Functional Status One Year After Heart Transplant

Improvements in Functional Status Among Survivors of Orthotopic Heart Transplantation Following High-risk Bridging Modalities

BACKGROUND

The 2018 heart allocation change has resulted in greater frequency of high-risk bridging to orthotopic heart transplantation (OHT). Although survival has been studied in these patients, functional status outcomes are less established. This study evaluated changes in functional status of OHT survivors based on bridging strategy.

METHODS

Adults (≥18 y) undergoing OHT between January 2015 and March 2020 were stratified by bridging modality: no bridging, inotropes only, intra-aortic balloon pump (IABP), temporary ventricular assist device (VAD), durable VAD, and extracorporeal membrane oxygenation (ECMO). Using paired analysis, the Karnofsky performance scale (0-100) was utilized to compare differences in function at listing, transplant, and follow-up.

RESULTS

In total, 13 142 patients underwent OHT. At the time of both listing and transplant, patients requiring IABP, temporary VAD, and ECMO displayed the lowest functional status (each median 20) compared with other groups (P < 0.001). Among survivors, the median performance status at follow-up was ≥80 for all groups, indicating total functional independence with no assistance required. Substantial improvement in Karnofsky score occurred from transplant to follow-up in survivors bridged with IABP (40), temporary VADs (60), and ECMO (50) (each P < 0.001). Among survivors with at least 90-day follow-up, the median Karnofsky score was 90 regardless of bridging modality.

CONCLUSIONS

Despite a higher mortality risk, critically ill patients who survive OHT after bridging with high-risk modalities experience acceptable functional status outcomes. These findings are important to place in the context of the impact that the 2018 allocation change has had on the landscape of OHT in the United States.

Self-efficacy, recovery and psychological wellbeing one to five years after heart transplantation: a Swedish cross-sectional study

BACKGROUND

Self-efficacy refers to a person´s confidence in carrying out treatment-related activities and constitutes the foundation of self-management as well as long-term follow-up after heart transplantation. Exploring the heart recipients´ experiences by means of self-report instruments provides healthcare professionals with valuable information on how to supply self-management support after heart transplantation.

AIMS

The aim was to explore self-efficacy in relation to the self-reported level of recovery and psychological wellbeing, among adult heart recipients, one to 5 years after transplantation.

METHODS

This cross-sectional study includes 79 heart recipients, due for follow-up one to 5 years after transplantation. Three different self-assessment instruments were employed: the self-efficacy for managing chronic disease 6-item scale; the postoperative recovery profile; and the psychological general wellbeing instrument.

RESULTS

The reported level of self-efficacy was high (median 8.3, maximum score 10). Significantly higher self-efficacy was seen among those who had returned to work (P = 0.003) and those without pre-transplant mechanical circulatory support (P = 0.033). In total, 65.5% (n = 52) reported being reasonably recovered, while 18.8% (n = 12) were not recovered. The median total psychological general wellbeing score was 108 (P25 = 24, P75 = 117), suggesting overall good psychological wellbeing in the whole group of heart recipients.

CONCLUSION

The heart transplant recipients in our study had an overall high level of self-efficacy. Low self-efficacy was found among those with a low self-reported level of recovery, pre-transplant treatment with mechanical circulatory support or who had not returned to work. This is important information for transplant professionals when helping heart recipients to balance their expectations about recovery.

Periodontal status and dental behaviour of heart transplant recipients and healthy controls

Objective: The aim of this study was to compare the periodontal status and dental behaviour of heart transplant recipients with systemically healthy controls.Material and Methods: Forty heart transplant recipients and 40 systemically healthy patients were included. A questionnaire was used to record demographic, systemic health and dental behaviour data, and the following clinical parameters were recorded: plaque index, bleeding on probing, probing depth, gingival recession, and clinical attachment level.Results: Mean probing depth (p = .045), mean gingival recession (p = .016), mean clinical attachment level (p = .021) and mean plaque index scores (p = .001) were higher in heart transplant recipients than the systemically healthy group. However, bleeding on probing was similar in both groups (p > .05). Tooth brushing frequency and number of participants who used dental floss/interdental brush was lower in the heart transplant group.Conclusion: Considering the poor oral hygiene and high clinical periodontal parameters of heart transplant recipients, periodontal evaluation should be done regularly before and after transplantation. The patient's daily oral hygiene regimens should be evaluated carefully in this evaluation session and modified based on their gingival health, manual skill and motivational levels. The importance of oral health and its effects on systemic health should also be explained to the transplant recipients in detail.

Oral health status of adult heart transplant recipients in China: A cross-sectional study

Limited information on the oral health status of adult heart transplant recipients (HTRs) is known, and no available data exist in China. A prerequisite dental evaluation is usually recommended for patients' postorgan transplantation because lifelong immunosuppression may predispose them to infection spread.The aim of this study was to investigate the oral health status of Chinese adult HTRs and determine the association between oral health status and history of heart transplantation (HT).We carried out a cross-sectional study to collect clinical, demographic, socioeconomic, and behavioral data from 81 adult patients who received heart transplantation during 2014 to 2015 in China. Clinical examinations for the presence of dental plaque, dental calculus, dental caries, and periodontal health conditions were performed in a standardized manner by one trained examiner. Sociodemographic, socioeconomic, and behavioral data were self-reported using questionnaires. The prevalence of the above conditions was compared with 63 age- and sex-matched controls. General liner regression analysis was used to assess associations between mean number of decayed, missing, and filled teeth (DMFT) and mean community periodontal index of treatment needs (CPITN) scores and history of heart transplant.Mean age of the HT group was 47.7 ± 12.2 years and men accounted for 69.1% of the sample. The overall median DMFT score in the HT group was 3 (1-5) and caries prevalence was 80.2%, which were similar to the control group (P > .05). The overall mean CPITN score of the HT group was 1.84, which was significantly higher than the control group (1.07, P = .001). Participants in the HT group had worse oral hygiene status and more teeth with probing depth ≥ 4 mm than controls (P = .043). Compared with participants who had no history of heart transplantation, HTRs presented worse periodontal health conditions (mean CPITN score, adjusted odds ratio (OR) = 1.39, 95% confidence interval (CI) = 1.12-1.71, P = .003) and similar dental caries status (DMFT score, adjusted OR = 0.58, 95% CI = 0.37-0.91, P = .058).Periodontal health status was positively associated with history of heart transplantation in Chinese adult HTRs.

Long-term outcomes and management of the heart transplant recipient

Cardiac transplantation remains the gold standard in the treatment of advanced heart failure. With advances in immunosuppression, long-term outcomes continue to improve despite older and higher risk recipients. The median survival of the adult after heart transplantation is currently 10.7 years. While early graft failure and multiorgan system dysfunction are the most important causes of early mortality, malignancy, rejection, infection, and cardiac allograft vasculopathy contribute to late mortality. Chronic renal dysfunction is common after heart transplantation and occurs in up to 68% of patients by year 10, with 6.2% of patients requiring dialysis and 3.7% undergoing renal transplant. Functional outcomes after heart transplantation remain an area for improvement, with only 26% of patients working at 1-year post-transplantation, and are likely related to the high incidence of depression after cardiac transplantation. Areas of future research include understanding and managing primary graft dysfunction and reducing immunosuppression-related complications.

Mortality, rehospitalization, and post-transplant complications in gender-mismatched heart transplant recipients

BACKGROUND

Limited research has been published on outcomes in heart transplant (HT) recipients with gender-mismatched donors.

OBJECTIVE

Compare 3-year post-transplant outcomes in 2 groups of gender-mismatched HT recipients and a no-mismatch group.

METHODS

Sample: 347 HT recipients: 21.3% (74) received a heart from the opposite gender: Group 1: same gender donor/recipient (273, 78.7%); Group 2: female donor/male recipient (40, 11.5%); Group 3: male donor/female recipient (34, 9.8%).

OUTCOMES

mortality, hospitalization, and complications.

RESULTS

Female patients with male heart donors had shorter 3-year survival, were rehospitalized more days after HT discharge, and had more treated acute rejection episodes and cardiac allograft vasculopathy. No differences were found in: HT length of stay, respiratory failure, stroke, cancer, renal dysfunction, steroid-induced diabetes, number of IV-treated infections, or the timing of infection and rejection.

CONCLUSION

Female HT recipients with male donors had worse 3-year outcomes as compared to male-mismatch and no-mismatch groups.

Clinical outcomes in overweight heart transplant recipients

BACKGROUND

Few studies have examined the impact of patient weight on heart transplant (HT) outcomes.

OBJECTIVES

Nine outcomes were compared in 2 groups of HT recipients (N = 347) based on their mean body mass index (BMI) during the first 3 years post-HT.

METHODS

Group 1 consisted of 108 non-overweight patients (BMI <25; mean age 52; 29.6% females; 16.7% minorities). Group 2 consisted of 239 overweight patients (BMI ≥25; mean age 52; 15.9% females; 13.8% minorities). Outcomes were: survival, re-hospitalization, rejections, infections, cardiac allograft vasculopathy (CAV), stroke, renal dysfunction, diabetes, and lymphoma.

RESULTS

Non-overweight patients had shorter survival, were re-hospitalized more days after the HT discharge, and had more lymphoma and severe renal dysfunction. Overweight patients had more CAV, steroid-induced diabetes, and acute rejections.

CONCLUSIONS

Overweight HT patients had better survival, but more rejections, CAV, and diabetes. Non-overweight HT patients had worse survival, plus more re-hospitalization time, lymphoma, and renal dysfunction.

Gender differences in appraisal of stress and coping 5 years after heart transplantation

OBJECTIVES

We examined whether gender differences exist regarding stress, symptom distress, coping, adherence, and social support 5 years after heart transplantation.

BACKGROUND

Differences exist in health-related quality of life outcomes by gender after heart transplantation; women report poorer outcomes.

METHODS

Patients (n = 210, female = 42), were from a prospective, multi-site, study of health-related quality of life long-term after heart transplantation. Patients completed self-report instruments 5 years after heart transplantation (mean = 4.98 ± 0.17 years after transplant). Statistical analyses included two-sample t-tests, Chi-square or Fisher's exact test, and multivariable modeling.

RESULTS

Women did not report more overall stress or symptom distress, but reported more difficulty adhering to the transplant regimen, yet more actual adherence than men. Women reported using more negative coping styles, but reported more satisfaction with social support.

CONCLUSIONS

Gender differences exist regarding appraisal of stress, coping styles, and coping resources long-term after heart transplantation. These differences may guide tailoring therapy regarding stress, poor coping, and lack of resources.

Repercussões no cotidiano dos pacientes pós-transplante cardíaco

Resumo Objetivo Conhecer as repercussões no cotidiano de pacientes submetidos a transplante cardíaco. Métodos Trata-se de estudo descritivo, qualitativo, conduzido em um centro de transplantes do nordeste brasileiro. Nove pacientes submetidos ao transplante cardíaco participaram do estudo, tendo sido utilizada para coleta dos dados a técnica de grupo focal, facilitada em quatro reuniões. Os recortes de suas falas resultaram em duas categorias temáticas: ser transplantado cardíaco - o antes e o depois; e sentimentos e percepções sobre o transplante cardíaco. Resultados A pessoa submetida ao transplante identificou as modificações positivas obtidas após o procedimento, porém ressentiu-se com as inúmeras proibições, com interferência direta em seu cotidiano; as limitações decorrentes do transplante ganharam destaque e não permitiram que os pacientes se sentissem realmente curados. Conclusão Os participantes reconheceram o transplante cardíaco como uma solução para seus sintomas clínicos, contudo, com significativa perda de autonomia, obrigando-os a um intenso esforço adaptativo.

Quality of life and metrics of achievement in long-term adult survivors of pediatric heart transplant

Many children who undergo heart transplantation will survive into adulthood. We sought to examine the QOL and capacity for achievement in long-term adult survivors of pediatric heart transplantation. Adults >18 yr of age who received transplants as children (≤18 yr old) and had survived for at least 10 yr post-transplant completed two self-report questionnaires: (i) Ferrans & Powers QLI, in which life satisfaction is reported as an overall score and in four subscale domains and is then indexed from 0 (very dissatisfied) to 1 (very satisfied); and (ii) a "Metrics of Life Achievement" questionnaire regarding income, education, relationships, housing status, and access to health care. A total of 20 subjects completed the survey. The overall mean QLI score was 0.77 ± 0.16. Subjects were most satisfied in the family domain (0.84 ± 0.21) and least satisfied in the psychological/spiritual domain (0.7 ± 0.28). Satisfaction in the domains of health/functioning and socioeconomic were intermediate at 0.78 and 0.76, respectively. Most respondents had graduated from high school, reported a median annual income >$50 000/yr, and lived independently. Adult survivors of pediatric heart transplant report a good QOL and demonstrate the ability to obtain an education, work, and live independently.

Factors associated with stress and coping at 5 and 10 years after heart transplantation

BACKGROUND

Heart transplant-related stressors and coping are related to poor outcomes early after transplant. The purposes of our study were to (1) identify the most frequent and bothersome stressors and most used and effective coping strategies and (2) compare the most frequent and bothersome stresses and most used and effective coping styles between patients at 5 and 10 years after heart transplantation. We also examined differences in coping styles by patient characteristics and factors associated with frequency and intensity of stress at 5 and 10 years after heart transplantation.

METHODS

This report is a secondary analysis of data from a prospective, multisite study of quality of life outcomes. Data are from separate cohorts of 199 patients at 5 years after transplant and 98 patients at 10 years. Patients completed the Heart Transplant Stressor Scale and Jalowiec Coping Scale. Statistical analyses included frequencies, measures of central tendency, t-tests, chi-square, and generalized linear models.

RESULTS

At 5 and 10 years after heart transplantation, the most bothersome stressors were regarding work, school, and financial issues. Patients who were 10 years after transplant reported less stress, similar stress intensity, and less use and perceived effectiveness of negative coping than patients who were 5 years after transplant. Long-term after transplant, demographic characteristics, psychologic problems, negative coping, and clinical factors were related to stress frequency and/or intensity.

CONCLUSIONS

Heart transplant-related stress occurs long-term after surgery. Types of transplant-related stress and factors related to stress confirm the importance of ongoing psychologic and clinical support after heart transplantation.

Beyond rose colored glasses: the adaptive role of depressive and anxious symptoms among individuals with heart failure who were evaluated for transplantation

The prospect of and the evaluative period for transplantation can be stressful for individuals with heart failure (HF). Little is known about the impact of psychosocial factors on service utilization and health outcomes. The current study examined the impact of depression, dysthymia, and anxiety on two-yr hospitalization and mortality among 96 individuals with HF who were evaluated for transplantation. Results revealed that only a small percentage of individuals endorsed sufficient symptomatology to meet criteria for a psychiatric, Axis I disorder (3.1% = anxiety; 2.1% = depression; 1.0% = dysthymia) although a significant proportion of the sample was prescribed an antidepressant or an anxiolytic (37%). Multivariable regression analysis was conducted to examine the association between significant independent demographic, medical, and psychiatric predictors and total duration of hospitalizations; logistic regression analysis was used to examine the relation between predictors and mortality. An increase in anxious symptoms was associated with a decrease in total number of days hospitalized during the two-yr period following the initial evaluation. Similarly, as depressive symptoms increased, risk of two-yr mortality decreased. Future research should assess communication between the patient and providers to further elucidate the potential relationship between psychiatric symptoms, service utilization/hospitalization, and mortality in this patient population.

Health-related quality of life in long-term survivors after heart and lung transplantation: a prospective cohort study

BACKGROUND

Health-related quality of life (HRQoL) represents an important outcome measure to assess the success of transplantation in the long term. This study evaluated HRQoL in heart (HTx) and lung (LTx) transplant survivors, and assessed potential outcome-related predictors from before to 5 years after transplantation.

METHODS

Study participants (n=170) were prospectively followed up from before to 5 years after HTx (n=82) or LTx (n=88), including HRQoL assessments (pretransplantation, 6, 12, and yearly between 24 and 60 months) using the Short Form-36, employment status index, and monitoring of adverse events.

RESULTS

Patient groups (HTx vs. LTx) differed with respect to gender (men 74% vs. 48%; P<0.03) and high-urgency waiting status (72% vs. 45%; P<0.0001). Both cohorts showed the most significant HRQoL improvements within the first year posttransplant (P<0.0001), and relatively stable conditions afterward. Marital (P<0.01) and employment status (P<0.01) impacted HRQoL in both groups. The incidence of bronchiolitis obliterans showed significantly lower HRQoL in LTx patients (29.3%; P<0.005).

CONCLUSIONS

HTx and LTx patients benefit from the transplant procedure with respect to HRQoL improvements for at least 5 years posttransplant; however, their trajectories during this time interval differ. Further research on organ-type-related predictors of HRQoL is necessary for the development of tailored psychosocial interventions.

Gender and age differences in symptom distress and functional disability one year after heart transplant surgery

OBJECTIVE

Symptoms and functional status are major concerns for heart transplant (HT) recipients. The study objective was to examine gender and age differences in symptom distress and functional disability 1 year after HT surgery.

METHODS

The sample (N = 237) consisted of 44 female and 193 male patients who were divided into younger (n = 66) and older (n = 171) groups with the breakpoint at age 50 years. Data from chart review and 2 questionnaires (Heart Transplant Symptom Checklist and Sickness Impact Profile) were analyzed with chi-square test, t tests, analysis of variance, and multivariate analysis of variance.

RESULTS

Women reported worse symptom distress (overall, plus cardiovascular, gastrointestinal, dermatologic symptoms) and more functional disability (overall, plus disability in ambulation, mobility, self-care, home management). Older patients reported more disability in ambulation and work. Gender by age interactions showed that older men reported worse genitourinary symptoms and younger women reported worse dermatologic symptoms.

CONCLUSION

There were more gender than age differences in symptoms and disability.

Symptom frequency and distress from 5 to 10 years after heart transplantation

BACKGROUND

Patterns of symptom frequency and distress have not been examined long-term after heart transplantation, nor have predictors of long-term symptom frequency and distress. This report identified the most commonly reported and distressful symptoms long-term after transplantation, described patterns of symptom frequency and distress over time, and examined predictors of symptom frequency and distress at 5 and 10 years after heart transplantation.

METHODS

The sample included 555 participants from a prospective, multisite, longitudinal study of quality of life outcomes. Patients were 78% male, 88% white, 79% married, and mean age of 54 years at time of heart transplantation. Data were collected using patient self-report and medical records review. Statistical analyses included descriptive statistics, Pearson correlations, t-tests, and generalized linear models.

RESULTS

Significant predictors of lower symptom frequency after heart transplantation were not having psychological problems and not having cardiac allograft vasculopathy at 5 years, and not having psychological problems and not having infection at 10 years. Significant predictors of less symptom distress were having more than a high school education, having no psychological problems, and having gout at 5 years, and being married at 10 years.

CONCLUSIONS

Symptom frequency is low and symptom distress is moderate long-term after heart transplantation. Significant relationships exist between both demographic and clinical variables and symptom frequency and distress. Identification of the most common and bothersome symptoms after heart transplantation provides clinicians with important information from which to develop a plan of care.

Patterns and predictors of physical functional disability at 5 to 10 years after heart transplantation

BACKGROUND

Researchers have not examined relationships between perception of physical functional disability and demographic, clinical, and psychological variables at 5 to 10 years after heart transplantation. Therefore, the purposes of this study were to describe physical functional disability over time and identify predictors of physical functional disability from 5 to 10 years after heart transplantation.

METHODS

The study enrolled 555 patients who were between 5 and 10 years post-heart transplant (age, 54 +/- 9 years; 78% male, 88% white, 79% married). Patients completed 6 instruments that measure physical functional disability and factors that may impact physical functional disability. Statistical analyses included calculation of frequencies, means +/- standard deviation (plotted over time), Pearson correlation coefficients, and multiple regression coupled with repeated measures.

RESULTS

Between 5 and 10 years after heart transplantation, physical functional disability was low, and 34% to 45% of patients reported having no functional disability. More physical functional disability was associated with having more symptoms, having depression/mood/negative affect and lower use of negative coping strategies, having more comorbidities and more specific comorbidities (e.g., more orthopedic problems and diabetes); higher New York Heart Association functional class; having more acute rejection, infection, or cardiac allograft vasculopathy; being female, older, less educated, and unemployed; higher body mass index; and more hospital readmissions (explaining 46% of variance [F = 84.75, p < 0.0001]).

CONCLUSIONS

Demographic, clinical, and psychological factors were significantly related to physical functional disability. Knowledge of these factors provides the basis for development of therapeutic plans of care.