Suicide Attempts a Concern in LVAD Recipients

Stephanie Edwards

April 09, 2020

New research shows an increased incidence of suicide attempts among recipients of a left-ventricular assist device (LVAD), findings from the multicenter ASSIST-ICD study show.

Data from the observational Determination of Risk Factors of Ventricular Arrhythmias After Implantation of Continuous Flow Left Ventricular Assist Device With Continuous Flow Left Ventricular Assist Device (ASSIST-ICD) study, which involved 19 centers in France, showed a 2% suicide risk after 18 months of follow-up, a concerning percentage when compared with the general population and patients with other chronic diseases.

"Suicide attempts are not uncommon and represent 2% of the LVAD-recipients discharged alive from hospital," says Vincent Galand, MD, CHU Rennes, France, told | Medscape Cardiology.

This rate is much higher than the suicide rate of the overall French population or of patients with chronic disease, he added. In France, the suicide attempt rate is approximately 0.03% in the general population, with an increase to 0.06% for those with chronic heart failure, the authors note.

The research letter was published online March 11 in Circulation.

A Call for Improvement of Care

Left ventricular assist device (LVAD) implantation is an alternative therapy for patients facing end-stage heart failure, used commonly as a bridge to transplantation, but also, more recently, as destination therapy.

Many complications can be associated with LVAD therapy, including infection, thrombosis, and stroke, Galand said. In addition, psychiatric disorders, including anxiety and depression, remain strongly associated with LVADs, yet data surrounding suicide risk in LVAD recipients are limited, the authors write.

"Despite significant improvement of survival and quality of life, life with an LVAD is far from optimal," Galand acknowledged. "Data regarding the psychiatric aspect and suicide risk in this population are scarce, especially due to small cohorts and single-center studies," he added.

Of the 659 LVAD therapy recipients in this study, 494 patients discharged from the hospital were assessed over an 18.8-month follow-up period. The mean age was 58.9 years, and 87% of the patients were men.

During follow-up, eight patients died by suicide and two attempted suicide. The patients who died did so by unplugging or sectioning the LVAD cable or overdosing on drugs. Of the patients who attempted, one overdosed on drugs and one sectioned the driveline.

Of the 10 patients who attempted or completed suicide, nine were men. Four patients did not have a psychiatric evaluation before the LVAD surgery; two had underlying psychiatric disorders.

The majority of patients (8 of 10) expressed feelings of sadness, solitude, or hopelessness, note the authors.

The investigators identified two important variables that were associated with the patients who attempted or died by suicide. Patients whose LVAD was destination therapy had a higher rate of suicide attempts. Of the 10, eight (80%) were destination therapy LVAD recipients.

This population of patients receiving an LVAD without the prospect of heart transplantation, "are at bigger risk of psychological distress and suicide attempt," Galand noted.

The patients who followed-up with an LVAD nurse coordinator, a medical professional with the potential to identify early symptoms of psychiatric disorders, had a lower rate of suicide attempt, accounting for only two (20%) of the 10 patients who attempted or died by suicide.

The authors conclude that including an LVAD coordinator is essential for long-term follow-up. "This person provides daily support for LVAD recipients and represents a crucial link between patients' families and medical teams," Galand said.

Additionally, the authors note the important role that the driveline plays, since the majority of patients who died by suicide did so by driveline section or battery disconnection. As a result, stronger driveline material remains a possibility, with wireless equipment being a hopeful alternative.

According to Galand and colleagues, "a breakthrough in this challenging field could be a wireless and transcutaneous energy transfer with internal batteries, avoiding complications related to driveline and batteries disconnection, and leading a better feeling of independence and improved quality of life."

The authors highlight the importance of including psychiatrists in the multidisciplinary team to ensure that psychiatric assessments are performed and early detection and management of psychological distress can be addressed. They also point to the need for changes to long-term follow-up and inclusion of an LVAD nurse coordinator.

The research was supported by the French Federation of Cardiology. The authors report no relevant disclosures.

Circulation. Published online March 11, 2020. Letter


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