Posttraumatic stress disorder after implantation of a mechanical assist device followed by heart transplantation: evaluation of patients and partners.

AIM: We sought to investigate the prevalence of posttraumatic stress disorder, anxiety, and depression in patients and their partners after implantation of a mechanical assist device as a bridge to heart transplantation. METHODS: This was a retrospective assessment of 41 patients (age 46.3 +/- 12.0 years; male-female ratio, 38:3; time since transplantation, 55.3 +/- 34.2 months [range, 7-122 months) and 27 partners (male-female ratio 2:25) by standardized instruments (Impact of Event Scale, Hospital Anxiety and Depression Scale), in 2 University Heart Transplant Centers (Vienna, Austria, Munster, Germany). The duration of the support systems (MicroMed DeBakey-VAD in 17 patients, Novacor in 10, Thoratec in 8, TCI HeartMate in 5, and Berlin Heart Incor in 1 patient) ranged from 28 to 711 (176 +/- 146) days. RESULTS: None of the patients, but 23% of the partners (n = 6), met the criteria for posttraumatic stress disorder (Maercker cutoff >0). The Impact of Event Scale (IES) sum scales differed significantly between the 2 groups (21.2 +/- 15.1, mean +/- SD) for the patients versus 38.1 +/- 27.8 for the partners, respectively; P = .001). Two percent of the patients, but 19% of the partners, showed mild to moderate depression; 4% of patients, but 23% of their partners, reported mild to moderate anxiety. None of the results were significantly influenced by the time since transplantation, patient age, diagnoses, type of assist device, or indication for heart transplantation. CONCLUSIONS: Despite patients being much closer to a life threat, their partners experience significantly more psychologic distress even in the long run. Our findings highlight the need for attention to the supporting persons.

Solid organ transplantation: are there predictors for posttransplant noncompliance? A literature overview.

BACKGROUND: Many studies confirm that noncompliance or poor compliance is one of the great problems in health care as it results in waste of resources and funds. METHODS: This overview includes literature on heart, liver, and kidney transplants with emphasis on heart transplantation in adult and pediatric transplant patients and addresses the following variables as potential predictors of postoperative compliance problems: demographic variables (age, marital status, gender) psychological variables (anxiety, denial) psychiatric disorders (major depression, anxiety, and personality disorders), poor social support, pretransplant noncompliance, obesity, substance abuse, and health-related variables (distance from transplant center, indication for transplantation, required pretransplant assist device). Relevant studies on these topics that were conducted up to 1999 are included and discussed in this overview. The most important results are presented in tables. RESULTS: Unfortunately, there has not been any systematic and comprehensive review of the literature on predictors of noncompliance in organ transplant patients so far. With organ transplantation noncompliance impairs both life quality and life span as it is a major risk factor for graft rejection episodes and is responsible for up to 25% of deaths after the initial recovery period. Therefore, it might be assumed that well-informed transplant patients are a highly motivated group whose compliance is just as high. This is not the case. However, even when graft loss means loss of life as in heart or liver transplantation, noncompliance occurs. To best select potential organ recipients, it would be ideal if patients who are very likely to show noncompliant behavior could be identified already before being transplanted. CONCLUSION: The literature overview shows the necessity of preoperative psychosocial screening regarding predictors for posttransplant noncompliance.

Living with a donor heart: feelings and attitudes of patients toward the donor and the donor organ.

For the patient, heart transplantation means more than an operation; adjustment to its rigors requires a high degree of personal strength and adequacy of coping skills. The goal of our study was to gain insight into how heart transplant patients cope with the fact that their own heart has been replaced by a donor organ from an unknown dead donor who was the target of disease, accident, or even suicide. Over a period of 2 years 44 transplant patients were interviewed after rehabilitation in a semi-structured interview regarding their feelings about and reactions to the graft and the donor. Their answers were recorded, transcribed, and analyzed as to content. Three groups of patients were identified: (1) the complete deniers (N = 15), who denied thinking about the donor; (2) the partial deniers (N = 17), who were aware of avoiding thinking about the donor; and those who coped (N = 12), who accepted the death of the donor as reality and also reported having more or less close connections with the donor. Eighty-two percent of the patients interviewed accepted the donor heart immediately as their own, whereas the remaining 18% avoided talking and thinking about the graft and donor. The findings are supported by verbatim statements of patients. The role of defense mechanisms in heart transplant patients is discussed.

Quality of life after orthotopic heart transplantation.

During the last decade heart transplantation has become the chosen method to treat terminally ill patients suffering from severe cardiac illness. It was the aim of our study to retrospectively survey life quality of donor organ recipients who underwent heart transplantation during the first years of transplantation at our center (1984 through 1987). Thirty-five patients were asked to evaluate their postoperative improvement or deterioration and their satisfaction with the level reached on visual scales. Life quality was defined in nine areas: physical, emotional, mental, vocational, and sexual status, financial situation, leisure activities, partnership, and overall life quality. The following results were obtained: (1) our former patients informed us about a distinct improvement in almost all dimensions (except financial situation). We found an absolute increase in life quality after heart transplantation. (2) Although improvement was ranked best for physical status, there was also a high amelioration in psychosocial fields. (3) A significant difference was seen between changes in condition and satisfaction in the financial situation (z = 2.3) and in partnership (z = 2.9), in which the latter was ranked higher. (4) The date of transplantation (less/more than 2 years ago) had no influence on the evaluation of postoperative life quality.

Noncompliance in organ transplant recipients: a literature review.

The consequences of failing to comply to doctor's instructions can be damaging and devastating for the individual patient and their family. Noncompliance also leads to waste, as it reduces the potential benefits of therapy, and to the extra cost of treating avoidable consequent morbidity. Life-long immunosuppression is a prerequisite for good graft function, and noncompliance is often associated with late acute rejection episodes, graft loss, and death. It might be assumed that transplant patients constitute a highly motivated group, and that compliance would be high. Unfortunately, this is not the case: overall noncompliance rates vary from 20 to 50%. This overview includes literature on heart, liver, and kidney transplants in adult and pediatric transplant patients. Compliance behavior after transplantation, noncompliance and its relationship to organ loss and death, retransplantation outcome after graft loss due to noncompliance, and reasons for postoperative noncompliance will be addressed.

Changes in activities performed in leisure time after open heart surgery.

To assess any changes made in the leisure activities performed after open heart surgery, 94 patients (48 with aortocoronary bypass operation, 46 with valve replacements) were asked exactly one year postoperatively whether activities, collected in a list of 21 items, had increased, decreased or remained equal since their operation. In spite of the fact that most leisure activities seemed to have remained unchanged, after operation patients seem to undertake activities quite contrary to their motivations for undergoing surgery in the first place: active participation (such as involvement in some kind of sport, going out to cinema, theatre, restaurants,...) decreases, whereas passive activities (such as watching sports on television, listening to music,...) increases significantly. Although 90% of the patients stated their physical, and 67% their emotional status, as being clearly improved compared to preoperative values, the experience of body limitations as well as of fear and anxiety seems to be so durable that the patients, now in good condition, become passive onlookers and cease to participate in social life.

[Research on quality of life in clinical studies: what is it and how is it measured?]. / Lebensqualitätsforschung in klinischen Studien: Was ist, wie misst man Lebensqualität?

The failure to investigate quality of life looms as a major gap in clinical studies. It was the aim of the survey to demonstrate 1) the problem of defining quality of life, 2) the importance of measuring it, especially with respect to evaluating optimal therapy and 3) measurement instruments and scales (disease-specific and overall well-being indices). Current remaining problems regarding quality of life research, as well as its use in clinical trials are discussed. It is stressed that quality of life should never be a mere slogan, but should be the focus for doctor and patient of interdisciplinary research regarding outcome of any therapy and indicator of its efficacy.

[Noncompliance in organ transplantation: a review]. / Noncompliance in der Organtransplantation: ein Uberblick.

The effectiveness of medical treatment depends not only on the appropriateness of the treatment modality but also on the patient's compliance with the intended regimen. The consequences of failing to comply can be damaging and devastating for the individual patient and his/her family. Noncompliance also leads to waste in two areas: first, a reduction of the potential benefits of therapy, and second, the additional cost of treating the avoidable consequent morbidity. A dramatic example of the consequences of noncompliance with the treatment regimen concerns patients who have had organ transplants: life-long immunosuppression is a pre-requisite for good graft function, and noncompliance is often associated with the occurrence of late acute rejection episodes, graft loss, and death. Here it might be assumed that these patients constitute a highly motivated group, and that compliance would be high. Unfortunately, this is not the case: overall noncompliance rates vary from 20 to 50%. There is no systematic and comprehensive review of the literature on noncompliance and its consequences in organ transplant patients to date. This overview includes literature on heart, liver and kidney transplants in adult and paediatric transplant patients and addresses the following issues: preoperative behaviour patterns as predictors of postoperative compliance problems, compliance behaviour after transplantation, noncompliance and its relationship to organ loss and death, retransplantation outcome after graft loss due to noncompliance, reasons for postoperative noncompliance, and ways to promote compliance.

[Surgical success following heart transplantation in relation to preoperative status]. / Der Operationserfolg nach Herztransplantation in Abhängigkeit vom präoperativen Zustand.

Patients waiting for heart transplantation have in common the acute threat of death with a maximal survival time of one year, but they differ in quality of life within the waiting period for a donor organ. The spectrum of life quality ranges from being able to work up to the day of transplantation to virtual immobility in an intensive care unit, controlled by machines right up to operation. Using the Quality of Life Index (Spitzer) and surgical assessment on a 3-tier scale following rehabilitation as measurements, a random study on 31 patients was conducted to determine whether a significant connection exists between preoperative quality of life and the result of operation. The statistical evaluation (Kendall's Tau-B = 0.7; p = 0.33) did not show any connection at all... Good preoperative quality of life cannot, therefore, be taken as indicator of surgical success in heart transplantation.

Acceptance of a pump-driven infusion therapy with prostaglandin E1 as a bridge to heart transplantation.

Ambulatory pump-driven intravenous infusions are a novel and - compared with hospitalization-cost-effective procedure to bridge refractory heart failure patients to cardiac transplantation. In the present study 13 patients received chronic infusions with prostaglandin E1 alone or in conjunction with catecholamines and the acceptance of this bridging therapy was investigated over a period of seven weeks. Prostaglandin E1 was uptitrated from 2.5 ng/kg/min to a maximum of 40 ng/kg/min, according to individual tolerance. 50% of the maximum tolerated dose of prostaglandin E1 was used for chronic infusion with a further dose reduction if side effects occurred. Altogether 8 patients who completed the therapy were analysed; of the remaining 5 three patients had a heart transplant, one patient died and one patient did not comply with the protocol. The drugs were administered by an automatic portable pump, which was connected to a subcutaneous tunneled catheter. During hospitalization patients and their relatives were instructed how to prepare drug solutions and to handle the infusion system. Patients' perceptions were investigated by visual analog scale questionnaires (rating scale zero to ten) before, and at weekly intervals during bridging therapy. Initial acceptance was documented as belief in therapy (9.4 +/- 1.2 SD), absence of fear of handling the pump (8.9 +/- 1.2 SD) and confidence of receiving help of close relatives (8.7 +/- 1.8 SD). During the observation period there were no statistically significant differences compared with this favorable starting position and no significant disruption of life style occurred. Pain in the joints-a prostaglandin E1-associated side effect-increased significantly (p < 0.05) at week 5, but returned to baseline levels during the following two weeks. At study end patients confirmed that they would repeat the experience (7.6 +/- 1.4 SD) and advise other patients to undergo this form of therapy (8.2 +/- 1.9 SD). Thus, this pilot study suggests that ambulatory pump-driven intravenous infusion therapy comprising prostaglandin E1 and catecholamines is acceptable to patients as a bridge to heart transplantation and that there should be no major difficulties regarding compliance.

[Correlation of psychological changes and spermiogram improvements following acupuncture]. / Korrelation psychischer Veränderungen und Spermiogrammverbesserungen nch Akupunktur.

The purpose of the study was to find the correlation between the effect of acupuncture on fertility and psychological effects. To investigate its influence on male subfertility, 28 patients received acupuncture treatment after informed consent. We evaluated subjective parameters by written psychological tests, while objective parameters consisted of measuring concentration, volume and motility in the spermiogram before and after acupuncture. There was a significant increase in sperm quality in all parameters but volume. The psychological test showed no change caused by acupuncture. Hence, we believe, that the effect of acupuncture on sperm quality is not caused by placebo-mechanisms.

[Psychological problems and management of cancer patients from the viewpoint of the clinical psychologist]. / Psychische Problematik und Betreuung der Krebspatienten aus der Sicht des klinischen Psychologen.

Since beginning of his illness the patient suffering from cancer no longer feels like active participant, but passive onlooker towards social life. He has to fight against intensive feelings of loss (e.g. loss of health, of organs, of abilities...); cancer always means leave-taking, grief and bereavement. Patients in hospitals have to suffer mainly from: decline of activities, decrease of subjectively perceived physical status, labile selfesteem, depression and exhaustion. It is pointed out that knowledge of one's self means an inalterable assumption for every person working with cancer patients.

[Heart transplantation: psychosocial correlations in the postoperative period]. / Herztransplantation: psychosoziale Korrelate der postoperativen Zeit.

Heart transplantation offers not only increased quantity but also highly improved quality of life. Nevertheless, it should not be seen as a panacea. Postoperatively the patients and their spouses face and have to overcome profound psychosocial problems. In this paper the five most important phases in the emotional adjustment to heart transplantation are discussed as to their significance for the patient, the patient's relationship to his/her partner and in view of the care by the medical team. These phases are a. the early postoperative period, b. rejection episodes, c. the postoperative inpatient phase, d. discharge and e. the first postoperative year. The paper highlights the difficulty of and the necessity for psychological care of heart transplant patients to reassure them emotionally and support them during phases of psychological instability.

[Pre- and postoperative psychosexual status of heart patients]. / Der prä- und postoperative psychosexuelle Status herzkranker Patienten.

Discussing the changed quality of life following open heart surgery the psychosexual status of 100 pre- and postoperative patients (aortocoronary bypass operation vs valve replacement) was assessed by standardized interviews. The preoperative interview showed only 9% of the patients having sexual intercourse during the last six months while 91% were sexually abstinent. As main reasons for the latter the patients named voluntary abstinence due to their illness (14%), negative advice of their doctor (22%) and no desire for sexual activity (33%). One year postoperatively the situation changed clearly. Within the last six months 47% of the former patients were sexually active, while 52% remained inactive. The open heart operation which improves life physically can also be seen as improving quality of life in respect to the psychosexual life of the patients. The interview data moreover show the great importance of medical advice in questions relating to sexuality which ought to be an absolutely necessary part of the dialogue with cardiological patients.

Heart transplantation: are there psychosocial predictors for clinical success of surgery?

50 adult patients were extensively psychosocially examined before undergoing heart transplantation. The data obtained and the clinical treatment data were compared with the clinical success of surgery (four groups ranging from excellent to unsatisfactory as determined by the surgeon one year after transplantation). Statistical evaluation by discriminant analysis resulted in the following predictors for successful surgery (all psychosocial): empathy, care and support by one partner (affective involvement), few demands for emotional communication (affective expression), self-control, ability to take stress, emotional stability, high frustration tolerance, low aggression level, and younger age. The following variables did not have predictive significance: schooling, occupation, social status, indication for transplantation, length of stay in intensive care and in hospital, extent of preoperative anxiety and depression, and the life-quality index according to Spitzer determined externally. The results show support by the partner to be the most significant psychosocial variable that can influence the clinical success of heart transplantation.

[Change in the quality of life following aortocoronary bypass and heart valve replacement: assessment of subjective surgical success]. / Veränderung der Lebensqualität nach aortokoronarem Bypass und Klappenersatz: Ein Gradmesser des subjektiven Operationserfolges.

Life quality of 100 consecutive male patients, half with coronary heart disease and half with valve diseases, was assessed 2 days prior to operation (A in the Tab.) as well as 1 year postoperatively (B in the Tab.) by standardized interview. The questionnaire included the physical condition and the emotional status, employment status, social interaction and sexuality. By far the majority of the interviewed patients showed a distinct improvement in all fields confirming a clearly positive effect of the heart operation on life quality: The number of persons employed increased by a third. The length of preoperative sick leave seems to be a good indicator for returning to work again: from 52 persons, having been preoperatively on sick leave for more than 2 weeks, 21 retired early after operation, 6 remained on sick leave and only 6 patients returned to full-time work again. On the other hand, 20 of the 24 patients who worked up to the time of operation took up their employment again postoperatively. Postoperative employment status does not seem to be primarily a question of physical improvement. Anxiety and fear of infarction recurrence or economic factors seem to be much more decisive for returning to work. However, the patients reported a distinct improvement of physical and emotional status: 85 described their physical condition, 63 their emotional status as "clearly improved" or "better". Less drugs were used in general, and the use of tranquillizers and soporifics was cut down to a third.(ABSTRACT TRUNCATED AT 250 WORDS)

[The hyperventilation syndrome as psychosomatic components of heart transplantation: case study]. / Das Hyperventilationssyndrom als psychosomatische Komponente einer Herztransplantation: Fallstudie.

The case study presents a patient with severe disturbance of self-esteem, suicidal family-background, narcissistic trauma and psychosomatic illness in form of a hyperventilation syndrome in the light of his heart transplantation. Helplessness and hopelessness of his psychological situation, his fear of separation, his paralyzing inability to come to any decision are seen against the background of a situation of absolute stress in which he had to struggle against his anxieties and fears and presumptions about the donor organ. There also is discussed whether a patient with such severe disturbances should really be accepted as a donor organ recipient, as well as whether in this case a supportive or analytic therapy would have been the appropriate choice. Annotations of the author about personal difficulties in therapy and at last its failing are added.

Psychosocial problems of donor heart recipients adversely affecting quality of life.

Heart transplantation has become an accepted therapy for patients suffering from terminal heart disease for whom neither standard forms of medication nor the usual surgery are of any benefit. Although results regarding postoperative quantity and quality of life are encouraging, it must not be overlooked that the patient and his family face, and have to overcome, profound psychosocial problems. The main stressors were identified in interviews with 47 heart transplant patients. The main preoperative problems were: the way of being informed about the diagnosis, the waiting period for transplantation, anguishing doubts about the decision to have a transplant, being a body without heart ('zombie'), guilt and shame regarding the donor, the reactions of others. Postoperatively the patients have to cope with: re-entering social systems, reactions of friends, neighbours and colleagues, rejection episodes, death of a fellow patient, the need to redesign family life. All the problems reported by the patients interviewed are discussed regarding their psychosocial implications, and hints are given on how to minimize them.

Long-term effects of heart transplantation: the gap between physical performance and emotional well-being.

The purpose of our study was to assess physical and emotional factors in heart transplant patients. A prospective design was used to compare patients' physical symptoms, emotional complaints, and restrictions at admission to the waiting list, immediately after, and 1 and 5 years after heart transplantation. Thirty-three patients were included (30 male, 3 female) in the study. Their mean age at admission was 48 +/- 10.2 years. Of these, 23 suffered from cardiomyopathy, 8 from coronary heart disease, and 2 from valvular insufficiency. At admission, the patients suffered from symptoms of cardiac insufficiency, and were restricted in sports, gardening, hobbies, sexual life, job, food-intake, and mobility. More than three-fourths rated their physical and emotional status as moderate to poor. Emotionally, they suffered from irritability, restlessness, depression, psychic lability, lowered drive, lack of social contact, low self-esteem, and anxiety. At the end of rehabilitation (4-8 weeks after the operation), all physical and emotional complaints, as well as restrictions had significantly decreased (p < 0.0001 to p < 0.001), except for trembling, numbness of hands/feet, and food-intake. One year postoperatively, patients reported even fewer physical complaints (p < 0.01). Three-fourths rated their physical and emotional status good or excellent. Five years postoperatively--in contrast to physical status, restrictions, and physical complaints--the emotional complaints had increased significantly (p < 0.0001). Patients reported excellent physical performance up to 5 years postoperatively. On the other hand, the study revealed that their emotional well-being had significantly deteriorated from 1 to 5 years postoperatively. Attention should, therefore, not only be paid to the good physical health of the survivors, but also to the worsening of their emotional status.

["You need a new heart". The problem of diagnostic disclosure from the viewpoint of the affected cardiologic patient]. / "Sie brauchen ein neues Herz". Das Problem der Diagnoseübermittlung aus der Sicht der betroffenen kardiologischen Patienten.

Heart transplantation has become a reasonable therapeutic option in treatment of patients with terminal heart diseases. Though it offers increased quantity as well as improved quality of life, information about needing a donor heart is a turning point in the patient's life. The aim of the study was to evaluate through postoperative interviews how that information was given by the doctors and how the patients had coped with it. It could be shown that 19 of the 49 interviewed patients took the information about needing a new heart as an expected event and chance, while for the remaining 30 it absolutely meant an unexpected information and a shock. Furthermore, only 3 persons reported about having had a helpful and empathic talk to their doctors. 26 about nothing but a short, cool information, and 10 held the shock about the way of information given by the doctors responsible for their bad preoperative psychical condition. Statements of patients are given to elucidate the results, which were discussed from the point of psychosomatics as well as from the communication sciences. At last, summarizing, rules for a helpful pretransplant-information to the patients were given.