scores from baseline to 1 year, persistently poor HRQOL (KCCQ-12 score < 45 at baseline and 1 year), and 1-year rehospitalization.

RESULTS

Among the final analytic cohort, 2024 (20.6%) patients had ≥ 1 psychosocial risk factors. Psychosocial risk factors were associated with a smaller improvement in KCCQ-12 scores from baseline to 1 year (mean ± SD, 29.1 ± 25.9 vs 32.6 ± 26.1; P = 0.015) for a difference of -3.51 (95% confidence interval [CI]: -5.88 to -1.13). Psychosocial risk factors were associated with persistently poor HRQOL (adjusted odds ratio [aOR] 1.35, 95% confidence interval [CI] 1.04-1.74), and 1-year all-cause readmission (adjusted hazard ratio [aHR] 1.11, 95% CI 1.05-1.18). Limited social support, major psychiatric disorder and repeated nonadherence were associated with persistently poor HRQOL, while major psychiatric disorder was associated with 1-year rehospitalization.

CONCLUSION

The presence of psychosocial risk factors is associated with lower KCCQ-12 scores and higher risk for readmission at 1 year after LVAD implantation. These associations are statistically significant, but further research is needed to determine whether these differences are clinically meaningful.

High level of psychosocial adjustment in patients on ongoing ventricular assist device support in the years one to three after VAD implantation-A national multi-center Study

BACKGROUND

Advanced heart failure therapies such as durable ventricular assist device (VAD) support require psychosocial adjustment for those affected. Since VAD implantation has become an established treatment strategy, a focus on psychosocial factors is needed.

OBJECTIVES

To investigate the construct of psychosocial adjustment and to further understand the role of social support.

METHODS

In a nation-wide, multi-center, cross-sectional study, we recruited 393 participants with ongoing VAD support (3mts-3yrs on device; clinicaltrials.gov ID: NCT04234230). Patient demographics, psychosocial adjustment (perceived social support, anxiety, depression, and quality of life), and major adverse events (thromboembolic events, bleeding, driveline infections) were assessed.

RESULTS

Overall, 85.8 % of the sample were male; mean age was 58.3 years (range 18-85). The majority of the sample (89.3 %) reported normal to high perceived social support. Participants expressed symptoms of anxiety within the normal range (M=6.0±3.9), mildly elevated depressive symptoms (HADS: M=7.6±2.9; PHQ-9: M=6.2±4.7), and good quality of life (KCCQ: M=65.3±17.9). Higher perceived social support was associated with lower levels of anxiety and depression, and higher levels of quality of life within our sample (all p<0.001). Driveline infection was the most prevalent adverse event (0.304 infections per person-years [32.6 % of patients]). Binary logistic regression models did not identify significant associations for the occurrence of adverse events and variables of psychosocial adjustment.

CONCLUSION

Our sample perceived high levels of psychosocial adjustment. High perceived social support was associated with better outcomes in levels of anxiety, depression, and quality of life, demonstrating potential for the future development and evaluation of targeted multi-professional social support interventions including peer- and caregiver support.

Health-Related Quality of Life in Patients With Ventricular Assist Device: Psychometric Evaluation of the German Version of the Quality of Life With a Ventricular Assist Device Questionnaire

BACKGROUND

Ventricular assist device (VAD) implantation has become an alternative treatment for patients with end-stage heart failure. In Germany, valid and reliable instruments to assess health-related quality of life in patients with VAD are lacking.

OBJECTIVE

The aim of this study was to present the psychometric validation of the German version of the Quality of Life with a Ventricular Assist Device questionnaire.

METHODS

In a multicenter, cross-sectional study, 393 participants (mean age, 58.3 years; 85.8% male, 60.3% bridge to transplant, and 72.8% living with VAD for ≤2 years) completed the German Quality of Life with a Ventricular Assist Device questionnaire of physical, emotional, social, cognitive, and meaning/spiritual domains. Item and confirmatory factor analyses were conducted to test item difficulty and discrimination and the underlying structure, respectively. To examine internal consistency, Cronbach α was assessed. Convergent construct validity was tested using the Kansas City Cardiomyopathy Questionnaire and the Patient Health Questionnaire-9. Readability was examined using Flesch Reading Ease index and Vienna Factual Text Formula.

RESULTS

The Quality of Life with a Ventricular Assist Device showed reasonable item difficulty (Ptotal = .67) and mostly moderate to high discriminatory power (rit > 0.30). In confirmatory factor analysis, root-mean-square error of approximation (0.07) was acceptable for model fit, but no other indices. Acceptable internal consistency was found (α ≥ 0.79), with the exception of the cognitive domain (α = 0.58). The overall questionnaire and single domains demonstrated convergent validity (r ≥ 0.45, P < .001). The questionnaire showed adequate readability (Flesch Reading Ease, 64.11; Vienna Factual Text Formula, 6.91).

CONCLUSION

Findings indicate a promising standardized clinical instrument to assess health-related quality of life in patients with VAD.

PROMIS: Physical, Mental and Social Health Outcomes Improve From Before to Early After LVAD Implant: Findings From the Mechanical Circulatory Support: Measures of Adjustment and Quality of Life (MCS A-QOL) Study

Study participants (n = 272) completed 12 Patient-Reported Outcomes Measurement Information System (PROMIS) physical, mental and social health measures (questionnaires) prior to implantation of a left ventricular assist device (LVAD) and again at 3 and 6 months postimplant. All but 1 PROMIS measure demonstrated significant improvement from pre-implant to 3 months; there was little change between 3 and 6 months. Because PROMIS measures were developed in the general population, patients with an LVAD, their caregivers and their clinicians can interpret the meaning of PROMIS scores in relation to the general population, helping them to monitor a return to normalcy in everyday life.

Impact of Different Therapeutic Strategies With Left Ventricular Assist Devices on Health-Related Quality of Life During Prolonged Device-Based Support

Background: Left ventricular assist device (LVAD) implantation improves survival and health-related quality of life (HRQoL) of patients with heart failure. However, the impact of LVADs or different LVAD-based therapeutic strategies on long-term HRQoL has not been investigated. We evaluated the long-term HRQoL of Japanese patients who were treated with different LVAD-based therapeutic strategies. Methods and Results: Patients whose data were recorded in the Japanese Registry for Mechanical Assisted Circulatory Support between January 2010 and December 2018 were divided into 3 groups: primary implantable LVAD (G-iLVAD; n=483), primary paracorporeal LVAD (n=33), and bridge-to-bridge from paracorporeal to implantable LVAD (n=65). HRQoL was evaluated using the EuroQoL 5-dimension 3-level (EQ-5D-3L) before and 3 and 12 months after LVAD implantation; the mean EQ-5D-3L visual analog scale (VAS) score in the G-iLVAD group at these time points was 47.4, 71.1, and 72.9, respectively (where scores of 0 and 100 indicate worst and best imaginable health state, respectively). Changes in the least squares means of the VAS scores at 3 and 12 months after implantation differed significantly among the 3 groups. Social function, disability, and physical and mental problems were significantly lower in the G-iLVAD than other groups. Conclusions: HRQoL improved significantly at 3 and 12 months after LVAD implantation in all groups. Physical function showed a stronger improvement than did social function, disability, and mental function.

Psychometric Testing of the Control Attitudes Scale-Revised for Patients With a Left Ventricular Assist Device

BACKGROUND

Perceived control, an indicator of the patient's ability to cope and thrive with a chronic illness, is a common target of nursing interventions. As of 2019, more than 25 000 patients had been implanted with a left ventricular assist device (LVAD) as a treatment of advanced heart failure. Patients with an LVAD experience significant life changes that affect anxiety, depression, health-related quality of life, and, presumably, perceived control. To adequately intervene and improve perceived control, a reliable and valid measure is needed.

OBJECTIVES

The objectives of this analysis were to (1) assess item discrimination and anticipated range of scores of the Control Attitudes Scale-Revised (CAS-R), (2) assess the internal consistency and validity of the CAS-R, and (3) examine perceived control in a sample of patients with an LVAD.

METHODS

Two cohorts of patients with an LVAD (n = 113) were combined to evaluate the psychometric qualities of the CAS-R. Correlations among patient-reported outcomes and perceived control were used to evaluate validity. Cronbach α was used to test internal consistency. Item response theory was used to measure item discrimination and anticipated scores. Descriptive statistics describe perceived control in the sample.

RESULTS

Overall, the CAS-R demonstrated good internal consistency and convergent validity with other patient-reported outcomes. Using the item response theory, we saw that the CAS-R was a good predictor of lower-moderate scorers but was not good at differentiating high performers. There were several items that were poor discriminators and could be altered or discarded to create a more predictive instrument.

CONCLUSIONS

The CAS-R is a valid and reliable instrument to measure perceived control in patients who have LVAD implants; however, more work could be done to improve item-level information.

Living with a left ventricular assist device: Capturing recipients experiences using group concept mapping software

Background

Left ventricular assist device (LVAD) implantation significantly impacts on a recipient’s symptoms and quality of life. Capturing their experiences and post implant journey is an important part of clinical practice, research and device design evolution. Patient reported outcome measures (PROMs) are a useful tool for capturing that experience. However, patient reported outcome measures need to reflect recipients’ experiences. Discussions with a patient partner group found that none of the frequently used cardiology PROMs captured their unique experiences.

Aims

To capture the experiences and important issues for LVAD recipients. Develop a conceptual map of domains and items that should be reflected in patient reported outcomes.

Methods

Group concept mapping (GCM) web-based software was used to remotely capture and structure recipients’ experiences across a wide geographical area. GCM is a semi-quantitative mixed method consisting of 3 stages: item generation, item sorting and rating (importance, relevance and frequency). Patient partners were involved in all aspects of the study design and development.

Results

18 LVAD recipients consented to take part. 101 statements were generated and multi-dimensional scaling, and hierarchical cluster analysis identified 9 clusters. Cluster themes included: Activities, Partner/family support, Travel, Mental wellbeing, Equipment and clothing, Physical and cognitive limitations, LVAD Restrictions, LVAD Challenges and positive impact of the LVAD (LVAD Positives). LVAD Positives were scored highest across all the rating variables, e.g., frequency (2.85), relevance (2.44) and importance (2.21). Other domains rated high for importance included physical and cognitive limitations (2.19), LVAD restrictions (2.11), Partner/family support (2.02), and Equipment and clothing (2.01).

Conclusion

Online GCM software facilitated the inclusion of geographically dispersed recipients and provided useful insights into the experiences of LVAD recipients. The conceptual framework identifies important domains and items that should be prioritised and included in patient reported outcomes in future research, LVAD design evolution, and clinical practice.

Research engagement and experiences of patients pre- and post-implant of a left ventricular assist device from the mechanical circulatory support measures of adjustment and quality of life (MCS A-QOL) study

PURPOSE

Adults living with mechanical circulatory support (MCS) present with unique challenges (e.g., left ventricular assist device [LVAD]-related self-care, adverse events) to research study enrollment, engagement, and completion. The purpose of this study was to understand the experiences of adults with MCS who were eligible for and enrolled in a study of health-related quality of life (HRQOL).

METHODS

In a secondary analysis of data from the Mechanical Circulatory Support: Measures of Adjustment and Quality of Life study, we used a mixed-methods approach to evaluate research engagement and experiences among adults preparing to undergo or currently living with MCS implant. First, we assessed the cascade of study engagement. Second, we assessed research experiences using a structured interview developed for this study.

RESULTS

Of 1011 participants approached for the study, 86.7% enrolled, 12.7% declined, and 0.6% were ineligible. Of 877 participants enrolled, 272 were pre-implant (of whom 88% completed assessments; "respondents") and 605 were post-implant (of whom 74% completed assessments). Only 14% of respondents reported difficulty completing the questionnaires, 54% had previously used an iPad to complete questionnaires, and 62% reported that their experience was "as expected." Respondents qualitatively described both positive (e.g., value of research) and negative (e.g., too much time) research experiences, difficulties completing questionnaires (e.g., online platform, health literacy issues), and provided recommendations for the questionnaires and delivery.

CONCLUSIONS

Participants enjoyed participating in HRQOL research focused on MCS and had unique perspectives for improving the questionnaires. It is important to minimize the burden of participation and critical to be flexible to meet participant preferences for research engagement.

TRIAL REGISTRATION

NCT03044535 (accessible at https://clinicaltrials.gov/ct2/show/NCT03044535 ), registered February 7, 2017.

Impact of Venlafaxine on Platelet Count and Activity—Case Report and Narrative Review

Venlafaxine (VEN) is considered to be one of the most effective antidepressants. It belongs to the group of serotonin (5-HT) and noradrenaline (NA) reuptake inhibitors (SNRIs). NA and 5-HT have receptors on the surface of platelets and are involved in platelet aggregation. In this case study, we present the case of a patient treated for one of the types of myeloproliferative neoplasm (MPN), essential thrombocythemia (ET), in whom VEN was added to pharmacotherapy during the treatment of a severe episode of depression with psychotic symptoms. We observed a gradual reduction in platelet count when increasing the dose of VEN. We also present a narrative review of literature about the effect of VEN on platelet counts and activity. We conclude that, in the group of patients taking VEN, attention should be paid to the rare adverse effect of a decrease in the number of platelets.

The predictive value of self-compassion for psychological adjustment in left ventricular assist device patients: an observational study

Aims

Implantation of a left ventricular assist device (LVAD) is an established treatment option for patients with advanced heart failure. However, apart from its challenging medical management, it comes with serious psychological implications. Empirical evidence suggests that self‐compassion, a self‐regulation strategy for countering negative self‐directed emotions, might be a promising approach in facilitating psychological adjustment also in LVAD patients. The aims of the present study were to investigate self‐compassion as a protective factor for anxiety and depressive symptoms, to test whether taking a decentred perspective mediates these effects, and to explore whether self‐compassion predicts the clinically rated functional health status.

Method and results

A sample of N = 45 patients (36 male) with a mean age of 60.5 years (SD = 10.8) from the outpatient department for terminal heart failure at the University Medical Center in Kiel, Germany, participated in the study. Patients completed self‐report measures for psychological adjustment (HADS), self‐compassion (SCS), and decentring (EQ). Functional health status was determined by the NYHA classification. The more patients were self‐compassionate, the less they reported anxiety (r = −0.28) and depressive symptoms (r = −0.34). Decentring mediated both effects. Moreover, self‐compassion predicted the functional health status, even when controlling for anxiety (odds ratio [OR] = 0.09) and depressive symptoms (OR = 0.11).

Conclusions

This study provides the first evidence for a significant interrelation between self‐compassion and common adverse psychological conditions in LVAD patients. Longitudinal data and the evaluation of interventions to strengthen self‐compassion are needed to further validate the beneficial effects of self‐compassion in LVAD patients in the future.

Patterns and predictors of dyspnoea following left ventricular assist device implantation

AIMS

Dyspnoea is a common symptom of heart failure (HF) that often prompts patients to seek treatment. Implantation of a left ventricular assist device (LVAD) has been associated with reduced dyspnoea but it is unclear if all patients experience similar improvements in dyspnoea over time following LVAD implantation. Our aim was to identify distinct trajectories of dyspnoea symptoms over time following LVAD implantation and predictors of dyspnoea trajectory. We hypothesized that at least two, distinct trajectories of dyspnoea would be observed following LVAD implantation.

METHODS AND RESULTS

This was a secondary analysis of data from the Profiling Biobehavioral Responses to Mechanical Support in Advanced Heart Failure study. In the parent study, sociodemographic and clinical data were collected prior to LVAD implantation and at 1, 3, and 6 months following LVAD implantation from a sample (n = 101) of patients with advanced HF. Latent growth mixture modelling was performed to identify distinct trajectories of dyspnoea symptoms. Backwards stepwise logistic regression was used to identify predictors of dyspnoea trajectory. Two, distinct trajectories of dyspnoea symptoms were identified: sustained improvement and unsustained improvement. Participants who experienced sustained improvement (86.7% of sample) demonstrated large, significant improvement in dyspnoea from pre-implantation to 3 months post-implant followed by smaller, non-significant improvement from 3 to 6 months. Participants who experienced unsustained improvement (13.3% of sample) demonstrated initial improvement from pre-implantation to 3 months post-implantation followed by worsening of dyspnoea from 3 to 6 months. Greater depressive symptoms at baseline and living alone were significant predictors of unsustained improvement.

CONCLUSION

Patients experience different patterns of dyspnoea over time following LVAD implantation. Clinicians should inquire about living arrangements and depressive symptoms at each visit to determine risk of unsustained improvement in dyspnoea.

Psychological burden and coping in destination therapy patients with a left ventricular assist device: a qualitative content analysis

BACKGROUND

Due to an increasing prevalence of heart failure and persistent shortage of donor hearts, the number of left ventricular assist device (LVAD) implantations is growing. As more patients live with LVADs for prolonged periods of time, psychosocial outcomes are becoming more relevant. This particularly applies to destination therapy (DT) patients, who live with the LVAD for the rest of their lives.

METHODS

We used a cross-sectional qualitative design to explore psychological burden, coping strategies and resources from the perspective of DT patients. Data was collected via semi-structured in-depth interviews with 18 patients who lived with the LVAD for 3 months to over 10 years. These were analyzed using an inductive content analysis. Due to the COVID-19 pandemic, changes to the recruitment strategy and data collection strategies of the original study protocol were applied. Patients and clinicians were involved throughout the research process to ensure validity of the results and implications.

RESULTS

We synthesized 10 psychosocial, health, and treatment-related burdens, identified 15 problem- and emotion-focused coping strategies and 5 personal and environmental resources patients used to cope with the burden.

CONCLUSIONS

The findings provide deeper insights into the complex and specific situation of LVAD patients to better address the patient situation in health care and promote positive psychosocial outcomes. So far, health care practice and quality vary significantly between clinics due to individual treatment protocols. Our results highlight the need to improve medical and psychosocial care. Overarching care concepts may be developed based on the implications.

Factors influencing health-related quality of life of patients with a left ventricular assist device: a systematic review and thematic synthesis

AIMS

Left ventricular assist devices (LVADs) are increasingly being used in the treatment of advanced heart failure. Left ventricular assist device patients frequently report improvements in health-related quality of life (HRQOL) post-implantation. However, HRQOL varies over time and between patients, which can be explained by patient-related and environmental factors, as individual studies suggest. This review aims to synthesize qualitative evidence on factors influencing HRQOL of LVAD patients.

METHODS AND RESULTS

We systematically searched the databases PubMed, Scopus, PsycINFO, and CINAHL for qualitative studies on factors influencing HRQOL of patients with continuous flow LVADs. The included papers were synthesized using a thematic synthesis. The results were validated in discussion with a patient and practical implications were jointly developed. We included 11 papers and developed 7 themes that represent influencing factors for HRQOL of LVAD patients: disease experiences, emotional reactivity, heart failure and mechanical circulatory support symptoms, medical care, self-care, self-concept, and social environment.

CONCLUSION

The identified themes highlight influencing factors on HRQOL. These help to explain variation in patient outcomes and to better consider the individual situation in rehabilitation. Based on the results, four strategies are proposed for promoting psychosocial outcomes: facilitate self-care, ensure social support, offer psychosocial support, and manage patient expectations.

"Talking Around It": A Qualitative Study Exploring Dyadic Congruence in Managing the Uncertainty of Living With a Ventricular Assist Device

BACKGROUND

Vital components of communicating goals of care and preferences include eliciting the patient and caregiver's definition of quality of life, understanding meaningful activities and relationships, and exploring wishes for care at the end of life. Although current literature suggests framing conversations regarding end of life through the lens of meaning and quality of life, there is limited literature exploring dyadic congruence surrounding these important constructs among patients with ventricular assist devices (VADs) and their caregivers.

OBJECTIVES

The purpose of this study was to explore congruence of VAD patient and caregiver perspectives regarding end of life, definitions of quality of life, and meaning in life while managing the uncertainty of living with a VAD.

METHODS

We used thematic analysis to analyze semistructured qualitative interviews of 10 patient-caregiver dyads 3 to 12 months after VAD implantation.

RESULTS

Three major themes were identified: (1) differing trajectories of uncertainty and worry, (2) a spectrum of end-of-life perspectives, and (3) enjoying everyday moments and independence. Overall, patients and caregivers had differing perspectives regarding uncertainty and end of life. Within-dyad congruence was most evident as dyads discussed definitions of meaning or quality of life.

CONCLUSIONS

Dyadic perspectives on end of life, meaning in life, and quality of life can inform how palliative care and VAD teams approach conversations about planning for the end of life. Findings from this study can inform future shared decision-making interventions for patients living with VADs and their caregivers.

Novel Acoustic Biomarker of Quality of Life in Left Ventricular Assist Device Recipients

Background Although technological advances to pump design have improved survival, left ventricular assist device (LVAD) recipients experience variable improvements in quality of life. Methods for optimizing LVAD support to improve quality of life are needed. We investigated whether acoustic signatures obtained from digital stethoscopes can predict patient-centered outcomes in LVAD recipients. Methods and Results We followed precordial sounds over 6 months in 24 LVAD recipients (8 HeartWare HVAD™, 16 HeartMate 3 [HM3]). Subjects recorded their precordial sounds with a digital stethoscope and completed a Kansas City Cardiomyopathy Questionnaire weekly. We developed a novel algorithm to filter LVAD sounds from recordings. Unsupervised clustering of LVAD-mitigated sounds revealed distinct groups of acoustic features. Of 16 HM3 recipients, 6 (38%) had a unique acoustic feature that we have termed the pulse synchronized sound based on its temporal association with the artificial pulse of the HM3. HM3 recipients with the pulse synchronized sound had significantly better Kansas City Cardiomyopathy Questionnaire scores at baseline (median, 89.1 [interquartile range, 86.2-90.4] versus 66.1 [interquartile range, 31.1-73.7]; P=0.03) and over the 6-month study period (marginal mean, 77.6 [95% CI, 66.3-88.9] versus 59.9 [95% CI, 47.9-70.0]; P<0.001). Mechanistically, the pulse synchronized sound shares acoustic features with patient-derived intrinsic sounds. Finally, we developed a machine learning algorithm to automatically detect the pulse synchronized sound within precordial sounds (area under the curve, 0.95, leave-one-subject-out cross-validation). Conclusions We have identified a novel acoustic biomarker associated with better quality of life in HM3 LVAD recipients, which may provide a method for assaying optimized LVAD support.

Do-(Not-)Mechanical-Circulatory-Support Orders: Should We Ask All Cardiac Surgery Patients for Informed Consent for Post-Cardiotomy Extracorporeal Life Circulatory Support?

Post-cardiotomy extracorporeal life support (PC-ECLS) has seen a substantial increase in use over the past 10 years. PC-ECLS can be a life-saving procedure and is mostly applied in the presence of unexpected, severe cardio-respiratory complication. Despite PC-ECLS being critical in allowing for organ recovery, it is unfortunately closely connected with an unpredictable outcomes, high morbidity, and, even in the case of cardiac function improvement, potential sustained disabilities that have a life-changing impact for the patient and his or her family. Since the decision to start PC-ECLS is made in an acute setting, there is often only limited or no time for self-determined choices. Due to the major impact of the intervention, it would be highly desirable to obtain informed consent before starting PC-ECLS, since the autonomy of the patient and shared-decision making are two of the most important ethical values in modern medicine. Recent developments regarding awareness of the impacts of a prolonged intensive care stay make this a particularly relevant topic. Therefore, it would be desirable to develop a structural strategy that takes into account the likelihood of such an intervention and the wishes and preferences of the patient, and thus the related autonomy of the patient. This article proposes key points for such a strategy in the form of a PC-ECLS informed consent, a do-(not-)mechanical-circulatory-support order (D(N)MCS), and specific guidelines to determine the extent of the shared decision making. The concept presented in this article could be a starting point for improved and ethical PC-ECLS treatment and application.

Patient-Reported Outcomes Measurement Information System (PROMIS) in Left Ventricular Assist Devices

BACKGROUND

Appropriate collection of quality of life (QOL) measurements for left ventricular assist device (LVAD) patients is challenging. Patient-Reported Outcomes Measurement Information System (PROMIS) is a popular tool that has been validated across multiple disciplines, but its applicability to the LVAD population remains unknown.

METHODS

This single-center, retrospective review included LVAD patients that completed a PROMIS assessment and Kansas City Cardiomyopathy Questionnaire (KCCQ-12) survey at clinical encounters postoperatively. Patients completed computer adaptive PROMIS assessments for physical function, pain interference and depression. All PROMIS domains are designed to follow a normal distribution (mean T-score 50, standard deviation 10) in the general population. Assessments were aggregated over time and correlation between the KCCQ-12 summary score and each PROMIS domain was assessed individually.

RESULTS

A total of 178 LVAD patients were included in the study. The median time between LVAD implantation and PRO collection was 16.5 [interquartile range, 7.9-37.8] months. Patients typically had worse physical function (T-score 38.8 [33.6-44.2]) but comparable pain (51.1 [38.7-59.2]) and depression (49.9 [41.7-57.5]) as the general population. The KCCQ-12 was more strongly correlated to PROMIS physical function (Spearman's ρ = 0.746) than pain (ρ = -0.539) or depression (ρ = -0.591).

CONCLUSIONS

PROMIS provides a robust QOL data collection system that can be implemented in a clinical setting without imposing a significant burden. Using this more holistic system may allow for better patient-centered care in order to address QOL limitations imposed by LVAD support that are not directly related to heart failure symptoms.

Living with a left ventricular assist device: psychological burden and coping: protocol for a cross-sectional and longitudinal qualitative study

INTRODUCTION

Due to technological progress and persistent shortage of donor hearts, left ventricular assist devices (LVADs) have become established in the treatment of advanced heart failure. Accordingly, more patients live with LVADs for prolonged periods. Related research focused primarily on clinical issues and little is known about psychosocial aspects of living with an LVAD. This study aims to explore psychological burden and coping following LVAD implantation.

METHODS AND ANALYSIS

An exploratory qualitative study with cross-sectional and longitudinal elements will be carried out. At least 18 patients with LVAD who have the device implanted from a few weeks to more than 3 years will be interviewed in the cross-sectional component using an interview guide. A subsample of patients who live with the LVAD for up to 3 months when recruited will be interviewed two additional times in the following year. The cross-sectional interviews will be analysed using an inductive qualitative content analysis to describe psychological burden, coping resources and behaviour from the patient's perspective. Based on the findings, the longitudinal interviews will be analysed with a deductive content analysis to explore psychological adjustment during the first year after implantation. The findings will provide a deeper understanding of the complex and specific situation of patients with LVAD and of psychological adjustment to living with a life-sustaining implant. This can help clinicians in considering individual aspects to promote patient outcomes and is the basis for further research on healthcare interventions or technical solutions to reduce burden and for developing rehabilitation measures to promote psychosocial outcomes.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the ethics committee of the School of Medicine and Health Sciences at the University of Oldenburg (2019-023). Study findings will be disseminated at national and international conferences and through peer-reviewed journals.

TRIAL REGISTRATION NUMBER

German Clinical Trials Register (DRKS00016883).

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.

Heart Failure Symptom Biology in Response to Ventricular Assist Device Implantation

BACKGROUND

We have a limited understanding of the biological underpinnings of symptoms in heart failure (HF), particularly in response to left ventricular assist device (LVAD) implantation.

OBJECTIVE

The aim of this study was to quantify the degree to which symptoms and biomarkers change in parallel from before implantation through the first 6 months after LVAD implantation in advanced HF.

METHODS

This was a prospective cohort study of 101 patients receiving an LVAD for the management of advanced HF. Data on symptoms (dyspnea, early and subtle symptoms [HF Somatic Perception Scale], pain severity [Brief Pain Inventory], wake disturbance [Epworth Sleepiness Scale], depression [Patient Health Questionnaire], and anxiety [Brief Symptom Inventory]) and peripheral biomarkers of myocardial stretch, systemic inflammation, and hypervolumetric mechanical stress were measured before implantation with a commercially available LVAD and again at 30, 90, and 180 days after LVAD implantation. Latent growth curve and parallel process modeling were used to describe changes in symptoms and biomarkers and the degree to which they change in parallel in response to LVAD implantation.

RESULTS

In response to LVAD implantation, changes in myocardial stretch were closely associated with changes in early and subtle physical symptoms as well as depression, and changes in hypervolumetric stress were closely associated with changes in pain severity and wake disturbances. Changes in systemic inflammation were not closely associated with changes in physical or affective symptoms in response to LVAD implantation.

CONCLUSIONS

These findings provide new insights into the many ways in which symptoms and biomarkers provide concordant or discordant information about LVAD response.

Coping, Mood, Quality of Life, and Outcomes in Recipients of Left Ventricular Assist Devices: A Cluster Analysis

OBJECTIVE

Left ventricular assist devices (LVADs) are increasingly used for temporary circulatory support until transplant or as destination therapy for patients with end-stage heart failure. Understanding patients' attitudes and resources is crucial to support them.

METHODS

Sixty-one LVAD recipients (55 [10] years, 10% women, 15% destination therapy) participating in cardiac rehabilitation (CR) postimplant underwent assessment of coping styles (Coping Orientation for Problem Experiences), quality of life (Medical Outcomes Study Short-Form 36, Minnesota Living with Heart Failure Questionnaire), and mood (Hospital Anxiety and Depression Scale).

RESULTS

Cluster analysis identified two homogeneous groups: C1 (n = 18) patients had higher anxiety (9.6 [5.0] versus 4.0 [2.7], p < .001), depression (10 [3.0] versus 4 [2.7], p < .001), and avoidant coping (29 [5.2] versus 21.2 [3.8], p < .001) scores and worse quality of life (Short-Form 36 of the Medical Outcomes Study Physical Component Scale 31 [5.3] versus 35.6 [6.9], p < .001; Mental Component Scale 34.3 [6.8] versus 50.3 [8], p < .001; MLHFQ physical 26 [7.2] versus 13.9 [8.2], p < .001; emotional 17.7 [3.4] versus 3.86 [3.2], p < .001) than C2 participants (n = 43). During 31 (15-54) months, 20 patients (33%) died. By Cox multivariable analysis, after adjustment for age, sex, Interagency Registry for Mechanically Assisted Circulatory Support level at surgery, and meters walked during 6 minutes at CR discharge, C1 was associated with mortality (hazard ratio = 2.858; 95% confidence interval = 1.102-7.408, p = .031; model χ = 7.286, df = 5, p = .20). Survival was 44% in C1 and 77% in C2 (log-rank p = .033).

CONCLUSIONS

Among patients discharged from CR after LVAD implant, one third show a profile characterized by worse perceived quality of life, mood disorders, and dysfunctional coping that is associated with long-term mortality, and these factors are potential targets for post-LVAD intensive support.

Adults Living With a Retro-auricular Left Ventricular Assist Device as Destination Therapy: An Interpretive Description

BACKGROUND

Increasingly, there is a trend toward the use of left ventricular assist devices (LVADs) for treating advanced heart failure, as both bridge-to-transplant therapy and destination therapy. Living with an LVAD profoundly influences patients' lives. Only a few study authors investigated the experience of people with abdominal LVADs, and nothing is known about the unique experience of those with retro-auricular LVADs.

OBJECTIVE

The aim of this study was to explore and describe experiences and lifestyle adjustments in adults with retro-auricular LVADs implanted as destination therapy.

METHODS

Interpretive description methodology was used to explore the experiences of a purposeful sample of 10 individuals with retro-auricular LVADs implanted as destination therapy. Data were collected using in-depth semistructured interviews. Data collection and analysis were simultaneous. Triangulation, journaling, and the "thoughtful clinician test" were used to increase trustworthiness of the findings.

RESULTS

Three primary themes describing the experience of people with retro-auricular LVADs were developed: "a new life," "self-care," and "resilience"; in addition, a crosscutting theme was identified: "support system." This article focuses on the theme "a new life," described as a continuum of events. Individuals with advanced heart failure struggle with symptom burden and consider the implantation of the device as the final option to delay death; then, they wait for the surgery that represents a turning point, after which they begin to recover through a process of adjustment until they reach a new normality.

CONCLUSIONS

Living with a retro-auricular LVAD impacts every aspect of people's lives. Knowing their experiences can help clinicians to develop targeted interventions and offer tailored support.

Quality of life in patients with advanced heart failure and an implanted left ventricular assist device: an umbrella review protocol

OBJECTIVE

This review aims to evaluate the effectiveness of implanted left ventricular assist devices on quality of life in patients with advanced heart failure.

INTRODUCTION

Approximately 500,000 patients worldwide are diagnosed with advanced heart failure. The preferred treatment for patients who remain symptomatic after standard medical treatment is heart transplantation. However, due to the shortage of donor organs, left ventricular assist devices are increasingly used as an alternative. This umbrella review is necessary to advise clinicians so they may provide patients and families with clear information on standard medical treatment, implanted left ventricular assist devices and heart transplantation.

INCLUSION CRITERIA

This umbrella review will consider research syntheses that include patients 16 years or over with advanced heart failure and an implanted left ventricular assist device. The primary outcome is quality of life, and secondary outcomes include patient survival rates and the New York Heart Association functional classification changes.

METHODS

An initial search of PubMed and CINAHL has been undertaken to identify articles and create a search strategy. Retrieved articles will be screened against the inclusion criteria. Included studies will be critically appraised for methodological quality according to JBI umbrella review methodology, and data will be extracted using the standardized JBI data extraction tool. The results will be presented in a Summary of Evidence, and a GRADE Summary of Findings will be produced for grading the quality of the evidence.

SSRI/SNRI Therapy is Associated With a Higher Risk of Gastrointestinal Bleeding in LVAD Patients

BACKGROUND

Gastrointestinal bleeding (GIB) is common in left ventricular assist device (LVAD) patients. Serotonin release from platelets promotes platelet aggregation, and selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) therapy inhibits the transporter responsible for re-uptake.

METHODS

We reviewed the records of LVAD (HeartMateII™, Abbott Medical, Lake Bluff, IL, USA and Heartware™, Medtronic, Minneapolis, MN, USA) patients at the Medical University of South Carolina and Johns Hopkins Hospital between January 2009 and January 2016. After exclusions, 248 patients were included for analysis. After univariate analysis, logistic regression multivariate analysis was performed to adjust for any demographic, cardiovascular, and laboratory data variables found to be associated with GI bleeding post-LVAD.

RESULTS

Gastrointestinal bleeding occurred in 85 patients (35%) with 55% of GIBs due to arteriovenous malformations (AVMs). Of the total cohort, 105 patients received an SSRI or SNRI during LVAD support. Forty-four (44) SSRI/SNRI (41.9%) and 41 non-SSRI/SNRI (28.7%) patients had a GIB (RR 1.46, p = 0.03). Twenty-six (26) (24.8%) of the SSRI/SNRI patients had a GIB due to AVMs versus 21 (14.7%) of the non-SSRI/SNRI patients (RR 1.69, p = 0.05). In fully-adjusted multivariate regression analysis, SSRI/SNRI therapy was independently associated with GIB (OR 1.78, p = 0.045). For GIB, the number needed to harm (NNH) was 7.6.

CONCLUSION

In conclusion, SSRI/SNRI therapy is independently associated with an increased risk of GIB in LVAD patients.

Implant Strategy-Specific Changes in Symptoms in Response to Left Ventricular Assist Devices

BACKGROUND

Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD.

METHODS

The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD.

RESULTS

The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P < .05); subsequent change in both symptoms were similar between groups (both P > .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05).

CONCLUSION

There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD.

Relationship between device acceptance and patient-reported outcomes in Left Ventricular Assist Device (LVAD) recipients

The number of Left Ventricular Assist Devices (LVADs) implanted each year is rising. Nevertheless, there are minimal data on device acceptance after LVAD implant, and on its relationship with patient-reported outcomes. We designed a cross-sectional study to address this knowledge gap and test the hypothesis that low device acceptance is associated with poorer quality of life, depression and anxiety. Self-report questionnaires were administered to assess quality of life (12-item Kansas City Cardiomyopathy Questionnaire quality of life subscale), level of anxiety (7-item Generalized Anxiety Disorder; GAD-7), level of depression (9-item Patient Health Questionnaire; PHQ-9) and device acceptance (Florida Patient Acceptance Survey; FPAS) to 101 consecutive patients presenting to LVAD clinic. Regression analysis showed a strong correlation between device acceptance and both psychological distress (p < 0.001) and quality of life (p < 0.001). Analysis of the sub-scales of the FPAS showed that patients had significant body image concerns, but return to function and device-related distress were the main drivers of the observed correlation between device acceptance and patient well-being. Younger age was associated with lower device acceptance (r = 0.36, p < 0.001) and lower quality of life (r = 0.54, p < 0.001). These findings suggest that interventions targeting device acceptance should be explored to improve outcomes in LVAD recipients.

Mental health interventions during ventricular assist device therapy: a scoping review

OBJECTIVES

Because of the high prevalence of psychological disorders among ventricular assist device patients, mental health support is consensually recommended. No study as yet has provided an overview of recommended and reported mental health interventions. This article presents the results of a scoping review on these questions.

METHODS

We searched standard databases for relevant search criteria and found 4 consensus guidelines and 13 publications with original research mentioning mental health interventions for ventricular assist device patients. These publications are synthesized and augmented with practical recommendations from our reports and from a single-centre experience of others.

RESULTS

Consensus guidelines recommend mental health interventions in 4 areas: screening and diagnostics, assessment, support and treatment and education. Interventions vary across treatment phases and by device therapy strategy, as do typical sources of mental distress. A flow chart of interventions over the course of treatment summarizes these findings.

CONCLUSIONS

The delivery of consensually recommended mental health support for ventricular assist device patients involves the performance of multiple, complex tasks that vary across treatment phases. Mental health professionals should have specialized skills and should interact frequently with other caregivers in care teams.

The Diaphragm Muscle Manual Evaluation Scale

This is a technical report describing how to use the Manual Evaluation Diaphragm (MED) scale, the only evaluation scale in the world to generate a value for the mobility of the main respiratory muscle. In a previously published paper, we described how the areas of the diaphragm should be palpated correctly because a valid manual diaphragmatic evaluation was lacking in the literature. The MED scale emerged as a logical consequence of manual palpation, to provide reference values and allow comparisons between the assessments of different health professionals in multidisciplinary teams. The scale is the first non-instrumental approach to obtaining data on diaphragm function and provides parameters by which the effects that a therapeutic approach has on the diaphragm can be measured.

Sexual activity in patients with left ventricular assist devices and their partners: impact of the device on quality of life, anxiety and depression

OBJECTIVES

Prolonged support with a left ventricular assist device (LVAD) has evolved as an alternative treatment strategy for patients with end-stage heart disease. This requires a shift in focus on sexual activity and psychosocial outcomes in patients with an LVAD and their partners.

METHODS

This cross-sectional study was designed to capture Sexual Activities in Left Ventricular Assist Device Patients Or PaRtners (SALVADOR) perceptions on illness-related changes in the quality of sexual activity and its impact on quality of life, anxiety and depression using standardized patient-reported outcome scales (Sexual Adjustment Scale, 36-Item Short Form Health Survey, Hospital Anxiety and Depression Scale). A total of 72 patients with LVADs (50% response rate) along with 48 partners participated.

RESULTS

For patients with an LVAD (median age 60 years; 84.7% male), median time on the device was 650 days; 69.5% stayed in long-term partnerships (median 23 years). Prevalence rates for illness-related changes in the quality of sexual activity were 58.3% for patients and 52.1% for partners. Device-related disturbances in sexual activities occurred due to battery pockets (patients/partners: 59.2%/37.6%; P = 0.006) and the driveline (46.3%/37.5%; P = 0.033) and led to significantly increased distress in patients/partners (battery pockets: 53.5%/41.3%; P = 0.006; driveline 54.9%/37.5%; P = 0.004). Disturbances in sexual activity were independently associated with higher rates of depression (odds ratio 1.33, 95% confidence interval 1.14-1.55; P = 0.001) in patients and lower mental quality of life (odds ratio 6.18, 95% confidence interval 1.13-33.98; P = 0.036) in partners.

CONCLUSIONS

Disturbances in sexual activity are common in patients with an LVAD and their partners while the patients are on durable long-term support. Counselling on long-term adjustment should provide a platform for information seeking on illness-related changes in the quality of sexual activity.

Quality of life with an LVAD: A misunderstood concept

The present study aims to synthesize current evidence on the impact of LVAD implantation on quality of life. Current evidence was systematically reviewed to obtain relevant quantitative and qualitative articles published after 2007. Sandelowski's recommended steps for meta-summary were used to analyze the 19 studies that met the inclusion criteria. LVADs can improve HF symptoms and some aspects of QoL. Emotional and physical adaptation involves many changes and learning to manage the device takes time. Functional limitations still exist and patients still lack independence. LVAD-related complications significantly impact QoL. Psychological distress remains high after implantation. LVADs significantly impact the caregiver as well and their perspective is not well heard in the existing evidence. It is important for providers to have ongoing, in-depth discussions with patients and their caregivers regarding treatment options, goals of care, anticipated end-of-life trajectories with an LVAD, possible LVAD-complications, and the caregiver burden associated with an LVAD.

Patient and Caregiver Determinants of Patient Quality of Life and Caregiver Strain in Left Ventricular Assist Device Therapy

BACKGROUND

Although current guidelines emphasize the importance of social support to the success of left ventricular assist device (LVAD) therapy, few studies examine the influence of the caregiver on patient outcomes or quantify the impact of LVAD caregiving on caregiver outcomes. The purpose of this analysis was to identify patient and caregiver determinants of patient quality of life (QOL) and caregiver strain in response to LVAD therapy.

METHODS AND RESULTS

Data on patients receiving LVAD therapy and their caregivers (n=50 dyads) were prospectively collected pre-implantation and 1, 3, and 6 months post-implantation. Growth curve modeling was used to describe change in patient QOL (Kansas City Cardiomyopathy Questionnaire) and caregiver strain (Multidimensional Caregiver Strain Index). Patient QOL improved most in the first month (β=23.22±3.76, P<0.001), followed by gradual gains over 6 months (β=1.90±0.64, P<0.01). Caregivers experienced worsening of strain in the first month (β=4.30±1.42, P<0.01), followed by gradual resolution to pre-implantation levels by 6 months (β=-0.71±0.23, P<0.01). Worse pre-implantation patient symptoms were associated with greater improvement in patient QOL (β=0.53±0.19, P<0.01) but worsening caregiver strain (β=0.15±0.07, P=0.04). Better relationship quality was associated with greater improvement in patient QOL (β=14.39±5.85, P=0.01) and less pre-implantation caregiver strain (β=-9.31±2.28, P<0.001). Nonspousal caregivers experienced less pre-implantation strain (β=-8.60±3.10, P=0.01), and patients with nonspousal caregivers had less improvement in QOL (β=-3.70±1.62, P=0.02).

CONCLUSIONS

A combination of patient and caregiver characteristics predicts patient and caregiver response to LVAD therapy. Including caregiver factors in future studies may be helpful in developing interventions that improve patient and caregiver outcomes, together.

First World Report of Internal Power Cable Repair in Left Ventricular Assist Device Jarvik 2000: Case Report

BACKGROUND

There are limited clinical reports concerning internal power cable fixing in left ventricular assist device (L-VAD) patients. Actually there are no reports in the literature about Jarvik 2000 internal cable repair. We show the first description of a technique for surgical reparation of such a fatal complication.

PATIENT HISTORY

The patient was a 62-year-old woman who had L-VAD implantation (Jarvik 2000) with outflow graft apposition in descending thoracic aorta through left thoracotomy access, in 2009. She arrived urgently on January 25, 2014 for Jarvik 2000 dysfunction correlated with head movements. The neck X-rays revealed the rupture of one of the nine power cables located inside the neck and the damaging of two more cables nearby to be ruptured. On the same day she got pump failure due to the final interruption of the remaining two cables, we were obliged to install femoro-femoral extracorporeal membrane oxygenation (ECMO) assistance, to repair the power cables, approaching them through a pacemaker extension cable. The L-VAD outflow was occluded with vascular ball occluder inserted via right axillary artery under fluoroscopy before ECMO installation. At the end the ECMO assistance was interrupted and the Jarvik 2000 was turned back on. The patient was dismissed from the hospital 12 days after the procedure.

DISCUSSION

At the moment the international literature is poor regarding this issue. This case provides evidence that in emergency conditions ECMO assistance is mandatory and a hybrid surgical and radiological approach could help to repair the damage in safe conditions.

Depression and anxiety in patients undergoing left ventricular assist device implantation

BACKGROUND

Depression and anxiety are associated with a worse prognosis in heart failure patients. The aim of this study was to identify the prevalence of depression and anxiety in left ventricular assist device (LVAD) candidates and assess their effect on post-LVAD outcomes.

METHODS

Based on the pre-LVAD psychological assessment, the total cohort of 246 patients were divided into 4 groups: 1) no depression or anxiety (NDep&Anx group, n = 138); 2) isolated depression (Dep group, n = 42); 3) isolated anxiety (Anx group, n = 32), and 4) combined depression and anxiety (Dep&Anx group, n = 34).

RESULTS

The Dep&Anx group was associated with higher prevalence of female gender (p = 0.03), higher body mass index (p = 0.03), elevated E/E' (p = 0.003), and increased Model For End-Stage Liver Disease (MELD) XI score (p = 0.04) prior to LVAD as compared to the other 3 subgroups. The prevalence of other major psychiatric disorders (p = 0.03) and narcotic dependence (p = 0.004) was higher in the Dep&Anx group. Post-LVAD implantation, heart rate and filling pressures were elevated and readmission rate was higher (p = 0.001) in the Dep&Anx group. There was no difference in survival between the groups (p = 0.40, Log-Rank test).

CONCLUSIONS

Pre-existing anxiety and depression was associated with worse HF pre- and post-LVAD implantation and higher readmissions rate after LVAD implantation.

Quality of Life, Depression, and Anxiety in Ventricular Assist Device Therapy: Longitudinal Outcomes for Patients and Family Caregivers

BACKGROUND

Patients who receive ventricular assist device (VAD) therapy typically rely on informal caregivers (family members or friends) to assist them in managing their device.

OBJECTIVE

The purpose of this study is to characterize changes in person-oriented outcomes (quality of life [QOL], depression, and anxiety) for VAD patients and their caregivers together from pre-implantation to 3 months post-implantation.

METHODS

This was a formal interim analysis from an ongoing prospective study of VAD patients and caregivers (n = 41 dyads). Data on person-oriented outcomes (QOL: EuroQol 5 Dimensions Visual Analog Scale; depression: Patient Health Questionnaire-8; anxiety: Brief Symptom Inventory) were collected at 3 time points (just prior to implantation and at 1 and 3 months post-implantation). Trajectories of change for patients and caregivers on each measure were estimated using latent growth modeling with parallel processes.

RESULTS

Patients' QOL improved significantly over time, whereas caregiver QOL worsened. Depression and anxiety also improved significantly among patients but did not change among caregivers. There was substantial variability in change on all outcomes for both patients and their caregivers.

CONCLUSIONS

This is the first quantitative study of VAD patient-caregiver dyads in modern devices that describes change in person-oriented outcomes from pre-implantation to post-implantation. This work supports the need for future studies that account for the inherent relationships between patient and caregiver outcomes and examine variability in patient and caregiver responses to VAD therapy.

Osteopathic treatment in a patient with left-ventricular assist device with left brachialgia: a case report

This study deals with an osteopathic approach used for a patient with left-ventricular assist device (L-VAD) affected by left brachialgia. Clinical examination revealed the presence of thoracic outlet syndrome and pectoralis minor syndrome, with compression of the left proximal ulnar nerve, related to the surgical sternotomy performed. The osteopathic techniques used can be classified as indirect and direct, addressed to the pectoralis minor and the first left rib, respectively. To our knowledge, this is the first text in literature with an osteopathic treatment in a patient with L-VAD.

Pain and Functional Status in Patients With Ventricular Assist Devices

CONTEXT

Ventricular assist devices (VADs) have been shown to improve survival and overall quality of life, but there are limited data on pain control and functional status in this patient population.

OBJECTIVES

This study examined changes in pain, functional status, and quality of life over time in VAD patients.

METHODS

Patients were enrolled in this prospective cohort study before or as early after VAD implant as possible and then followed for up to 48 weeks. The Brief Pain Inventory was used to assess pain. The Katz Independent Activities of Daily Living questionnaire was used to assess functional status. The Kansas City Cardiomyopathy Questionnaire, a 23-item questionnaire covering five domains (physical function, symptoms, social function, self-efficacy, and quality of life), was used to assess quality of life and health status.

RESULTS

Eighty-seven patients were enrolled at four medical centers. The median Brief Pain Inventory severity score was 2.8 (interquartile range 0.5-5.0) before implantation and 0.0 (interquartile range 0.0-5.3) 48 weeks after implantation (P = 0.0009). Katz Independent Activities of Daily Living summary scores also demonstrated significant improvement over time (P < 0.0001). Kansas City Cardiomyopathy Questionnaire summary scales demonstrated significant improvement with time (P < 0.0016).

CONCLUSION

This study demonstrated that patients with VADs experienced improved pain, functional status, and quality of life over time. These data may be useful to help patients make decisions when they are considering undergoing VAD implantation.

Adaptation and coping in patients living with an LVAD: A metasynthesis

OBJECTIVE

To synthesize information supporting coping and adaptation of LVAD patients and to identify opportunities for future interventions.

BACKGROUND

Left Ventricular Assist Device (LVAD) patients demonstrate improvements in quality of life and functional status, but qualitative research has not been meaningfully integrated.

METHODS

Qualitative meta-synthesis using Lazarus and Folkmans' Transactional Model of stress and coping.

RESULTS

Four distinct stages of adaptation were identified: Pre-LVAD, Implant Hospitalization, Early Home Adaptation and Late Home Adaptation. Each stage includes tasks in physical, psychological and social domains. Two themes emerged: 1) Primary Appraisal: Every stage is a new challenge and 2) Secondary Appraisal: Routines are achievable, emotions are more difficult.

CONCLUSIONS

Emotional challenges including fear and anxiety related to life-limiting illness and changed social roles need to be honestly addressed. Individuals living with LVAD achieve a sense of independence, enjoy social interactions and meaningful activities through addressing practical and emotional problems to facilitate coping.

[Rehabilitation standards for follow-up treatment and rehabilitation of patients with ventricular assist device (VAD)]

The increasing use of ventricular assist devices (VADs) in terminal heart failure patients provides new challenges to cardiac rehabilitation physicians. Structured cardiac rehabilitation strategies are still poorly implemented for this special patient group. Clear guidance and more evidence for optimal modalities are needed. Thereby, attention has to be paid to specific aspects, such as psychological and social support and education (e.g., device management, INR self-management, drive-line care, and medication).In Germany, the post-implant treatment and rehabilitation of VAD Patients working group was founded in 2012. This working group has developed clear recommendations for the rehabilitation of VAD patients according to the available literature. All facets of VAD patients' rehabilitation are covered. The present paper is unique in Europe and represents a milestone to overcome the heterogeneity of VAD patient rehabilitation.

Beyond the VAD: Human Factors Engineering for Mechanically Assisted Circulation in the 21st Century

Thousands of ventricular assist devices (VADs) currently provide circulatory support to patients worldwide, and dozens of heart pump designs for adults and pediatric patients are under various stages of development in preparation for translation to clinical use. The successful bench-to-bedside development of a VAD involves a structured evaluation of possible system states, including human interaction with the device and auxiliary component usage in the hospital or home environment. In this study, we review the literature and present the current landscape of preclinical design and assessment, decision support tools and procedures, and patient-centered therapy. Gaps of knowledge are identified. The study findings support the need for more attention to user-centered design approaches for medical devices, such as mechanical circulatory assist systems, that specifically involve detailed qualitative and quantitative assessments of human-device interaction to mitigate risk and failure.

Learning self-care after left ventricular assist device implantation

The number of heart failure (HF) patients living with a left ventricular assist device (LVAD) as destination therapy is increasing. Successful long-term LVAD support includes a high degree of self-care by the patient and their caregiver, and also requires long-term support from a multidisciplinary team. All three components of self-care deserve special attention once an HF patient receives an LVAD, including activities regarding self-care maintenance (activities related both to the device and lifestyle), self-care monitoring (e.g., monitoring for complications or distress), and self-care management (e.g., handling alarms or coping with living with the device). For patients to perform optimal self-care once they are discharged, they need optimal education that focuses on knowledge and skills through a collaborative, adult learning approach.

Mid-term survival after continuous-flow left ventricular assist device versus heart transplantation

There is a paucity of data about mid-term outcome of patients with advanced heart failure (HF) treated with left ventricular assist device (LVAD) in Europe, where donor shortage and their aging limit the availability and the probability of success of heart transplantation (HTx). The aim of this study is to compare Italian single-centre mid-term outcome in prospective patients treated with LVAD vs. HTx. We evaluated 213 consecutive patients with advanced HF who underwent continuous-flow LVAD implant or HTx from 1/2006 to 2/2012, with complete follow-up at 1 year (3/2013). We compared outcome in patients who received a LVAD (n = 49) with those who underwent HTx (n = 164) and in matched groups of 39 LVAD and 39 HTx patients. Patients that were treated with LVAD had a worse risk profile in comparison with HTx patients. Kaplan-Meier survival curves estimated a one-year survival of 75.5 % in LVAD vs. 82.3 % in HTx patients, a difference that was non-statistically significant [hazard ratio (HR) 1.46; 95 % confidence interval (CI) 0.74-2.86; p = 0.27 for LVAD vs. HTx]. After group matching 1-year survival was similar between LVAD (76.9 %) and HTx (79.5 %; HR 1.15; 95 % CI 0.44-2.98; p = 0.78). Concordant data was observed at 2-year follow-up. Patients treated with LVAD as bridge-to-transplant indication (n = 22) showed a non significant better outcome compared with HTx with a 95.5 and 90.9 % survival, at 1- and 2-year follow-up, respectively. Despite worse preoperative conditions, survival is not significantly lower after LVAD than after HTx at 2-year follow-up. Given the scarce number of donors for HTx, LVAD therapy represents a valid option, potentially affecting the current allocation strategy of heart donors also in Europe.