The effect of psychiatric comorbidities on morbidity and mortality in patients with left ventricular assist device

INTRODUCTION: Heart failure (HF) is one of the leading health problems in the world due to its increasing frequency and prevalence. While the prevalence of HF varies from 0.3% to 2%, this number is 3-5% over 65 years old and 25% over 75 years old. Within 4 years after diagnosis, 50% of patients die; the death rate for severe HF reaches 50% within 1 year. With the increasing number of patients diagnosed with HF in recent years, the limited availability of donor organs for cardiac transplantation, medical and surgical contraindications are increasing the use of mechanical circulatory support devices in these patients. The most common example of mechanical circulatory support is left ventricular assist devices (LVAD). Although there are studies to evaluate mortality, morbidity and rehospitalization rates in patients with coexisting psychiatric disorders with end-stage HF, the literature on the effects of specific psychosocial risk factors on clinical outcomes in patients with LVAD is limited. Because of the increased use of LVAD, pre-evaluation of these patients is important as a prognostic indicator in terms of LVAD treatment. This preliminary assessment is expected to improve the success of the treatment and to provide psychotherapeutic support after implantation and to make lifestyle changes for high-risk patients. OBJECTIVE: The main objective of this study is to investigate the effects of psychiatric disorders (presents prior to LVAD treatment) on the post-operative clinical outcomes in end-stage HF patients. The second objective of this study is to examine the long-term effect of LVAD treatment on mental status. METHOD: 120 end-stage HF patients who underwent LVAD treatment between December 2010 and January 2016 in Ege University Faculty Of Medicine Cardiovascular Surgery Department were included in the study. The psychosocial assessment performed during LVAD implantation, demographic characteristics and the clinical records of the patients was obtained from the medical records. While 58 of the patients had psychiatric disorders, 62 patients had not any psychiatric disorders. In order to investigate the long-term effect of LVAD treatment on mental status, 45 patients who were still undergoing LVAD treatment were contacted by telephone, information about the study was given; SCID-I (Structured Clinical Interview for DSM IV Axis-1 Disorders) was administered to 25 patients who wanted to participate in the study. RESULTS: In our study, patients who had psychiatric disorders before LVAD operation were found to have a longer lenght of hospital stay and intensive care stay than patients without any psychiatric disorder. (p=0,002 and p=0,006) There was no significant difference between inpatient mortality and mortality rates within 1 year after operation in patients with psychiatric disorders before LVAD operation compared to patients without psychiatric disorder. (p= 0,118 and p= 0,171) Patients with psychiatric disorders before LVAD operation have increased morbidity rates at 1 year according to patients without psychiatric disorders. (p=0,009) Patients who had a psychiatric disorder before the LVAD operation had higher rates of rehospitalizations at 1 year than those without psychiatric disorders. (p=0,013) The rates of delirium after surgery were found to be higher in patients with psychiatric disorders compared to patients without psychiatric disorders. (p= 0,001) There were no significant differences in the hospital costs between the patients with psychiatric disorders before the LVAD operation and the patients without psychiatric disorders. (p= 0,153) According to the subdiagnosis groups, patients with depressive disorder were found to have a statistically higher rate of lenght of hospital stay, lenght of intensive care stay, postoperative delirium rates, morbidity and hospitalization rates at 1 year after operation compared to patients without psychiatric disorders. There was no statistically significant difference between the groups according to the DSM IV diagnoses of the patients for the pre- and post-LVAD treatment. (p=1,00). According to the test, 32% of the patients had pre-LVAD psychiatric disorder and 68% had no psychiatric disorder. CONCLUSION: Patients with psychiatric disorders before LVAD operation had longer length of hospital stay, lenght of intensive care stay, higher rates of postoperative delirium rates, morbidity and hospital re-admission rates at 1 year compared to patients without psychiatric disorders. When evaluated according to subdiagnostic groups, depressive symptoms were found to be significantly related to worse clinical outcomes. Considering the negative effect of psychiatric symptoms before the LVAD treatment on post-operative clinical outcomes in our study, it is important to monitor the pre-LVAD psycho-social assessment, as well as the patients' psychiatric symptoms before and after LVAD treatment. In future studies, there is a need of elaboration of pre-LVAD psychosocial assessments, structuring psychopharmacological treatment to attract attention to the effects on psychiatric findings; to plan for these variables as prospective follow-up monitoring that would reveal their association with post-operative clinical outcomes. KEY WORDS: left ventricular assist device, psychosocial assessment, depression, anxiety, insomnia, clinical outcomes