Baseline Quality-of-Life of Caregivers of Patients With Heart Failure Prior to Advanced Therapies: Findings From the Sustaining Quality of Life of the Aged: Transplant or Mechanical Support (SUSTAIN-IT) Study.

BACKGROUND: We compared health-related quality of life (HRQOL), depressive symptoms, anxiety, and burden in caregivers of older patients with heart failure based on the intended therapy goal of the patient: awaiting heart transplantation (HT) with or without mechanical circulatory support (MCS) or prior to long-term MCS; and we identified factors associated with HRQOL. METHODS: Caregivers (n = 281) recruited from 13 HT and MCS programs in the United States completed measures of HRQOL (EQ-5D-3L), depressive symptoms (PHQ-8), anxiety (STAI-state), and burden (Oberst Caregiving Burden Scale). Analyses included ANOVA, Kruskal-Wallis tests, χ2 tests, and linear regression. RESULTS: The majority of caregivers were female, white spouses with ≤ 2 comorbidities, median [Q1,Q3] age = 62 [57.8, 67.0] years. Caregivers (HT with MCS = 87, HT without MCS = 98, long-term MCS = 96) reported similarly high baseline HRQOL (EQ-5D-3L visual analog scale median score = 90; P = 0.67 for all groups) and low levels of depressive symptoms. STAI-state median scores were higher in the long-term MCS group vs the HT groups with and without MCS, (38 vs 32 vs 31; P < 0.001), respectively. Burden (task: time spent/difficulty) differed significantly among groups. Caregiver factors (number of comorbidities, diabetes and higher anxiety levels) were significantly associated with worse caregiver HRQOL, R2 = 26%. CONCLUSIONS: Recognizing caregiver-specific factors, including comorbidities and anxiety, associated with the HRQOL of caregivers of these older patients with advanced HF may guide support strategies.

Improvement in quality of life outcomes 2 weeks after left ventricular assist device implantation.

BACKGROUND: The successful use of left ventricular assist devices (LVADs) as a bridge to heart transplantation has prompted our examination of quality of life (QOL) outcomes. The purposes of this study are to describe QOL in patients 1 to 2 weeks after LVAD implantation and to compare QOL in a smaller cohort of patients from before to 1 to 2 weeks after surgery. METHODS: Data were collected from a convenience sample of 81 patients who completed booklets of questionnaires that measure domains of QOL 1 to 2 weeks after LVAD insertion and from 30 of 81 patients who completed booklets at both the pre-implantation and post-implantation periods. Patients completed booklets of 6 to 8 self-reporting instruments, with acceptable reliability and validity. Data were analyzed using descriptive and comparative statistics (chi-square, Mann-Whitney U and Wilcoxon signed ranks tests) with p = 0.01 considered statistically significant. RESULTS: One to 2 weeks after LVAD implantation, patients were quite satisfied with their lives, experienced moderately low amounts of stress, coped well, and perceived themselves as having good health and QOL, low symptom distress, and moderately low functional disability. Patients reported significantly better QOL, more satisfaction with health and functioning, and were significantly less distressed by symptoms from immediately pre-operatively to post-operatively. However, patients reported significantly more self-care disability and more dissatisfaction with socioeconomic areas of life from before to immediately after surgery. Psychological distress was low and did not change with time. CONCLUSION: Given that QOL improved from before to after LVAD implantation, our findings provide a springboard for investigation of the impact of LVADs on long-term QOL outcomes.

Intraaortic balloon pumping through the common iliac artery: management of the ambulatory intraaortic balloon pump patient.

Indications for use of the intraaortic balloon pump have expanded as advances in the treatment of heart disease have continued. The intraaortic balloon pump is the most widely used circulatory assist device inserted as short term or long term therapy. Because the percutaneous femoral artery approach requires bedrest, new techniques for intraaortic balloon pump insertion that allow greater mobility are being developed for patients who require long term ventricular support. The goal of ambulation in these patients is to prevent potential complications associated with prolonged immobility. This paper reviews the use of the common iliac artery as an alternate site for intraaortic balloon pump insertion that allows the patient to ambulate and exercise. Pre and post procedure management as well as potential complications of intraaortic balloon pump insertion are discussed.

Are preoperative obesity and cachexia risk factors for post heart transplant morbidity and mortality: a multi-institutional study of preoperative weight-height indices. Cardiac Transplant Research Database (CTRD) Group.

BACKGROUND: The relationship between pre-transplant body weight and post-transplant outcome has only recently been identified using a single, indirect measure of weight (percent ideal body weight [PIBW]). The literature is equivocal regarding which index is the better indicator of body weight. The purpose of this study was to determine (1) if pre-heart transplant body weight, measured by body mass index (BMI) and PIBW, is associated with post-heart transplant morbidity and mortality and (2) if patient gender, age, and etiology of heart disease affect this association. METHODS: The sample included 4,515 patients who received a heart transplant from January 1, 1990-December 31, 1995 at 38 institutions participating in the Cardiac Transplant Research Database (CTRD). Patients were divided into groups according to their BMI and PIBW. Data were described using frequencies, measures of central tendency, Pearson correlation coefficients, stratified actuarial analyses and log rank tests for comparisons, and a multivariable risk factor analysis in the hazard domain. RESULTS: For all patients (n = 4,515), being <80% or >140% of IBW before heart transplant was a risk factor for increased mortality after heart transplant. The association between pre-heart transplant PIBW and post-heart transplant survival was affected by gender, age, and etiology of heart disease. In males, a higher PIBW was a significant risk factor for death early after transplant (p = .0003). Although not significant, there was a trend for a higher PIBW being a risk factor for death in females throughout the post transplant period (p = .07). No differences in cause of death were found for PIBW and BMI. In male and female recipients <55 years, being overweight pre-heart transplant was a risk factor for infection. In patients with pre-transplant ischemic heart disease, the greatest risk for infection was found in patients who were >140% of IBW. Pre-heart transplant BMI and PIBW were not associated with acute rejection or cardiac allograft arteriopathy after transplant. CONCLUSIONS: In conclusion, being cachectic or obese preoperatively is associated with decreased survival in all patients after heart transplantation. Being obese preoperatively is associated with increased infection after heart transplant in males and females <55 years and in patients with ischemic heart disease. Of the 2 indices of body weight used in this study, percent ideal body weight appears to be the better predictor of future morbidity and mortality following heart transplantation.

Preoperative psychosocial predictors of hospital length of stay after heart transplantation.

The effect of psychosocial factors on hospital length of stay (LOS) after heart transplantation has not been reported. This study examines relationships between preoperative psychosocial variables and LOS and identifies preoperative psychosocial predictors of LOS after transplant. A nonrandom sample of 307 patients at two medical centers completed a self-administered booklet of psychosocial measures. A chart review was also conducted. Psychosocial problems included anxiety, stress, and inadequate coping; questionable understanding of heart failure and treatment; substance abuse; and noncompliance. Self-care disability, a history of noncompliance, and more emotional disability predicted 8% of LOS. This supports the inclusion of psychosocial issues and functional disability in post-heart transplant clinical pathways.

Predictors of quality of life in patients at one year after heart transplantation.

BACKGROUND: A multivariate approach to the study of relationships between quality of life and demographic, physical, and psychosocial variables after heart transplantation has not been examined in a large, multi-site sample. The purpose of this study was to describe quality of life, examine relationships between quality of life and demographic, physical, and psychosocial variables, and identify predictors of quality of life in patients who were 1 year post heart transplantation. METHODS: Data were collected from a nonrandom sample of adult patients (n = 232) who were 1 year post heart transplantation at a Midwestern or Southern medical center. Nine self-administered instruments and chart review were used to gather data from patients. All tools had adequate psychometric support. Descriptive statistics, Pearson correlations, and step-wise multiple regression were used to analyze data. Level of significance was set at 0.05. RESULTS: Patients were most satisfied with the areas of quality of life regarding social interaction and least satisfied with their psychological state. Patients experienced an average amount of stress, were coping fairly well, reported overall good quality of life, and were very satisfied with the outcome of their transplant surgery. Nine out of 16 variables were significant predictors of quality of life and explained 66% of the variance in quality of life: less stress, more helpfulness of information from health care providers, better health perception, better compliance with the transplant regimen, more effective coping, less functional disability, less symptom distress, older age, and fewer complications. CONCLUSIONS: Predictors of quality of life at 1 year after heart transplantation were primarily psychological. Additional variance in quality of life was explained by physical, somatic sensation, demographic, and health status variables. Knowledge of these factors provides (1) information to identify patients who are at risk for poor quality of life at 1 year after heart transplantation and (2) direction for the development of interventions to improve quality of life.

Patient compliance at one year and two years after heart transplantation.

BACKGROUND: The purpose of this report is to determine the extent of difficulty following and self-reported compliance with prescribed activities at 1 year after heart transplantation, identify postoperative predictors of compliance at 1 year after transplantation, and compare difficulty following and compliance with the therapeutic regimen at 1 year versus 2 years after transplantation. METHODS: Data were collected from a nonrandom sample of 120 adult patients 1 year after heart transplantation and 76 of 120 patients 2 years after transplantation. Patients were 83% male, mean age 54 years, 86% were married, 28% were employed, and 91% were in NYHA class I at 1 year after transplantation. Data were collected from the Assessment of Problems with the Heart Transplant Regimen, Quality of Life Index, Heart Transplant Symptom Checklist, Sickness Impact Profile, Heart Transplant Stressor Scale, Jalowiec Coping Scale, Social Support Index, Heart Transplant Intervention Scale, Rating Question Form, and chart review. Data were analyzed via frequencies, multiple regression, paired t-tests, and the Wilcoxon matched-pairs signed-ranks test. RESULTS: At both 1 year and 2 years after transplantation, patients had almost no difficulty following the heart transplantation regimen and complied almost all of the time with taking medications, attending clinic, and completing scheduled tests. Patients complied less with following a diet, exercising, and taking their vital signs. Predictors of compliance at 1 year after heart transplantation differed by prescribed activity, explaining from 13% to 52% of variance (p < or = 0.0001). CONCLUSIONS: These findings indicate the need to continue the study of heart transplant recipient compliance longitudinally for individual prescribed activities and provide evidence and direction for the development of interventions to enhance patient compliance.

Quality of life 6 months after heart transplantation compared with indicators of illness severity before transplantation.

BACKGROUND: Quality of life is an important healthcare outcome to study. Quality of life after heart transplantation has not been compared with indicators of severity of illness before heart transplantation. OBJECTIVE: To compare differences in quality of life 6 months after heart transplantation with two preoperative indicators of severity of illness: New York Heart Association classification and United Network for Organ Sharing status. METHODS: Data were collected from a nonrandom sample of 219 adult patients who had received a heart transplant 6 months earlier. Patients were divided into groups on the basis of their New York Heart Association classification and United Network for Organ Sharing status immediately before transplantation. Instruments used were the Heart Transplant Symptom Checklist, Heart Transplant Stressor Scale, Rating Question Form, Quality of Life Index, Sickness Impact Profile, and Jalowiec Coping Scale. Data were analyzed with descriptive statistics, chi-square tests, and independent t tests. RESULTS: Quality of life 6 months after receiving a heart transplant varied with severity of illness before transplantation. These differences in quality of life were in the following domains: physical and occupational function, psychological state, and social interaction. Six months after receiving a heart transplant, patients who were more severely ill before transplantation were less satisfied with their lives, perceived that they were not doing as well, experienced more family-related stress, and used more negative coping strategies than did patients who were less severely ill preoperatively. CONCLUSIONS: These findings indicate the need for further study of quality of life in the transplant recipients who are the most critically ill in intensive care settings before surgery, to develop interventions to improve recipients' quality of life, and to evaluate effectiveness of those interventions longitudinally.

Symptom distress three months after heart transplantation.

BACKGROUND: Although symptoms of heart failure abate after heart transplantation, other symptoms caused by the surgery, immunosuppressant drugs, and complications can be new sources of symptom distress for patients after operation. METHODS: This two-site National Institutes of Health study compared symptom distress in 173 adult heart transplant recipients from before operation to 3 months after operation. The Heart Transplant Symptom Scale was used to measure 92 symptoms related to heart disease and heart failure, transplantation, medication side effects, and complications commonly found in this population. Analysis was via paired t tests with Bonferroni correction. Most patients (93%) were receiving a triple immunosuppressant regimen of cyclosporine, azathioprine, and prednisone. RESULTS: Total symptom distress decreased significantly (p = 0.013) from before operation to 3 months after heart transplantation. The 23 symptoms that decreased the most (p = 0.000) after operation accounted for a cumulative total reduction of 583% less symptom distress. These symptoms were primarily cardiopulmonary, neuromuscular, and emotional. The 10 symptoms that worsened the most (p = 0.000) after operation accounted for a cumulative total increase of 284% more symptom distress. These symptoms were primarily dermatologic, neurologic, and gastrointestinal and were all side effects of prednisone and cyclosporine. CONCLUSIONS: The net change in symptom distress resulted in 299% less symptom distress in this cohort at 3 months after heart transplantation. This significant improvement in symptom outcomes scientifically documents the effectiveness of heart transplantation in reducing symptoms of heart failure, along with accompanying emotional symptoms. These research findings therefore reinforce and support the positive symptom outcomes often reported anecdotally in clinical practice.

Preoperative obesity is associated with decreased survival after heart transplantation.

BACKGROUND: It is difficult to assess candidacy of obese patients for heart transplantation because the effect of obesity before heart transplantation on posttransplantation outcome has not been examined. Therefore, the purpose of this study was to examine the impact of both preoperative weight and postoperative weight gain on outcome after heart transplantation. METHODS: The retrospective sample included 193 consecutive patients undergoing transplantation between March 1984 and June 1991 (mean age 47 +/- 14 years, 75% male). Data were gathered from retrospective chart review. Percent ideal body weight was calculated for each patient. Patients were divided into three groups based on pretransplantation percent ideal body weight: < 90% ideal body weight (n = 30), 90% to 110% ideal body weight (n = 79), and > 110% ideal body weight (n = 84). Chi-square, analysis of variance, Kaplan-Meier survival distributions, and the Cox Proportional Hazards Model were used for analyses. RESULTS: Patients > 110% ideal body weight tended to have more coronary artery disease and higher serum triglyceride levels and significantly higher cholesterol levels than patients < 90% ideal body weight. After heart transplantation, no significant differences were found among the three pretransplantation percent ideal body weight groups regarding acute rejection, infection, and allograft arteriopathy. Survival was significantly worse among patients who were overweight before surgery (p = 0.018). A multivariate survival analysis showed that percent ideal body weight was an independent predictor of survival after heart transplantation (p = 0.046). CONCLUSIONS: Despite a similar incidence of infection and rejection after heart transplantation among the three percent ideal body weight groups, obesity before heart transplantation is associated with significantly decreased survival after heart transplantation.

Improvement in quality of life in patients with heart failure who undergo transplantation.

BACKGROUND: Very few studies have examined quality of life longitudinally in heart failure patients from before or after heart transplantation. The purpose of this study was to compare quality of life of patients with heart failure at the time of listing for a heart transplant with that 1 year after the operation. Major dimensions of quality of life measured in this study were health, physical and emotional functioning, and psychosocial functioning. METHODS: A convenience sample of 148 patients (80% male and mean age 52 years) was recruited from a midwestern and southern medical center. Data were collected from chart review and six patient-completed instruments: the Heart Transplant Symptom Checklist, Sickness Impact Profile, Heart Transplant Stressor Scale, Jalowiec Coping Scale, Quality of Life Index, and Rating Question Form. Informed consent was obtained, and patients who agreed to participate in the study completed the booklet of self-administered instruments. Statistical analyses included frequencies, measures of central tendency, paired t-tests, and Wilcoxon signed-ranks tests. RESULTS: Total symptom distress decreased significantly overall from before to after heart transplantation (before = 0.19 versus after = 0.15, p < 0.0001). Patients rated themselves as having significantly poorer health while listed as a heart transplant candidate than at 1 year after surgery (before = 4.5 versus after = 7.5, p < 0.0001). Although the overall level of functional disability was fairly low before and 1 year after transplantation, patients still reported significant improvement after surgery (before = 0.21 versus 1 year after = 0.13, p < 0.0001). No significant differences were found in total stress, which was low to moderate (before = .026 versus 1 year after = 0.26, p = not significant), coping use (before = 0.48 versus 1 year after = 0.48, p = not significant), or coping effectiveness (before = 0.40) versus 1 year after = 0.42, p = not significant), from before to 1 year after heart transplantation. However, changes in types of symptoms, functional disability, stressors, and coping were noted over time. Overall satisfaction with life, which was fairly high at both time periods, increased significantly from the time of listing for a transplant to 1 year after surgery (before = 0.72 versus 1 year after = 0.82, p <0.0001), and overall quality of life improved significantly from before to after heart transplantation (before = 5.5 versus after = 7.8, p < 0.0001). CONCLUSIONS: End-stage heart failure patients had improved quality of life from before to 1 year after heart transplant due to less total symptom distress, better health perception, better overall functional status, more overall satisfaction with life, and improved overall quality of life. However, post-transplant patients still experienced some symptom distress, functional disability, and stress, but were coping well.

When to transplant: Recipient selection for heart transplantation.

Heart transplantation is an accepted therapeutic alternative for patients with end-stage heart failure. The most common diagnoses of patients who require heart transplantation are ischemic and nonischemic cardiomyopathy. Evaluation for heart transplantation involves an examination of the patient's heart disease including left ventricle ejection fraction, hemodynamic status, presence of ventricular ectopy, New York Heart Association functional class, symptoms, exercise tolerance, and sympathetic nervous system activation. In addition, absolute and relative contraindications must be identified to determine their influence on a patient's candidacy. Care must be taken to determine the best use of a donor heart, a scarce resource, with regard to posttransplant morbidity, mortality, and quality of life.

Predictors of compliance with diet 6 months after heart transplantation.

OBJECTIVE: To examine and predict patient compliance with diet 6 months after heart transplantation. DESIGN: Prospective, correlational design, with nonrandom sample. SETTING: Midwestern and southern medical centers. PATIENTS: Ninety-four adult patients who had undergone heart transplantation 6 months previously (mean age 55 years; primarily married men). VARIABLES: Sixteen independent variables measured by nine instruments (with acceptable preliminary reliability and validity data) and chart review were used to predict compliance with diet 6 months after heart transplantation. STATISTICS: Descriptive statistics, correlations, and multiple regression were used to analyze the data. RESULTS: More than 85% of patients were compliant with their diet most or all of the time, and more than 70% of patients experienced little or no difficulty complying with their diet. Difficulty with dietary compliance, gastrointestinal symptoms, and health perception predicted dietary compliance (accounting for 38% of variance). CONCLUSIONS: This study will contribute to enhanced patient care and may decrease morbidity and deaths after transplantation.

Predictors of quality of life in patients with advanced heart failure awaiting transplantation.

BACKGROUND: Quality of life is an important outcome to measure in patients with end-stage heart disease who are awaiting heart transplantation. The purposes of this study were threefold: (1) to assess life satisfaction in multiple areas, (2) to examine correlations between life satisfaction and demographic, physiologic, and psychosocial variables, and (3) to identify predictors of quality of life in patients with advanced heart failure who were awaiting heart transplantation. METHODS: Data were collected from a convenience sample of 359 adult heart transplant candidates from a midwestern and a southern medical center. Eight instruments were used to gather data from patients. All tools had adequate psychometric support. Data were analyzed by using descriptive statistics, Pearson correlations, and stepwise multiple regression analysis. RESULTS: Results showed that patients were most satisfied with significant others (e.g., emotional support from others, children, and family's health) and least satisfied with their health and functioning (e.g., current health status, ability to travel, and energy for daily activities). Significant correlations were found between total life satisfaction and age, New York Heart Association Functional classification, total number of daily medications, functional disability, symptom distress, stress, coping, helpfulness of heart transplant team interventions, health perception, expectation of transplant success, and overall quality of life. CONCLUSIONS: Eleven of 19 variables were significant predictors of higher quality of life in patients with advanced heart failure awaiting heart transplantation and accounted for 49% of explained variance: less symptom distress, better health perception, greater helpfulness of heart transplant team interventions, less stress, better coping ability, less functional disability, less use of fatalistic coping, older age, greater effectiveness of optimistic coping, being unemployed, and the expectation of transplant success.

Stressors in patients awaiting a heart transplant.

The authors identify 39 common preoperative stressors found in 175 heart transplant candidates from two medical centers. Relevance of the 10 worst and 10 least stressors during the preop wait is discussed. The 10 worst stressors were finding out about the need for a transplant, having end-stage heart disease, family worrying, illness symptoms, waiting for a donor, uncertainty about the future, no energy for leisure activities, constantly feeling worn out, less control over life, and dependency on others. The impact of transplant waiting time on the perceived stressfulness of illness factors is also examined. One factor was more stressful for those waiting longer than the median time of 1 month; 16 factors were more stressful for those waiting less than 1 month. The novelty or familiarity of the factor seemed to influence the stressfulness ratings of many variables during the period of waiting for the transplant.

Quality of life in patients with chronic heart failure.

Quality of life as an outcome of medical treatment and nursing care is important and has received more attention by researchers during the last decade. Patients with heart failure generally describe a perceived poor quality of life, while advanced heart failure patients report improved quality of life after transplantation. Findings on quality of life after implantation of mechanical assist devices to treat heart failure are very limited. The refinement of a definition of quality of life and improved methods to study quality of life will contribute to a better understanding of this complex concept in heart failure patients.