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K L Grady,
P Meyer,
A Mattea,
C White-Williams,
S Ormaza,
A Kaan,
B Todd,
S Chillcott,
D Dressler,
A Fu,
W Piccione,
M R Costanzo
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ABSTRACT: The successful use of left ventricular assist devices (LVADs) as a bridge to heart transplantation has prompted our examination of quality of life (QOL) outcomes. The purposes of this study are to describe QOL in patients 1 to 2 weeks after LVAD implantation and to compare QOL in a smaller cohort of patients from before to 1 to 2 weeks after surgery.
Data were collected from a convenience sample of 81 patients who completed booklets of questionnaires that measure domains of QOL 1 to 2 weeks after LVAD insertion and from 30 of 81 patients who completed booklets at both the pre-implantation and post-implantation periods. Patients completed booklets of 6 to 8 self-reporting instruments, with acceptable reliability and validity. Data were analyzed using descriptive and comparative statistics (chi-square, Mann-Whitney U and Wilcoxon signed ranks tests) with p = 0.01 considered statistically significant.
One to 2 weeks after LVAD implantation, patients were quite satisfied with their lives, experienced moderately low amounts of stress, coped well, and perceived themselves as having good health and QOL, low symptom distress, and moderately low functional disability. Patients reported significantly better QOL, more satisfaction with health and functioning, and were significantly less distressed by symptoms from immediately pre-operatively to post-operatively. However, patients reported significantly more self-care disability and more dissatisfaction with socioeconomic areas of life from before to immediately after surgery. Psychological distress was low and did not change with time.
Given that QOL improved from before to after LVAD implantation, our findings provide a springboard for investigation of the impact of LVADs on long-term QOL outcomes.
The Journal of Heart and Lung Transplantation 07/2001; 20(6):657-69. · 4.33 Impact Factor
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ABSTRACT: Indications for use of the intraaortic balloon pump have expanded as advances in the treatment of heart disease have continued. The intraaortic balloon pump is the most widely used circulatory assist device inserted as short term or long term therapy. Because the percutaneous femoral artery approach requires bedrest, new techniques for intraaortic balloon pump insertion that allow greater mobility are being developed for patients who require long term ventricular support. The goal of ambulation in these patients is to prevent potential complications associated with prolonged immobility. This paper reviews the use of the common iliac artery as an alternate site for intraaortic balloon pump insertion that allows the patient to ambulate and exercise. Pre and post procedure management as well as potential complications of intraaortic balloon pump insertion are discussed.
Progress in Cardiovascular Nursing 02/2000; 15(1):14-20.
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ABSTRACT: The effect of psychosocial factors on hospital length of stay (LOS) after heart transplantation has not been reported. This study examines relationships between preoperative psychosocial variables and LOS and identifies preoperative psychosocial predictors of LOS after transplant. A nonrandom sample of 307 patients at two medical centers completed a self-administered booklet of psychosocial measures. A chart review was also conducted. Psychosocial problems included anxiety, stress, and inadequate coping; questionable understanding of heart failure and treatment; substance abuse; and noncompliance. Self-care disability, a history of noncompliance, and more emotional disability predicted 8% of LOS. This supports the inclusion of psychosocial issues and functional disability in post-heart transplant clinical pathways.
The Journal of cardiovascular nursing 11/1999; 14(1):12-26. · 1.43 Impact Factor
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ABSTRACT: The relationship between pre-transplant body weight and post-transplant outcome has only recently been identified using a single, indirect measure of weight (percent ideal body weight [PIBW]). The literature is equivocal regarding which index is the better indicator of body weight. The purpose of this study was to determine (1) if pre-heart transplant body weight, measured by body mass index (BMI) and PIBW, is associated with post-heart transplant morbidity and mortality and (2) if patient gender, age, and etiology of heart disease affect this association.
The sample included 4,515 patients who received a heart transplant from January 1, 1990-December 31, 1995 at 38 institutions participating in the Cardiac Transplant Research Database (CTRD). Patients were divided into groups according to their BMI and PIBW. Data were described using frequencies, measures of central tendency, Pearson correlation coefficients, stratified actuarial analyses and log rank tests for comparisons, and a multivariable risk factor analysis in the hazard domain.
For all patients (n = 4,515), being <80% or >140% of IBW before heart transplant was a risk factor for increased mortality after heart transplant. The association between pre-heart transplant PIBW and post-heart transplant survival was affected by gender, age, and etiology of heart disease. In males, a higher PIBW was a significant risk factor for death early after transplant (p = .0003). Although not significant, there was a trend for a higher PIBW being a risk factor for death in females throughout the post transplant period (p = .07). No differences in cause of death were found for PIBW and BMI. In male and female recipients <55 years, being overweight pre-heart transplant was a risk factor for infection. In patients with pre-transplant ischemic heart disease, the greatest risk for infection was found in patients who were >140% of IBW. Pre-heart transplant BMI and PIBW were not associated with acute rejection or cardiac allograft arteriopathy after transplant.
In conclusion, being cachectic or obese preoperatively is associated with decreased survival in all patients after heart transplantation. Being obese preoperatively is associated with increased infection after heart transplant in males and females <55 years and in patients with ischemic heart disease. Of the 2 indices of body weight used in this study, percent ideal body weight appears to be the better predictor of future morbidity and mortality following heart transplantation.
The Journal of Heart and Lung Transplantation 09/1999; 18(8):750-63. · 4.33 Impact Factor
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ABSTRACT: A multivariate approach to the study of relationships between quality of life and demographic, physical, and psychosocial variables after heart transplantation has not been examined in a large, multi-site sample. The purpose of this study was to describe quality of life, examine relationships between quality of life and demographic, physical, and psychosocial variables, and identify predictors of quality of life in patients who were 1 year post heart transplantation.
Data were collected from a nonrandom sample of adult patients (n = 232) who were 1 year post heart transplantation at a Midwestern or Southern medical center. Nine self-administered instruments and chart review were used to gather data from patients. All tools had adequate psychometric support. Descriptive statistics, Pearson correlations, and step-wise multiple regression were used to analyze data. Level of significance was set at 0.05.
Patients were most satisfied with the areas of quality of life regarding social interaction and least satisfied with their psychological state. Patients experienced an average amount of stress, were coping fairly well, reported overall good quality of life, and were very satisfied with the outcome of their transplant surgery. Nine out of 16 variables were significant predictors of quality of life and explained 66% of the variance in quality of life: less stress, more helpfulness of information from health care providers, better health perception, better compliance with the transplant regimen, more effective coping, less functional disability, less symptom distress, older age, and fewer complications.
Predictors of quality of life at 1 year after heart transplantation were primarily psychological. Additional variance in quality of life was explained by physical, somatic sensation, demographic, and health status variables. Knowledge of these factors provides (1) information to identify patients who are at risk for poor quality of life at 1 year after heart transplantation and (2) direction for the development of interventions to improve quality of life.
The Journal of Heart and Lung Transplantation 04/1999; 18(3):202-10. · 4.33 Impact Factor
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ABSTRACT: The purpose of this report is to determine the extent of difficulty following and self-reported compliance with prescribed activities at 1 year after heart transplantation, identify postoperative predictors of compliance at 1 year after transplantation, and compare difficulty following and compliance with the therapeutic regimen at 1 year versus 2 years after transplantation.
Data were collected from a nonrandom sample of 120 adult patients 1 year after heart transplantation and 76 of 120 patients 2 years after transplantation. Patients were 83% male, mean age 54 years, 86% were married, 28% were employed, and 91% were in NYHA class I at 1 year after transplantation. Data were collected from the Assessment of Problems with the Heart Transplant Regimen, Quality of Life Index, Heart Transplant Symptom Checklist, Sickness Impact Profile, Heart Transplant Stressor Scale, Jalowiec Coping Scale, Social Support Index, Heart Transplant Intervention Scale, Rating Question Form, and chart review. Data were analyzed via frequencies, multiple regression, paired t-tests, and the Wilcoxon matched-pairs signed-ranks test.
At both 1 year and 2 years after transplantation, patients had almost no difficulty following the heart transplantation regimen and complied almost all of the time with taking medications, attending clinic, and completing scheduled tests. Patients complied less with following a diet, exercising, and taking their vital signs. Predictors of compliance at 1 year after heart transplantation differed by prescribed activity, explaining from 13% to 52% of variance (p < or = 0.0001).
These findings indicate the need to continue the study of heart transplant recipient compliance longitudinally for individual prescribed activities and provide evidence and direction for the development of interventions to enhance patient compliance.
The Journal of Heart and Lung Transplantation 04/1998; 17(4):383-94. · 4.33 Impact Factor
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ABSTRACT: Quality of life is an important healthcare outcome to study. Quality of life after heart transplantation has not been compared with indicators of severity of illness before heart transplantation.
To compare differences in quality of life 6 months after heart transplantation with two preoperative indicators of severity of illness: New York Heart Association classification and United Network for Organ Sharing status.
Data were collected from a nonrandom sample of 219 adult patients who had received a heart transplant 6 months earlier. Patients were divided into groups on the basis of their New York Heart Association classification and United Network for Organ Sharing status immediately before transplantation. Instruments used were the Heart Transplant Symptom Checklist, Heart Transplant Stressor Scale, Rating Question Form, Quality of Life Index, Sickness Impact Profile, and Jalowiec Coping Scale. Data were analyzed with descriptive statistics, chi-square tests, and independent t tests.
Quality of life 6 months after receiving a heart transplant varied with severity of illness before transplantation. These differences in quality of life were in the following domains: physical and occupational function, psychological state, and social interaction. Six months after receiving a heart transplant, patients who were more severely ill before transplantation were less satisfied with their lives, perceived that they were not doing as well, experienced more family-related stress, and used more negative coping strategies than did patients who were less severely ill preoperatively.
These findings indicate the need for further study of quality of life in the transplant recipients who are the most critically ill in intensive care settings before surgery, to develop interventions to improve recipients' quality of life, and to evaluate effectiveness of those interventions longitudinally.
American Journal of Critical Care 04/1998; 7(2):106-16. · 1.66 Impact Factor
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ABSTRACT: Although symptoms of heart failure abate after heart transplantation, other symptoms caused by the surgery, immunosuppressant drugs, and complications can be new sources of symptom distress for patients after operation.
This two-site National Institutes of Health study compared symptom distress in 173 adult heart transplant recipients from before operation to 3 months after operation. The Heart Transplant Symptom Scale was used to measure 92 symptoms related to heart disease and heart failure, transplantation, medication side effects, and complications commonly found in this population. Analysis was via paired t tests with Bonferroni correction. Most patients (93%) were receiving a triple immunosuppressant regimen of cyclosporine, azathioprine, and prednisone.
Total symptom distress decreased significantly (p = 0.013) from before operation to 3 months after heart transplantation. The 23 symptoms that decreased the most (p = 0.000) after operation accounted for a cumulative total reduction of 583% less symptom distress. These symptoms were primarily cardiopulmonary, neuromuscular, and emotional. The 10 symptoms that worsened the most (p = 0.000) after operation accounted for a cumulative total increase of 284% more symptom distress. These symptoms were primarily dermatologic, neurologic, and gastrointestinal and were all side effects of prednisone and cyclosporine.
The net change in symptom distress resulted in 299% less symptom distress in this cohort at 3 months after heart transplantation. This significant improvement in symptom outcomes scientifically documents the effectiveness of heart transplantation in reducing symptoms of heart failure, along with accompanying emotional symptoms. These research findings therefore reinforce and support the positive symptom outcomes often reported anecdotally in clinical practice.
The Journal of Heart and Lung Transplantation 07/1997; 16(6):604-14. · 4.33 Impact Factor
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ABSTRACT: It is difficult to assess candidacy of obese patients for heart transplantation because the effect of obesity before heart transplantation on posttransplantation outcome has not been examined. Therefore, the purpose of this study was to examine the impact of both preoperative weight and postoperative weight gain on outcome after heart transplantation.
The retrospective sample included 193 consecutive patients undergoing transplantation between March 1984 and June 1991 (mean age 47 +/- 14 years, 75% male). Data were gathered from retrospective chart review. Percent ideal body weight was calculated for each patient. Patients were divided into three groups based on pretransplantation percent ideal body weight: < 90% ideal body weight (n = 30), 90% to 110% ideal body weight (n = 79), and > 110% ideal body weight (n = 84). Chi-square, analysis of variance, Kaplan-Meier survival distributions, and the Cox Proportional Hazards Model were used for analyses.
Patients > 110% ideal body weight tended to have more coronary artery disease and higher serum triglyceride levels and significantly higher cholesterol levels than patients < 90% ideal body weight. After heart transplantation, no significant differences were found among the three pretransplantation percent ideal body weight groups regarding acute rejection, infection, and allograft arteriopathy. Survival was significantly worse among patients who were overweight before surgery (p = 0.018). A multivariate survival analysis showed that percent ideal body weight was an independent predictor of survival after heart transplantation (p = 0.046).
Despite a similar incidence of infection and rejection after heart transplantation among the three percent ideal body weight groups, obesity before heart transplantation is associated with significantly decreased survival after heart transplantation.
The Journal of Heart and Lung Transplantation 10/1996; 15(9):863-71. · 4.33 Impact Factor
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ABSTRACT: Very few studies have examined quality of life longitudinally in heart failure patients from before or after heart transplantation. The purpose of this study was to compare quality of life of patients with heart failure at the time of listing for a heart transplant with that 1 year after the operation. Major dimensions of quality of life measured in this study were health, physical and emotional functioning, and psychosocial functioning.
A convenience sample of 148 patients (80% male and mean age 52 years) was recruited from a midwestern and southern medical center. Data were collected from chart review and six patient-completed instruments: the Heart Transplant Symptom Checklist, Sickness Impact Profile, Heart Transplant Stressor Scale, Jalowiec Coping Scale, Quality of Life Index, and Rating Question Form. Informed consent was obtained, and patients who agreed to participate in the study completed the booklet of self-administered instruments. Statistical analyses included frequencies, measures of central tendency, paired t-tests, and Wilcoxon signed-ranks tests.
Total symptom distress decreased significantly overall from before to after heart transplantation (before = 0.19 versus after = 0.15, p < 0.0001). Patients rated themselves as having significantly poorer health while listed as a heart transplant candidate than at 1 year after surgery (before = 4.5 versus after = 7.5, p < 0.0001). Although the overall level of functional disability was fairly low before and 1 year after transplantation, patients still reported significant improvement after surgery (before = 0.21 versus 1 year after = 0.13, p < 0.0001). No significant differences were found in total stress, which was low to moderate (before = .026 versus 1 year after = 0.26, p = not significant), coping use (before = 0.48 versus 1 year after = 0.48, p = not significant), or coping effectiveness (before = 0.40) versus 1 year after = 0.42, p = not significant), from before to 1 year after heart transplantation. However, changes in types of symptoms, functional disability, stressors, and coping were noted over time. Overall satisfaction with life, which was fairly high at both time periods, increased significantly from the time of listing for a transplant to 1 year after surgery (before = 0.72 versus 1 year after = 0.82, p <0.0001), and overall quality of life improved significantly from before to after heart transplantation (before = 5.5 versus after = 7.8, p < 0.0001).
End-stage heart failure patients had improved quality of life from before to 1 year after heart transplant due to less total symptom distress, better health perception, better overall functional status, more overall satisfaction with life, and improved overall quality of life. However, post-transplant patients still experienced some symptom distress, functional disability, and stress, but were coping well.
The Journal of Heart and Lung Transplantation 09/1996; 15(8):749-57. · 4.33 Impact Factor
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K L Grady
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ABSTRACT: Heart transplantation is an accepted therapeutic alternative for patients with end-stage heart failure. The most common diagnoses of patients who require heart transplantation are ischemic and nonischemic cardiomyopathy. Evaluation for heart transplantation involves an examination of the patient's heart disease including left ventricle ejection fraction, hemodynamic status, presence of ventricular ectopy, New York Heart Association functional class, symptoms, exercise tolerance, and sympathetic nervous system activation. In addition, absolute and relative contraindications must be identified to determine their influence on a patient's candidacy. Care must be taken to determine the best use of a donor heart, a scarce resource, with regard to posttransplant morbidity, mortality, and quality of life.
The Journal of cardiovascular nursing 02/1996; 10(2):58-70. · 1.43 Impact Factor
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ABSTRACT: The authors identify 39 common preoperative stressors found in 175 heart transplant candidates from two medical centers. Relevance of the 10 worst and 10 least stressors during the preop wait is discussed. The 10 worst stressors were finding out about the need for a transplant, having end-stage heart disease, family worrying, illness symptoms, waiting for a donor, uncertainty about the future, no energy for leisure activities, constantly feeling worn out, less control over life, and dependency on others. The impact of transplant waiting time on the perceived stressfulness of illness factors is also examined. One factor was more stressful for those waiting longer than the median time of 1 month; 16 factors were more stressful for those waiting less than 1 month. The novelty or familiarity of the factor seemed to influence the stressfulness ratings of many variables during the period of waiting for the transplant.
Behavioral Medicine 02/1994; 19(4):145-54. · 1.14 Impact Factor
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Transplantation Proceedings 11/1993; 25(5):2978-80. · 1.00 Impact Factor
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Transplantation Proceedings 07/1990; 22(3 Suppl 1):6-11. · 1.00 Impact Factor
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ABSTRACT: Myocarditis is a disease process that is poorly understood. The incidence of myocarditis may vary with age, sex, and season of the year. The pathogenesis of myocarditis has been studied in animal models. Several investigators have documented the development of myocardial damage in mice after infection with a virus. Patients with myocarditis may present with highly variable clinical pictures ranging from no clinical manifestations to overt clinical congestive heart failure or sudden death. Endomyocardial biopsy is necessary to confirm the diagnosis of myocarditis. There are conflicting data regarding treatment of myocarditis. Immunosuppression may be useful in reducing myocardial inflammation and preventing irreversible myocardial damage. Nurses participate in care of patients during evaluation and treatment for myocarditis. Ongoing assessment of cardiac function is imperative at all times.
Heart and Lung The Journal of Acute and Critical Care 08/1989; 18(4):347-53. · 1.32 Impact Factor
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ABSTRACT: The accessibility and success of cardiac transplantation promotes transplantation for a broad range of recipients, including those requiring intravenous inotropes or mechanical-assist devices. To determine if survival is dependent on preoperative requirements for hemodynamic support, we studied 230 patients who underwent transplant at the Loyola, Stanford, and UTAH programs from December 1, 1984 through November 30, 1986, and who were followed up for 34 months postoperatively. Group 1 (n = 132 of 230, 57%) patients required only oral medical therapy to maintain hemodynamic compensation; Group 2 (n = 69 of 230, 30%) patients were dependent on intravenous inotropic support; and Group 3 (n = 29 of 230, 13%) patients required mechanical assistance. Pretransplant characteristics showed that dilated cardiomyopathy was more common in Group 2 patients, and lower cardiac index and ejection fraction were more prevalent in Group 3 patients as expected. Although survival was lower in Group 3 only at 1 month (Group 1, 98.5%; Group 2, 92.8%; and Group 3, 86.2%; p less than 0.01), the survival advantage in Groups 1 and 2 was lost by 3 months, with 1-year survival rates of 88.6% in Group 1, 81.2% in Group 2, and 82.8% in Group 3. Allograft survival and cause of death were not different among the three groups. Acute rejection occurred at a lower monthly frequency in the first 4 months in Group 3 (Group 1, 0.47 +/- 0.03; Group 2, 0.47 +/- 0.05; and Group 3, 0.29 +/- 0.06; p less than 0.01), whereas infectious complications occurred at similar frequencies.(ABSTRACT TRUNCATED AT 250 WORDS)
Circulation 12/1988; 78(5 Pt 2):III78-82. · 14.74 Impact Factor
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ABSTRACT: After surgery, 100 adult cardiac surgical patients participated in a study to determine what information was important to them and how well prepared they were. Questionnaires were administered 5 to 10 days after surgery and 1 to 4 weeks after discharge. In general patients received information that they perceived to be important, and they believed that preparation was more than adequate. Patients indicated a need to know more information about medication side effects than they received, and they did not desire as much information about emotional changes or sexual activity as the literature suggested.
Heart and Lung The Journal of Acute and Critical Care 08/1988; 17(4):349-55. · 1.32 Impact Factor
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ABSTRACT: The efficacy of OKT*3 monoclonal antibody in reversing acute cardiac allograft rejection was investigated in 10 cardiac transplant recipients aged 5 to 57 years (mean 34 +/- 18) and treated with the same induction and maintenance immunosuppression. Serial endomyocardial biopsies, right heart catheterization, and echocardiograms were performed for rejection surveillance. After intensified immunosuppression with equine antithymocyte globulins and steroids, nine patients showed persistent rejection (lymphocytic infiltration and myocyte necrosis). Conventional immunosuppression was contraindicated in one patient. OKT*3 (5 mg by intravenous push daily for 14 days) resulted in complete resolution of rejection in nine of 10 patients (90%). After therapy with OKT*3 mean right atrial and pulmonary arterial wedge pressure were significantly lower (9.1 +/- 4.0 vs 4.8 +/- 2.0 mm Hg and 13.4 +/- 4.3 vs 8.0 +/- 3.3 mm Hg, respectively; p less than .05). Cardiac index was doubled in two patients with rejection-induced cardiac dysfunction (1.5 vs 3.2 and 1.6 vs 2.7 liters/min/m2). Only two patients developed antibodies to OKT*3. Fever, nausea and headache occurred with the first three doses of OKT*3 and did not recur. One patient developed aseptic meningitis. OKT*3 effectively reverses refractory cardiac allograft rejection before the development of irreversible graft dysfunction. Patients who do not develop antibodies to OKT*3 can be retreated with this drug. Adverse reactions to OKT*3 are self-limited.
Circulation 12/1987; 76(5 Pt 2):V71-80. · 14.74 Impact Factor
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IMJ. Illinois medical journal 09/1985; 168(2):91-7.
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ABSTRACT: Nutritional status before and after heart transplantation was analyzed from retrospective data on 65 patients (82% male, mean age, 43.1 years, and mean length of illness before transplantation, 57.3 months). Of all the patients 93% were on a 2 gm low sodium diet, and 55% were on a low saturated fat and low cholesterol diet before surgery. After surgery 100% of patients were on the same salt-, fat-, and cholesterol-restricted diet. Visceral protein stores (determined from albumin and total lymphocyte count) and somatic protein stores (determined from weight-for-height calculations, triceps skin fold, and arm muscle circumference) increased significantly from before surgery to 6 months after surgery. The number of patients with adequate visceral protein stores increased from 66.1% to 98.1%, and those with adequate somatic protein stores increased from 67.2% to 84.6%. Weight was analyzed over time with analysis of variance. Patients gained weight (preoperative mean = 72.8 kg and postoperative mean at 6 months = 80.2 kg), and ideal body weight increased from 102% to 114%. With paired t tests the following differed before and after surgery (p less than or equal to 0.05): cholesterol levels increased from 180 to 262 mg/dl, and triglyceride concentrations increased from 139 to 221 mg/dl. In conclusion, patient protein stores returned to normal after surgery, patients increased body weight to more than 110% of ideal, and cholesterol and triglyceride levels became elevated.
The Journal of heart transplantation 7(2):123-7.
