Quality of life. Organ transplantation and artificial organs.

Changes in quality of life for patients who require transplantation or permanent artificial organ support begin with the onset of serious organ dysfunction. These changes, which initially are almost universally negative, greatly affect close family members as well as the patient. To the extent that alternate therapies are available, transplantation appears preferable to chronic artificial organ support in allowing the patient to return to work, to school, or to similar self-selected activities. There is some evidence that transplant and artificial organ patients may describe their subjective well-being more positively than would be anticipated from objective data. There is also evidence, at least for hemodialysis patients, that this satisfaction is time-limited. The right to choose death over life dependent on a machine is being exercised by some alert patients as well as by family members and attending physicians when the patient is not competent. Little data is available regarding the long-range impact of transplantation or artificial organ support on members of the patients' families, but in the author's experience one characteristic predominates. To the extent that the life-extending therapy can be forgotten, or is non-intrusive, for days or weeks at a time, as can be the case with transplantation, family functioning returns to normal. The adjustments needed to cope successfully with the stresses of the acute phase are completed. To the extent that reminders and uncertainties of the therapy are chronically present, family interaction continues to center upon (or is designed to avoid) the patient. The family's resilience and capacity to maintain its integrity diminish with each new stressful event.

Artificial heart and assist devices: directions, needs, costs, societal and ethical issues.

A Working Group appointed by the Director of the National Heart, Lung, and Blood Institute (NHBLI) has reviewed the current status of mechanical circulatory support systems (MCSS), and has examined the potential need for such devices, their cost, and certain societal and ethical issues related to their use. The media have reported the limited clinical investigative use of pneumatically energized total artificial hearts (which actually replace the patient's heart) and left ventricular assist devices (which support or replace the function of the left ventricle by pumping blood from the left heart to the aorta with the patient's heart in place). However, electrically energized systems, which will allow full implantation, permit relatively normal everyday activity, and involve battery exchange or recharge two or three times a day, are currently approaching long-term validation in animals prior to clinical testing. Such long-term left ventricular assist devices have been the primary goal of the NHLBI targeted artificial heart program. Although the ventricular assist device is regarded as an important step in the sequence of MCSS development, the Working Group believes that a fully implantable, long-term, total artificial heart will be a clinical necessity and recommends that the mission of the targeted program include the development of such systems. Past estimates of the potential usage of artificial hearts have been reviewed in the context of advances in medical care and in the prevention of cardiovascular disease. In addition, a retrospective analysis of needs was carried out within a defined population. The resulting projection of 17,000-35,000 cases annually, in patients below age 70, falls within the general range of earlier estimates, but is highly sensitive to many variables. In the absence of an actual base of data and experience with MCSS, projection of costs and prognoses was carried out using explicit sets of assumptions. The total cost of a left ventricular assist device, its implantation and maintenance for a projected average of 4 1/2 years of survival might be approximately $150,000 (in 1983 dollars). The gross annual cost to society could fall in the range of $2.5-$5 billion. Ethical issues associated with use of the artificial heart are not unique. For individual patients these relate primarily to risk-benefit, informed consent, patient selection, and privacy. However, for society as a whole, the larger concern relates to the distribution of national resources.(ABSTRACT TRUNCATED AT 400 WORDS)

Rehabilitation after cardiac transplantation.

The physical, occupational, and social status of 56 patients who survived six or more months after cardiac transplantation at Stanford University Medical Center was reviewed. Fifty-one (91%) were classified as successfully rehabilitated. Four (7%) retained substantial physical disability, and one (2%) experienced psychiatric disability. These results demonstrate the therapeutic usefulness of cardiac transplantation in carefully selected recipients.