Psychiatric problems of heart transplant candidates with left ventricular assist devices

Abstract

Most heart transplant candidates are equipped with left ventricular assist devices (LVADs). LVAD therapy is associated with characteristic psychiatric and psychosocial problems. To investigate the mental states of heart transplant candidates, psychiatric diagnosis, psychological or behavioral problems, and the need for treatment were evaluated around the time of registration to the waiting list and during follow-up. Saitama Medical University Hospital has been designated a hospital for heart transplantation since October 2002. The subjects were 14 heart transplant candidates (9 male candidates and 5 female candidates, mean age 29 years) at the hospital from September 1997 to October 2005. These 14 candidates were equipped with LVADs. The waiting periods on LVAD support were from 119 days to 1028 days, and the average waiting period was 313 days. Six candidates among the 14 had more than one DSM-IV diagnosis. Seven candidates were diagnosed with adjustment disorder, which was the most frequent diagnosis. Three candidates had depressive disorder, one had psychotic disorder, and one had dissociative disorder. Three candidates had acute cognitive dysfunction (delirium) due to their general medical condition. All three had other disorders with mainly psychological elements. Nine candidates (64%) were diagnosed with disorders with mainly psychological elements. Antipsychotics were used for the candidates in psychotic states and with delirium, and there was a need for crisis intervention. Antidepressants and antianxiety drugs were used for the candidates with depressive disorder; they needed intensive observation. Four candidates (28%) needed some attention and some antianxiety drugs or hypnotics. Psychiatric interventions were not necessary in five candidates (36%).

Patient-Reported Outcomes in Left Ventricular Assist Device Therapy

“…Some studies found that only 2% of LVAD patients experienced depression and only 4% experienced anxiety, 20 whereas others found a considerable group of LVAD patients experiencing a depressive or adjustment disorder (21% and 37%-50%, respectively). 29,31 In trials (ie, the Randomized Evaluation of Mechanical Assistance in the Treatment of Congestive Heart Failure trial) comparing LVAD patients using pulsatile devices with patients using optimal medical treatment and transplant recipients, LVAD support was associated with a significant improvement in health status and depressive symptoms in contrast to medication alone (PϽ0.05 for both). 26,30,32 However, LVAD patients do not seem to attain the same level of health status compared with transplant recipients, with transplant recipients experiencing more improvements in mobility, self-care ability, physical ability, and social functioning than LVAD patients.…”

“…Patients supported by pulsatile devices showed relatively high mean depression scores just after LVAD implantation. 26,29,31 The retrospective study 19 of Bunzel et al 20 found no significant difference in depression scores between patients receiving therapy via pulsatile vs continuous-flow devices; these patients might be more vulnerable to psychological distress, based on the higher rate of complications and the characteristics of the device (eg, short durability, large size, noise, and large batteries). Hence, these differences in findings could well be explained by sample size limitations, differences in subtype of devices, and the time of collecting data.…”

“…26,33 In most studies, the baseline assessment was conducted before hospital discharge, which varied between 1 and 2 weeks 12 to Ϸ1 month after LVAD implantation. 32 The 3 cross-sectional studies used a variety of assessment times ranging from Ͻ6 weeks after implantation 29,30 to up to 2 months after LVAD implantation. 31 Two studies 26,32 compared the PROs of LVAD patients with transplant recipients or patients receiving optimal medical treatment.…”

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

“…One study [29] reported the following complications: 14% recovered after CVA, 14% died from CVA, 21% became infected, and 21% experienced delirium. Psychiatric diagnoses by DSMIV criteria included adjustment reaction in 50%, of patients, delirium in 21%, depression NOS in 14%, major depression (MDD) in 7%, brief psychosis in 7%, and dissociative disorder in 7%.…”

Guidelines for Treatment of Acute Heart Failure (JCS 2011)

“…Because patients using VAS are prone to depression, anxiety, feelings of irritation, and fear of death, a team of cardiologists, nurses, psychiatrists, clinical psychotherapists, and psychiatric liaison nurses should offer mental support. 63 Family members of patients using VAS need practical support to reduce the burden of patient care as well as mental support.…”