Implant Strategy-Specific Changes in Symptoms in Response to Left Ventricular Assist Devices

Abstract

Background: Although we know that the quality of life generally improves after left ventricular assist device (LVAD) implantation, we know little about how symptoms change in response to LVAD.

Methods: The purpose of this study was to compare the changes in symptoms between bridge and destination therapy patients as part of a prospective cohort study. Physical (dyspnea and wake disturbances) and affective symptoms (depression and anxiety) were measured before LVAD and at 1, 3, and 6 months after LVAD. Multiphase growth modeling was used to capture the 2 major phases of change: initial improvements between preimplant and 1 month after LVAD and subsequent improvements between 1 and 6 months after LVAD.

Results: The sample included 64 bridge and 22 destination therapy patients as the preimplant strategy. Destination patients had worse preimplant dyspnea and wake disturbances, and they experienced greater initial improvements in these symptoms compared with bridge patients (all P < .05); subsequent change in both symptoms were similar between groups (both P > .05). Destination patients had worse preimplant depression (P = .042) but experienced similar initial and subsequent improvements in depression in response to LVAD compared with bridge patients (both P > .05). Destination patients had similar preimplant anxiety (P = .279) but experienced less initial and greater subsequent improvements in anxiety after LVAD compared with bridge patients (both P < .05).

Conclusion: There are many differences in the magnitude and timing of change in symptom responses to LVAD between bridge and destination therapy patients. Detailed information on changes in specific symptoms may better inform shared decision-making regarding LVAD.

Figure 1. Changes in quality of life in response to LVAD by implant strategy

Changes in quality of life, as measured by 3-items of the Kansas City Cardiomyopathy Questionnaire, are depicted comparing pre-operative assessment with measure taken at 1, 3 and 6 months after LVAD; the mean and 95% confidence interval is represented by column height and the high and low whisker bars, respectively. Solid lines and lighter bar graphs represent bridge therapy patients, and dashed lines and darker bars represent destination therapy patients. Two phases of change in quality of life are depicted; the initial response to LVAD between pre-implant and 1 month post-implant (Δ₁), and the subsequent change between 1 and 6 months post-implant (Δ₂). The effect size of each phase of change is presented as Cohen’s d (d) (0.2–0.3 = small, ≈ 0.5 = moderate, and ≥ 0.8 = large effect). The difference (diff) and significance thereof (sig) of HRQOL pre-implant and during each phase of change between destination and bridge therapy patients are presented below the figure. Abbreviations: BT = bridge therapy; Diff. = difference; DT = destination therapy; KCCQ = Kansas City Cardiomyopathy Questionnaire; LVAD = left ventricular assist device; Sig. = significance; t = t-test.

Figure 2. Changes in dyspnea and wake disturbances in response to LVAD by implant strategy

Changes in dyspnea (A; as measured by the Heart Failure Somatic Perception Scale dyspnea score) and wake disturbances (B; as measured by the Epworth Sleepiness Scale) are depicted comparing pre-operative assessment with measure taken at 1, 3 and 6 months after LVAD; the mean and 95% confidence interval is represented by column height and the high and low whisker bars, respectively. Solid lines and lighter bar graphs represent bridge therapy patients, and dashed lines and darker bars represent destination therapy patients. Two phases of change in symptoms are depicted; the initial response to LVAD between pre-implant and 1 month post-implant (Δ₁), and the subsequent change between 1 and 6 months post-implant (Δ₂). The effect size of each phase of change is also presented as Cohen’s d (d) (0.2–0.3 = small, ≈ 0.5 = moderate, and ≥ 0.8 = large effect). The difference (diff) and significance thereof (sig) of symptoms pre-implant and during each phase of change between destination and bridge therapy patients are presented below the figure. Abbreviations: BT = bridge therapy; Diff. = difference; DT = destination therapy; ESS = Epworth Sleepiness Scale; HFSPS = Heart Failure Somatic Perception Scale; LVAD = left ventricular assist device; Sig. = significance; t = t-test.

Figure 3. Changes in depression and anxiety in response to LVAD by implant strategy

Changes in depression (A; as measured by the patient health questionnaire) and anxiety (B; as measured by the brief symptom inventory) are depicted comparing pre-operative assessment with measure taken at 1, 3 and 6 months after LVAD; the mean and 95% confidence interval is represented by column height and the high and low whisker bars, respectively. Solid lines and lighter bar graphs represent bridge therapy patients, and dashed lines and darker bars represent destination therapy patients. Two phases of change in symptoms are depicted; the initial response to LVAD between pre-implant and 1 month post-implant (Δ₁), and the subsequent change between 1 and 6 months post-implant (Δ₂). The effect size of each phase of change is also presented as Cohen’s d (d) (0.2–0.3 = small, ≈ 0.5 = moderate, and ≥ 0.8 = large effect). The difference (diff) and significance thereof (sig) of symptoms pre-implant and during each phase of change between destination and bridge therapy patients are presented below the figure. Abbreviations: BSI = Brief Symptom Inventory; BT = bridge therapy; Diff. = difference; DT = destination therapy; PHQ9 = patient health questionnaire; LVAD = left ventricular assist device; Sig. = significance; t = t-test.