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Patient Reported Outcomes andQuality ofLife following Heart Transplantation

AlexJacobPoovathoor, JasonAli, andMariusBerman

Introduction

It is well-established that heart transplantation is the gold-standard treatment for eligible patients with end-stage heart failure. The survival benet over medical management and durable LVADs has been demonstrated in multiple studies [1–4]. The main challenge of this life-saving treatment is the availability of donor organs, leading to prolonged waiting times on the list, often with signicant deterioration of symptoms, and even demise. In the UK, 10% of non-urgent patients will die on the waiting list in 2years and only 17% will be transplanted [5]. For those that receive an organ, the average waiting time is

1.6years [5].

A. J. Poovathoor (*) University of Cambridge, Cambridge, UK

Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK

J. Ali · M. Berman Department of Cardiothoracic Surgery, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK e-mail: jason.ali@nhs.net; marius.berman@nhs.net

For those who receive a heart transplant, along with prolongation in life-expectancy one should recognize a signicant improvement is heart- failure related symptoms and quality of life. The survival prognosis for heart transplantation is 12.5years, and the 1-year conditional survival is 14.8years, so the gap between outcomes from cardiac transplantation and natural history is notable [6]. The survival over 1 and 5years of heart transplants between 1982 and 2013 was 82% and 69%, respectively [6]. Heart transplantation is a remarkably successful operation, and there is a signicant improvement prognostically. Not only this, death in association with heart transplantation is continually decreasing. The survival for 1-year survivors between 2002 and 2009 was 12.5 years, now increased to

14.8years [6].

However, post-transplant management is a multidisciplinary journey with the patient in the center that involves life-long pharmacological treatment, blood tests, biopsies etc., which can have an impact in the physical and mental wellbeing of the recipient and overall QoL. In this chapter we sought to examine QoL parameters using established tools in assessing the effect of heart transplantation against patients’ pre-transplant status but also against other patient groups, including LVAD recipients.

https://doi.org/10.1007/978-3-031-09815-4_5

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

A. J. Poovathoor et al.

Methods

Literature Search

A literature search was performed in the PubMed database with the following terms: ((((((((((((((((patient reported outcomes) OR (prom)) OR (quality of life)) OR (QoL)) OR (SF-

36)) OR (short form 36)) OR (HRQoL)) OR (health related quality of life)) OR (EQ5D)) OR (euroqol 5d)) OR (Minnesota Living with Heart Failure Questionnaire)) OR (MLHFQ)) OR (Kansas City Cardiomyopathy Questionnaire)) OR (KCCQ)) OR (Quality of Life Index cardiac version)) OR (WHOQOL-BREF)) AND ((((cardiac transplant) OR (heart transplant)) OR (heart failure surgery)) OR (end-stage heart failure surgery)).

Date of search: 15-12-2020.

Study Selection

Exclusion of studies that are: non- English, paediatric cohorts; focusing mainly on depression without a holistic approach to QoL; combining heart transplant with other organ transplants without differentiating the outcomes; and using QoL tools that are not holistic in approach.

Study Classication

From the studies we identied as eligible, we subsequently carried out classication and critical appraisal based on the comparative arms as follows:

1. comparative studies: vs LVADs control group. Patients implanted with a bridge to transplant left ventricular assist device compared to HTx recipients. Table5.1.

2. comparative studies: vs medical therapy con- trol group. Patients stabilized on best medical therapy compared to HTx recipients. Table5.2.

3. comparative studies: vs waiting-list control group . Patients on the transplant waiting-list compared to recipients. Table5.3.

4. longitudinal studies: pre-operation and post- operation intervals. Assessing baseline quality of life with heart failure, then at intervals post-operatively. Table5.4.

5. longitudinal studies: post—operation inter- vals only. Studies that focused on outcomes at post-operative intervals only. Table5.5.

6. longitudinal studies: long-term follow-up. studies that focused on outcomes in long-term survivors (dened as >5years). Table 5.6.

Refer to Fig.5.1 for a comparison of four heartfailure- specic quality of life instruments commonly used in the selected studies.

Results

Comparative Studies

vs. LVADs

Grady etal. [7] conducted a longitudinal, multisite study comparing paired QoL data of 40 LVAD patients at 3 months post-LVADimplantation vs 3 months post-HTx. Patients after HTx were found to be more satised with their lives and with their health and functioning. Furthermore, an improvement in mobility, selfcare ability, physical ability and overall functional ability was observed from 3 months post-LVAD-implantation to 3 months post- HTx. However, self-care stress and hospital/clinicrelated stress were seen to be lower in the postLVAD period.

As compared to Grady et al’s study, which used patients implanted with LVADs as a bridgeto- transplant and following them longitudinally to post-HTx, Jakovljevic etal. [8] compared the QoL in LVAD and HTx recipients using two separate cohorts. This LVAD bridge-to-destination group comprised of 14 patients, and was compared to 12 post-HTx patients. Physical activity and QoL were assessed at 4 to 6weeks (baseline)

5 Patient Reported Outcomes andQuality ofLife following Heart Transplantation

Patients more satised with

lives overall and health and

functioning at 3months

post-HTx vs. post-LVAD

implant. Mobility, self-care

ability, physical ability and

overall functional ability

improved from 3months after

LVAD implant to 3months

after HTx. Work/school/

nancial stress lower post-HTx

LVAD implantation and HTx

increased daily physical

activity by 60% and 52%. level

of activity unchanged at 3, 6,

and 12months. QoL improved

in LVAD implantation and HTx

groups but unchanged

afterward. HTx higher activity

level vs. LVAD implantation-

associated with better QoL

vs post-LVAD implant

Best QoL in recipients; EQ-5D

scores highest in recipients

30±6 vs. 63±7 (6 Mo post-Tx/LVAD)

29±7 vs. 60±5 (12 Mo post-Tx/LVAD)

HRQOL

MLHFQ 39±5 vs. 57±7 (3 Mo post-Tx/LVAD)

instrument

used QoL scores (gures given as HTx vs. LVAD) Main ndings related to HRQOL

Short- and

long-term effects of

bridge to transplant

LVAD implantation

Study intent and

number of patients

United

Kingdom

Effect of Left

Ventricular Assist

and HTx on physical

Device Implantation

and Heart

Transplantation on

activity and QoL.

n=40 (+14 healthy

subjects)

Habitual Physical

Activity and Quality

of Life

Health and Functioning=0.78±0.16 vs. 0.68±0.17

(p=0.0003)

QLI Life Satisfaction=0.79±0.13 vs. 0.75±0.12 (p=0.01)

Compare QOL of

patients listed for

HTx with bridge to

transplant LVAD at

3months after

LVAD implantation

vs. 3months after

HTx. n=40

United

States of

America

Change in Quality of

Life From After Left

Ventricular Assist

Device Implantation

to After Heart

Transplantation

KCCQ domains

Symptom stability=54.7±21.6 vs. 60.9±21.7

Self-efcacy=93.4±15.0 vs. 93.8±11.1

Symptom frequency=77.1±26.3 vs. 68.5±25.3

Symptom burden=77.8±25.1 vs. 69.5±25.5

Total symptom score=77.5±25.1 vs. 69.0±24.7

Physical limitation=75.4±31.1 vs. 56.5±25.9

Clinical summary score=76.6±26.1 vs. 62.6±23.8

KCCQ

EQ-5D

QoL in patients

assessed for HTx,

listed for HTx on

medical therapy,

supported with

bridge to transplant

LVAD and patients

after HTx. n=386

United

Kingdom

Quality of life of

advanced chronic

heart failure: medical

care, mechanical

circulatory support

and transplantation

QoL=71.4±28.5 vs. 44.1±23.2

Social limitation=67.0±34.2 vs. 41.6±27.0

Overall summary score=73.0±27.2 vs. 52.6±22.0

EQ-5D index score=0.74±0.27 vs. 0.58±0.26

Jakovljevic

etal. (2014)

Table 5.1 Comparative studies: vs LVAD control group. Patients implanted with a bridge to transplant left ventricular assist device compared to HTx recipients

Study Title Country

[8]

Grady etal.

(2003)

[7]

Emin etal.

(2016)

[9]

HTx: Heart Transplant; LVAD: Left Ventricular Assist Device

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Physical health score signicantly

improved over time in all patients;

changes in mental health were minimal.

Although all patients continued to have

low HRQOL scores at the time of

follow-up, medically stable patients had

higher mental health scores and less

depressive symptoms

Highest QoL in recipients. EQ-5D scores

highest in recipients

A. J. Poovathoor et al.

QoL scores (gure given as HTx vs.

medical therapy) Main ndings related to HRQOL

IQR) vs. 46.9 (37.7–56.7 IQR)

Mental health=41.9 (38.8–51.2

IQR) vs. 49.2 (49.2–57.8 IQR)

HRQOL

instrument used

SF 12 Physical health=35.2 (32.4–44.6

Study intent and

number of patients

Comparative

effects of HTx

or medical

treatment on

HRQOL. n=77

United

States of

America

Two-year follow-up of

quality of life in

patients referred for

heart transplant

KCCQ domains

Symptom stability=54.7±21.6

vs. 33.9±23.8

Self-efcacy=93.4±15.0 vs.

79.5±18.7

Symptom frequency=77.1±26.3

KCCQ

EQ-5D

QoL in patients

assessed for

HTx, listed for

HTx on medical

therapy,

supported with

United

Kingdom

Quality of life of

advanced chronic heart

failure: medical care,

mechanical circulatory

support and

transplantation

vs. 43.5±22.5

Symptom burden=77.8±25.1

vs. 47.9±20.7

Total symptom

score=77.5±25.1 vs. 45.7±20.6

bridge to

transplant LVAD

and patients

after HTx.

n=386

Physical limitation=75.4±31.1

vs. 34.7±25.8

Clinical summary

score=76.6±26.1 vs. 40.2±22.0

QoL=71.4±28.5 vs. 24.4±20.4

Social limitation=67.0±34.2 vs.

27.3±27.2

Overall summary

score=73.0±27.2 vs. 33.3±21.1

EQ-5D index score=0.74±0.27

vs. 0.44±0.27

Study Title Country

Evangelista

etal. (2005)

Table 5.2 Comparative studies: vs medical therapy control group. Patients stabilized on best medical therapy compared to HTx recipients

[13]

Emin etal.

(2016)

[9]

5 Patient Reported Outcomes andQuality ofLife following Heart Transplantation

Psychologic adaptation, and perceived

functional capability improved in

transplant recipients. More weakness after

surgery in recipients- major symptom that

limited activities. No signicant

differences in QOL changes over time

between medical therapy group and

recipients at 41months. QOL for medical

therapy group may not be different from

recipients

daily physical activity by 60% and 52%.

level of activity unchanged at 3, 6, and

12months. QoL improved in LVAD

implantation and HTx groups but

unchanged afterward. HTx higher activity

level vs LVAD implantation- associated

with better QoL

QoL scores (gure given as HTx vs.

medical therapy) Main ndings related to HRQOL

HRQOL

instrument used

questionnaires

Study intent and

number of patients

QOL at the time

transplantation

evaluation and

again after

41months in

patients

stabilized with

Extended comparison

of quality of life

between stable heart

failure patients and

heart transplant

recipients

MLHFQ 39±5 vs. 74±4 LVAD implantation and HTx increased

medical therapy

and recipients.

n=31

Short- and

United

Effect of Left

long-term effects

of LVAD

implantation and

HTx on physical

activity and

Kingdom

Ventricular Assist

Device Implantation

and Heart

Transplantation on

Habitual Physical

QoL. n=40

(+14 healthy

subjects)

Activity and Quality of

Life

Study Title Country

Walden

etal. (1994)

[46]

Jakovljevic

etal. (2014)

[8]

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A. J. Poovathoor et al.

Table 5.3 Comparative studies: vs waiting-list control group. Patients on the transplant waiting-list compared to recipients

Study Title Country

Mantovani etal. (2017) [15]

Emin etal. (2016) [9]

Comparison of quality of life between patients on the waiting list and heart transplant recipients

Quality of life of advanced chronic heart failure: medical care, mechanical circulatory support and transplantation

Brazil Compare

United Kingdom

Study intent and number of patients

QOL between wait-listed patients and recipients. n=56

QoL in patients assessed for HTx, listed for HTx on medical therapy, supported with bridge to transplant LVAD and patients after HTx. n=386

HRQOL instrument used

SF-36 Physical functioning=9.5 vs.

KCCQ EQ-5D

QoL scores (gures given as HTx vs wait-list)

32.1

Role-physical=22.6 vs. 29.6 Bodily pain=18.2 vs. 29.1 General health=9.1 vs. 32.2 Vitality=14.9 vs. 31.1 Social functioning=17.6 vs.

30.0

Role-emotional=24.8 vs. 29.2 Mental health=24.6 vs. 29.2

KCCQ domains Symptom stability=54.7±21.6

vs. 47.8±29.5 Self- efcacy=93.4±15.0 vs.

74.2±22.2

Symptom frequency=77.1±26.3 vs.

45.5±26.8 Symptom burden=77.8±25.1 vs. 48.5±25.5

Total symptom score=77.5±25.1 vs.

47.0±24.9

Physical limitation=75.4±31.1 vs.

43.3±26.7

Clinical summary score=76.6±26.1 vs.

45.0±23.5 QoL=71.4±28.5 vs.

27.0±22.1 Social limitation=67.0±34.2 vs. 23.7±23.4

Overall summary score=73.0±27.2 vs.

35.5±21.5

EQ-5D index score=0.74±0.27 vs.

0.50±0.30

Main ndings related to HRQOL

Signicant difference between two groups in the QOL score and four dimensions. Mean rank=16.9in wait-listed patients, = 30.7in transplant recipients. Lowest scores for general health and highest scores for role- emotional in wait-listed patients. Highest scores for general health and the lowest scores for bodily pain in recipients

Best QoL in recipients. EQ-5D scores highest in patients after HTx

5 Patient Reported Outcomes andQuality ofLife following Heart Transplantation

Table 5.3 (continued)

HRQOL instrument used

MLHFQ (lower score denotes higher QoL)

SF 12 Physical health=35.2

QoL scores (gures given as HTx vs wait-list)

LHFQ total=28.0±26.4 vs.

52.3±26.1 (p=0.000) Physical=11.3±11.2 vs.

19.9±12.1 (p=0.000) Emotional=7.5±8.2 vs.

12.8±7.8 (p=0.001)

(32.4–44.6 IQR) vs. 40.4 (26.9–54.0 IQR) Mental health=47.6 (36.758.8 IQR) vs. 42.4 (38.6–53.0 IQR)

Study Title Country

Evangelista etal. (2004) [14]

Evangelista etal. (2005) [13]

Functional Status and Perceived Control Inuence Quality of Life in Female Heart Transplant Recipients

Two-year follow-up of quality of life in patients referred for heart transplant

United States of America

Study intent and number of patients

Describe and compare QOL and psychologic well-being of recipients and waiting list candidates, correlates of QOL in female recipients. n=100

Comparative effects of surgical or medical treatment on HRQOL. n=77

Main ndings related to HRQOL

Overall QOL scores higher in recipients than candidates. Higher physical and emotional health for recipients compared with candidates. Functional status, depression and perceived control signicant correlates of QOL among female recipients, accounted for 49% variance in overall QOL

Physical health score signicantly improved over time in all patients, changes in mental health were minimal. Although all patients continued to have low HRQoL scores at the time of follow-up, medically stable patients had higher mental health scores and less depressive symptoms

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Fewer than half had good QOL, one-third

had demoralization syndrome.

Demoralization syndrome combined with

post-transplant time, age, use of

mechanical circulatory support during

hospitalization and stress status accounted

for 35.2% of PCS.Demoralization

syndrome combined with age and religion

accounted for 40.3% of MCS

A. J. Poovathoor et al.

QOL pre-HTx=3.16±1.47, post-

HTx=7.60±1.21. After HTx people

consider their physical health better.

Positive correlation between the

assessment of QoL and that of physical

and mental health

PCS=38.83±7.65 (baseline) vs.

44.54±7.93 (3 Mo) vs 45.18±7.69 (6 Mo)

vs. 48.15±7.59 (12 Mo)

MCS=48.89±9.59 (baseline) vs.

HRQOL

instrument used QoL scores Main ndings related to HRQOL

SF-12 Group 1 (<1year post-Tx)

Study intent and number

of patients

Compare different

post-transplant times

of recipients in terms

of QOL,

demoralization

Quality of life,

demoralization

syndrome and

health-related

lifestyle in cardiac

Study Title

Wu etal.

(2019)

Table 5.4 Longitudinal studies: pre-operation and post-operation intervals. Assessing baseline quality of life with heart failure, then at intervals post-operatively

[24]

49.98±7.70 (3 Mo) vs. 48.15±8.25 (6

Mo) vs. 49.27±7.58 (12 Mo)

Group 2 (1–3years post-Tx)

PCS=46.70±8.43 (baseline) vs.

46.55±8.40 (3 Mo) vs. 46.91±8.43 (6

Mo) vs. 44.62±8.67 (12 Mo)

syndrome and

health- related lifestyle,

predictors of quality of

life. n=99

transplant

recipients—a

longitudinal study in

Taiwan

MCS=46.35±8.19 (baseline) vs.

45.29±13.05 (3 Mo) vs. 48.16±8.21 (6

Mo) vs. 49.30±9.66 (12 Mo)

Group 3 (>3years post-Tx)

PCS=45.75±8.93 (baseline) vs.

45.10±9.28 (3 Mo) vs. 44.54±9.62 (6

Mo) vs. 46.73±8.43 (12 Mo)

MCS=47.92±9.44 (baseline) vs.

49.98±8.15 (3 Mo) vs. 50.93±8.87 (6

Mo) vs. 50.39±8.82 (12 Mo)

Physical=2.079±0.79 (Pre-Tx) vs.

4.10±0.39 (Post-Tx)

Mental=2.56±0.98 (Pre-Tx) vs.

3.92±0.75 (Post-Tx)

authors’

questionnaire

(Scale of 1 to

Quality of life of

patients before and

after HTx, n=63

Comparative analysis

of the quality of life

for patients prior to

and after heart

transplantation

Czyżewski

etal. (2014)

[23]

5 Patient Reported Outcomes andQuality ofLife following Heart Transplantation

Correlation in the changes of perceived

HRQoL between the preoperative and

each postoperative stage. HRQoL in the

postdischarge-12th month stage reached

2.29 times preoperative scores

Progressive improvement in physical,

psychologic, and social areas post-HTx,

HRQoL stable at 6months

Large and rapid change in health status

(continued)

post-HTx; absence of spontaneous

improvement prior to transplant and

gradual deterioration post-transplant.

NHP scores relate closely to clinical

categorization. Pre-Tx NHP scores may

be useful prognostic indicator for post-Tx

survival

31.25±18.08 (Pre-Tx) vs. 60.00±16.04

(Post-Tx ICU transition) vs. 64.38±14.99

(1day pre-discharge) vs. 68.75±14.58 (1

Mo post-discharge) vs. 72.50±7.07 (3 Mo

post-discharge) vs. 72.50±11.65 (6 Mo

post-discharge) vs. 71.25±11.26 (12 Mo

post-discharge)

interviewed x7

HRQOL

Study intent and number

(QoL %)

instrument used QoL scores Main ndings related to HRQOL

Relationships between

the changes in the

HRQoL and working

capacity (WC),

changes in various

aspects of physical

well being related to

of patients

Changes in Health-

Related Quality of

Life and Working

Competence Before

and After Heart

HRQoL and WC in

Transplantation:

One-Year Follow-Up

in Taiwan

Physical functioning=21.92 (Pre-Tx) vs.

51.92 (3 Mo) vs. 75.00 (6 Mo) vs. 69.61

(12 Mo)

Role Limitations Due to Physical

SF 36

interview

the rst year. n=10

Evolution of HRQOL

during the rst year.

n=13

Health-Related

Quality of Life

Evolution in Patients

After Heart

Problems=0 (Pre-Tx) vs. 33.84 (3 Mo)

vs. 57.69 (6 Mo) vs. 53.84 (12 Mo)

Body Pain=77.11 (Pre-Tx) vs. 76.15 (3

Mo) vs. 91.53 (6 Mo) vs. 77.88 (12 Mo)

General Health=24.23 (Pre-Tx) vs. 29.23

Transplantation

3 Mo)

Sleep=30.71(pre-Tx) vs. 11.05 (3 Mo)

Social isolation=23.86 (pre-Tx) vs. 3.88

(3 Mo)

Physical mobility=32.29 (pre-Tx) vs.

(3 Mo) vs. 43.07 (6 Mo) vs. 77.88 (12 Mo)

Vitality=14.61 (Pre-Tx) vs. 45.76 (3 Mo)

vs. 65.84 (6 Mo) vs. 53.84 (12 Mo)

Social Functioning Role Limitations Due

to Emotional Problems=20.78 (Pre-Tx)

vs. 47.94 (3 Mo) vs. 66.66 (6 Mo) vs. 51.27

(12 Mo)

Mental Health=47.07 (Pre-Tx) vs. 60.92

(3 Mo) vs. 73.53 (6 Mo) vs. 63.69 (12 Mo)

Energy=27.21 (pre-Tx) vs. 18.00 (3 Mo)

Pain=24.65 (pre-Tx) vs. 12.25 (3 Mo)

Emotional reactions=31.22 (pre-Tx) vs.

5.90 (

NHP (mean

rank score)

Examine relationship

between the survival

and QoL. n=1036

Measuring the

effectiveness of heart

transplant

programmes: quality

of life data and their

relationship to

5.50 (3 Mo)

survival analysis

Study Title

Shih etal.

(2003)

[37]

Martín-

Rodríguez

etal. (2008)

[21]

O’Brien

etal. (1987)

[38]

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Negative correlation between BDI and

subgroups on SF36. Signicant

improvements noted in all subgroups on

the SF36 after the HTx

LVAD implantation and HTx increased

daily physical activity by 60% and 52%.

Physical health score signicantly

improved over time in all patients,

changes in mental health were minimal.

Although all patients continued to have

low HRQOL scores at the time of

follow-up, medically stable patients had

higher mental health scores and less

depressive symptoms

level of activity unchanged at 3, 6, and

A. J. Poovathoor et al.

12months. QoL improved in LVAD

implantation and HTx groups but

unchanged afterward. HTx higher activity

level vs. LVAD implantation—associated

with better QoL

vs. 68.52±22.65 (post-Tx)

Physical role=27.68±36.34 (pre-Tx) vs.

65.37±36.35 (post-Tx)

Bodily pain=40.15±21.62 (pre-Tx) vs.

HRQOL

instrument used QoL scores Main ndings related to HRQOL

SF-36 Physical function=35.00±25.68 (pre-Tx)

Study intent and number

of patients

Relationship between

depressive symptoms

and anxiety with QoL

and functional

capacity. n=34

The relationship

between depressive

symptoms and

anxiety and quality

of life and functional

Study Title

Karapolat

etal. (2007)

Table 5.4 (continued)

[22]

63.00±24.03 (post-Tx)

General health=40.67±19.57 (pre-Tx)

vs. 66.11±19.35 (post-Tx)

Vitality=50.00±16.76 (pre-Tx) vs.

71.67±20.05 (post-Tx)

Social function=44.63±28.12 (pre-Tx)

capacity in heart

transplant patients

vs. 71.04±31.37 (post-Tx)

Emotional role=18.49±26.67 (pre-Tx)

vs. 68.85±35.82 (post-Tx)

Mental Health=59.41±20.89 (pre-Tx)

vs. 72.30±18.31 (post-Tx)

(pre-Tx) vs. 35.2 (32.4–44.6 IQR) (post-Tx)

Mental health=47.6 (36.7–58.8 IQR)

(pre-Tx) vs. 41.9 (38.8–51.2 IQR) (post-Tx)

SF 12 Physical health=30.3 (20.1–35.8 IQR)

Comparative effects of

surgical or medical

treatment on HRQoL.

n=77

Two-year follow-up

of quality of life in

patients referred for

heart transplant

Evangelista

etal. (2005)

[13]

(6 Mo) vs. 29±7 (12 Mo)

MLHFQ 72±8 (pre-Tx) vs. 39±5 (3 Mo) vs. 30±6

Short- and long-term

effects of LVAD

implantation and HTx

on physical activity

and QoL. n=40 (+14

healthy subjects)

Transplantation on

Habitual Physical

and Heart

Activity and Quality

Effect of Left

Ventricular Assist

Device Implantation

Jakovljevic

etal. (2014)

[8]

of Life

SF 12: Short Form 12; SF 36: Short Form 36; NHP: Nottingham Health Prole; MLHFQ: Minnesota Living with Heart Failure Questionnaire; PCS: Physical Component Score;

MCS: Mental Component Score; Mo: month; Tx: transplant

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