Adult: Mechanical Circulatory Support
Value of psychosocial evaluation for left ventricular assist device candidates

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Abstract

Objective

Left ventricular assist devices require a psychosocial assessment to determine candidacy despite limited data correlating with outcome. Our objective is to determine whether the Stanford Integrated Psychosocial Assessment for Transplant, a tool validated for transplant and widely used by left ventricular assist device programs, predicts left ventricular assist device program hospital readmissions and death.

Methods

We performed a retrospective analysis of adults at the Cleveland Clinic with Stanford Integrated Psychosocial Assessment for Transplant scores before primary left ventricular assist device program implantation from April 1, 2013, to December 31, 2018. The primary outcome was unplanned hospital readmissions censored at death, transplantation, and transfer of care. The secondary outcome was death.

Results

There were 263 patients in the left ventricular assist device program with a median (Q1, Q3) Stanford Integrated Psychosocial Assessment for Transplant score of 16 (8, 28). During a median follow-up 1.2 years, 56 died, 65 underwent transplantation, and 21 had transferred care. There were 640 unplanned hospital readmissions among 250 patients with at least 1 outpatient visit at our center. In a multivariable analysis, Stanford Integrated Psychosocial Assessment for Transplant components but not total Stanford Integrated Psychosocial Assessment for Transplant score was associated with readmissions. Psychopathology (Stanford Integrated Psychosocial Assessment for Transplant C-IX) was associated with hemocompatibility (coefficient 0.21 ± standard error 0.11, P = .040) and cardiac (0.15 ± 0.065, P = .02) readmissions. Patient readiness was associated with noncardiac (Stanford Integrated Psychosocial Assessment for Transplant A-III, 0.24 ± 0.099, P = .016) and cardiac (Stanford Integrated Psychosocial Assessment for Transplant A-low total, 0.037 ± 0.014, P = .007) readmissions. Poor living environment (Stanford Integrated Psychosocial Assessment for Transplant B-VIII) was associated with device-related readmissions (0.83 ± 0.34, P = .014). Death was associated with organic psychopathology or neurocognitive impairment (Stanford Integrated Psychosocial Assessment for Transplant C-X, 0.59 ± 0.21, P = .006).

Conclusions

Total Stanford Integrated Psychosocial Assessment for Transplant score was not associated with left ventricular assist device program readmission or mortality. However, we identified certain Stanford Integrated Psychosocial Assessment for Transplant components that were associated with outcome and could be used to create a left ventricular assist device program specific psychosocial tool.

Section snippets

Population

From April 1, 2013, to January 1, 2019, 374 patients underwent primary durable LVAD implant. We excluded patients aged less than 18 years (N = 21), patients who did not have a SIPAT assessment before LVAD (N = 51, Figure E1), patients with a total artificial heart (N = 1), patients requiring temporary or durable biventricular support (N = 24), and patients undergoing device exchange (N = 14). Our final cohort consisted of 263 patients (Figure E2). The study was approved by the Cleveland Clinic

Baseline Characteristics

Our cohort consisted of 263 patients with LVADs (46% bridge to transplantation, 54% destination therapy) with 100 (38%) Heartware devices (Medtronic, Minneapolis, Minn), 80 (30%) HeartMate 2 devices (Medtronic), and 83 (32%) HeartMate 3 devices (Medtronic) followed for a median of 1.2 years (Table 1). The mean age of patients was 58 years, with the majority white, married men. Most patients had a dilated nonischemic cardiomyopathy and were Interagency Registry for Mechanically Assisted

Discussion

Durable mechanical circulatory support implantation remains one of the few cardiac operations that requires a psychosocial evaluation1 despite limited data predicting any adverse outcome.2 This requirement is based on the complexity of lifelong LVAD management and need to determine transplant candidacy. SIPAT is commonly used for psychosocial evaluations by LVAD programs since validated to predict transplant outcome8 but has not been validated to predict outcome after LVAD implants. On the

Conclusions

SIPAT is a useful psychometric tool to evaluate patients with advanced heart failure and efficient because the same test known to predict outcome in transplant has now been shown to predict LVAD outcomes. Although the total SIPAT score was not associated with readmission or mortality, SIPAT domains were associated with LVAD outcome. For instance, patient readiness was associated with noncardiac and cardiac readmissions, social support was associated with device-related readmissions, and

References (25)

Informed Consent: Cleveland Clinic Institutional Review Board (IRB) number 15-643, approved May 13, 2019 (5/21/2019-5/20/20) and renewed May 15, 2020 (5/21/2020-5/20/2021). Date and number of IRB approval: Approved June 17, 2019, IRB #15-643.

Supported by Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic. Dr Hsich is supported by the National Heart, Lung, and Blood Institute of the National Institute of Health under Award Number HL141892.

Additional SIPAT Research Group collaborators: Shinya Unai, MD, Terrence Roncagli, LISW-S, Alexandra C. W. Sakai, MSW, LISW-S, from the Cleveland Clinic Heart and Vascular Institute, Transplant Center.

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