Standardized Psychosocial Assessment Before Left Ventricular Assist Device Implantation

Association of the Stanford Integrated Psychosocial Assessment for Transplant and 1-Year Outcome of Living Kidney Transplantation in Japan

BACKGROUND

Because most kidney transplantations in Japan are performed on the basis of living donors, after-transplant outcomes should achieve optimum results, overcoming participants' possible reduced adherence.

OBJECTIVE

To investigate the association between the Japanese version of the Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT-J) and outcomes, 1 year after the patient's living kidney transplant (LKT).

METHODS

The prospective cohort study was undertaken at Tokyo Women's Medical University Hospital from January 2020 to July 2021, with a 1-year follow-up period. The SIPAT-J assesses 18 psychosocial risk factors: (1) Patient's Readiness Level and Illness Management (SIPAT A), (2) Social Support System Level of Readiness (SIPAT B), (3) Psychological Stability and Psychopathology (SIPAT C), and (4) Lifestyle and Effect of Substance Use (SIPAT D). The evaluators, a psychiatrist and 3 clinical psychologists, conducted an independent, blinded application of the SIPAT-J using participants' medical records. The study focused on physical composite outcomes, psychiatric outcomes, and nonadherent behaviors.

RESULTS

The participants were 173 LKT recipients (median age [interquartile range], 51 [38-59]); 67.1% were male and 67.1% were employed. The median (interquartile range) SIPAT scores were SIPAT A [7 (5-9)], SIPAT B [7 (5-9)], SIPAT C [2 (0-4)], SIPAT D [3 (3-4)], and SIPAT total [20 (16-23)]. The physical composite outcome was 25 (14.5%), psychiatric outcome 9 (5.2%), and nonadherent behavior 17 (9.8%). SIPAT C (odds ratio = 1.34, 95% confidence interval = 1.06-1.72, P = 0.02) was significantly associated with the psychiatric outcome. SIPAT B (odds ratio = 1.49, 95% confidence interval = 1.12-1.98, P = 0.01) and SIPAT total (odds ratio = 1.13, 95% confidence interval = 1.03-1.24, P = 0.01) were significantly associated with nonadherent behaviors. There was no significant association between the SIPAT and physical composite outcomes.

CONCLUSION

This study is the first to examine the association between SIPAT and physical and psychiatric outcomes 1 year after LKT, controlling for follow-up periods and factors other than SIPAT. Comprehensive psychosocial assessment before LKT and early identification of factors that may negatively affect transplant success can allow targeted interventions to be implemented and increase the likelihood of favorable recipient outcomes.

Racial and Ethnic Disparities in Ambulatory Heart Failure Ventricular Assist Device Implantation and Survival

BACKGROUND

Durable left ventricular assist devices (VADs) improve survival in eligible patients, but allocation has been associated with patient race in addition to presumed heart failure (HF) severity.

OBJECTIVES

This study sought to determine racial and ethnic differences in VAD implantation rates and post-VAD survival among patients with ambulatory HF.

METHODS

Using the INTERMACS (Interagency Registry of Mechanically Assisted Circulatory Support) database (2012-2017), this study examined census-adjusted VAD implantation rates by race, ethnicity, and sex in patients with ambulatory HF (INTERMACS profile 4-7) using negative binomial models with quadratic effect of time. Survival was evaluated using Kaplan-Meier estimates and Cox models adjusted for clinically relevant variables and an interaction of time with race/ethnicity.

RESULTS

VADs were implanted in 2,256 adult patients with ambulatory HF (78.3% White, 16.4% Black, and 5.3% Hispanic). The median age at implantation was lowest in Black patients. Implantation rates peaked between 2013 and 2015 before declining in all demographic groups. From 2012 to 2017, implantation rates overlapped for Black and White patients but were lower for Hispanic patients. Post-VAD survival was significantly different among the 3 groups (log rank P = 0.0067), with higher estimated survival among Black vs White patients (12-month survival: Black patients: 90% [95% CI: 86%-93%]; White patients: 82% [95% CI: 80%-84%]). Low sample size for Hispanic patients resulted in imprecise survival estimates (12-month survival: 85% [95% CI: 76%-90%]).

CONCLUSIONS

Black and White patients with ambulatory HF had similar VAD implantation rates but rates were lower for Hispanic patients. Survival differed among the 3 groups, with the highest estimated survival at 12 months in Black patients. Given higher HF burden in minoritized populations, further investigation is needed to understand differences in VAD implantation rates in Black and Hispanic patients.

Characterization of the stanford integrated psychosocial assessment for transplant for heart, liver, and kidney transplant candidates in Japan

BACKGROUND

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive psychosocial assessment proven useful for predicting the outcomes of organ transplantation that is expected to be useful in Japan. However, the characteristics of organ-specific SIPAT scores for organ transplant recipient candidates in Japan are unclear and, to date, the SIPAT has not been properly utilized in clinical practice. The purpose of this study was to present basic data that can be used to establish the relation between SIPAT scores and post-transplantation psychosocial outcomes as well as organ-specific outcomes.

METHODS

This study included 167 transplant recipient candidates (25 heart, 71 liver, and 71 kidney) who completed a semi-structured interview based on the Japanese version of SIPAT (SIPAT-J) prior to transplantation. The differences between organs in terms of SIPAT scores and differences in SIPAT scores based on demographic data were comparatively analyzed.

RESULTS

The total SIPAT scores were higher for liver recipient candidates than for heart recipient candidates (P = .019). Regarding the subscales, SIPAT B (social support system) scores were higher for liver and kidney recipient candidates than for heart recipient candidates (P = .021), whereas SIPAT C (psychological stability and psychopathology) scores were higher for liver recipient candidates than for kidney recipient candidates (P = .002). Recipient candidates with a history of psychiatric treatment and those who were unemployed had higher SIPAT scores, regardless of the transplant organ, than recipient candidates without a history of psychiatric treatment and those who were employed (P < .001, P = .016, respectively).

CONCLUSIONS

There were notable differences in the total SIPAT-J and subscale scores among the liver, heart, and kidney recipient candidates. Each organ was associated with specific psychosocial issues that should be addressed before transplantation. Interventions such as information provision and patient education based on SIPAT assessment results for each organ may improve recipient post-transplant outcomes.

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.

Value of psychosocial evaluation for left ventricular assist device candidates

OBJECTIVE

Left ventricular assist devices require a psychosocial assessment to determine candidacy despite limited data correlating with outcome. Our objective is to determine whether the Stanford Integrated Psychosocial Assessment for Transplant, a tool validated for transplant and widely used by left ventricular assist device programs, predicts left ventricular assist device program hospital readmissions and death.

METHODS

We performed a retrospective analysis of adults at the Cleveland Clinic with Stanford Integrated Psychosocial Assessment for Transplant scores before primary left ventricular assist device program implantation from April 1, 2013, to December 31, 2018. The primary outcome was unplanned hospital readmissions censored at death, transplantation, and transfer of care. The secondary outcome was death.

RESULTS

There were 263 patients in the left ventricular assist device program with a median (Q1, Q3) Stanford Integrated Psychosocial Assessment for Transplant score of 16 (8, 28). During a median follow-up 1.2 years, 56 died, 65 underwent transplantation, and 21 had transferred care. There were 640 unplanned hospital readmissions among 250 patients with at least 1 outpatient visit at our center. In a multivariable analysis, Stanford Integrated Psychosocial Assessment for Transplant components but not total Stanford Integrated Psychosocial Assessment for Transplant score was associated with readmissions. Psychopathology (Stanford Integrated Psychosocial Assessment for Transplant C-IX) was associated with hemocompatibility (coefficient 0.21 ± standard error 0.11, P = .040) and cardiac (0.15 ± 0.065, P = .02) readmissions. Patient readiness was associated with noncardiac (Stanford Integrated Psychosocial Assessment for Transplant A-III, 0.24 ± 0.099, P = .016) and cardiac (Stanford Integrated Psychosocial Assessment for Transplant A-low total, 0.037 ± 0.014, P = .007) readmissions. Poor living environment (Stanford Integrated Psychosocial Assessment for Transplant B-VIII) was associated with device-related readmissions (0.83 ± 0.34, P = .014). Death was associated with organic psychopathology or neurocognitive impairment (Stanford Integrated Psychosocial Assessment for Transplant C-X, 0.59 ± 0.21, P = .006).

CONCLUSIONS

Total Stanford Integrated Psychosocial Assessment for Transplant score was not associated with left ventricular assist device program readmission or mortality. However, we identified certain Stanford Integrated Psychosocial Assessment for Transplant components that were associated with outcome and could be used to create a left ventricular assist device program specific psychosocial tool.

Natural Language Processing for Computer-Assisted Chart Review to Assess Documentation of Substance use and Psychopathology in Heart Failure Patients Awaiting Cardiac Resynchronization Therapy

CONTEXT

Advanced heart failure (HF) patients often experience distressing psychological symptoms, frequently meeting diagnostic criteria for psychological disorders, including anxiety, depression, and substance use disorder. Patients with device-based HF therapies have added risk for psychological disorders, with consequences for their physiological functioning, including adverse cardiac outcomes.

OBJECTIVES

This study used natural language processing (NLP) for computer-assisted chart review to assess documentation of mental health and substance use in HF patients awaiting cardiac resynchronization therapy (CRT), a device-based HF therapy.

METHODS

We applied NLP to clinical notes from electronic health records (EHR) of 965 consecutive patients, with 9821 total clinical notes, at two academic medical centers between 2004 and 2015. We developed and validated a keyword library capturing terms related to mental health and substance use, while balancing specificity and sensitivity.

RESULTS

Mean age was 71.6 years (SD = 11.8), 78% male, and 87% non-Hispanic White. Of the 544 patients (56.4%) with documentation of mental health history, 9.7% had their mental health assessed and 6.6% had a plan documented. Of the 773 patients (80.1%) with documentation of substance use history, 10 (1.0%) had an assessment, and 3 (0.3%) had a plan.

CONCLUSION

Despite clinical recommendations and standards of care, clinicians are under documenting assessments and plans prior to CRT. Future research should develop an algorithm to prompt clinicians to document this content. Such quality improvement efforts may ensure adherence to standards of care and clinical guidelines.

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

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

Association of race and gender with primary caregiver relationships and eligibility for advanced heart failure therapies

BACKGROUND

Caregiver support is considered necessary after heart transplant (HT) and left ventricular assist device (LVAD) for patients with end-stage heart failure (HF). Few studies have demonstrated how caregivers differ by gender and race, and whether that impacts therapy eligibility.

METHODS

We examined caregiver relationships among 674 patients (32% women, 55% Black) evaluated at Emory University from 2011 to 2017. Therapy readiness was assessed using the Stanford Integrated Assessment for Transplant (SIPAT). Evaluation outcome according to caregiver relationship was compared using χ² analysis. Multivariable logistic regression determined the association between caregiver and eligibility according to gender and race.

RESULTS

Women and Black patients were less likely to have spouses as their support person (P < .001). Women were less likely to be considered eligible for advanced therapies (adjusted odds ratio [aOR] .64, 95% confidence interval [CI] .46-.89; P = .008), with Black women having lower eligibility than White women (aOR .28, 95% CI .11-.72; P = .008). Social support and SIPAT scores did not significantly influence eligibility by gender or race.

CONCLUSION

Lack of caregiver support is considered a relative contraindication to advanced therapies. Type of caregiver in our cohort varied according to race and gender but did not explain differences in eligibility for advanced therapies.

Psychological Journey of a Patient With a Ventricular Assist Device: A VAD Coordinator's Perspective

BACKGROUND

A thorough psychosocial assessment is needed during the evaluation of candidacy for ventricular assist device placement to identify potential barriers that would limit success with the device. Ventricular assist device coordinators are generally involved in the psychosocial assessment of the patient, allowing them to provide a more holistic approach to ventricular assist device candidacy during discussions at multidisciplinary meetings. There is a gap in the literature describing the psychological journey of patients after ventricular assist device implantation and the challenges ventricular assist device coordinators face when caring for this complex population.

OBJECTIVE

The psychological journey of 3 patients with a ventricular assist device was explored to determine if common themes exist and to describe the experiences faced by the ventricular assist device coordinators with each patient.

METHODS

Three patient case scenarios are described, as are the interactions with the patients' ventricular assist device coordinator team members.

RESULTS

All 3 case scenarios demonstrate similarities of younger ages, the need of family and social support, and ventricular assist device coordinators who went beyond the call of duty to assist in the successful heart transplantation for 2 cases and the successful decommission of the ventricular assist device in another case.

CONCLUSION

The psychosocial needs of patients with a ventricular assist device and ventricular assist device coordinators require ongoing assessment because of the many physical and emotional challenges that arise during the time a patient has an implanted ventricular assist device.

Psychosocial Assessment of Transplant Candidates: Inter-rater Reliability and Concurrent Validity of the Japanese Version of the Stanford Integrated Psychosocial Assessment for Transplantation

BACKGROUND

The Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) is a comprehensive instrument developed to provide a standardized, objective, and evidence-based psychosocial evaluation of the main pretransplant psychosocial risk factors that may influence transplant outcomes.

OBJECTIVE

Because established assessment procedures or standardized tools designed to perform pre-solid organ transplant psychosocial evaluation are currently unavailable in Japan, the present study aimed to develop and preliminarily validate the Japanese version of the SIPAT.

METHODS

First, the Japanese version of the SIPAT was developed using standard forward-back-translation procedures. Then, the Japanese versions of the SIPAT and the Japanese version of Psychosocial Assessment of Candidates for Transplant were retrospectively and blindly applied to 107 transplant cases by 4 independent raters.

RESULTS

The interrater reliability of the scores obtained with the Japanese version of the SIPAT was excellent (Pearson's correlation coefficient = 0.86). The concurrent validity of the SIPAT to the Psychosocial Assessment of Candidates for Transplant for each examiner was substantial (Spearman's rank correlation coefficient = -0.66).

CONCLUSION

These findings suggest that the Japanese version of the SIPAT is a promising and reliable instrument. Further research is required to test the predictive validity of the Japanese version of the SIPAT.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of Socioeconomic Status on Outcomes After Ventricular Assist Device Implantation Using the Area Deprivation Index

BACKGROUND

This study evaluates the Area Deprivation Index (ADI) as a novel prognostic metric of socioeconomic status for patients with a left ventricular assist device.

METHODS AND RESULTS

A retrospective analysis of patients with a left ventricular assist device at a high-volume institution from 2007 to 2018 was conducted. Socioeconomic status was determined using the ADI, a multifactorial neighborhood-based metric where higher ADI denotes worse socioeconomic status. Patients were stratified into 4 ADI cohorts. Long-term survival was compared with multivariate analysis. Of the 380 patients stratified by ADI, 35 were in the 10th percentile or lower, 218 were in the 11th-50th percentile, 104 were in the 51st-89th percentile, and 23 were in the 90th percentile or higher. Baseline characteristics were comparable. On multivariate analysis, being male (hazard ratio [HR], 0.14; P = .01), bridge-to-transplant (HR, 0.14; P = .03), and not requiring biventricular support (HR, 0.02; P < .01) were protective, whereas chronic kidney disease (HR, 9.07; P < .01) and an elevated total bilirubin (HR, 3.56; P = .02) were harmful. The ADI as a continuous variable did not affect survival; however, categorically, a higher ADI was protective (ADI 90-100: HR, 0.07; P = .04).

CONCLUSIONS

Socioeconomically disadvantaged patients had noninferior outcomes given appropriate pre-implant optimization and workup.

The Impact of a High-risk Psychosocial Assessment on Outcomes After Durable Mechanical Circulatory Support

Patient adherence is vital to the success of durable mechanical circulatory support (MCS), and the pre-MCS assessment of adherence by the multidisciplinary advanced heart failure team is a critical component of the evaluation. We assessed the impact of a high-risk psychosocial assessment before durable MCS implantations on post-MCS outcomes. Between January 2010 and April 2018, 319 patients underwent durable MCS at our center. We excluded those who died or were transplanted before discharge. The remaining 203 patients were grouped by pre-MCS psychosocial assessment: high-risk (26; 12.8%) versus acceptable risk (177; 87.2%). We compared clinical characteristics, nonadherence, and outcomes between groups. High-risk patients were younger (48 vs. 56; p = 0.006) and more often on extracorporeal membrane oxygenation at durable MCS placement (26.9% vs. 9.0%; p = 0.007). These patients had a higher incidence of post-MCS nonadherence including missed clinic appointments, incorrect medication administration, and use of alcohol and illicit drugs. After a mean follow-up of 15.3 months, 100% of high-risk patients had unplanned hospitalizations compared with 76.8% of acceptable-risk patients. Per year, high-risk patients had a median of 2.9 hospitalizations per year vs. 1.2 hospitalizations per year in acceptable-risk patients. While not significant, there were more driveline infections over the follow-up period in high-risk patients (27% vs. 14.7%), deaths (27% vs. 18%), and fewer heart transplants (53.8% vs. 63.8%).The pre-MCS psychosocial assessment is associated with post-MCS evidence of nonadherence and unplanned hospitalizations. Attention to pre-MCS assessment of psychosocial risk factors is essential to optimize durable MCS outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

A systematic review of psychosocial design considerations for the next generation of mechanical circulatory support

BACKGROUND

Biomedical engineers are developing new mechanical circulatory support pumps. Clinicians are generating and analysing new evidence for their prescription and management. Industrial designers are generating usable solutions for wearable components and controllers. However, psychosocial considerations may be falling between the cracks of the three disciplines because of their multi-faceted nature.

OBJECTIVES

This article seeks to identify psychosocial needs raised in previous work, re-frame them as needs for future products and services, and discuss routes to solutions.

METHODS

SLR extracted 225 statements on psychosocial considerations from 42 included articles. 23 codes were inductively generated and applied to relevant datapoints. Codes were consolidated under 4 main themes and re-framed as solvable problems.

RESULTS

Identified themes: expanded remote care, improved multidisciplinary management tools, creating easier interactions; and extending patient engagement.

CONCLUSIONS

Design-driven methods have been used to solve analogous problems in other contexts and can address the identified psychosocial problems if implemented fully.

Psychosocial Risk and Its Association With Outcomes in Continuous-Flow Left Ventricular Assist Device Patients

BACKGROUND

Advanced heart failure therapies such as left ventricular assist device (LVAD) implantation require intricate follow-up and complex care. We sought to explore the burden of psychosocial risk factors among patients with LVAD and their impact on postimplant outcomes using the Interagency Registry for Mechanically Assisted Circulatory Support.

METHODS

Adult patients in the Interagency Registry for Mechanically Assisted Circulatory Support requiring durable LVAD between 2008 and 2017 were included. Individuals were determined to have psychosocial risk if they had one of the following: (1) limited social support; (2) limited cognition; (3) substance abuse (alcohol and drug); (4) severe psychiatric disease (including major depression and other major psychiatric diagnosis); and (5) repeated noncompliance. Univariate and multivariate Cox proportional hazard regression models were used to analyze predictors of survival and complications.

RESULTS

A total of 15 403 continuous-flow LVAD recipients were included. A total of 3163 (20.5%) had one or more psychosocial risk factors. The most prevalent psychosocial risk factor was substance abuse in 1941 (12.6%) recipients. Patients with psychosocial risk factors were significantly younger at LVAD implant, less likely to be White, and less likely to be female compared with those without psychosocial risk, P<0.001 for all. Patients with psychosocial risk were significantly more likely to receive an LVAD as destination therapy, P<0.001. In adjusted models, patients with psychosocial risk were at increased hazards for device-related infection, gastrointestinal bleeding, pump thrombosis, and readmission and reduced hazards for cardiac transplantation (P<0.05 for all). There was no statistically significant difference in survival on pump support or stroke.

CONCLUSIONS

Psychosocial risk is an important component of patient selection for advanced heart failure therapies. Addressing these specific components may help improve access to advanced therapies and post-LVAD outcomes.

The Approach to the Psychosocial Evaluation of Cardiac Transplant and Mechanical Circulatory Support Candidates

PURPOSE OF REVIEW

We update evidence underlying the recommendations of a 2018 multi-society consensus report regarding the psychosocial evaluation of individuals for cardiothoracic transplantation and mechanical circulatory support (MCS). In the present review, we focus on heart transplantation and MCS.

RECENT FINDINGS

Expert opinion and new evidence support the inclusion of ten core content areas in the psychosocial evaluation. Prospective data indicate that psychosocial factors can predict post-transplantation/post-implantation outcomes. Such factors include treatment adherence history, mental health and substance use history, cognitive impairment, knowledge about treatment options, and social factors such as socioeconomic status. For other factors (e.g., coping, social support), new evidence is weaker because it derives largely from cross-sectional studies. Concerning evaluation process issues, expert opinion remains consistent with consensus recommendations, but there is a dearth of empirical evidence. The psychosocial evaluation can identify factors relevant for candidacy for heart transplantation and MCS implantation. It enables the provision of interventions to improve patients' viability as candidates, and facilitates care planning.

Considerations for Referral: What Happens to Patients After Being Turned Down for Left Ventricular Assist Device Therapy

BACKGROUND

Left ventricular assist device (LVAD) therapy has revolutionized the treatment options for patients with advanced heart failure. Patient selection is essential for obtaining successful results. However, few data exist concerning the outcomes of patients evaluated for LVAD therapy but subsequently rejected or deferred.

METHODS AND RESULTS

This is a retrospective review of all patients referred for LVAD therapy at our institution between January 2009 and December 2016. Baseline demographics and Interagency Registry for Mechanically Assisted Circulatory Support profiles were collected, and reasons for rejection or deferral for LVAD placement were investigated. A total of 669 patients were referred for LVAD therapy, and 228 patients (34%) were turned down. The yearly acceptance rate ranged between 57% and 75%. The average age of the turned-down cohort was 60.8 ± 12.5 years; 83% were men. Reasons for rejection included: patient being too sick (34%); psychosocial concerns (25%); patient declined (16%); decision was deferred for medical optimization (15%); or patient being too well (10%). The percentage of patients who were rejected due to psychosocial concerns has increased over time (P = 0.02), whereas the rate of deferral for medical optimization has remained stable (P = 0.10). One-year survival after initial LVAD consultation was 42% in those who were too sick, 64% in those with psychosocial concerns, 68% in patients who declined, 86% in those deferred for medical optimization; and 100% in those too well (P < 0.01).

CONCLUSIONS

One-year survival is reduced among patients who were initially turned down for LVAD therapy, except for those in whom this decision was deferred for medical optimization or because the patient was too well. Psychosocial concerns have become a significant barrier to LVAD therapy.

Presurgical Psychological Evaluation: Risk Factor Identification and Mitigation

Presurgical psychological evaluations (PPEs) are becoming an established component of the surgical process, though methods of conducting PPEs are variable. There is a lack of clarity about the goals of PPEs, the types of information that should be included, and the process for integrating information and making recommendations to the referring physicians/surgeons. This review proposes an empirically supported model for PPEs that is systematic, but flexible enough to be utilized across the broad range of surgical evaluations. This five-step method is termed the Risk Identification and Mitigation (RIM) model and is discussed in detail. The RIM model presented in this review can both serve as a structure to be utilized in under-researched PPE areas and as a stimulus for future empirical investigations.