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Ann Thorac Surg 2009;88:e48-e49. doi:10.1016/j.athoracsur.2009.07.029
© 2009 The Society of Thoracic Surgeons
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Case Reports

Left Ventricular Assist Devices: Psychosocial Challenges in the Elderly

Paula Marcus, MD*

Department of Psychiatry, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

Accepted for publication July 14, 2009.

* Address correspondence to Dr Marcus, Department of Psychiatry, Montefiore Medical Center, Albert Einstein College of Medicine, Rosenthal Room 21, 111 E 210th St, Bronx, NY 10467 (Email: pamarcus{at}montefiore.org).


   Abstract
Top
 Abstract
Introduction
 Comment
 References
 
As the baby boom generation ages, the number of people with heart failure is expected to rise exponentially. A rapid increase in the demand for heart transplants will result in an increased use of left ventricular assist devices. This case illustrates the challenges facing transplant teams in evaluating elderly heart failure patients as candidates for assist devices. The critical elements of a psychosocial assessment are described.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
More than 5 million Americans suffer from mild to severe heart failure, and advanced heart failure is a major cause of death in people 65 years of age and older [1]. In the next few decades, as the baby boom generation ages, this number is expected to double. For patients in whom optimal medication therapy can no longer provide symptom relief adequate enough to maintain a reasonable quality of life, heart transplantation or use of implanted mechanical assist devices may be considered.

The Food and Drug Administration approved the first left ventricular assist device (LVAD) as a "bridge" to heart transplantation in 1994, allowing patients to live outside of the hospital while waiting for a donor heart. In 2001, results of the landmark Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure study (also known as the REMATCH trial) showed that patients with LVADs had dramatically higher survival rates than patients treated with medications alone [2]. The development of smaller devices (such as the HeartMate II; Thoratec, Pleasanton, CA) has made placement into patients with thin or small frames easier. In 2002, the Food and Drug Administration approved the HeartMate VE (Thoratec) as "destination therapy" for patients who likely would not survive end-stage heart failure but who were not eligible for heart transplantation; this device, however, is not small. Now, LVADs can be offered as definitive therapy to prolong life and improve function.

As the medical, surgical, and technological treatment of heart failure has advanced, the decision-making process regarding eligibility for placement of an LVAD has become more complex, particularly for elderly patients. The Centers for Medicaid and Medicare Services have established guidelines for the selection of candidates for heart transplantation; however, with the exception of the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial, there is little evidence to inform physicians in selecting appropriate candidates for destination LVAD therapy.

The psychosocial assessment is an important part of the evaluation of the myriad of factors affecting an individual's suitability as a heart transplant candidate. This aspect of the evaluation process addresses social support systems (loosely defined as personal support, housing, vocational status, financial, and environmental issues), coping abilities, and strategies, capacity to understand the risks and benefits, ability to adhere to a therapeutic regimen, ability to understand the basics of device management and care, ability to cope with the stresses of chronic disease and management, and mental health history, including substance abuse and its possible impact on the success or failure of transplantation. Our center uses all of these factors in our psychosocial evaluation for LVAD candidacy as well (Table 1).


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  		Table 1 Psychosocial and Cognitive Evaluation (Critical Elements)
 
Neurocognitive functioning is an important consideration in all age groups, but this has a special relevance in the elderly [3]. Although frank dementia may disqualify a candidate, subtle cognitive changes associated with cerebrovascular disease may have a profound impact on a person's ability to carry out instrumental activities of daily living (eg, managing medications, the capacity to exercise command and self-control, and the ability to direct others to provide care) and these may also be more difficult to uncover. Cognitive deficits, such as executive dysfunction, may exist in the absence of memory impairment; Kennedy and Smyth illustrate how these assessments can be easily performed at the bedside [4]. Neuropsychological testing is rarely needed, but it can help to inform the team as to the best approaches when teaching the patient to care for his device. Thus, even when an older person has adequate social support, subtle cognitive impairment can add to the challenges of care giving for any older adult, but particularly for one managing the complexity of treatment with an LVAD.

Interestingly, heart transplant recipients between the ages of 65 and 69 have as good or better long-term survival as their younger counterparts. They often have less comorbidity than the younger cohort [5]. However, since 69 is often considered the upper age limit for a heart transplant, the elderly are more likely to receive an LVAD as destination therapy than as a bridge-to-transplant.

Advanced age coincident with severe heart failure may be accompanied by deterioration in physical well-being, including weight loss, cachexia, poor nutritional status, muscle loss, and exercise intolerance. These secondary effects of heart failure may increase surgical risk, prolong recuperation, and increase post-surgical complications for the elderly LVAD recipient.

Although the Randomized Evaluation of Mechanical Assistance for the Treatment of Congestive Heart Failure trial found that LVAD patients had longer life spans than medically managed patients, patients receiving LVADs as destination therapy tend to have poorer psychological functioning and quality of life [6]. In this sense, LVAD therapy for the elderly can be conceptualized as outside the palliative care treatment paradigm. Robinson and Jurchak [7] discuss the impact on families and patients when technology is considered an imperative rather than an option. They conclude that a multidisciplinary team approach, aided by ethics consultation when indicated, can help guide decisions regarding the benefits and burdens of technology.

Some patients who receive an LVAD as a bridge-to-heart transplantation may have post-surgical changes in their health status that make them ineligible for a subsequent transplant. This can result in significant psychological pain for the patient who will live the remainder of his life dependent on his LVAD.

A 67-year-old man with congestive heart failure received an LVAD as a bridge-to-heart transplantation. He was retired and lived with his wife of more than 40 years. The two adult children were both married and lived nearby; they provided emotional support but were unable to assist with daily needs.

The patient's wife had a chronic anxiety disorder that was exacerbated by her husband's illness and the necessity of learning how to care for the LVAD. When swallowing problems developed post-surgery, which necessitated percutaneous endoscopic gastrostomy feedings, her anxiety rose again.

The patient had visual hallucinations develop after his discharge home. Low-dose anti-psychotic medication helped manage the symptoms. A diagnosis of Cheyne-Stokes respiration and subsequent nasal oxygen at night alleviated the hallucinations.

The bedroom was located up a steep flight of stairs and adjacent to the only bathroom, which added to the physical burdens of care giving for the patient. As in this case, most caregivers are women, spouses, or daughters, and the burden of care giving can have a profound impact on the caregiver's health.

Once the patient recovered from the LVAD implantation, his chronic lung disease worsened, and progression of his peripheral vascular disease made the patient an ineligible candidate for transplantation. This revelation engendered anger toward the treatment team, probably as a displacement of his feelings of helplessness and fear of abandonment. Major depression was diagnosed, and he responded favorably to a course of anti-depressant medication and supportive therapy. The patient's ability to accept support from others has allowed the team to be of assistance both to the patient and his caregiver as he copes with life dependent on LVAD therapy.


   Comment
Top
 Abstract
 Introduction
 Comment
References
 
When confronted with a choice of medication management of heart failure or implantation of left ventricular assist device, many elderly patients will choose the latter when it offers the possibility of prolonging their lives, either as "destination therapy" or as a bridge-to-heart transplant. Studies have shown improved quality of life for LVAD patients who are later explanted with recovery of heart function or go on to receive a transplant; however, for patients with LVADs as destination therapy, quality of life is not as improved and psychological functioning is sometimes challenged [6].

The psychosocial assessment determines coping styles (ie, avoidant behavior taxes the resources of the treatment team), assesses cognitive ability through simple testing at the bed side, and explores social supports. A discussion of advance directives will help inform the decision-making of the candidate and his support system. This case illustrates that a multidisciplinary approach to evaluation of elderly patients for LVAD candidacy, especially as destination therapy, is crucial to successful outcomes.


   References
Top
 Abstract
 Introduction
 Comment
 References
 

  1. Kannel WB, Ho K, Thom T, et al. Changing epidemiological features of cardiac failure Br Heart J 1994;72:S3-S9.[Free Full Text]
  2. Rose EA, Gelijns AC, Moskowitz AJ, et al. Long-term mechanical left ventricular assistance for end-stage heart failure N Engl J Med 2001;345:1435-1443.[Medline]
  3. Shapiro PA, Levin HR, Oz MC. Left ventricular assist devices (psychosocial burden and implications for heart transplant programs) Gen Hosp Psychiatry 1996;18:30S-35S.[Medline]
  4. Kennedy GJ, Smyth CA. Screening older adults for executive dysfunction: an essential refinement in cognitive assessment AJN 2008;108:60-69.[Medline]
  5. Owen JE, Bonds CL, Wellisch DK. Psychiatric evaluations of heart transplant candidates: predicting post-transplant hospitalizations, rejection episodes, and survival Psychosomatics 2006;47:213-222.[Medline]
  6. Wray J, Hallas CN, Banner NR. Quality of life and psychological well-being during and after left ventricular assist device support Clin Transplant 2007;21:622-627.[Medline]
  7. Robinson EM, Jurchak M. Ethical issues raised by LVADs and Mr. T's story. J Clin Ethics 2003;14:201-207.[Medline]




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