Psychosocial assessment of candidates and risk classification of patients considered for durable mechanical circulatory support.

BACKGROUND: The psychosocial assessment of candidates for transplantation (PACT), developed to assess candidates for heart transplant, has not been routinely used to assess left ventricular assist device (LVAD) candidacy. We examined the efficacy of the PACT to assess psychosocial outcomes in LVAD patients. METHODS: We reviewed patients who received LVAD implants between June 2006 and April 2011 and retrospectively applied the PACT. We determined the accuracy of identifying social success with the PACT and revised domains to reflect criteria influencing social success for LVAD patients. RESULTS: Forty-eight patients (72% men, 44% non-white, 50.4 years old) were divided into high-scoring and low-scoring groups. Nine patients with low PACT scores were falsely categorized as high-risk, whereas 4 with high scores had poor social outcomes. The score had a high positive-predictive value (0.86) but low negative-predictive value (0.31). The PACT was revised (modified [m]PACT) to measure indicators, such as social support and understanding of care requirements, identified to more closely affect LVAD outcome. The mPACT exhibited improved accuracy. A reclassification table was developed, and the net reclassification index was 0.32. The percentage of patients incorrectly classified for social risk decreased from 27% with the PACT to 8% with the mPACT. Patients with higher mPACT scores had decreased 30-day readmission rates (26% vs 67%, p = 0.045) after device implantation. CONCLUSIONS: By emphasizing social support, psychologic health, lifestyle factors, and device understanding, the mPACT showed improved performance in risk-stratifying candidates for LVAD therapy. Prospective validation is warranted.

Caregiving for patients requiring left ventricular assistance device support.

BACKGROUND: The responsibility of caregiving for patients requiring left ventricular assistance device (LVAD) support may be significant. However, little is known about their experience. Data from the Interagency Registry for Mechanically Assisted Circulatory Support (2006-2009) reported that 1722 patients had received LVADs as a bridge to transplantation, recovery, or destination therapy. The use of this advanced technology in the management of endstage heart failure is expected to continue, suggesting increased involvement of family members and significant others. The purpose of this qualitative study was to describe the experiences of caregivers of patients who received LVAD therapy as a bridge to transplantation. METHODS: Semistructured interviews allowed participants to describe their experiences as caregivers. Interviews were audiotape-recorded and transcribed verbatim. An analysis was conducted using Sandelowski's three-step process for the analysis of phenomenological data: data dwelling, open coding, and data reduction. RESULTS: Participants (n=5 women and 1 man; age, 51 years; range=44 to 66 years; duration of caregiving, 183.9 days; range, 26 to 372 days; relationship to patient: spouse=3, parent=1, significant other=1, and friend=1) were designated caregivers of patients discharged home with an LVAD. Two themes emerged: sacrifice and moving beyond. Caregivers sacrificed relationships with friends and family, jobs and livelihood, health, and peace of mind in their roles as caregivers. "Moving beyond" reflected coping and adaptation to the sacrifices of being a caregiver. CONCLUSIONS: Experiences described by caregivers suggest that they successfully incorporated the role of caregiver for patients with a complex therapeutic regimen into their daily lives. The specific findings should guide healthcare professionals in their efforts to support caregivers.

Lifestyle and health status differ over time in long-term heart transplant recipients.

OBJECTIVE: To describe differences in lifestyle and health status across 5 post-transplant periods. METHODS: The sample consisted of 126 heart transplant recipients (87% men) grouped by time after transplantation: group 1, 12 to 24 months (n= 13); group 2, 25 to 48 months (n= 19); group 3, 49 to 72 months (n=24); group 4, 72 to 96 months (n=27); and group 5, > or =97 months (n=43). Data were obtained using demographic and health status evaluation forms and the Lifestyle Profile-II, which measures physical activity, nutrition, health responsibility, interpersonal relationships, stress management, and spiritual growth. RESULTS: Most often reported lifestyle attributes were spiritual growth and interpersonal relationships. Least often reported was physical activity. Pairwise comparisons revealed that groups 3 (chi2 = 16.4; SD = 4.8; P = .03) and 4 (chi2 = 16.6; SD= 5.8; P = .04) had lower physical activity than group 2 (chi2 = 21.3; SD = 5.2). Health status evaluation revealed that there were no group differences in systolic (P = .46) or diastolic (P = .77) blood pressure. Although creatinine was elevated, there were no group differences (P = .86). High-density lipoprotein was higher than 42 mg/dL in all groups, but there were differences across groups in low-density lipoprotein (P = .003). Groups 1 (chi2 = 139.2; SD = 38.5) and 2 (chi2 = 141.0; SD = 47.8) were different than group 5 (chi2 = 112.9; SD = 36.1; P = .05). There were group differences in cholesterol (P = .002), with lower levels in groups 4 (chi2 = 190.5; SD= 38.6) and 5 (chi2 = 186.3; SD = 37.7) as compared to group 2 (chi2 = 230.8; SD = 66.5). CONCLUSIONS: Identifying posttransplant periods in which healthy behaviors and health status may be vulnerable to decline is important for providing ongoing education and psychological support to transplant recipients who manage a complex regimen.