Author + information
- Peter M. Eckman, MD†,⁎ (, )
- Vinayak Dhungel, MBBS†,
- Stacy Mandras, MD‡,
- Meredith A. Brisco, MD§,
- Sitaramesh Emani, MD∥,
- Sue Duval, PhD¶,
- JoAnn Lindenfeld, MD#,
- Nasir Sulemanjee, MD⁎⁎,
- George G. Sokos, DO†† and
- Jamie Feldman, MD, PhD‡‡
- ↵⁎Department of Medicine, Cardiovascular Division, University of Minnesota Medical School, 420 Delaware Street, SE, MMC 508, Minneapolis, Minnesota 55455
To the Editor:
Impaired sexual function is common in patients with heart failure (1) and following cardiac transplant. Left ventricular assist devices (LVADs) improve survival, functional capacity, and quality of life for end-stage heart failure, but data regarding their impact on sexual function and satisfaction are limited to early devices and one small sample of continuous-flow devices from a single center (2,3). This study examined the prevalence and types of sexual dysfunction among LVAD recipients. A secondary aim was to evaluate the changes in sexual function following LVAD, through the use of a self-recall questionnaire.
We anonymously surveyed 301 patients at 7 centers, using the established Changes in Sexual Function Questionnaire-14 (CSFQ-14) (4), along with self-recall questions comparing 4 domains of sexual function (desire, arousal, orgasm, and pain) before and after LVAD implantation. Individual answers were graded using a 5-point Likert scale. The total CSFQ-14 score includes all 14 items. Sexual dysfunction was defined by a total score of ≤41 in males and ≤47 in females. Respondents were given an opportunity to provide additional comments regarding sexual function. Logistic regression models were used to identify univariate associations between sexual dysfunction and pre hoc-defined predictors. Multivariable analysis was not performed because of small sample size. Paired Student t-tests were used to compare pre- and post-LVAD self-recall questionnaire items. Data are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Funding was provided by Thoratec (Pleasanton, California). The study was designed and implemented entirely by the study authors, who maintained control of the data and performed the analysis.
Fifty-nine responses were received, of which 24% were from females. Among respondents, 39% were older than 60, almost half (49%) were supported with an LVAD for more than 1 year, and comorbidities such as hypertension (46%), diabetes (36%), and ischemic heart disease (61%) were common.
The mean ± SD total CSFQ-14 score for all participants was 34.5 ± 10.8. The mean total CSFQ-14 score for men was 34.6 ± 10.4, and 71% met the criteria for sexual dysfunction. The mean total CSFQ-14 score for women was 34.2 ± 12.2, and 79% met the criteria for sexual dysfunction (p = NS for men vs. women).
Figure 1A shows scores categorized by sex along with values from previous studies (5). Mean desire subscores were 13.2 ± 3.7 for men and 10.8 ± 3.7 for women (p = 0.036). The mean arousal subscores were 6.7 ± 3.5 for men and 7.4 ± 3.6 for women (p = NS). The mean orgasm and completion subscores were 7.7 ± 3.2 for men and 8.9 ± 4.0 for women (p = NS).
Age over 60 (OR: 7.35 [95% CI: 1.48 to 36.5], p = 0.008) and history of ischemic heart disease (OR: 3.85 [95% CI: 1.15 to 12.81], p = 0.028) were directly associated with sexual dysfunction, and the use of beta-blockers (OR: 0.20 [95% CI: 0.04 to 0.98], p = 0.048) or phosphodiesterase-5 (PDE5) inhibitors (OR: 0.071 [95% CI: 0.0073 to 0.70], p = 0.017) was inversely associated with sexual dysfunction in univariate analysis.
No significant changes in desire or pain were observed when all patients were considered or when data were evaluated by sex. Significant decreases in arousal scores were noted for both sexes (Fig. 1B). Orgasm scores decreased in men post-implantation but were unchanged in women. More than half of the patients reported worsening in desire, arousal, and orgasm post-LVAD. Only a small fraction (4%) reported improvement in pain. Interestingly, post-LVAD sexual dysfunction correlated with significantly lower arousal and orgasm scores pre-LVAD compared to patients without post-LVAD dysfunction.
Psychological issues were similar among male and female respondents. Fear of damaging the LVAD (60%), self-harm (49%), device alarms (28%), and hurting one's partner (21%) were cited as barriers. Driveline site, awkwardness, obstruction, heart rate, and energy drain were cited infrequently, although 72% of respondents reported the equipment was “somewhat” of an obstacle or a “major” obstacle to satisfaction. A total of 47% of patients felt their LVAD negatively affected self-image, which more than half felt was at least somewhat important for sexual satisfaction.
Responses to open-ended questions were highly variable (Table 1).
Although LVADs improve cardiac output, the impact on endothelial function, psychological health, social circumstances, and relationships may not be uniformly favorable. A significant proportion of respondents reported no change or worsening of sexual function, although it is unclear if this was driven by physiological changes or a myriad of other factors that impact sexual health. In contrast to findings from a prior study (2), we were surprised that only a minority of participants reported improvement, particularly in desire, after an LVAD. The lack of change does not follow the improvement in the quality of life that is expected after implantation.
To the best of our knowledge, this study provides the largest examination of sexual function in female LVAD recipients. Sexual dysfunction was more prominent in females, who were more likely to rate the impact of body image highly, mirroring findings in healthy people. Changes in factors more related to blood flow alterations, such as arousal and orgasm, decreased similarly between sexes.
The study design and low response rate limit the ability to draw firm conclusions from our data. These data should inform subsequent studies designed to evaluate and improve understanding of the specific factors involved in sexual health post-LVAD. The data do provide us, however, with important insights on how we may improve patient care. Equipment was frequently cited as an obstacle; and along with the fear of damaging the LVAD, it appears that improvements to external components may have a favorable impact on sexual function.
Willingness to address concerns about sexual function may foster discussion regarding the safety of and barriers to sexual activity.
Please note: This work was supported by Thoratec. Dr. Dhungel was supported in part by a grant from Thoratec. Dr. Eckman has received grant support and honoraria from Thoratec and HeartWare. Dr. Lindenfeld reports relationships with St. Jude, Boston Scientific, Zona, Zensun, Pozen, and CardioMEMs. Dr. Emani has received travel reimbursement from Thoratec. Dr. Sokos was a member of the Speaker's Bureau for Actelion Pharmaceuticals. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation