Denial for Advanced Heart Failure Therapies Due to Psychosocial Stressors: Who Comes Back?

•Few patients are reevaluated if denied for advanced therapies for psychosocial issues.•Of patients reevaluated after initial denial, most were approved.•Potential bias both in initial selection and in selection for reevaluation.•Caregiver and substance use concerns were most common issues at second denial. Psychosocial evaluations to assess candidacy for advanced heart failure therapies are not standardized across institutions, potentially contributing to disparities in approval for advanced therapies. Remediation rates of psychosocial stressors among patients with advanced HF and reconsideration for advanced therapies have not been well-described. We performed a retrospective, single-center study of 647 adults evaluated for heart transplant and ventricular assist device implantation between 2014 and 2020, of whom 89 (14%) were denied for psychosocial stressors, including caregiver, substance use, housing, financial, or mental health concerns. Later reevaluation occurred in 32 patients (36%), of whom 23 were then approved. Patients initially declined were mostly male (76%), White (74%), and urban (79%). Reevaluation occurred in more women than men (43% vs 34%), Black patients than White (43% vs 37%), and urban patients than rural (39% vs 28%). Patients had fewer psychosocial stressors at reevaluation (median 0.5) than at initial denial (median 2.0). Caregiver and substance use concerns were the most prevalent stressors in patients never returning for or subsequently denied at reevaluation. Caregiver and substance use concerns were common in patients denied for psychosocial reasons. Future efforts should focus on early screening for these stressors and the implementation of a systematic reevaluation process.