Psikiyatrik komorbiditenin sol ventrikül destek cihazı takılan hastalarda morbidite ve mortalite üzerine etkisi
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Dosyalar
Tarih
2018
Yazarlar
Dergi Başlığı
Dergi ISSN
Cilt Başlığı
Yayıncı
Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
GİRİŞ: Kalp yetmezliği (KY) giderek artan sıklığı ve yaygınlığı nedeniyle tüm dünyada önde gelen sağlık sorunlarından biridir. KY'nin genel nüfustaki yaygınlığı %0,3-2 arasında değişmekle birlikte 65 yaş ve üzerinde bu rakam %3-5'lere, 75 yaş ve üzerinde %25'lere varmaktadır. Tanı sonrası 4 yıl içinde hastaların %50'si ölmekte; şiddetli KY tanısında ölüm oranı 1 yıl içinde %50'ye ulaşmaktadır. Son yıllarda KY tanısı alan hastaların sayısında artışla birlikte kalp nakli için donör organların sınırlı kullanılabilirliği, tıbbi ve cerrahi kontrendikasyonlar bu hastalarda mekanik dolaşım desteği cihazlarının kullanımını giderek arttırmaktadır. Mekanik dolaşım desteğinin en yaygın örneği sol ventrikül destek cihazlarıdır (SVDC). Son dönem KY ile psikiyatrik bozuklukların birlikte görülmesinin hastalarda mortalite, morbidite ve rehospitalizasyon oranlarını artırdığına dair çalışmalar mevcut olsa da SVDC hastalarında spesifik psikososyal risk faktörlerinin klinik sonuçlara etkileri üzerine literatür sınırlıdır. Artan SVDC kullanımından dolayı bu hastaların ön değerlendirilmesi SVDC tedavisi açısından prognostik yordayıcı olarak önem arz etmektedir. Bu ön değerlendirmekle birlikte uygulanan tedavinin başarısının artacağı ve implantasyondan sonra psikoterapötik desteğin sağlanması ve yüksek riskli hastalar için yaşam tarzı değişikliklerinin yapılması için yararlı olacağı düşünülmektedir. AMAÇ: Bu çalışmanın ana amacı son dönem KY hastalarında uygulanan SVDC tedavisi öncesinde mevcut olan psikiyatrik bozuklukların operasyon sonrası klinik sonuçlar üzerine olan etkilerini araştırmaktır. Bu çalışmanın ikincil amacı SVDC tedavisinin uzun dönemde ruhsal durum üzerindeki etkisini incelemektir. YÖNTEM: Çalışmaya Aralık 2010 -Ocak 2016 tarihleri arasında Ege Üniversitesi Tıp Fakültesi Hastanesi Kalp ve Damar Cerrahisi tarafından SVDC tedavisi uygulanmış 120 son dönem KY hastası dahil edilmiştir. SVDC implantasyonu sırasında uygulanan psikososyal değerlendirme, hastaların demografik özellikleri ve klinik veriler tıbbi kayıtlardan elde edilmiştir. Hastaların 58'inde psikiyatrik bozukluk saptanırken, 62 kişide psikiyatrik bozukluk saptanmamıştır. SVDC tedavisinin uzun dönemde ruhsal durum üzerindeki etkisini incelemek amacıyla halen SVDC tedavisi devam eden 45 hastaya telefonla ulaşılmış, çalışma hakkında bilgi verilmiş; çalışmaya katılmak isteyen 25 hastayla randevu sonrasında görüşülerek SCID-I (DSM IV Eksen 1 Bozuklukları İçin Yapılandırılmış Klinik Görüşme) uygulanmıştır. BULGULAR: Çalışmamızda SVDC operasyonu öncesi psikiyatrik bozukluk saptanan hastalarda psikiyatrik bozukluk saptanmayan hastalara göre hastane yatış süresi ve yoğun bakım yatış süresinin uzadığı saptanmıştır. (p=0,002 ve p=0,006) SVDC operasyonu öncesi psikiyatrik bozukluk saptanan hastalarda psikiyatrik bozukluk saptanmayan hastalara göre hastane içi mortalite ve operasyon sonrasındaki 1 yıl içerisinde mortalite oranları oranları arasında anlamlı fark bulunmamıştır. (p= 0,118 ve p= 0,171) SVDC operasyonu öncesi psikiyatrik bozukluk saptanan hastalarda psikiyatrik bozukluk saptanmayan hastalara göre 1 yılda morbidite oranları artmaktadır. (p=0,009) SVDC operasyonu öncesi psikiyatrik bozukluk saptanan hastalarda psikiyatrik bozukluk saptanmayan hastalara göre 1 yılda rehospitalizasyon oranlarının yüksek olduğu görülmüştür. (p=0,013) Ameliyattan sonra deliryuma girme oranları, psikiyatrik bozukluk saptanan hastalarda psikiyatrik bozukluk saptanmayan hastalara kıyasla daha yüksek bulunmuştur. (p= 0,001) SVDC operasyonu öncesi psikiyatrik bozukluk saptanan hastalarla psikiyatrik bozukluk saptanmayan hastalar arasında hastane masrafları açısından anlamlı fark saptanmamıştır. (p= 0,153) Alt tanı gruplarına göre değerlendirildiğinde depresif bozukluk saptanan hastalarda psikiyatrik bozukluk saptanmayan hastalara göre hastane yatış süresi, yoğun bakım yatış süresi, operasyon sonrası deliryum oranları, aynı zamanda operasyon sonrası 1 yılda morbidite, hastane yeniden yatış oranlarının istatistiksel olarak anlamlı yüksek olduğu saptanmıştır. Hastaların SVDC öncesi ve sonrası yapılan psikiyatrik muayene zamanı DSM IV tanıları açısından karşılaştırılması zamanı gruplar arasında istatistiksel anlamlı fark saptanmamıştır. (p=1,00). Yapılan teste göre hastaların %32'sinde SVDC öncesi psikiyatrik bozukluk saptanırken, %68'inde psikiyatrik bozukluk saptanmamıştır. SVDC sonrası yapılan psikiyatrik muayenede aynı oranlar saptanmıştır. SONUÇ: SVDC operasyonu öncesi psikiyatrik bozukluk saptanan hastalarda psikiyatrik bozukluk saptanmayan hastalara göre hastane yatış süresi, yoğun bakım yatış süresi uzamış, operasyon sonrası deliryum oranları, aynı zamanda operasyon sonrası 1 yılda morbidite, hastane yeniden yatış oranları artmıştır. Alt tanı gruplarına göre değerlendirildiğinde depresif bulguların kötü klinik sonuçlarla anlamlı ilişkisi olduğu saptanmıştır. Çalışmamızda SVDC tedavisi öncesi mevcut olan psikiyatrik bulguların operasyon sonrası klinik sonuçlara olan negatif etkisi göz önünde bulundurulacak olursa, SVDC öncesi psiko-sosyal değerlendirmenin, aynı zamanda SVDC tedavisinden önce ve sonra hastaların psikiyatrik belirtiler açısından izlenmesinin önemli olduğu görülmektedir. Gelecek çalışmalarda, SVDC öncesi psiko-sosyal değerlendirmelerin ayrıntılandırılmasına, psikofarmakolojik tedavinin psikiyatrik bulgular üzerindeki etkilerine dikkat çekecek şekilde yapılandırılması; bu değişkenlerin operasyon sonrası klinik sonuçlarla ilişkilerini ortaya koyacak şekilde ileriye dönük izleme şeklinde planlanmasına ihtiyaç vardır.
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.
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.
Açıklama
Anahtar Kelimeler
Sol Ventrikül Destek Cihazı, Psikososyal Değerlendirme, Depresyon, Anksiyete, İnsomnia, Klinik Sonuçlar, Left Ventricular Assist Device, Psychosocial Assessment, Depression, Anxiety, Clinical Outcomes, Insomnia
