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Does cognition improve following LVAD implantation? Gen Thorac Cardiovasc Surg 2018; 66:456-463. [PMID: 29796750 DOI: 10.1007/s11748-018-0947-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/18/2018] [Indexed: 10/16/2022]
Abstract
BACKGROUND Studies of cognition after LVAD surgery have produced mixed results. To explore whether cognition would improve, decline, or remain stable after LVAD surgery, we examined cognition before and 1- and 3-months after LVAD surgery. Patients with post-surgical stroke were excluded. METHODS 28 subjects (mean age = 54.31 ± 12 years) comprised an observational case series from the DuraHeart LVAS device® trial. Cognitive testing was performed at baseline, 1-month, and 3-month post-surgery, and included tests of attention, memory, language, visualmotor speed (TMT) and visualconstruction. RESULTS No difference in cognition was found between baseline and 1-month exams (means z score improvement = 0.06, p = 0.43) but cognition improved significantly between baseline and 3-month exams (mean z score improvement = 0.34, p < 0.00001). Examination of individual test scores found, after correction for multiple comparisons, only the TMT variable was significantly different at the 3-month exam. CONCLUSIONS We found significantly improved cognition 3 months after LVAD surgery in a subset of patients without post-surgical stroke. The reasons for the lack of cognitive improvement at the 1-month post-surgical assessment may include ongoing medical and physiological disruptions in the immediate post-operative period. Further research into the sources of delayed improvement is warranted. Cognitive assessments performed immediately after surgery should be interpreted with caution because the results may not reflect longer term cognitive outcomes. LVAD patients may require additional support to successfully manage their health in the weeks immediately following surgery but assistance needs may decrease over time.
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Weerahandi H, Goldstein N, Gelfman LP, Jorde U, Kirkpatrick JN, Meyerson E, Marble J, Naka Y, Pinney S, Slaughter MS, Bagiella E, Ascheim DD. The Relationship Between Psychological Symptoms and Ventricular Assist Device Implantation. J Pain Symptom Manage 2017; 54:870-876.e1. [PMID: 28807706 PMCID: PMC5705533 DOI: 10.1016/j.jpainsymman.2017.05.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 04/03/2017] [Accepted: 05/09/2017] [Indexed: 02/03/2023]
Abstract
CONTEXT Ventricular assist devices (VADs) improve quality of life in advanced heart failure patients, but there are little data exploring psychological symptoms in this population. OBJECTIVE This study examined the prevalence of psychiatric symptoms and disease over time in VAD patients. METHODS This prospective multicenter cohort study enrolled patients immediately before or after VAD implant and followed them up to 48 weeks. Depression and anxiety were assessed with Patient-Reported Outcomes Measurement Information System Short Form 8a questionnaires. The panic disorder, acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) modules of the Structured Clinical Interview for the DSM were used. RESULTS Eighty-seven patients were enrolled. After implant, depression and anxiety scores decreased significantly over time (P = 0.03 and P < 0.001, respectively). Two patients met criteria for panic disorder early after implantation, but symptoms resolved over time. None met criteria for ASD or PTSD. CONCLUSIONS Our study suggests VADs do not cause serious psychological harms and may have a positive impact on depression and anxiety. Furthermore, VADs did not induce PTSD, panic disorder, or ASD in this cohort.
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Affiliation(s)
- Himali Weerahandi
- Division of General Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Nathan Goldstein
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Laura P Gelfman
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ulrich Jorde
- Division of Cardiology, Montefiore Medical Center, Bronx, New York, USA
| | - James N Kirkpatrick
- Department of Medicine, University of Washington Medicine, Seattle, Washington, USA
| | - Edith Meyerson
- Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Judith Marble
- Department of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoshifumi Naka
- Department of Surgery, College of Physicians and Surgeons, Columbia University, New York, New York, USA
| | - Sean Pinney
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Mark S Slaughter
- Thoracic and Cardiovascular Surgery Division, Department of Surgery, Jewish Hospital Louisville, Louisville, Kentucky, USA
| | - Emilia Bagiella
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Sen A, Larson JS, Kashani KB, Libricz SL, Patel BM, Guru PK, Alwardt CM, Pajaro O, Farmer JC. Mechanical circulatory assist devices: a primer for critical care and emergency physicians. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:153. [PMID: 27342573 PMCID: PMC4921031 DOI: 10.1186/s13054-016-1328-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Mechanical circulatory assist devices are now commonly used in the treatment of severe heart failure as bridges to cardiac transplant, as destination therapy for patients who are not transplant candidates, and as bridges to recovery and “decision-making”. These devices, which can be used to support the left or right ventricles or both, restore circulation to the tissues, thereby improving organ function. Left ventricular assist devices (LVADs) are the most common support devices. To care for patients with these devices, health care providers in emergency departments (EDs) and intensive care units (ICUs) need to understand the physiology of the devices, the vocabulary of mechanical support, the types of complications patients may have, diagnostic techniques, and decision-making regarding treatment. Patients with LVADs who come to the ED or are admitted to the ICU usually have nonspecific clinical symptoms, most commonly shortness of breath, hypotension, anemia, chest pain, syncope, hemoptysis, gastrointestinal bleeding, jaundice, fever, oliguria and hematuria, altered mental status, headache, seizure, and back pain. Other patients are seen for cardiac arrest, psychiatric issues, sequelae of noncardiac surgery, and trauma. Although most patients have LVADs, some may have biventricular support devices or total artificial hearts. Involving a team of cardiac surgeons, perfusion experts, and heart-failure physicians, as well as ED and ICU physicians and nurses, is critical for managing treatment for these patients and for successful outcomes. This review is designed for critical care providers who may be the first to see these patients in the ED or ICU.
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Affiliation(s)
- Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA.
| | - Joel S Larson
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA.,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Stacy L Libricz
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Bhavesh M Patel
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
| | - Pramod K Guru
- Department of Critical Care Medicine, Mayo Clinic Jacksonville, Florida, USA
| | - Cory M Alwardt
- Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - Octavio Pajaro
- Division of Cardiovascular and Thoracic Surgery, Mayo Clinic Hospital, Phoenix, Arizona, USA
| | - J Christopher Farmer
- Department of Critical Care Medicine, Mayo Clinic Hospital, 5777 E. Mayo Blvd, Phoenix, AZ, 85054, USA
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Fendler TJ, Spertus JA, Gosch KL, Jones PG, Bruce JM, Nassif ME, Flint KM, Dunlay SM, Allen LA, Arnold SV. Incidence and predictors of cognitive decline in patients with left ventricular assist devices. Circ Cardiovasc Qual Outcomes 2015; 8:285-91. [PMID: 25925372 DOI: 10.1161/circoutcomes.115.001856] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 03/31/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND After left ventricular assist device (LVAD) placement for advanced heart failure, increased cerebral perfusion should result in improved cognitive function. However, stroke (a well-known LVAD complication) and subclinical cerebral ischemia may result in transient or permanent cognitive decline. We sought to describe the incidence and predictors of cognitive decline after LVAD using a valid, sensitive assessment tool. METHODS AND RESULTS Among 4419 patients in the Interagency Registry for Mechanically Assisted Circulatory Support who underwent LVAD implantation between May 2012 and December 2013, cognitive function was assessed in 1173 patients with the Trail Making B Test before LVAD and at 3, 6, and 12 months. The test detects several forms of cognitive impairment, including subclinical stroke. Cognitive decline was defined as a clinically important increase during follow-up using a moderate Cohen d effect size of 0.5×baseline SD (32 s). The cumulative incidence of cognitive decline in the year after LVAD implantation, treating death and transplantation as competing risks, was 29.2%. In adjusted analysis, older age (≥70 versus <50 years; hazard ratio, 2.24; 95% confidence interval 1.46-3.44; P(trend)<0.001) and destination therapy (hazard ratio, 1.42; 95% confidence interval, 1.05-1.92) were significantly associated with greater risk of cognitive decline. CONCLUSIONS Cognitive decline occurs commonly in patients in the year after LVAD and is associated with older age and destination therapy. These results could have important implications for patient selection and improved communication of risks before LVAD implantation. Additional studies are needed to explore the association between cognitive decline and subsequent stroke, health status, and mortality in patients after LVAD.
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Affiliation(s)
- Timothy J Fendler
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.).
| | - John A Spertus
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Kensey L Gosch
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Philip G Jones
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Jared M Bruce
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Michael E Nassif
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Kelsey M Flint
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Shannon M Dunlay
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Larry A Allen
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
| | - Suzanne V Arnold
- From the Mid-America Heart Institute, Kansas City, MO (T.J.F., J.A.S., K.L.G., P.G.J., S.V.A.); University of Missouri-Kansas City (T.J.F., J.A.S., J.M.B., S.V.A.); Washington University School of Medicine, Saint Louis, MO (M.E.N.); University of Colorado School of Medicine, Aurora (K.M.F., L.A.A.); and Mayo Clinic of Rochester, MN (S.M.D.)
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