Suicide after ventricular assist device implantation

Depression among Patients with an Implanted Left Ventricular Assist Device: Uncovering Pathophysiological Mechanisms and Implications for Patient Care

Depression is a common and devastating mental illness associated with increased morbidity and mortality, partially due to elevated rates of suicidal attempts and death. Select patients with end-stage heart failure on a waiting-list for a donor heart undergo left ventricular assist device (LVAD) implantation. The LVAD provides a circulatory flow of oxygenated blood to the body, mimicking heart functionality by operating on a mechanical technique. LVAD improves functional capacity and survivability among patients with end-stage heart failure. However, accumulating data suggests that LVAD recipients suffer from an increased incidence of depression and suicide attempts. There is scarce knowledge regarding the pathological mechanism and appropriate treatment approach for depressed LVAD patients. This article summarizes the current evidence on the association between LVAD implantation and occurrence of depression, suggesting possible pathological mechanisms underlying the device-associated depression and reviewing the current treatment strategies. The summarized data underscores the need for a rigorous pre-(LVAD)-implantation psychiatric evaluation, continued post-implantation mental health assessment, and administration of antidepressant treatment as necessary.

Practice Issues for Evaluation and Management of the Suicidal Left Ventricular Assist Device Patient

There is a high prevalence of depression among left ventricular assist device patients, who present with an increased risk of suicidality given access to means via the device either with nonadherence or disconnection. Suicidality via device nonadherence/disconnection is an underresearched clinical issue, as paradoxically this life-saving procedure can also provide a method of lethal means to patients with significant mental health concerns. A case study is used to highlight the course of an attempted suicide by ventricular assistive device nonadherence. Clinical implications and recommendations for practice include a thorough psychological evaluation presurgery, monitoring quality of life and coping styles before and after placement, psychological testing, outlining specific suicide protocols, psychiatric care considerations for patients with highly specialized medical devices, and related ethical concerns.

Driveline Site Is Not a Predictor of Infection After Ventricular Assist Device Implantation

Driveline infections (DLIs) remain a major source of morbidity for patients requiring long-term ventricular assist device (VAD) support. We aimed to assess whether VAD driveline exit site (DLES) (abdomen versus chest wall) is associated with DLI. All adult patients who underwent insertion of a HeartWare HVAD or HeartMate II (HMII) between 2009 and 2016 were included. Driveline infection was defined as clinical evidence of DLI accompanied by a positive bacterial swab and need for antibiotics. Competing risks analysis was used to assess the association between patient characteristics and DLI. Ninety-two devices (59 HMII) were implanted in 85 patients (72 men; median age 57.4 years) for bridge to transplant or destination therapy. VAD DLES was chest in 28 (30.4%) devices. Median time on VAD support was 347.5 days (IQR 145.5, 757.5), with 28 transplants and 29 deaths (27 on device). DLI occurred in 24 patients (25 devices) at a median of 140 days (IQR 67, 314) from implant. Staphylococcus aureus accounted for 15 infections (60%). Freedom from infection was 72.8% (95% confidence interval [CI] 53.1-78.0%) at 1 year and 41.9% (95% CI 21.1-61.5%) at 3 years. In competing risks regression, abdominal DLES was not predictive of DLI (hazard ratio, HR 1.65 [95% CI 0.63, 4.29]), but body mass index (BMI) >30 kg/m was (HR 2.72 [95% CI 1.25, 5.92]). In conclusion, risk of DLI is high among patients on long-term VAD support, and a nonabdominal DLES does not reduce this risk. The only predictor of DLI in this series was an elevated BMI.

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.

Algorithms to guide ambulance clinicians in the management of emergencies in patients with implanted rotary left ventricular assist devices

Advances in left ventricular assist device (LVAD) therapy have resulted in increasing numbers of adult LVAD recipients in the community. However, device failure, stroke, bleeding, LVAD thrombosis and systemic infection can be life-threatening emergencies. Currently, four LVAD systems are implanted in six UK transplant centres, each of which provides device-specific information to local emergency services. This has resulted in inconsistent availability and content of information with the risks of delayed or inappropriate decision-making. In order to improve patient safety, a consortium of UK healthcare professionals with expertise in LVADs developed universally applicable prehospital emergency algorithms. Guidance was framed as closely as possible on the standard ABCDE approach to the assessment of critically ill patients.

The Ventricular Assist Device in the Life of the Child: A Phenomenological Pediatric Study

What is it like for a child to live with an artificial heart? The use of some medical therapies in children requires developmental considerations, is associated with psychosocial consequences, and calls for ethical sensitivities. A critical case is the ventricular assist device (VAD), a mechanical pump used to support the functioning of a failing heart. As a pediatric therapy, the device can be used as a temporary solution for poor heart function, a bridge to transplantation or recovery, or as a destination therapy. While the mechanical-technical operation of the VAD is well understood, the clinical-technical aspects of young people living with this device are largely unexplored. Drawing on interviews of school-aged children, the aim of this phenomenological study is to explore how a VAD may structure or condition a child's meaningful experience of their world outside the hospital. The driveline of an implanted VAD is the peripheral attachment, extruding through the skin to connect the controller-power supply. The materiality of the device may be interruptive, restrictive, and disturbing to the psycho-physical being and sense of self-identity of the child as a child. And while a child equipped with a VAD is not necessarily conspicuous among other children, the child may experience the device as an exposing presence, while living with the worry of a caregiver who takes on the role not simply of parent but of watchful health professional. A phenomenological understanding of the VAD should assist parents and caregiving health professionals knowing how to deal with specific issues arising in the life of the VAD child.

Psychiatric Aspects of Organ Transplantation in Critical Care: An Update

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

Patient perspectives about depressive symptoms in heart failure: a review of the qualitative literature

BACKGROUND

Scientists have systematically established the prevalence and the consequences of depressive symptoms in patients with heart failure (HF). However, a comprehensive understanding of patient perspectives about depressive symptoms, in combination with HF, has not been published. A patient-centered approach may support the design of interventions that are effective and acceptable to patients with HF and depressive symptoms.

OBJECTIVE

The aim of this study was to review qualitative findings about patient perspectives of contributing factors, associated symptoms, consequences, and self-care strategies used for depressive symptoms in HF.

METHODS

Qualitative studies were included if they were published between 2000 and 2012, if they were in English, and if they described emotional components about living with HF. Three electronic databases were searched using the key words heart failure, qualitative, and depression or psychosocial or stress or emotional.

RESULTS

Thirteen studies met the inclusion criteria. Patients with HF reported that financial stressors, overall poor health, past traumatic life experiences, and negative thinking contributed to depressive symptoms. The patients described cognitive-affective symptoms of depression and anxiety but not somatic symptoms of depression. Perceived consequences of depressive symptoms included hopelessness, despair, impaired social relationships, and a decreased ability to engage in HF self-care. Recommended management strategies consisted of enhanced social support and cognitive strategies.

CONCLUSIONS

Depressive symptoms in patients with HF were associated with a number of contributing factors, including those not specifically related to their disease, and serious consequences that reduced their self-care ability. Nonpharmacological management approaches to depressive symptoms that include improved social support or cognitive interventions may be effective and acceptable strategies.

Existential Psychotherapy With a Person Who Lives With a Left Ventricular Assist Device and Awaits Heart Transplantation

This is a case report about long-term existential psychotherapy with a person who lived with a ventricular assist device after a fulminant heart attack and who awaited heart transplantation. The therapeutic relationship lasted over 2.5 years with over 120 therapy sessions in total. The frequency of meetings was flexible. Most meetings took place in the therapy office at the hospital, with 50 minutes per session on a weekly basis. In the acute care phase and in a subsequent crisis, this frequency was increased to daily meetings in the inpatient unit. Using heuristic inquiry as a methodological approach, a co-constructed case report was generated, including verbatim transcript from recorded therapy sessions. Core existential-humanistic themes are highlighted and discussed against the background of the underlying theory.

Prospective, multicenter study of ventricular assist device infections

BACKGROUND

Ventricular assist devices (VADs) improve survival and quality of life in patients with advanced heart failure, but their use is frequently complicated by infection. There are limited data on the microbiology and epidemiology of these infections.

METHODS AND RESULTS

One hundred fifty patients scheduled for VAD implantation were enrolled (2006-2008) at 11 US cardiac centers and followed prospectively until transplantation, explantation for recovery, death, or for 1 year. Eighty-six patients (57%) received HeartMate II devices. Data were collected on potential preoperative, intraoperative, and postoperative risk factors for infection. Clinical, laboratory, and microbiological data were collected for suspected infections and evaluated by an infectious diseases specialist. Thirty-three patients (22%) developed 34 VAD-related infections with an incidence rate of 0.10 per 100 person-days (95% confidence interval, 0.073-0.142). The median time to infection was 68 days. The driveline was the most commonly infected site (n=28); 18 (64%) were associated with invasive disease. Staphylococci were the most common pathogen (47%), but pseudomonas or other Gram-negative bacteria caused 32% of infections. A history of depression and elevated baseline serum creatinine were independent predictors of VAD infection (adjusted hazard ratio=2.8 [P=0.007] and 1.7 [P=0.023], respectively). The HeartMate II was not associated with a decreased risk of infection. VAD infection increased 1-year mortality (adjusted hazard ratio=5.6; P<0.0001).

CONCLUSIONS

This prospective, multicenter study demonstrates that infection frequently complicates VAD placement and is a continuing problem despite the use of newer, smaller devices. Depression and renal dysfunction may increase the risk of VAD infection. VAD infection is a serious consequence because it adversely affects patient survival.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT01471795.

Miniaturization of mechanical circulatory support systems

Heart failure (HF) is increasing worldwide and represents a major burden in terms of health care resources and costs. Despite advances in medical care, prognosis with HF remains poor, especially in advanced stages. The large patient population with advanced HF and the limited number of donor organs stimulated the development of mechanical circulatory support (MCS) devices as a bridge to transplant and for destination therapy. However, MCS devices require a major operative intervention, cardiopulmonary bypass, and blood component exposure, which have been associated with significant adverse event rates, and long recovery periods. Miniaturization of MCS devices and the development of an efficient and reliable transcutaneous energy transfer system may provide the vehicle to overcome these limitations and usher in a new clinical paradigm in heart failure therapy by enabling less invasive beating heart surgical procedures for implantation, reduce cost, and improve patient outcomes and quality of life. Further, it is anticipated that future ventricular assist device technology will allow for a much wider application of the therapy in the treatment of heart failure including its use for myocardial recovery and as a platform for support for cell therapy in addition to permanent long-term support.

Ethical challenges with deactivation of durable mechanical circulatory support at the end of life: left ventricular assist devices and total artificial hearts

Left ventricular assist devices (LVADs) and total artificial hearts (TAHs) are surgically implanted as permanent treatment of unrecoverable heart failure. Both LVADs and TAHs are durable mechanical circulatory support (MCS) devices that can prolong patient survival but also alter end-of-life trajectory. The permissibility of discontinuing assisted circulation is controversial because device deactivation is a life-ending intervention. Durable MCS is intended to successfully replace native physiological functions in heart disease. We posit that the presence of new lethal pathophysiology (ie, a self-perpetuating cascade of abnormal physiological processes causing death) is a central element in evaluating the permissibility of deactivating an LVAD or a TAH. Consensual discontinuation of durable MCS is equivalent with allowing natural death when there is an onset of new lethal pathophysiology that is unrelated to the physiological functions replaced by an LVAD or a TAH. Examples of such lethal conditions include irreversible coma, circulatory shock, overwhelming infections, multiple organ failure, refractory hypoxia, or catastrophic device failure. In all other situations, deactivating the LVAD/TAH is itself the lethal pathophysiology and the proximate cause of death. We postulate that the onset of new lethal pathophysiology is the determinant factor in judging the permissibility of the life-ending discontinuation of a durable MCS.

Lifestyle adjustments of adults with long-term implantable left ventricular assist devices: a phenomenologic inquiry

OBJECTIVE

To explore and describe the lifestyle adjustments made by adult recipients of a long-term implantable left ventricular assist device (LVAD).

METHODS

A phenomenologic inquiry was used to uncover the lifestyle adjustments of 7 men and 2 women, ages 31 to 70 years, who had an LVAD for more than 3 months after hospital discharge.

RESULTS

An overarching theme, "adjustment takes time," represents the lifestyle adjustments of the study participants. Early adjustment was highlighted by participants' concerns with physical, psychologic, and environmental aspects, whereas late adjustment was highlighted by behaviors associated with acceptance of the LVAD as an integral component of their bodies and lives.

CONCLUSION

This study provides insight into the patient's perspective regarding the challenges faced in living with an LVAD. The findings inform health care providers in the acute and critical care settings in assisting patients to positively adjust with the lifestyle imposed by an LVAD.