LVAD destination therapy: applying what we know about psychiatric evaluation and management from cardiac failure and transplant

Abstract

Left ventricular assist devices (LVADs) have evolved into long-term use as destination therapy for those with severe end-stage heart failure due to other medical risks. Success with LVAD depends on adherence to a complicated mechanical regimen, and acceptance of a life that is far from normal. Patients with LVADs share characteristics with other end-stage cardiac failure patients and those waiting for or receiving heart transplants. Understanding the more thoroughly studied issues of psychiatric disorders, adherence, and behavioral correlates of success in heart failure and transplantation may identify feasible strategies for optimizing care of LVAD patients and suggest directions for future research. Depression and distress complicate post-transplant care. Psychiatric morbidity is associated with poor outcomes, including graft rejection, non-adherence, hospitalizations, infection, and death. With a high risk of embolic neurological events, patients' ability for self-care may be compromised. Psychiatric symptoms are underdiagnosed and undertreated, which may impact overall survival and quality of life.

Patient-Reported Outcomes in Left Ventricular Assist Device Therapy

“…10 -14 Device type and settings might influence the level of psychological morbidity because patients receiving pulsa-tile LVAD therapy have a higher rate of complications and are bothered by the clicking noise from the device. 15 In other heart failure populations, psychological morbidity has been associated with poor treatment adherence, poor self-efficacy, and an unhealthy lifestyle. 15, 16 Yet, it is not known whether patients receiving LVAD therapy who have psychological problems are identified and, hence, treated.…”

“…15 In other heart failure populations, psychological morbidity has been associated with poor treatment adherence, poor self-efficacy, and an unhealthy lifestyle. 15, 16 Yet, it is not known whether patients receiving LVAD therapy who have psychological problems are identified and, hence, treated.…”

“…In contrast to transplant recipients, LVAD patients are recurrently reminded of their device because of the need to clean the driveline insertion site and change batteries frequently. 15 Furthermore, organ recipients appear to redefine "normal" life and what it entails after transplantation. 32 Overall, there was a substantial difference between the studies in the handling and reporting of PROs, depending on whether PROs were assessed as primary or secondary outcomes.…”

“…This is surprising given that 15% to 36% of patients with heart failure experience depression, 40,41 40% experience anxiety, 16 and 10% to 17% experience posttraumatic stress disorder. 42,43 Symptoms of depression and anxiety can be disabling 15 and are associated with an increased risk of declines in physical health, 16 mortality, higher medication costs, 15 noncompliance with treatment, malignancies, 44,45 and hospital readmissions. 8 The limited available evidence suggests that there may be a link between LVAD technology and the patient's psychological adjustment.…”

Challenge of Informing Patient Decision Making

“…25,26 Adaptation of lifestyle is required, 3,25,27 and availability of social support is essential. 3,5,26 As another part of the informed decision-making process, therefore, the patient considering DT requires information on what to expect in daily life on MCS.…”