LVAD recipients see heightened risk of suicide

Heart patients with implanted left ventricular assist devices (LVADs) are more likely to both attempt and succeed in committing suicide than other chronically ill patients, according to a study out of France.

The study, led by Marion Charton, MD, of the Universié de Rennes, and published in Circulation March 10, analyzed the psychological outcomes of LVAD implantation in 494 end-stage heart failure patients enrolled in the ASSIST-ICD study. ASSIST-ICD, which included 659 LVAD recipients in total, spanned 19 centers in France.

Charton et al. said that, as with any chronic disease, people with end-stage HF may struggle disproportionately with feelings of hopelessness or depression. LVAD patients in particular may be dealing with alterations in their body image, feeling burdensome to their caregivers or feeling disappointed that they’re unable to return to a full-time job.

The researchers studied ASSIST-ICD patients who were discharged successfully from the hospital, reviewing their history of suicide attempts alongside clinical data, psychiatric history and patient characteristics of suicide or suicide attempts. In all, 10 of 494 patients—2%—either attempted or completed suicide over 18.8 months of follow-up. Eight were successful in their attempts and died either by drug intoxication or unplugging or sectioning their LVAD cable; one person attempted suicide by drug intoxication and another attempted suicide by driveline section.

Nine of the people who attempted or completed suicide were men, and just two had a history of a psychiatric disorder. Of note, 80% of the cohort was implanted with an LVAD as destination therapy, compared with 33.5% of LVAD patients who didn’t contemplate or commit suicide.

Charton and colleagues said their suicide rate of 2% in LVAD patients greatly exceeds the national suicide attempt rate in France, which is around 0.03% per year. It’s also higher than the elevated 0.06% per year rate observed in patients with chronic diseases.

“In our series, the incidence of suicide in LVAD recipients appears even higher than in those with other chronic diseases,” the authors wrote in Circulation. “In the INTERMACS registry, psychiatric episodes were estimated around 1%, but the prevalence of suicide was not specified.” 

The team said that of the 10 patients in their analysis who attempted or completed suicide, four hadn’t received a psychiatric evaluation prior to LVAD surgery. That suggests psychiatrists should be key players in multidisciplinary LVAD teams, and that it may be worth it to assess patients’ satisfaction or dissatisfaction with the implant after LVAD surgery. Suicide attempts in the study occurred on average 12.5 months after implantation.

Charton and co-authors said the reasons for the increased suicide rate in LVAD patients are, of course, only speculative. But they landed on two variables that seemed most closely linked to attempted or successful suicide: implantation of an LVAD as destination therapy and follow-up at a medical center without an LVAD coordinator.

“If confirmed by others, the latter is a potentially modifiable practice that could be tested as a means to lower the frequency of suicide,” the authors wrote. “There is plausibility to this finding given that LVAD coordinators are in a unique position, serving as a link between patients’ families and medical teams, and could identify early symptoms of psychiatric disorders. Similarly, staff at cardiac rehabilitation centers may have this opportunity, although our data did not address this possibility.”