Association of Psychosocial Risk Factors With Quality of Life and Readmissions 1 Year After LVAD Implantation.

BACKGROUND: Among patients with advanced heart failure (HF), treatment with a left ventricular assist device (LVAD) improves health-related quality of life (HRQOL). We investigated the association between psychosocial risk factors, HRQOL and outcomes after LVAD implantation. METHODS: A retrospective cohort (n = 9832) of adults aged ≥ 19 years who received durable LVADs between 2008 and 2017 was identified by using the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS). Patients were considered to have psychosocial risk factors if ≥ 1 of the following were present: (1) substance abuse; (2) limited social support; (3) limited cognitive understanding; (4) repeated nonadherence; and (5) major psychiatric disease. Multivariable logistic and linear regression models were used to evaluate the association between psychosocial risk factors and change in Kansas City Cardiomyopathy Questionnaire (KCCQ)-12 scores from baseline to 1 year, persistently poor HRQOL (KCCQ-12 score < 45 at baseline and 1 year), and 1-year rehospitalization. RESULTS: Among the final analytic cohort, 2024 (20.6%) patients had ≥ 1 psychosocial risk factors. Psychosocial risk factors were associated with a smaller improvement in KCCQ-12 scores from baseline to 1 year (mean ± SD, 29.1 ± 25.9 vs 32.6 ± 26.1; P = 0.015) for a difference of -3.51 (95% confidence interval [CI]: -5.88 to -1.13). Psychosocial risk factors were associated with persistently poor HRQOL (adjusted odds ratio [aOR] 1.35, 95% confidence interval [CI] 1.04-1.74), and 1-year all-cause readmission (adjusted hazard ratio [aHR] 1.11, 95% CI 1.05-1.18). Limited social support, major psychiatric disorder and repeated nonadherence were associated with persistently poor HRQOL, while major psychiatric disorder was associated with 1-year rehospitalization. CONCLUSION: The presence of psychosocial risk factors is associated with lower KCCQ-12 scores and higher risk for readmission at 1 year after LVAD implantation. These associations are statistically significant, but further research is needed to determine whether these differences are clinically meaningful.

Hepatitis B vaccination in heart transplant candidates.

BACKGROUND: Various options have been proposed to expand the limited heart donor pool, including candidate vaccination permitting use of hepatitis B core antibody-positive (HbcAb(+)) donors. From 2001 to 2004, 263 potential heart donors were turned down due to hepatitis B core antibody positivity. In 2001, we initiated a protocol of a routine vaccination against hepatitis B virus (HBV) at transplant evaluation. The efficacy of HBV vaccination in patients with advanced heart failure is not known. METHODS: A single-center retrospective chart review was completed for patients who successfully completed the 3-dose HBV vaccine series and hepatitis B surface antibody (HBsAb) post-vaccination titer. We reviewed post-vaccine quantitative titers, patient characteristics and donor serologies. Seroconversion was defined as a HBsAb titer >10 mIU/ml. RESULTS: Twenty-nine patients had a complete vaccine series with HBsAb quantitative titers. Thirteen patients seroconverted on the initial attempt. Sixteen were non-seroconverters. Of these, 6 were transplanted prior to repeat series with titers, 7 remain wait-listed awaiting complete repeat series, and 3 completed a repeat series, of whom 2 seroconverted. None of the Status 1B patients seroconverted. Seroconverters had higher ejection fractions (EFs), lower serum creatinine levels and higher functional status. CONCLUSIONS: HBV vaccination of patients with advanced heart failure was successful in approximately 50% of patients and was most successful in Status 2 patients. Early initiation of the vaccine series may increase utilization of HBcAb(+) donors. HBV vaccination is unlikely to benefit Status 1 patients.

Long-term results of angioplasty vs stenting in cardiac transplant recipients with allograft vasculopathy.

BACKGROUND: Allograft vasculopathy remains a major limiting factor in long-term graft survival. The absence of symptoms and diffuse nature of the disease make clinical detection and therapy more difficult. Limited data exist on the long-term outcome of percutaneous interventions in this group of patients. METHODS: Medical records and cardiac catheterizations from the Cardiac Cath Lab database were retrospectively reviewed for all cardiac transplant recipients who had undergone a percutaneous intervention. Procedural results, complications, use of stents and angiographic follow-up were recorded. Re-stenosis was defined as a lesion >50% in the target vessel at follow-up angiography. RESULTS: Thirty-three patients underwent 97 percutaneous interventions with a mean of 2.9 interventions per patient. Mean age at the time of first intervention was 52 +/- 13 (mean +/- standard deviation) years. Mean time from transplant to first intervention was 5 +/- 3.0 years. The primary procedural success rate was 99%. Thirty-four procedures involved placement of a stent, 63 were angioplasty alone. There were no procedure-related complications. Seventy percent of lesions were de novo and 30% were re-stenotic lesions. Six-month, 12-month and 5-year target vessel re-stenosis rates in the stent group were 31%, 46% and 69%, and in the percutaneous transluminal coronary angioplasty (PTCA) group were 41%, 53% and 68%, respectively. Thirteen patients (39.3%) died or were re-transplanted, at 1.9 +/- 2.29 (mean +/- SD) years after their first intervention. Twenty patients were alive at 4.5 +/- 2.99 years after the first intervention. CONCLUSIONS: Percutaneous intervention can be performed safely in cardiac transplant recipients. Stent placement reduces early and mid-term re-stenosis, but late re-stenosis occurs in 70% of lesions. Late re-stenosis, development of new coronary lesions, and need for repeat intervention are common, regardless of the method used for percutaneous intervention, emphasizing the diffuse and progressive nature of transplant coronary disease.