Advanced heart failure therapies such as ventricular assist devices and home inotrope use are becoming more common. Technology advances as well as increased indications for use of such therapies is leading to a higher percentage of patients with end-stage heart failure receiving these therapies at end of life. We present a case of a young man with dilated cardiomyopathy who undergoes advanced cardiac care in the setting of progressively declining cardiac function. Our case outlines the importance of acute care, palliative care, and hospice services being coordinated prior to and during acute-care services to provide goal-concordant and expeditious care. With advancing medical therapies for heart disease, increased coordination and collaboration of services are needed, particularly between hospice and acute-care services.

Background: Patients presented with the option of undergoing ventricular assist device (VAD) therapy are by definition very sick, and often in crisis. They are typically told that they have a high likelihood of dying in the next year without VAD. Though most patients have improved functional status and quality of life (QoL), repeated hospitalizations and potentially catastrophic complications in the post implant period can be burdensome. Objective: To assess for decisional regret or ambivalence about VAD implant. Methods: During a 3 year pilot program of outpatient palliative care embedded in a cardiology/CT surgery clinic, all post VAD implant patients were referred to palliative care as part of routine care. As part of their assessment, they were administered a survey consisting of a 5 question decision regret scale that has been validated for a wide range of treatment decision making, and has correlated well with decision satisfaction and decisional conflict. The results were entered into a QI database. On a scale of 0 (no regret) to 100 (regret), scores >25 were considered to reflect significant ambivalence about their decision to have VAD implant. Scores between 10-25 were defined as mild ambivalence. Patients were also administered the PHQ-9 depression inventory. Results: 129 unique patients were seen as outpatients over a period of 49 months. 102 (79%) completed decision regret surveys. Of these, the majority (64/102, 63%) scored 0, 7/102 (7%) scored > 25, and another 29/102 (28%) scored between 10 and 25. The average age of the patients scoring > 25 on the scale was 46, compared with the average age of 55 of the whole cohort. Of those that expressed some degree of ambivalence (n=36) about their decision, 11/35 (31%) met criteria for at least moderate depression on the PHQ-9, compared with 18% for the whole cohort. Though 26% of the total cohort had VADs as BTT, 20/36 (44%) ambivalent patients and 3/7 (57%) very ambivalent patients were living with their VAD as BTT. The percent of patients expressing ambivalence < or > 6 months post implant was equivalent (33%). Conclusions: In this preliminary study, as expected, a majority of patients do not regret their decision. However a significant minority expressed some ambivalence about this decision, and a small number expressed significant ambivalence. Ambivalence was more common in those who are younger, those with VAD as BTT, and in patients with depression. Ambivalence is likely a marker for patients whose expectations for quality of life with VAD are not being met. It is important to recognize pre-implant that patients have different decision-making needs, and that managing their expectations may be a key component of helping them to adjust post VAD. It is also important to identify those patients who would benefit from more post implant support to optimize their quality of life.

Incidence of Depression and Anxiety in Patients with Durable Ventricular Assist Devices Background: There is a high incidence of depression in patients with heart failure and the presence of depression is associated with worse outcomes. There have been few reported data on depression in patients with left ventricular assist devices (LVADs). Methods: Patients with LVAD were seen by a palliative care practitioner embedded in the cardiology/CT surgery outpatient clinic at a large quaternary care hospital as part of routine post VAD management. The patients were screened for anxiety and depression as part of the palliative care clinical assessment, using previously validated PHQ-9 and GAD-7 tools. Their scores were entered into a QI database. Patients were considered to have scores concerning for depression if the total PHQ-9 score was greater than or equal to 10 (moderate depression) or if they met USPTF scoring criteria for major or other depressive disorders. Scores of greater than or equal to 10 on the GAD-7 were considered concerning for generalized anxiety disorder. Results: 129 unique post LVAD patients were seen over 40 months, over a timeframe of 3 months to 5 years post implant. Of these, 110 (85%) were screened for depression using the PHQ-9 tool, usually at the first visit, or at a second follow up visit. 20 (18%) of those surveyed had met the above criteria for at least moderate depression, and 6(5%) had scores ≥ 15 consistent with at least moderate to severe depression. 83 were surveyed for anxiety using the GAD-7, and 8 (10%) had scores ≥ 10. Four patients had significant scores for both anxiety and depression. Of those patients who screened positive for significant depression, most (13/20, 65%) had a history of depression and were on antidepressants (13/20, 65%). Conclusion: The incidence of depression and/or anxiety in patients with LVAD, although higher than that of the general population (depression reported as 5-9%), appears to be on the low end of par with that reported in heart failure (depression incidence reported as 13-48% in the outpatient HF population). In our cohort, depression or anxiety were primarily observed in patients who already had a history of such. This finding is somewhat reassuring in that VAD therapy does not appear to induce these symptoms de novo. Nonetheless, patients with such a history are likely at risk for worsening symptoms with the significant stressor of undergoing VAD implant. Given the negative impact of depression on quality of life, this population should be carefully screened and supported both pre and post VAD implant.

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