Oral Papers: Medical Specialties I: Cardiology, Endorine, Renal
Robert Kormos, MD, FRCS(C), FACS, FAHA
Brack G Hattler Professor of Cardiothoracic Transplantation
University of Pittsburgh School of Medicine and Heart and Vascular Institute, University of Pittsburgh Medical Center
Background/Significance: A psychosocial evaluation is required for candidates for long-term mechanical circulatory support (MCS)(Dew, 2018). Despite guidelines and recommendations for elements to be included in this evaluation, few data indicate whether evaluation findings are prognostic for adverse post-implantation clinical outcomes. We examined this issue with respect to survival time, unplanned rehospitalization, and adverse medical events (AEs).
Methods: A single-site retrospective analysis was performed using prospectively collected data for all patients aged ≥18 receiving long-term MCS between 4/2004-12/2016, with follow-up post-implantation through 6/2017. We coded pre-implant psychosocial evaluations with an established rating system (Psychosocial Assessment of Candidates for Transplantation, Modified for MCS; m-PACT)(Maltby, 2014). The m-PACT yields a Total score (calculated so that higher=less favorable; range=0-20) and scores for 10 components reflecting social support; mental health; substance use; ability to perform activities of daily living; and knowledge and adherence to current medical requirements. Competing risk models (competing risks: transplant, weaning from MCS) were estimated to determine associations of m-PACT Total and component scores with survival time on MCS, time to unplanned rehospitalization, and time to any of 14 classes of AEs. Pre-implant demographic (age, sex, race/ethnicity) and clinical factors (BMI, MCS intent-to-treat as bridge vs. destination, INTERMACS severity profile score) were controlled.
Results: In 238 MCS patients (M±SD age 56±13, 81% male, 83% white, 62% bridge to transplant, median time on MCS=256 days, interquartile range, 124-785 days). Neither postimplantation survival time nor time to rehospitalization were significantly associated with m-PACT Total. However, for each 1-point m-PACT Total score increase, AE risk increased by 7% (hazard ratio, HR=1.07, CI: 1.01,1.15, p=.028). The individual AEs most affected were cardiovascular dysfunction and device malfunctions. The m-PACT components accounting for the influence of m-PACT Total on AE risk were poorer medical adherence at the time of the evaluation (HR=1.74, CI: 1.14,1.67, p=.001), and mental health problems (HR=1.20, CI: 1.02,1.61, p=.035).
Discussion/Conclusions: Beyond an earlier pilot effort examining m-PACT prediction of 30-day readmissions (Maltby, 2014), ours is the first study to examine a range of clinically important outcomes in a large sample over a period up to several years. Findings suggest that the psychosocial evaluation provides prognostic information for post-implant outcomes. Strategies incorporating input from behavioral health/consultation-liaison psychiatry specialists to address psychosocial risk factors either pre-implant or early post-implant may help reduce AE risk and thereby promote patient well-being during MCS.
Dew MA, DiMartini AF, Dobbels F, et al. The 2018 ISHLT/APM/AST/ICCAC/STSW recommendations for the psychosocial evaluation of adult cardiothoracic transplant candidates and candidates for long-term mechanical circulatory support. J Heart Lung Transplant 2018;37(7):803-23. Co-published, Psychosomatics 2018;59(5):415-40.
Maltby MC, Flattery MP, Burns B, et al. Psychosocial assessment of candidates and risk classification of patients considered for durable mechanical circulatory support. J Heart Lung Transplant 2014;33(8):36-41.