The behavioral and psychosocial evaluation is a critical component of determining whether a patient is an appropriate candidate for MCS implantation. A great deal of self-care and responsibility are required to live successfully with MCS. Patients who are not fully engaged in self-care after MCS may suffer from disastrous outcomes. Patients being evaluated for advanced therapies should evidence willingness and capacity to engage in required health behaviors, compliance with medical recommendations, sufficient social support, and cognitive and psychological stability. All of these elements should be considered when determining whether MCS will be helpful, or potentially harmful, to someone with advanced heart failure. There are two scenarios when conducting a psychosocial evaluation for MCS candidacy: bridge to transplant and destination therapy. While the evaluation is typically the same for both scenarios, MCS centers may modify criteria for patients who are being implanted for destination therapy [8, 9].

There is a dearth of research examining the standardization of psychosocial assessment criteria for MCS, especially for destination therapy MCS [8, 9]. There has been some attempt at creating standardized assessment tools [8, 9], but studies are limited by small sample sizes and single-center designs. Nonetheless, a number of consistent variables emerge that are important to consider in the psychosocial assessment of an MCS candidate.

A psychologist on a MCS team will interview the patient about his or her psychosocial history, health behaviors, compliance, social support, and psychiatric functioning. ◘ Table 45.1 provides domains of assessment topics, along with examples of specific content to assess. First, social support (practical support and emotional support) assessment is a critical part of the psychosocial assessment. The criterion for having a caregiver present 24/7 is variable among device programs and includes consideration of the patient’s functional capacity, frailty, and cognitive functioning. Meeting with caregivers can provide an understanding of their willingness and ability to provide sufficient support and care for that particular patient’s needs.

While it is important to assess and reinforce adaptive health behaviors (e.g., exercise and a healthy diet), there are certain health behaviors that may be considered relative contraindications for device implantation [9]. For example, smoking tobacco may be a relative contraindication, or the patient may be strongly encouraged to quit if they are being considered for destination therapy. However, complete abstinence is typically required for someone who is a bridge-to-transplant candidate.

It is especially important to assess history and current symptoms of clinical depression and anxiety, as presence of these symptoms interact with other areas of assessment. For example, depression is associated with poorer self-care behaviors, a generally more unhealthy lifestyle, such as smoking and minimal physical activity [10], and poorer compliance with medications [11], all of which are necessary for maintaining good health with MCS. Assessing the patient’s cognitive status is also important, given that even mild cognitive impairment is a risk factor for increased mortality following surgery [12]. In addition to informally assessing the patient’s cognitive status via interview, a brief screening tool (e.g., the Montreal Cognitive Assessment [MoCA]), validated in cardiac populations [13, 14], may also be utilized to provide objective data.

Following assessment, the data should be used to formulate impressions about each of the assessment domains, and from those impressions, concrete and specific recommendations should be communicated to the MCS team. For example, if the patient is a poor historian, tangential, and seems to have difficulty processing questions, it may be recommended that the patient undergo comprehensive neuropsychological testing. If clinical depressive symptoms are present, it may be recommended that the patient continues to follow up with a health psychologist or another mental health professional, including a psychiatric consult, if psychotropic medication seems warranted.

During the period of shared decision making and evaluation for MCS, advanced heart failure patients need to be informed about postimplant outcomes. HRQOL, both before and after implant, is an important patient-centric outcome to discuss with patients and their families who are considering MCS as a treatment option (◘ Fig. 45.2). Patients with advanced heart failure have very poor HRQOL [15]. They have frequent and distressing symptoms, including fatigue, shortness of breath, paroxysmal nocturnal dyspnea, lack of energy, difficulty sleeping, daytime drowsiness, and weakness [15]. Poor HRQOL in advanced heart failure patients is associated with symptom distress [15].

Patients need to be informed that overall HRQOL improves from before to as long as 2 years after continuous-flow MCS [16], including destination therapy [17]. Findings from the Risk Assessment and Comparative Effectiveness of Left Ventricular Assist Device and Medical Management (ROADMAP) study, a prospective, nonrandomized observational study of outcomes in ambulatory NYHA class IIIB/IV non-inotrope patients, demonstrated greater improvement in HRQOL in MCS patients, as compared to optimal medical management patients through 12 months [18]. Furthermore, while patients with lower INTERMACS profiles (i.e., higher severity of heart failure) had worse HRQOL prior to implant, by 12 months after implant, HRQOL improved significantly for all profiles and did not differ significantly among profiles at 6 and 12 months after implant [19]. Lastly, while patients who undergo destination therapy implantation are typically older, may have comorbidities that preclude heart transplantation, and have a higher risk for postimplant adverse events (especially if older) and lower survival, than those who are bridge to transplant, destination therapy MCS patient HRQOL nonetheless significantly improves from before to after surgery [17].

Early substantial improvement also occurs in heart failure symptomatology and domains of HRQOL. Patients report that most symptoms of heart failure (e.g., shortness of breath and peripheral edema) abate relatively soon after implant, while other symptoms (e.g., fatigue and decreased energy level) persist for several weeks to months [20]. New symptoms emerge after MCS implant (e.g., dizziness/syncope and gastrointestinal bleeding) [20]. Most patients also report significantly fewer problems with mobility, usual activities, and self-care from before to 12 months after implant [16, 19]. Patients often returned to home management, work, and leisure activities [20]. Reports of decreased anxiety/depression [18] and pain/discomfort from before to after implant were also noted, which varied somewhat by preimplant INTERMACS profile [19]. Anxiety and depression often decreased later after implant when patients had adjusted to living with MCS [20].