A 60-year-old man is admitted for end-stage heart failure and is being considered for a left ventricular assistance device (LVAD) as a bridge to cardiac transplantation. The patient has a history of 3 myocardial infarctions and a low ejection fraction secondary to ischemic cardiomyopathy. He is informed that when an LVAD is used for this purpose the recipient must meet eligibility criteria for transplantation. He has no other medical conditions and appears to meet the medical criteria for LVAD and heart transplant. The patient has a history of major depressive disorder and attempted suicide in his late 20s. He also has a history of alcohol abuse. He has no current depressive symptoms and states that he has not used alcohol "to excess" in the past 6 months. The patient lives alone and has no close family except for a niece who visits occasionally. He has been homeless in the past but not recently. Mental status examination shows the patient to be cognitively intact; his stated mood is "scared" and his affect is full range and appropriate. His thought process is linear and his thought content shows no delusions. The patient has no hallucinations or suicidal ideation. Based on these findings, which of the following statements is most accurate regarding the determination of this patient's eligibility for heart transplantation?

Question

A 60-year-old man is admitted for end-stage heart failure and is being considered for a left ventricular assistance device (LVAD) as a bridge to cardiac transplantation.  The patient has a history of 3 myocardial infarctions and a low ejection fraction secondary to ischemic cardiomyopathy.  He is informed that when an LVAD is used for this purpose the recipient must meet eligibility criteria for transplantation.  He has no other medical conditions and appears to meet the medical criteria for LVAD and heart transplant.  The patient has a history of major depressive disorder and attempted suicide in his late 20s.  He also has a history of alcohol abuse.  He has no current depressive symptoms and states that he has not used alcohol "to excess" in the past 6 months.  The patient lives alone and has no close family except for a niece who visits occasionally.  He has been homeless in the past but not recently.  Mental status examination shows the patient to be cognitively intact; his stated mood is "scared" and his affect is full range and appropriate.  His thought process is linear and his thought content shows no delusions.  The patient has no hallucinations or suicidal ideation.  Based on these findings, which of the following statements is most accurate regarding the determination of this patient's eligibility for heart transplantation?

Quizplus · Accepted Answer

Explanation: Although this patient is an appropriate transplant candidate from a medical standpoint, his psychosocial history raises several concerns. The presence of active substance or alcohol abuse is considered an absolute contraindication to cardiac transplantation. The lack of adequate psychosocial supports is considered a relative contraindication, as a patient's ability to comply with drug therapy after transplantation is a major concern. Further evaluation of the extent of this patient's current alcohol use as well as the adequacy of his psychosocial supports is necessary. His report that he is not drinking "to excess" must be followed up with further details of amounts, pattern, and complications of his current alcohol use. Further details regarding his support system should also be obtained to determine if inadequate social support would prevent compliant care. This patient is not currently depressed, and his history of depression and his suicide attempt are not contraindications. Decisions about appropriateness for transplantation are made by a team of clinicians on a case-by-case basis. (Choice B) The extent of current or recent alcohol use has not yet been established. Active alcohol abuse, if present, would be a contraindication to transplantation and would require treatment before proceeding. At this point, it is inappropriate to recommend alcohol abuse treatment as a precondition to transplantation. If alcohol abuse treatment is required, it must be customized to the needs of the patient. (Choice C) The patient is not currently depressed, and antidepressants are not indicated. (Choice D) Psychosocial evaluation is an important component of the evaluation of transplant recipients. This patient's alcohol use and the adequacy of his psychosocial supports should be factored into the decision. (Choice E) The patient cannot be excluded based on the information provided. Further assessment is necessary. Educational objective: Potential transplant recipients with active substance or alcohol abuse and inadequate social supports can present a challenge to the organ transplant team. A detailed psychosocial evaluation is necessary to determine a patient's suitability for organ transplantation. References: Psychosocial challenges in solid organ transplantation. (http://www.ncbi.nlm.nih.gov/pubmed/26370201)

A 60-Year-Old Man Is Admitted for End-Stage Heart Failure and Is