Outcomes of biventricular mechanical support patients discharged to home to await heart transplantation.

BACKGROUND: The use of left ventricular assist devices has grown rapidly in recent years for patients with end-stage heart failure. A significant proportion of patients require both left- and right-sided support with biventricular assist devices (BiVADs) as a bridge to transplantation. Traditionally, these patients have waited in the hospital until they receive a transplant. PURPOSE: The aim of this study was to characterize the clinical course of BiVAD patients discharged to home to await heart transplantation. METHODS: Between November 2009 and July 2011, 24 adult patients underwent Thoratec paracorporeal BiVAD placement at the University of California Los Angeles, all with an Interagency Registry for Mechanically Assisted Circulatory Support score 1 or 2. The disposition, complications, and rehospitalizations of these subjects were retrospectively reviewed. RESULTS: Fourteen of the 24 patients were successfully discharged to home, with a mean time of 60 ± 27 days from BiVAD implantation to discharge. Ninety-three percent (13/14) of the patients sent home went on to be transplanted. Eleven of the 14 (79%) came in from home to receive their transplant. The mean time from BiVAD implantation to transplantation was 100 ± 65 days. Of the 14 patients discharged to home, there were 18 readmissions in 8 patients. CONCLUSION: In this small single-center review, we found that complex medical patients with BiVADs can be discharged to home and can await a heart transplant from home under the close management of multidisciplinary acute care and outpatient teams.

Higher-risk SIPAT score predicts increased risk of long-term mortality in orthotopic heart transplant recipients.

BACKGROUND: Orthotopic heart transplantation (OHT) improves survival in eligible patients. Organ scarcity necessitates extensive clinical and psychosocial evaluations before listing. The Stanford Integrated Psychosocial Assessment for Transplant (SIPAT) predicts risk for poor psychosocial outcomes and morbidity in the first year post-transplant, yet it is unknown whether it predicts long-term outcomes. METHODS: Blinded examiners obtained data from a retrospective cohort of 51 OHT recipients from a high-volume center. Patients with "Excellent" or "Good" SIPAT score indicating low psychosocial risk for transplant (E/G) were compared with those who met "Minimum Acceptable Criteria" or were "High Risk" (MAC/HR). Associations were examined between SIPAT group and outcomes. RESULTS: MAC/HR versus E/G recipients had significantly reduced survival in the 10 years post-OHT (mean 6.7 vs 8.8 years, p = 0.027; 55% vs 82% survival proportions, p = 0.037). MAC/HR patients were more likely to live in a county with greater income inequality (p = 0.025) and have psychiatric history pre-OHT (p = 0.046). Both groups had otherwise similar demographics and medical history. A lower proportion of MAC/HR patients adhered to medications post-OHT and a greater proportion had psychiatric illness, though differences were not significant. CONCLUSIONS: Higher-risk SIPAT scores predict reduced long-term survival post-OHT. Further efforts are crucial to improve outcomes in higher-risk patients.

Correlates of health-related quality of life in patients with heart failure.

BACKGROUND: The purpose of this study was to explore health-related quality of life (HRQOL) in patients with advanced heart failure undergoing heart transplantation evaluation. The overall aim of the study was to determine whether patients' demographic characteristics, functional status, neuroticism, social network, social support, spirituality, and time since symptom onset are related to the physical and mental components of a patient's HRQOL. METHODS: A descriptive, correlational design was used. Patients (N = 61) were recruited from 2 university-affiliated, outpatient, heart failure programs. Data were collected from chart review, a 6-minute walk, and patient-completed instruments. HRQOL, including physical and mental health components, was assessed with use of the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36). RESULTS: Demographic characteristics, functional status, neuroticism, social network, social support, spirituality, and time since symptom onset explained 26% of the variability in the physical health component of HRQOL and 44% of the variability in the mental health component of HRQOL in patients with advanced heart failure. In analyzing the data for the most parsimonious model, New York Heart Association classification, 6-minute walk distance, and neuroticism explained 49% of the variability in the mental health component of HRQOL. CONCLUSIONS: New York Heart Association classification, 6-minute walk distance, and neuroticism are related to the mental health component of HRQOL and can be easily included in the assessment of patients with heart failure who are undergoing heart transplantation evaluation. The findings of the current study require replication but may be used to identify patients with heart failure who are potentially at risk for reduced HRQOL.

Temporal trends in treatment and outcomes for advanced heart failure with reduced ejection fraction from 1993-2010: findings from a university referral center.

BACKGROUND: Randomized trials have demonstrated the efficacy of several new therapies for heart failure (HF) with reduced ejection fraction over the preceding 2 decades. This study investigates whether these therapeutic advances have translated into improvement in outcomes for patients with advanced HF referred to a heart transplant center. METHODS AND RESULTS: Patients with HF (n=2507) referred to a single university center were analyzed in three 6-year eras during which medical and device therapies were evolving: 1993 to 1998 (era 1), 1999 to 2004 (era 2), and 2005 to 2010 (era 3). Impaired hemodynamics and comorbidities were more frequent at time of referral in later eras, whereas other HF severity parameters where similar or improved. Successive eras had greater usage of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, ß-blockers, aldosterone antagonists, implantable cardioverter defibrillators, and cardiac resynchronization therapy, consistent with evolving evidence and guideline recommendations over the study period. All-cause mortality and sudden death were significantly lower in era 2 and 3 compared with era 1. After multivariable risk adjustment, era 3 had significantly decreased 2- and 3-year all-cause mortality risk and significantly decreased 1- and 3-year sudden death risk compared with era 1. However, progressive HF death and the combined outcome of mortality/urgent transplant/ventricular assist device were modestly increased in the latter eras. CONCLUSIONS: Over the past 2 decades, patients with advanced HF referred to and managed at a tertiary university referral center have benefited from advances in HF medications and devices, as evidenced by improvements in overall survival and sudden death risk.