Bakgrund: Hjärtsvikt är en kronisk sjukdom som ökar med stigande ålder över hela världen. Personer med hjärtsvikt har en hög symtombörda och det leder till begränsningar såväl psykiskt som fysiskt och socialt. Syfte: Att beskriva upplevelser i livets slutskede hos personer som lever med svår hjärtsvikt. Metod: Litteraturöversikt baserad på 13 kvalitativa vetenskapliga artiklar som analyserades enligt Fribergs modell. Resultat: Analysen resulterade i fem kategorier; Begränsningar i det dagliga livet, En förändrad identitet, Att uppleva trygghet, Att leva mellan hopp och förtvivlan och att planera för livets slut. Slutsats: Personer som lever med hjärtsvikt i livets slutskede upplever att de blir påverkade fysiskt, psykiskt, socialt och existentiellt i det dagliga livet. Personerna upplever en förlust av identitet. Att känna trygghet och kontinuitet upplevdes som viktiga komponenter för att hantera sjukdomens oförutsägbara natur. / Background: Heart failure is a chronic disease, increasing in the world as the population gets older. Persons living with heart failure has high symtom burden and that leads to limitations in a physical, psychological and social way. Aim: To describe experiences in the end of life among person´s living with advanced heart failure. Method: A literature study based on 13 scientific qualitative articles that was analyzed according to Friberg´s model. Results: The analysis resulted in five categories; Limitations in the daily life, a changed identity, sense of security, Living between hope and despair and Planning for the end of life. Conclusion: Persons living with advanced heart failure in the end of life experience that they become affected in their daily life in a physical, psychological, social and existential way. They experience a loss of their identity. To feel secure and continuity are important factors in dealing with the uncertainty of the disease.

The purpose of this study was to evaluate graded exercise responses to treadmill exercise in patients with a total artificial heat (SynCardia, Tucson, AZ). Additionally, this study sought to compare the exercise response in total artificial heart (TAH) patients to both advanced heart failure (HF) patients on medical management only and HeartMate II (Thoratec Corp., Pleasanton, CA) left‐ventricular assist device (HMII) patients. For patients with biventricular heart failure the TAH is a viable option to bridge patients until transplant becomes available. Its demonstrated improvement in mortality and increasing usage necessitates a shift in focus to quality of life in the TAH patient including functional ability. The evaluation of cardiorespiratory responses to graded exercise provides an objective measure of functional ability. There is very limited information in the literature on the exercise response of the mechanical circulatory support (MCS) device patient, particularly the TAH patient. A review was performed on MCS patients who underwent symptom‐limited cardiopulmonary exercise testing (CPET) following device implant of either TAH or HMII. ANOVA was performed to compare differences between the two device groups and HF patients listed for heart transplant. Fourteen TAH patients underwent CPET (9 male, 5 female) with peak oxygen consumption (VȩO2) of 0.926 + .168 L∙min, 36 + 8% % predicted, 11.0 + 2.3 ml.kg.min or 3.1 + 0.7 METs. Ventilatory anaerobic threshold (VAT) was 0.706 + .181 L∙min. Peak (VȩO2, % pred. (VȩO2 and VAT were significantly lower in the TAH compared with HMII and advanced HF (p = 0.0012, p = 0.0106, p = 0.0009, respectively). Peak RER was significantly higher (p = <.0001) and OUES was significantly lower (p = 0.0004) in the TAH. Exercise capacity is significantly reduced in the TAH patient below that observed in HMII LVAD and advanced HF patients. This provides a baseline for expected functional status and has implications on the ADL tolerance of these individuals. The next step is to develop strategies to ameliorate this continued exercise intolerance. The documents herein contain a review of literature including a background in heart failure and the use of the exercise response in the heart failure patient. An overview is also presented on the use of MCS describing physiology, device function, and exercise physiology of the MCS device patient. A manuscript has also been included detailing a cross‐sectional review of the effects of graded exercise in the TAH patient and comparing it to the HMII and advanced HF patient.

Bakgrund: I Europa antas cirka en till två procent av den vuxna befolkningen lida av hjärtsvikt och prevalensen beräknas vara cirka 10 procent hos personer över 70 år. Hjärtsvikt innebär att hjärtas pumpförmåga försämras och personen med hjärtsvikt drabbas ofta av typiska symtom för hjärtsvikt och kliniska fynd och kräver farmakologisk behandling. Trots en adekvat behandling är syndromet progriderande och övergår till sist i kronisk avancerad hjärtsvikt med hög symtombörda och hög mortalitet. Livskvaliteten hos personer med kroniska sjukdomar är ofta låg och livskvaliteteten hos personer med kronisk avancerad hjärtsvikt anses vara betydligt lägre än hos den genomsnittliga befolkningen. Syfte: Syftet med litteraturöversikten var att belysa vilka faktorer som påverkar livskvaliteten hos patienter med kronisk avancerad hjärtsvikt i ett palliativ skede. Metod: Arbetet utfördes som en litteraturöversikt med systematisk litteratursökning som utfördes i databaserna CINAHL och PubMed. Litteraturöversikten består av 16 vetenskapliga artiklar med kvantitativ och kvalitativ design vilka analyserades med en integrerad analys. Resultat: Resultatet visade att både personliga och omgivande faktorer var av betydelse. Fysiska och psykiska symtom kunde påverka livskvaliteten negativt medan en godkommunikation, kunskap och information samt vilken vårdtyp som erhölls var faktorer somkunde styrka livskvaliteten. Slutsats: Personer med kronisk avancerad hjärtsvikt lider ofta av en ökad fysisk och psykisk symtombörda där livskvaliteten kan påverkas negativt. Det visar också vikten av ett gott samarbete mellan patient och sjuksköterska där vårdtypen kunde utgöra en stor skillnad förpersonen. / Background: In Europe, about one to two percent of the adult population is assumed to suffer from heart failure and prevalence increases to an estimated 10 percent in people over the age of 70. Heart failure means that the pumping ability of the heart deteriorates and the person often suffers from serious symptoms, requiring pharmacological treatment. Despite there being adequate treatments widely available, the syndrome often turns in to advanced heartfailure with severe symptoms and a high mortality rate. The quality of life for people with chronic diseases is often low and lower still for people with chronic advanced heart failure. Those suffering are considered to have a significantly lower quality of life than the averageperson. Aim: The aim of the literature review was to highlight which factors affect the quality of life of patients with chronic advanced heart failure at a palliative stage. Method: The study was conducted as a literature review with systematic literature search conducted in the CINAHL and PubMed databases. The literature review consists of 16 scientific articles with quantitative and qualitative design that were analyzed with anintegrated analysis. Results: The results showed that both personal and surrounding factors were of importance. Physical and psychological symptoms could negatively affect quality of life, while good communication, knowledge, and information, as well as the type of care were factors thatcould improve the quality of life. Conclusion: Persons with chronic advanced heart failure often suffer from the burdens of both physical and mental symptoms, where the quality of life is negatively affected. It also shows the importance of good cooperation between patient and nurse, where a certain type of carecould represent a major improvement for the person.

Hjärtsvikt är ett komplext syndrom med hög morbiditet och mortalitet – och som blir allt vanligare världen över. Avancerad hjärtsvikt kan ha betydande konsekvenser för patienten. Ur denna synvinkel ville vi ta reda på hur patienter med avancerad hjärtsvikt upplever sin situation. Syftet med litteraturöversikten var att belysa vuxna patienters upplevelser av att leva med avancerad hjärtsvikt. Metoden var en litteraturöversikt med systematisk sökstrategi. Inklusionskriterier var kvalitativa originalartiklar där deltagande personer hade diagnosen hjärtsvikt i avancerad fas och var över 18 år. Exklusionskriterium var artiklar som inte var godkända av en etisk kommitté alternativt etiknämnd. 15 kvalitativa originalartiklar inkluderades. En induktiv tematisk analys gjordes utifrån Braun och Clark (2006). Resultatet utmynnade i fyra teman och tio subteman. Det första temat “Symtomens inverkan på det dagliga livet” innefattade två subteman vilka var “Fysiska dimensioner” och “Psykiska dimensioner”. “Vårdrelaterade upplevelser” var det andra temat med “Uppfattningar om diagnos, prognos och behandling”, “Upplevelser av tillförlitlig och bristfällig vård” och “Ekonomisk börda” som subteman. Det tredje temat var “Copingstrategier” som inbegrep “Kognitiva copingstrategier” och “Religion och spiritualitet som copingstrategi”. Sista temat var “Emotionella och sociala aspekter av att leva och dö med avancerad hjärtsvikt”. Subteman var “Betydelsen av sociala relationer”, “Att förlora sin självständighet” och “Tankar och känslor inför framtiden och döden”. Slutsatsen var att patienters upplevelser av avancerad hjärtsvikt var mångfacetterade och hade inverkan på flera aspekter av deras liv. Överlag uttryckte patienterna ett behov av information och kunskap om sitt tillstånd. / Heart failure is a complex syndrome that has both high morbidity and mortality - and is becoming more and more common world-wide. Advanced heart failure can have significant consequences for the patient. It was from this standpoint we wanted to look into how patients with advanced heart failure experience their situation. The aim of the literature review was to elucidate adult patients’ experiences of living with advanced heart failure. The method used was a literature review with a systematic search strategy. The inclusion criteria were qualitative original articles in which participants were diagnosed with advanced heart failure and were adults (18 years old or older). The exclusion criterion were articles without approval from an ethics committee or a review board. In total 15 original articles were included in this paper. An inductive thematic analysis was made based on Braun and Clark (2006). The result led to four themes and ten subthemes. “The symptoms impact on daily life” included two subthemes which were “Physical dimensions” and “Psychological dimensions”. “Care-related experiences” were the second theme with “Perceptions of diagnosis, prognosis and treatment”, “Experiences of reliable and inadequate care” and “Financial burden” as subthemes. The third theme was “Coping strategies” that included “Cognitive coping strategies” and “Religion and spirituality as a coping strategy”. The last theme was “Emotional and social aspects of living with, and dying from, advanced heart failure”. Subthemes were “The importance of social relationships”, “To lose one's independence” and “Thoughts and feelings about the future and death”. The conclusion was that many patients’ experience of living with advanced heart failure were diverse and influenced several aspects of their lives. But in general, most patients expressed a need for information and knowledge about their condition.

The general purpose of this thesis is to establish capability and accuracy of speckle tracking echocardiography (STE) in assessing left atrial (LA), left ventricular (LV) and right ventricular (RV) function and their correlation with myocardial fibrosis, filling pressure and clinical outcomes in advanced heart failure (HF) patients before and after heart transplantation (HT). I demonstrated that HT recipients had impaired LV twist dynamics in the form of reduced rotation twist angle and untwist rate but time to peak twist was not different from the age matched controls and other cardiac surgical patients. With a longitudinal study conducted on patients with refractory HF, the best prognostic power has been shown by RV strain analysis. Among the indexes of LV function, the LV ejection fraction (LVEF) demonstrated the lowest diagnostic accuracy; instead LV global circumferential strain (GCS) showed a better sensitivity and specificity than LV global longitudinal strain (GLS). When analyzing the relationship between different severity of myocardial fibrosis and LV cavity function, the strongest function parameter that correlated with severity of myocardial fibrosis was GLS. In contrast, none of diastolic LV function or even measures of exercise capacity correlated with myocardial fibrosis. In patients with end-stage HF, global peak atrial longitudinal strain (PALS), an index of atrial reservoir function was dependent by pulmonary capillary wedge pressure (PCWP) and LV fibrosis, but not influenced by LV systolic function. Results from this study confirm previous evidence of correlation between impaired global PALS and increased PCWP.

Plasma levels of B-type natriuretic peptide (BNP) are a strong and independent predictor of prognosis in patients with advanced heart failure (CHF). However, the importance of this biomarker has been documented only in CHF of common causes such as dilated or ischemic cardiomyopathy. We hypothesized that BNP can serve as a strong predictor of end-stage CHF in group of patients with advanced CHF due to congenital heart disease (CHD) with the right ventricle in systemic position (SRV). The second hypothesis was that BNP monitoring in patients with implanted left ventricular assist device (LVAD) Heart Mate II could detect serious complications which negatively affect prognosis. We performed a retrospective analysis in 28 consecutive patients with severe systolic dysfunction of the SRV (ejection fraction 23 ± 6%) evaluated as heart transplant (HTx) candidates between May 2007 and October 2014. During a median follow-up of 29 months (interquartile range, 9-50), 14 pts reached primary endpoints of the study (death, urgent HTx, and LVAD implantation). We have considered these events equivalent to end-stage CHF. Using ROC analysis, we identified the first measured value of BNP as the strongest predictor of prognosis with the area under the curve (AUC) of 1.00, followed by the New York Heart Association...