Reversibility of Frailty After Bridge-to-Transplant Ventricular Assist Device Implantation or Heart Transplantation.

BACKGROUND: We recently reported that frailty is independently predictive of increased mortality in patients with advanced heart failure referred for heart transplantation (HTx). The aim of this study was to assess the impact of frailty on short-term outcomes after bridge-to-transplant ventricular assist device (BTT-VAD) implantation and/or HTx and to determine if frailty is reversible after these procedures. METHODS: Between August 2013 and August 2016, 100 of 126 consecutive patients underwent frailty assessment using Fried's Frailty Phenotype before surgical intervention: 40 (21 nonfrail, 19 frail) BTT-VAD and 77 (60 nonfrail, 17 frail) HTx-including 17 of the 40 BTT-VAD supported patients. Postprocedural survival, intubation time, intensive care unit, and hospital length of stay were compared between frail and nonfrail groups. Twenty-six frail patients were reassessed at 2 months or longer postintervention. RESULTS: Frail patients had lower survival (63 ± 10% vs 94 ± 3% at 1 year, P = 0.012) and experienced significantly longer intensive care unit (11 vs 5 days, P = 0.002) and hospital (49 vs 25 days, P = 0.003) length of stay after surgical intervention compared with nonfrail patients. Twelve of 13 frail patients improved their frailty score after VAD (4.0 ± 0.8 to 1.4 ± 1.1, P < 0.001) and 12 of 13 frail patients improved their frailty score after HTx (3.2 ± 0.4 to 0.9 ± 0.9, P < 0.001). Handgrip strength and depression improved postintervention. Only a slight improvement in cognitive function was seen postintervention. CONCLUSIONS: Frail patients with advanced heart failure experience increased mortality and morbidity after surgical intervention with BTT-VAD or HTx. Among those who survive frailty is partly or completely reversible underscoring the importance of considering this factor as a dynamic not fixed entity.

Cognitive impairment improves the predictive validity of physical frailty for mortality in patients with advanced heart failure referred for heart transplantation.

BACKGROUND: The aim of this study was to identify whether the addition of cognitive impairment, depression, or both, to the assessment of physical frailty provides better outcome prediction in patients with advanced heart failure referred for heart transplantation (HT). METHODS: Beginning in March 2013, all patients with advanced heart failure referred to our Transplant Unit have undergone a physical frailty assessment using the Fried frailty phenotype. Cognition was assessed with the Montreal Cognitive Assessment and depression with the Depression in Medical Illness questionnaire. We assessed the value of 4 composite frailty measures: physical frailty (PF ≥ 3 of 5 = frailty), "cognitive frailty" (CogF ≥ 3 of 6 = frail), "depressive frailty" (DepF ≥ 3 of 6 = frail), and "cognitive-depressive frailty" (ComF ≥ 3 of 7 = frail) in predicting outcomes. RESULTS: Frailty was assessed in 156 patients (109 men, 47 women), aged 53 ± 13 years, and with a left ventricular ejection fraction of 27% ± 14%. Inclusion of cognitive impairment or depression in the definition of frailty increased the proportion classified as frail from 33% using PF to 42% using ComF. During follow-up, 28 patients died before ventricular assist device implantation or HT. Frailty was associated with significantly lower ventricular assist device- and HT-free survival, with CogF best capturing early mortality: 12-month survival for non-frail and frail cohorts was 81% ± 5% vs 58% ± 10% (p < 0.02) using PF and 85% ± 5% vs 56% ± 9% (p < 0.002) using CogF. Combining the Depression in Medical Illness score with PF or CogF did not strengthen the relationship between frailty and mortality. CONCLUSIONS: The addition of cognitive impairment to the assessment of PF strengthened its capacity to identify advanced heart failure patients referred for HT who are at high risk of early death.

The Prevalence and Prognostic Significance of Frailty in Patients With Advanced Heart Failure Referred for Heart Transplantation.

BACKGROUND: Frailty is a clinically recognized syndrome of decreased physiological reserve. The heightened state of vulnerability in these patients confers a greater risk of adverse outcomes after even minor stressors. Our aim was to assess the prevalence and prognostic significance of the frailty phenotype in patients referred for heart transplantation. METHODS: Consecutive patients referred or on the waiting list for heart transplantation from March 2013 underwent frailty assessment. Frailty was defined as a positive response to 3 or more of the following 5 components: weak grip strength, slowed walking speed, poor appetite, physical inactivity, and exhaustion. In addition, markers of disease severity were obtained, and all patients underwent cognitive (Montreal Cognitive Assessment) and depression (Depression in Medical Illness-10) screening. RESULTS: One hundred twenty patients (83 men:37 women; age, 53 ± 12 years, range, 16-73 years; left ventricular ejection fraction, 27 ± 14%) underwent frailty assessment. Thirty-nine of 120 patients (33%) were assessed as frail. Frailty was associated with New York Heart Association class IV heart failure, lower body mass index, elevated intracardiac filling pressures, lower cardiac index, anemia, hypoalbuminemia, hyperbilirubinemia, cognitive impairment, and depression (all ρ < 0.05). Frailty was independent of age, sex, heart failure duration, left ventricular ejection fraction, or renal function. Frailty was an independent predictor of increased all-cause mortality: 1 year actuarial survival was 79 ± 5% in the nonfrail group compared with only 54 ± 9% for the frail group (P < 0.005). CONCLUSIONS: Frailty is prevalent among patients with advanced symptomatic heart failure referred for heart transplantation and is associated with increased mortality.

Interaction between physical activity and continuous-flow left ventricular assist device function in outpatients.

OBJECTIVE: Studies have shown that pump output by continuous-flow left ventricular assist devices (LVADs) increases with graded exercise testing. However, data on pump behavior during activities of daily living and sleep, where cardiac output requirements vary markedly, are lacking. We sought to determine pump parameters and activity levels in stable patients receiving outpatient LVAD therapy. METHODS AND RESULTS: Eleven outpatients (mean age 51 ± 14 years, 9 male) with centrifugal continuous-flow LVADs underwent monitoring of LVAD flow, heart rate (HR), energy expenditure, and physical activity over 1 week in an outpatient setting. Physical activity was recorded with the use of a combined pedometer, accelerometer, and calorimeter Sensewear armband. Pump, HR, and physical activity parameters were time matched for correlation analysis. Outpatients had an average pump flow of 5.67 ± 1.27 L/min and engaged predominately in low levels of physical activity (mean daily step count 3,249/day). Across the entire cohort, pump flow exhibited strong univariate relationships with patients' energy expenditure (r = 0.73), step count (r = 0.69), HR (r = 0.73), sleep (r = -0.89), and skin temperature (r = -0.85; P < .0001 for all). Multivariate analysis suggested that pump output was predominantly affected by recumbent position, energy expenditure and skin temperature (r(2) = 0.84; P < .0001). Pump flow and power consumption were significantly lower during sleep than during wake periods (5.48 ± 1.31 L/min vs 5.80 ± 1.26 L/min; P < .001). CONCLUSIONS: Pump output from continuous-flow LVADs is adaptive to changes in activities of daily living. Circadian variation in pump flow is mostly explained by recumbency and activity levels. Despite adequate pump flow, many LVAD patients continue to live sedentary lifestyles.

Lung transplantation in adolescents and young adults with cystic fibrosis.

CONTEXT: Little is known about adolescents' and young adults' experience with cystic fibrosis while waiting for or after receiving a lung transplant. The psychological and psychosocial factors that may influence these patients' transplant outcomes are yet to be fully explored. OBJECTIVE: To explore the psychosocial impact of the lung transplant journey on adolescents and young adults with cystic fibrosis. DESIGN: A questionnaire-based pilot study was used to enable descriptive, comparative, and correlational analyses between pretransplant and posttransplant groups. SETTING: A major lung transplant unit in Australia. PARTICIPANTS: Twenty-seven patients (9 before and 18 after transplantation) participated in the study. The mean ages were 18.7 years (SD 4.2) and 22.6 years (SD 3.9) in the pretransplant and posttransplant groups, respectively. RESULTS: In all domains of the Short Form 36 except Mental Health and Social Functioning, the posttransplant group had significantly higher scores (P < .05) compared to the pretransplant group. The Hospital and Anxiety and Depression Scale total Distress score in the posttransplant group was related to the number of rejection episodes (r = 0.47, P = .049) as well as hospital admissions (r = 0.51, P = .012), The number of rejection episodes was significantly related to patients' perceived level of self-efficacy (P = .025), importance to health (P = .001), and ease (P =.10) of monitoring their symptoms. CONCLUSION: This study provides some insight into the needs of adolescents and young adults with cystic fibrosis and the differences between those who are awaiting a transplant and those who have received a transplant. Assessing the young person's perceptions in relation to activities such as exercising, monitoring symptoms, and taking medications can give helpful insights into the transition phase, but require further research.