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.

Thymoglobulin induction and steroid avoidance in cardiac transplantation: results of a prospective, randomized, controlled study.

BACKGROUND: Chronic use of corticosteroids (CS) following transplantation is associated with significant long-term morbidities. Minimizing exposure to CS to improve long-term outcomes, without compromising allograft function, remains an important goal in transplantation. OBJECTIVES: This single-center, prospective, randomized, open-label study was designed to evaluate the efficacy of Thymoglobulin as part of a CS-sparing regimen in cardiac transplantation. METHODS: Thirty-two low-risk cardiac transplant patients were randomized in a 1:1 ratio to receive either a Thymoglobulin-based CS-avoidance regimen (CS-avoidance group; n = 16) or a long-term CS-based regimen with no antibody induction (control group; n = 16). Pulse CS therapy was used for the treatment of acute cellular rejection in both groups. RESULTS: Baseline characteristics were similar between groups. At one yr, there was no significant difference in the mean incidence of acute cellular rejection (>or=3A) episodes between the CS-avoidance and control groups, 0.81+/-1.05 and 1.07+/-1.03, respectively. Importantly, the CS-avoidance patients had significant improvement in muscle strength and less bone loss compared with the control patients during the first six months post-transplant. CONCLUSIONS: CS-avoidance regimen with Thymoglobulin induction appeared to be safe and effective in cardiac transplantation. Further studies are required to demonstrate the long-term safety and benefits of such a regimen.

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.

Patterns and predictors of quality of life at 5 to 10 years after heart transplantation.

BACKGROUND: Although studies have provided us with a cross-sectional analysis of long-term quality of life (QOL) after transplantation, relatively few longitudinal studies have been done that allow us to understand changes in QOL over time. The purposes of our study were to describe QOL over time and identify predictors of QOL longitudinally from 5 to 10 years after heart transplantation. METHODS: All 555 subjects enrolled in this study completed booklets of questionnaires. These patients had a mean age of approximately 54 years (range 21 to 75 years) at time of transplant. Seventy-eight percent were men and 88% were white. Participants completed nine self-report QOL instruments for this study. Statistical analyses included frequencies, means +/- standard deviations (plotted over time), Pearson correlation coefficients and multiple regression coupled with repeated measures. RESULTS: At 5 to 10 years after heart transplantation, recipients reported high levels of satisfaction with overall QOL and with health-related QOL, which was stable over the 5-year period. Predictors of satisfaction with overall QOL (that individually accounted for 1% variance or more) were primarily psychosocial variables (overall model explaining 71% of variance), whereas predictors of satisfaction with QOL related to health and functioning (that also explained > or =1% variance) included symptom distress and physical function, as well as psychosocial variables (overall model explaining 72% of variance). CONCLUSIONS: At 5 to 10 years after heart transplantation, QOL remained positive and stable. Bio-psychosocial variables predicted satisfaction with overall QOL and health-related QOL. Understanding of these bio-psychosocial variables provides direction for the development of long-term therapeutic strategies after heart transplantation so that patients can have good post-transplant outcomes.

Cost effectiveness of biventricular pacemakers in heart failure patients.

BACKGROUND: Biventricular pacemakers have been shown to reduce mortality and hospitalizations in heart failure (HF) patients and are indicated for those with a New York Heart Association functional class of III or IV and a QRS interval of >130 ms. However, these devices currently cost in the region of dollar US 33,500 and require replacement upon battery depletion. Therefore, determination of the cost effectiveness of resynchronization therapy is important, although little data have been published to date on this topic. METHODS AND RESULTS: A cost-utility analysis from the healthcare perspective was performed using HF patients who received a biventricular pacing device in the Cleveland Clinic Foundation. The comparator was a similarly profiled group of patients who did not receive the device but were treated medically. A Markov model was used to investigate the cost effectiveness at 1 and 5 years. Second-order Monte-Carlo simulation was used to determine the variability in results, using probabilistic sensitivity analysis. Medical treatment was dominated by biventricular pacemaker treatment at both 1 and 5 years of follow-up. CONCLUSION: Biventricular device insertion is an economically attractive treatment option for clinically indicated HF patients.