Psychological difficulties of LVAD patients and caregivers: A follow up over 1 year from discharge

The Pivotal Role of an Early Post-Acute Cardiac Rehabilitation as an Evidence-Based Management of Left Ventricular Assist Device Patients

BACKGROUND

Left Ventricular Assist Device (LVAD) implantation is an important treatment option for patients with advanced CHF. Referral to an early, intensive cardiac rehabilitation (CR) program in these patients seems still underused. This observational descriptive study aimed to evaluate the feasibility and efficacy of an early intensive CR program in LVAD recipients, also comparing results with a matched group of advanced HFrEF patients.

METHODS

The study involved patients with LVAD implantation due to HFrEF who were admitted to our intensive post-acute CR program from several surgery wards from 2009 to 2023. They underwent a twice-a-day individualized exercise program and physiotherapeutic treatment, according to clinical stability and functional assessment. The study exclusively focused on the in-hospital rehabilitation period and documented cardiac and non-cardiac complications, including the Hemocompatibility-Related Adverse Events (HRAEs). The Barthel index (BI) was used to assess functional recovery from admission to discharge. Results in a subgroup of 210 LVAD patients matched on a 1:1 basis with an HFrEF population were also analyzed.

RESULTS

One patient died during the inward rehabilitation period (respiratory failure). The majority (70.0%) of patients improved their disability (BI 67 ± 24 to 84 ± 23, p < 0.001). HRAEs occurred in 25 patients (9.1%). Compared to the HFrEF group, LVAD patients showed similar improvement in disability (p = 0.54).

CONCLUSIONS

The study suggests that an early intensive post-acute CR program can significantly improve functional capacity and disability in LVAD patients, similar to HFrEF patients admitted to the same program. Our data support scientific recommendations suggesting participation of LVAD to a CR.

Evolving Paradigms in Home Left Ventricular Assist Device Therapy - Reducing Caregiver Burden in the Era of Advanced Technology

BACKGROUND

In Japan, caregiver presence 24 h/day, 7 days a week is required for patients with left ventricular assist devices (LVADs) during the first 6 months after discharge, with ongoing cohabitation recommended thereafter. This study evaluated the incidence of LVAD pump stoppages during home care, the role of caregivers in preventing adverse events, and the need for continuous caregiver support.

METHODS AND RESULTS

A retrospective analysis was conducted on 264 patients who underwent LVAD implantation between 2010 and 2023 and were managed at home. In all, 116 power loss incidents were documented, with 65 leading to pump stoppages. Notably, no stoppages occurred in patients using the EVAHEART or HeartMate 3 devices, which are equipped with backup battery systems. Of the 65 stoppages, 83% were resolved by patients and only 6% required caregiver intervention. The Zarit Burden Interview revealed a mean caregiver burden score of 30.1, comparable to that of caregivers for patients with severe brain damage.

CONCLUSIONS

The burden experienced by caregivers of LVAD patients is substantial, but with the advent of advanced devices like the HeartMate 3, the need for caregiver support 24 h/day, 7 days a week may be reconsidered. The findings of this study suggest that continuous caregiver presence may not be essential for all LVAD patients, potentially easing the burden on caregivers.

The experience of bodily image for patients with left ventricular assist device

Introduction

Mechanical Cardiac Support and Left Ventricular Assist Devices (LVAD) have been demonstrated to prolong Heart Failure patients' survival and improve their quality of life. LVAD implantation has a considerable effect on patients' body image. Patients find it hard to accept the device as an extension of their body, especially the driveline. The study aimed to examine the relationships between anxiety and depressive symptoms, acceptance of illness, beliefs about pain control, and quality of life with body image among LVAD-implanted patients.

Methods

The cross-sectional study included 54 conveniently recruited patients who completed the Body Image Scale, SF-12, Acceptance of Illness Scale, Beliefs about Pain Control Questionnaire, NRS, HADS, and demographic and clinical data. Multiple regression analyses examined the associations between the research variable.

Results

The mean Age of the participants was 59.64 (SD=9.63), and 96.3% were men. The mean scores were: Body Image Scale - 28.33 (SD=5,91); Acceptance of Illness Scale - 25.51 (SD=5.92); beliefs about pain control: internal factors - 15.85 (SD=4.96), the influence of physicians - 17.57 (SD=3.15), random events - 14.37(SD=3.32), NRS=2.80(SD=1.86), HADS anxiety - 5.33 (SD=4.12), HADS depression - 4.66 (SD=3.10), SF12MCS-45.49 (SD=6.48), SF-12PCS-41,33 (SD=6.48). The presence of anxiety and depressive symptoms and complications after LVAD significantly predicted low body image concerns.

Discussion

Healthcare professionals should be aware of challenges regarding body image faced by LVAD-implanted patients and address related factors, especially anxiety and depression.

Outcomes of Left Ventricular Assist Devices as Destination Therapy: A Systematic Review with Meta-Analysis

BACKGROUND

Heart failure (HF) is a chronic condition that significantly affects morbidity and mortality. For patients with end-stage HF who are not candidates for heart transplantation, left ventricular assist devices (LVADs) provide mechanical circulatory support as a long-term solution, known as destination therapy (DT).

OBJECTIVE

This meta-analysis aims to synthesize evidence on the survival rates, complications, and quality-of-life improvements associated with LVADs used as destination therapy in patients with end-stage HF.

METHODS

A systematic search of databases, including PubMed, Embase, Cochrane Library, Web of Science, and Scopus, was conducted to identify relevant studies. Studies were selected based on predefined inclusion and exclusion criteria. Data from 12 studies were extracted and analyzed using a random-effects model. Survival rates, complications (e.g., infection and bleeding), and quality-of-life measures were the primary outcomes evaluated.

RESULTS

The analysis showed significant improvements in survival, with a pooled effect size of 0.848 (95% CI: 0.306-1.390, p = 0.002). Complication rates varied, with infections and bleeding being the most common adverse events. Quality of life also improved significantly post-LVAD implantation, with a standardized mean difference of 0.78 (95% CI: 0.65-0.91).

CONCLUSIONS

LVADs as destination therapy provide a viable option for improving the survival and quality of life of end-stage HF patients, despite the associated risks of complications. Further research is needed to refine patient selection and management strategies to optimize outcomes.

Development and validation of a questionnaire on bodily experience in VAD patients (BE-S)

BACKGROUND

Little is known about the disturbance in bodily experience (BE) following ventricular assist device (VAD) implantation. The level of disturbance in BE serves as an indicator of the status of the patients' adaptation process to the device. This process encompasses coping with both the more affective, psychological conflicts and the more cognitive, practical challenges of living with the VAD. To provide an economical screening tool for everyday clinical practice, we refined and validated a questionnaire on BE in VAD patients.

METHODS

Seven specific items were derived from clinical experience and presented to 365 VAD patients (85% male; time since implantation: 3-36 months). The item structure was examined using factor analyses and probabilistic test theory. Discriminant validity and change sensitivity were determined in relation to associated psychometric instruments.

RESULTS

Four items were found to constitute the unidimensional bodily experience scale (BE-S). Besides a high internal consistency of the scale (ω = 0.86), the RMSEA of >0.01 indicates a very good model fit. The BE-S has high convergent validity with related constructs (Hospital Anxiety and Depression Scale, Kansas City Cardiomyopathy Questionnaire). Change sensitivity analyses proved the BE-S alone to be significantly sensitive to the temporal dynamics of psychological adaptation processes following VAD implantation.

CONCLUSION

The BE-S constitutes a valid and economical tool for clinical practice to assess patients' disturbance in BE after VAD implantation. It is a valuable tool for identifying patients with difficulties in adapting to the VAD. Subsequently, it enables early and focused therapeutic support for these patients at risk.

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.

Association between psychosocial factors and left ventricular assist device implant outcomes: A systematic review

BACKGROUND

Psychosocial assessment is a core component of the multidisciplinary evaluation for left ventricular assist device (LVAD) implantation. The degree to which psychosocial conditions are considered a contraindication to LVAD implantation continues to be debated. This systematic review examines modifiable psychosocial factors as predictors of outcomes in patients undergoing LVAD implantation.

METHODS

We conducted a systematic review following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. The search resulted in 2509 articles. After deduplication, abstract and full-text review, 20 relevant articles were identified.

RESULTS

Included studies evaluated socioeconomic status (n = 6), caregiver characteristics (n = 6), non-adherence (n = 6), substance use (n = 13), and psychiatric disorder (n = 8). The most commonly measured outcomes were all-cause death, readmission rate, and adverse events. Studies varied widely in definition of each psychosocial factor and selected outcomes. No psychosocial factor was consistently associated with a specific outcome in all studies. Socioeconomic status was generally not associated with outcomes. Non-adherence, psychiatric disorder, and substance use were associated with higher risks of mortality, adverse events, and/or readmission. Findings on caregiver characteristics were mixed.

CONCLUSION

Of the psychosocial factors studied, non-adherence, psychiatric disorder, and substance use were the most consistently associated with an increased risk of mortality, readmission, and/or adverse events. Heterogeneity in research methodology and study quality across studies precludes firm conclusions regarding the impact of psychosocial factors on long-term patient outcomes. The results of this review reveal a need for adequately powered studies that use uniform definitions of psychosocial factors to clarify relationships between these factors and outcomes after LVAD implantation.

Long-term quality of life, psychological distress, and caregiver burden in octogenarians with LVAD: A single-centre experience

With the general population aging, both life expectancy and the number of left ventricular assist device (LVAD) implantations in elderly patients are growing. Nevertheless, their perceived long-term quality of life, including psychological aspects, coupled with the respective caregiver's burden, remain under-reported. In light of the rising number of octogenarians with LVAD who necessitate broader healthcare provider involvement, we assessed the long-term quality of life, as defined by both the 36-item short-form health (SF-36) survey and the EuroQol 5 dimensions, 5-level questionnaire (EQ-5D-5L)-including the visual analog scale-in octogenarian LVAD patients who had received treatment at our institution. Additionally, we evaluated the psychological health of octogenarian LVAD patients using the psychological general well-being index (PGWBI), alongside their caregivers' well-being through the 22-item version of the Zarit Burden Interview (ZBI). Of 12 octogenarian LVAD patients, 5 were alive and willing to answer questionnaires. Mean age at implant was 74 ± 2 years. Median follow-up was 2464 (IQR = 2375-2745) days. Although variable, the degree of health and psychological well-being perceived by octogenarian patients with LVAD was "good." Interestingly, the burden of assistance reported by caregivers, though relevant, was greatly varied, suggesting the need to better define and address psychological long-term aspects related to LVAD implantation for both patients and caregivers with a broad-spectrum approach.

Person with Heart Failure and Care Partner Dyads: Current Knowledge, Challenges, and Future Directions: State-of-the-Art Review

Over the past decade, there has been substantial growth in heart failure (HF) research that focuses on persons with HF and their care partners (family members or other close friends that provide unpaid support) as an interdependent team, or care dyad. In this state-of-the-art review, we use a dyadic lens to identify and summarize current research on HF care dyads, from qualitative studies, to nonexperimental quantitative studies, to randomized controlled trials. Although much work has been done, this literature is younger and less well-developed than care dyad literatures from other conditions (eg, cancer, Alzheimer's disease). We discuss the substantial challenges and limitations in this body of work, with an eye toward addressing common issues that impact rigor. We also look toward future directions, and discuss the promise dyadic research holds for improving patient, care partner, and relationship health.

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.

Self-care behaviours of patients with left ventricular assist devices in Israel: changes during the COVID-19 pandemic

AIMS

Left ventricular assist devices (LVADs) support the hearts of patients with advanced heart failure. Following LVAD implantation, patients face a complex regimen of self-care behaviours including self-care maintenance, self-care monitoring and self-care management. However, during the COVID-19 pandemic, symptoms of anxiety and depression may have interfered with their self-care. Currently, little is known on how specific self-care behaviours of LVAD-implanted patients changed during the COVID-19 pandemic. We aim to describe the changes in self-care behaviours among patients with an implanted LVAD in Israel during the COVID-19 pandemic and explore the factors related to self-care behaviour change.

METHODS

A prospective observational cross-sectional study design. A convenience sample of 27 Israeli LVAD-implanted patients (mean age 62.4 ± 9, 86% male, 78.6% living with a partner) completed the LVAD Self-Care Behaviour Scale (1 = never to 5 = always) and Hospital Anxiety and Depression Scale (0 = not at all to 3 = most of the time). Data were collected before and after the onset of the COVID-19 pandemic in Israel. Statistical analyses included paired t-tests, Pearson's correlations, and one-way repeated measures ANOVAs.

RESULTS

During the COVID-19 pandemic, a significant decrease was found in patients' adherence to checking and recording their LVAD speed, flow, power and PI (Pulsatility Index) (P = 0.05), checking their INR (P = 0.01), and daily weighing (P < 0.01). The prevalence of some behaviours (e.g. regularly exercising) increased in some patients and decreased in others. Patients living without a partner worsened their adherence to some of the self-care behaviours (e.g. taking medicines as prescribed), compared with those living with a partner (M_b  = 5.0 ± 0 and M_d  = 5.0 ± 0, delta = 0 vs. M_b  = 5.0 ± 0 and M_d  = 4.6 ± 0.9, delta = -0.4, respectively; F = 4.9, P = 0.04). Women, and not men, tended to improve their adherence to the self-care behaviour such as avoiding kinking, pulling, or moving the LVAD driveline at the exit site (M_b  = 4.0 ± 1.0 and M_d  = 5.0 ± 0, delta = 1.0 vs. M_b  = 4.5 ± 0.9 and M_d  = 4.4 ± 1.2, delta = -0.1, F = 4.7, P = 0.04, respectively). In total, 41% (11) patients reported neither anxiety nor depression, 11% (3) reported anxiety, 15% (4) reported depression, and 44% (12) reported both anxiety and depression. No associations between anxiety and/or depression and self-care behaviours were found.

CONCLUSIONS

Priorities in self-care behaviours among patients with implanted LVAD changed after the onset of the COVID-19 pandemic. Factors that assisted with adherence to self-care behaviours included living with a partner and being female. The current results may guide further research on identifying behaviours that are at risk of not being maintained during a time of emergency.

“The heart in a bag”: The lived experience of patient-caregiver dyads with left ventricular assist device during cardiac rehabilitation

Objective

The Left Ventricular Assist Device (LVAD) has increasingly become a primary therapeutic option for longer-waiting heart transplant lists. Although survival rates are growing, the device requires complex home care. Therefore, the presence of a caregiver trained in the LVAD management is important for the success of the therapy. The LVAD leads both patients and their caregivers to experience new challenges and adapt to new lifestyle changes and limitations – but their subjective beliefs before home management remained little explored.

Design

This study identified, using a phenomenological hermeneutic approach, the main components of the LVAD experience of six patient-caregiver dyads interviewed during cardiac rehabilitation.

Results

We identified 4 master themes: Being between life and death, Being human with a heart of steel, Sharing is caring (and a burden), and Being small and passive.

Conclusion

The knowledge from this study can be used as a guide for healthcare providers in counseling LVAD recipients and their caregivers.

Weight stigma in patients with overweight and obesity: validation of the Italian Weight Self-Stigma Questionnaire (WSSQ)

PURPOSE

This study aimed to explore the factorial structure of the Italian Weight Self-Stigma Questionnaire (WSSQ) (Study1); and to test structural validity, internal consistency, test-retest reliability, and measurement invariance of the questionnaire across gender, Body Mass Index (BMI), age and occurrence of previous hospitalization for obesity (Study2).

METHODS

At admission into a hospital-based program for weight reduction and rehabilitation, 150 inpatients with overweight/obesity (68% females) completed the WSSQ (Study1). In Study2, in addition to the WSSQ, 446 inpatients (61.9% females) completed the Weight Bias Internalization Scale (WBIS), the Body Uneasiness Test (BUT), and the Center for Epidemiologic Studies Depression Scale (CES-D). A subsample of 40 patients also re-completed the WSSQ at discharge from the hospital.

RESULTS

The Italian WSSQ showed good overlap with the original factorial structure (Study1) and results were confirmed in Study2. Test-retest reliability and convergent validity showed adequate values. Measurement invariance revealed that WSSQ was perfectly invariant across both BMI and the occurrence of previous hospitalizations for obesity. In both studies, the internal consistency of the questionnaire was deemed acceptable.

CONCLUSIONS

The Italian WSSQ is a valid, reliable, and invariant tool for the assessment of weight-related self-stigma among patients with overweight/obesity. Future studies should assess its longitudinal invariance as well as its responsiveness to weight reduction treatments.

LEVEL OF EVIDENCE

V, descriptive study.

Top Ten Tips Palliative Care Clinicians Should Know About Solid Organ Transplantation

Solid organ transplantation (SOT) is a life-saving procedure for people with end-stage organ failure. However, patients experience significant symptom burden, complex decision making, morbidity, and mortality during both pre- and post-transplant periods. Palliative care (PC) is well suited and historically underdelivered for the transplant population. This article, written by a team of transplant specialists (surgeons, cardiologists, nephrologists, hepatologists, and pulmonologists), PC clinicians, and an ethics specialist, shares 10 high-yield tips for PC clinicians to consider when caring for SOT patients.