From the *Center for Medical Ethics & Health Policy, Baylor College of Medicine, Houston, Texas; and †Houston Methodist DeBakey Heart & Vascular Center and J.C. Walter Jr. Transplant Center, Houston Methodist Hospital, Houston, Texas.
ASAIO J. 2017 Nov/Dec;63(6):740-744. doi: 10.1097/MAT.0000000000000567.
Left-ventricular assist device (LVAD) therapy is a growing mechanical circulatory support therapy used to treat patients with advanced heart failure. There is a general assumption among clinicians that patients would prefer to accept a heart to any other treatment were they eligible. However, little research has been done to clarify the nuances of patient treatment preferences for LVAD therapy versus transplantation. The objective of this study was to investigate this treatment preference assumption from patients' perspectives. In a single-site study, 15 LVAD patients, 15 LVAD candidates, 15 LVAD decliners, and 15 LVAD caregivers (n = 60) participated in structured, in-depth interviews to assess decisional processes and treatment preferences for advanced heart failure. The interview guides were consistent with the Ottawa framework on decision-making processes. All participants were identified by the LVAD coordination team and recruited consecutively between February and November 2014. The patient and candidate groups included both LVAD designations: destination therapy (n = 22), bridge-to-transplant (n = 4), as well as four participants who deferred designation pending worsening clinical status. The interviews were analyzed using qualitative description with constant comparisons, aided by ATLAS.ti. Although LVAD eligible patients generally show a preference for heart transplantation as the ideal treatment for heart failure, some patients begin to show ambivalence as they experience LVAD therapy and begin to prefer LVAD as a long-term, destination treatment. Some themes that emerged from the interviews concerning transplantation centered on the consequences of multiple major surgeries (i.e., LVAD placement followed by heart transplantation, n = 18), fears surrounding lifestyle changes of accepting a heart transplant (n = 14) and life satisfaction with an LVAD as a "new normal" (n = 18). Findings suggest that experience with an LVAD can sometimes cause ambivalence about transplant with some patients preferring LVAD as destination even when transplant is an option. We provide clinical and programmatic implications of this, concluding with practical recommendations for how to fully address patients' goals of treatment as their health and situation changes over time.
左心室辅助装置 (LVAD) 治疗是一种日益增长的机械循环支持治疗方法，用于治疗晚期心力衰竭患者。临床医生普遍认为，如果患者符合条件，他们更愿意接受心脏移植而不是其他任何治疗。然而，很少有研究来阐明患者对 LVAD 治疗与移植治疗的细微差别。本研究的目的是从患者的角度调查这种治疗偏好假设。在一项单站点研究中，15 名 LVAD 患者、15 名 LVAD 候选者、15 名 LVAD 拒绝者和 15 名 LVAD 护理人员（n=60）参与了结构化的深入访谈，以评估决策过程和对晚期心力衰竭的治疗偏好。访谈指南与渥太华决策过程框架一致。所有参与者均由 LVAD 协调团队确定，并于 2014 年 2 月至 11 月期间连续招募。患者和候选者组均包括两种 LVAD 设计：目标治疗（n=22）、桥接移植（n=4），以及四名因临床状况恶化而推迟指定的参与者。使用定性描述和恒比法对访谈进行分析，由 ATLAS.ti 辅助。尽管 LVAD 合格患者通常对心脏移植作为心力衰竭的理想治疗方法表示偏好，但一些患者在经历 LVAD 治疗后开始表现出矛盾心理，并开始更喜欢 LVAD 作为长期的、目标治疗。一些关于移植的主题从访谈中出现，集中在多次大手术的后果上（即 LVAD 放置后进行心脏移植，n=18）、接受心脏移植对生活方式改变的恐惧（n=14）以及对 LVAD 的生活满意度作为“新常态”（n=18）。研究结果表明，有时，LVAD 的经验会导致对移植的矛盾心理，一些患者即使有移植的选择，也更喜欢将 LVAD 作为目标治疗。我们提供了这方面的临床和计划影响，并得出了一些实际建议，以随着时间的推移，充分满足患者的治疗目标，同时考虑到他们的健康和情况的变化。
