Left ventricular assist device (LVAD) implantation is an alternative therapy for end-stage heart failure. Numerous complications are associated with LVADs, including psychiatric disorders such as anxiety and depression. Data regarding the suicide risk in this population are lacking. We aimed at describing the incidence of suicide in LVAD recipients included in the multicenter ASSIST-ICD observational study (Determination of Risk Factors of Ventricular Arrhythmias After Implantation of Continuous Flow Left Ventricular Assist Device With Continuous Flow Left Ventricular Assist Device).

ASSIST-ICD (https://www.clinicaltrials.gov; unique identifier: NCT02873169) is a study of LVAD implanted in 19 French centers. Detailed methods have been published.¹ Among the 659 LVAD recipients included, 494 (87% men; mean age, 58.9 years [range, 50.3 to 65.8]) were discharged from the hospital and included in this study. History of suicide attempts was reviewed. Clinical data, psychiatric history, and characteristics of suicide or suicide attempts were collected for each patient. The study was approved by an institutional review committee, and the participants gave informed consent.

Among the 494 patients, 10 (2.0%) attempted or completed suicide over 18.8 months of follow-up. Eight completed suicide, either by unplugging or sectioning their LVAD cable or drug intoxication; 1 attempted suicide by drug intoxication; and 1 attempted suicide by driveline section. Their characteristics are summarized in the Table. Nine were men, and 2 had a history of a psychiatric disorder. Of note, 8 of 10 (80%) patients were implanted as destination therapy compared with 162 of 484 (33.5%) patients without suicide (P=0.006). Of the 10 patients who attempted or completed suicide, 4 did not have a psychiatric evaluation before LVAD surgery. The median duration of hospital stay after LVAD surgery was 46.5 days (range, 36.0 to 70.0) and suicide attempt occurred on average 12.5 months after the LVAD implantation. Six patients experienced ≤1 hospitalization after initial hospital discharge. A majority of patients (8 of 10) expressed psychiatric symptoms, such as sadness, solitude, or hopelessness. Of 10 patients who attempted or completed suicide, 2 (20%) were followed in a center with an LVAD coordinator compared with 293 of 484 (60.5%) patients without suicide attempt (P=0.02).

In France, the suicide attempt rate is ~0.03% per year (200,000 events/year). This frequency increases among patients with chronic diseases such as chronic heart failure (0.06%/year). In our series, the incidence of suicide in LVAD recipients (2% after 18.8 months of follow-up) appears even higher than in those with other chronic diseases. In the INTERMACS registry (Interagency Registry for Mechanically Assisted Circulatory Support), psychiatric episodes were estimated around 1%, but the prevalence of suicide was not specified.²

The reasons for the apparently increased incidence of attempted or completed suicide in LVAD recipients are speculative. Our data identified 2 variables that were associated with attempted or completed suicide: implantation for destination therapy and follow-up at a 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. 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. We found a high frequency of psychiatric symptoms (80%) among those who attempted or completed suicide, highlighting the role for psychiatrists as part of a multidisciplinary LVAD team.

A number of potential factors, such as alteration of body image, lack of return to full-time employment, feeling burdensome to caregivers, or increased dependence on the medical team, could contribute to the development of psychiatric symptoms in LVAD recipients. Ensuring that patients have rigorous motivation for the treatment, social support, and extensive preoperative education about life after LVAD implantation may mitigate the development of such symptoms. Assessing patients’ satisfaction or decision regret after LVAD implantation could identify those requiring psychological support and detect emerging signs of psychological distress, especially in patients implanted as destination therapy.³

In conclusion, we found a 2.0% risk of attempted or completed suicide in LVAD recipients, which is higher than in the general population or those with other chronic diseases in France. These data emphasize the need to develop strategies to minimize the risk of this event in LVAD recipients, especially among those implanted as destination therapy.

Table. Patient Characteristics and Follow-Up

DT indicates destination therapy; INTERMACS, Interagency Registry for Mechanically Assisted Circulatory Support; LVAD, left ventricular assist device; and NA, not available.

Editorial support was provided by Dr William J. Hucker.

This research was supported by the French Federation of Cardiology.

None.

The full author list is available on page 935.

https://www.ahajournals.org/journal/circ

The data, analytic methods, and study materials are not available to other researchers.

左心室辅助装置（LVAD）植入是终末期心力衰竭的替代疗法。LVAD与许多并发症相关，包括精神疾病，如焦虑症和抑郁症。缺乏有关该人群自杀风险的数据。我们旨在描述多中心ASSIST-ICD观察研究（确定连续流左室辅助装置和连续流左室辅助装置植入后室性心律失常的危险因素的确定）中LVAD接受者的自杀率。

ASSIST-ICD（https://www.clinicaltrials.gov；唯一标识符：NCT02873169）是对法国19个中心植入的LVAD的研究。详细的方法已经出版。¹在包括的659名LVAD接受者中，有494名（男性占87％；平均年龄58.9岁[范围，从50.3至65.8]）已出院并纳入本研究。回顾了自杀未遂的历史。收集每位患者的临床数据，精神病史以及自杀或自杀未遂的特征。这项研究得到了机构审查委员会的批准，参加者给予了知情同意。

在494例患者中，有10例（2.0％）在18.8个月的随访中未曾自杀。通过拔出或切开LVAD电缆或中毒使八人完全自杀；1例因药物中毒而自杀；另有1人在传动系自杀未遂。表中总结了它们的特性。男性9人，其中2人有精神病史。值得注意的是，每10名患者中有8名（80％）被植入作为目的地疗法，而484名患者中有162名（33.5％）没有自杀（P= 0.006）。在10名企图自杀或自杀的患者中，有4名在LVAD手术前没有进行精神病评估。LVAD手术后的中位住院时间为46.5天（范围为36.0至70.0），平均在LVAD植入后12.5个月内自杀未遂。初次出院后，有6名患者住院≤1。大多数患者（10人中有8人）表现出精神病症状，例如悲伤，孤独或绝望。在10名企图自杀或完全自杀的患者中，有2名（20％）在有LVAD协调员的中心接受随访，而484名（60.5％）无自杀企图的患者为293名（P = 0.02）。

在法国，每年的自杀未遂率约为0.03％（200,000个事件/年）。在患有慢性疾病（例如慢性心力衰竭）的患者中，此频率增加（0.06％/年）。在我们的系列文章中，LVAD接受者的自杀发生率（在18.8个月的随访后为2％）似乎比其他慢性病患者更高。在INTERMACS注册表（机械辅助循环支持机构间注册表）中，精神病发作的发生率约为1％，但未明确自杀的发生率。²

LVAD接受者未遂或完全自杀的发生率明显增加的原因是推测性的。我们的数据确定了与自杀未遂或自杀完全相关的两个变量：用于目的地治疗的植入以及在没有LVAD协调员的情况下在中心进行的随访。如果得到其他人的确认，则后者是一种可能会改变的做法，可以作为降低自杀频率的一种手段进行测试。鉴于LVAD协调员处于独特的位置，可以充当患者家庭与医疗团队之间的纽带，并且可以确定精神疾病的早期症状，因此这一发现是合理的。同样，心脏康复中心的工作人员可能有此机会，尽管我们的数据并未解决这种可能性。

LVAD接受者的许多潜在因素，例如身体形象的改变，缺乏全职工作的返回，对护理人员的负担感到沉重或对医疗团队的依赖性增加，都可能导致LVAD接受者出现精神症状。确保患者有严格的治疗动机，社会支持和广泛的术前教育，以了解LVAD植入后的生活可能会减轻此类症状的发展。LVAD植入后评估患者的满意度或决定后悔可以发现那些需要心理支持的患者，并发现出现心理困扰的迹象，尤其是在作为目标疗法植入的患者中。³

总之，我们发现LVAD接受者企图自杀或完全自杀的风险为2.0％，高于法国的普通人群或患有其他慢性疾病的人群。这些数据强调需要制定策略以使LVAD接受者（尤其是作为目标疗法植入的接受者）这一事件的风险降至最低。

表。患者特征和随访

DT表示目的地疗法；INTERMACS，机械辅助循环支持机构间注册处；LVAD，左心室辅助装置；和NA，不可用。

William J. Hucker博士提供了编辑支持。

这项研究得到了法国心脏病联合会的支持。

没有。

完整的作者列表在第935页上可用。

https://www.ahajournals.org/journal/circ

数据，分析方法和研究材料不适用于其他研究人员。