Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA.
Department of Psychology, University of Pittsburgh, Pittsburgh, PA.
Transplantation. 2021 Mar 1;105(3):608-619. doi: 10.1097/TP.0000000000003287.
Psychosocial evaluations are required for long-term mechanical circulatory support (MCS) candidates, no matter whether MCS will be destination therapy (DT) or a bridge to heart transplantation. Although guidelines specify psychosocial contraindications to MCS, there is no comprehensive examination of which psychosocial evaluation domains are most prognostic for clinical outcomes. We evaluated whether overall psychosocial risk, determined across all psychosocial domains, predicted outcomes, and which specific domains appeared responsible for any effects.
A single-site retrospective analysis was performed for adults receiving MCS between April 2004 and December 2017. Using an established rating system, we coded psychosocial evaluations to identify patients at low, moderate, or high overall risk. We similarly determined risk within each of 10 individual psychosocial domains. Multivariable analyses evaluated whether psychosocial risk predicted clinical decisions about MCS use (DT versus bridge), and postimplantation mortality, transplantation, rehospitalization, MCS pump exchange, and standardly defined adverse medical events (AEs).
In 241 MCS recipients, greater overall psychosocial risk increased the likelihood of a DT decision (odds ratio, 1.76; P = 0.017); and postimplantation pump exchange and occurrence of AEs (hazard ratios [HRs] ≥ 1.25; P ≤ 0.042). The individual AEs most strongly predicted were cardiac arrhythmias and device malfunctions (HRs ≥ 1.39; P ≤ 0.032). The specific psychosocial domains predicting at least 1 study outcome were mental health problem severity, poorer medical adherence, and substance use (odds ratios and HRs ≥ 1.32; P ≤ 0.010).
The psychosocial evaluation predicts not only clinical decisions about MCS use (DT versus bridge) but important postimplantation outcomes. Strategies to address psychosocial risk factors before or soon after implantation may help to reduce postimplantation clinical risks.
无论是否将机械循环支持（MCS）作为终末期治疗（destination therapy，DT），都需要对长期接受 MCS 的患者进行心理社会评估。尽管指南规定了 MCS 的心理社会禁忌证，但目前尚未全面研究哪些心理社会评估领域对临床结局最具预测性。我们评估了整体心理社会风险是否可以预测结局，以及哪些特定的领域对结果有影响。
对 2004 年 4 月至 2017 年 12 月期间在单中心接受 MCS 的成年人进行回顾性分析。使用已建立的评分系统对心理社会评估进行编码，以确定患者的整体风险低、中或高。我们还确定了 10 个单独心理社会领域内的风险。多变量分析评估了心理社会风险是否预测了 MCS 使用（DT 或桥接）的临床决策，以及植入后的死亡率、移植、再入院、MCS 泵更换和标准定义的不良医疗事件（AE）。
在 241 例 MCS 患者中，较高的整体心理社会风险增加了 DT 决策的可能性（比值比，1.76；P=0.017）；以及植入后泵更换和 AE 的发生（风险比[HR]≥1.25；P≤0.042）。预测至少 1 项研究结局的个体 AE 为心律失常和器械故障（HR≥1.39；P≤0.032）。预测至少 1 项研究结局的特定心理社会领域为心理健康问题严重程度、较差的医疗依从性和物质使用（比值比和 HR≥1.32；P≤0.010）。
心理社会评估不仅可以预测 MCS 使用（DT 与桥接）的临床决策，还可以预测重要的植入后结局。在植入前或植入后不久采取策略来解决心理社会危险因素，可能有助于降低植入后的临床风险。
