...impact implantation of a ventricular assist device on patients' bodies and lives.

* METHODS This' qualitative retrospective study included 6 patients (4 men and 2 women) and 3 of these patients' relatives. Patients were from 17 to 50 years old and had used Thoratec, Heartmate, or VentrAssist devices.

* RESULTS The participants' accounts clustered around a number of themes, 2 of which are reported here: (1) body and self and (2) trust. Each theme comprised several subthemes: body and self had subthemes of shock, restrictions, scarring, and infection; trust had subthemes of keeping me alive, device failure, and confidence.

* CONCLUSIONS The ventricular assist device has a considerable effect on a patient's body and sense of self This effect is often accommodated without much difficulty, but some patients and their families need additional psychological support during and after use of a ventricular assist device. Assessment before implantation of such a device can sometimes reveal this need, but such assessment may not be possible in emergency procedures. Trusting the new heart or the native recovered heart may be difficult for some patients. Further research is needed to understand this phenomenon. (American Journal of Critical Care. 2007;16:72-81)

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The ventricular assist device (VAD) is a mechanical heart pump used to take over the function of a failing heart. It can be used to stabilize and support a patient until a suitable donor heart can be found for transplantation, a process called bridging to transplantation. The VAD is also used to support a failing heart and allow the patient's own heart to return to strength after acute illnesses such as fulminant myocarditis; this process is called bridging to recovery. The extreme shortage of donor hearts and the ever-increasing population of patients with heart disease suggest that VADs will play a major role in the treatment of patients with end-stage heart disease in the future. These patients need intensive physical care, nursing, and psychological support.

Some patients are supported with internal or implantable VADs; others are supported with external or paracorporeal VADs. In general, patients with implantable VADs are easier to mobilize and discharge home from the hospital. Which system is used depends on the underlying cardiac condition, the urgency of treatment required, whether the patient needs univentricular or biventricular support, and the size of the patient's body. All implantable VADs have drivelines that run from the device within the body to the controller and battery pack outside the body. The driveline is a narrow, flexible tube with wires that connect the pumping part of the machine to the external controller and power pack. This driveline usually traverses the skin on the abdominal wall. The requirement for percutaneous access not only increases the risk of infection but also affects the patient's sense of his or her body as whole. Patients who have recovered from the operation to insert a VAD can return home on VAD support while they await transplantation, but only if they have adequate psychosocial backup. Healthcare professionals should take a holistic approach to patients in this situation and consider not only the patient's physical care, but also psychological resources and adjustment of the patient's family. (1)

As the use of VADs increases, the literature in this area is expanding rapidly. Publications describe the use and reliability of VADs (2-4) and patients' quality of life during and after VAD support. (5,6) Other studies have investigated perceptions and concerns of patients and caregivers (7) and psychosocial and sexual concerns. (8) A small qualitative study (9) investigated coping with prolonged hospitalization and the patients' use of coping strategies, and another study (10) has focused on the patient's spouse, who takes responsibility for 24-hour support between implantation of the VAD and heart transplantation if the patient returns home. The role of the caregiver becomes more important if devices are used for long-term support of the heart (destination therapy).

Psychosocial research is underdeveloped in this area. The experience of body-image disruption that may result from implantation with a life-supporting device and the implications for life after transplantation have not been explored. Work has begun to examine changes in body image among patients with implantable cardioverter defibrillators (11,12) and pacemakers, (13) but these are fully implantable devices, whereas the use of a VAD with its internal and external elements may have different implications.

Formal measurement methods for body image and quality of life are not routinely used in patients with VADs at the hospital where this study took place (Papworth Hospital NHS Foundation Trust). (In a recent clinical study of the VentrAssist device, quality of life was assessed. In the "bridge to transplant" arm of the study the Utility-Based Quality of Life Heart [UBQ-H] questionnaire was used, and for the chronic support patients the Minnesota Living with

Heart Failure Questionnaire, the Short Form-36, and the UBQ-H were used. In a recently completed 3-year study of the cost-effectiveness of VADs, the Short Form-36, Euro-Quality of Life instrument, the Functional Limits Profile [UK version of the Sickness Impact Profile], and the Hospital Anxiety and Depression Scale were used with patients.) Our study was established with the aim of determining the impact of an implanted mechanical device on body image, psychological functioning, and social functioning. Approval was obtained from the appropriate research ethics committee.

Methods Design

Interpretative phenomenological analysis' (14,15) was the methodological basis for this study, following an idiographic approach to analysis by looking in detail at a single case and then moving on to examine the others, case by case.

Study Participants and Procedure

As this was a pilot study, we aimed to recruit patients with a wide range of experiences in order to have a broad base on which to commence the main study. Upon recruitment into the study, patients were from 22 to 50 years old and had...

NOTE: All illustrations and photos have been removed from this article.



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