Psychosocial Evaluation of Candidates for Mechanical Circulatory Support and Risk for Adverse Post-Implantation Medical Outcomes

Purpose A psychosocial evaluation is required for candidates for long-term mechanical circulatory support (MCS). Despite guidelines and recommendations for elements to be included in this evaluation, few data indicate whether evaluation findings are prognostic for adverse outcomes after MCS implantation. We examined this issue with respect to post-implant survival time, 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 4/2004-12/2017. We coded pre-implant psychosocial evaluations with an established rating system (Psychosocial Assessment of Candidates for Transplantation, Modified for MCS; m-PACT). 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 and 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 unscheduled rehospitalization, and time to any of 14 classes of AEs. Pre-implant demographic and clinical factors 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), survival time and time to rehospitalization were not 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 types of 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). Conclusion The psychosocial evaluation may provide prognostic information for post-implant outcomes. Strategies to address psychosocial risk factors either before implant or as soon as possible post-implant may help to reduce AE risk and thereby promote patient well-being during MCS.