Table of Contents
Sociodemographic variables
A total of 416 individuals completed the survey questionnaire (response rate of 40.7%). One minor was excluded along with eight additional individuals who completed less than 50% of DDI-related questions. As a result, 407 datasets were included in the analysis. Table 1 provides sociodemographic information and details related to the transplant process.
Heart transplant burden
Participants showed hospitalized patients' burdens after HTX on a scale of 0 (“no burden”) to 10 (“highly likely burden”). Psychological burden (mean = 5.19, SD = 3.09, no response of 9) was reported to be as high as physical burden (mean = 5.18, SD = 3.03, missing response of 8). Additionally, 14.6% said they were diagnosed and had an anxiety disorder or depression after HTX (n = 58, 9 responses).
Surgical procedures
First, the frequency of patients' surgical preconceptions was assessed before and after HTX. Before the surgery, a total of 7.5% were always thinking about future implants (“Never”, n = 27, 46 missing responses), 2.8% thought about it only “once” (n = 10). The majority of participants considered HTX in “everyday” (44.9%, n = 162), followed by “at least once a week” (20.8%, n = 75), “at least once a month” (5.3%, n = 19), and even “frequently” (18.8%, n = 68).
After surgery, 22 participants were not mentally immersed in the surgical procedure at any time (“Never”, 5.5%, 6 responses lost). Again, the highest percentage of recipients was thinking about “everyday” (33.7%, n = 135) in HTX. Then, “at least once a week” (23.2%, n = 93), “at least once a month” (9.7%, n = 39), and even “frequently” (26.2%, n = 105). Eight recipients refused to have any thoughts about the surgery (both before and after) (2.2%, 47 responses missing).
Nine recipients said they had thought about surgery rather than after surgery was performed (2.5%), while on the contrary, 19 recipients had no relevant ideas about surgery before HTX, but developed them after HTX (5.3%).
As long as thoughts occurred, they mostly continued in “minority” (50.7%, n = 190, 32 missing answers) or “number” (29.1%, n = 109) minutes. Few thoughts reported to be followed by shorter (“several seconds”, 16.8%, n = 63) or less (“time”, 3.5%, n = 13).
Prevalence of donor and donation images
DDI occurrence was evaluated before and after HTX. Of all recipients, 59.8% reported DDI (n=202, 69 no responses) before HTX, increasing to 91.0% after HTX (n=364, 7 missing responses).
Of the 336 participants who provided valid responses before and after HTX, 198 (58.9%) reported experiencing DDI at both time points. Only two participants who reported DDI Pre-HTX reported DDI Post-HTX (0.6%). 27 recipients did not report DDIs for either Pre-htx or Post-HTX (8.0%). In summary, we may confirm the hypothesis that DDI increases Post-HTX.
Most respondents indicated that DDI occurs “at a stage.” For 29.5% of respondents, DDI continues to the present (n = 75). Figure 1 shows the frequency of DDI before and after HTX, showing a clear increase in DDI after HTX.
Prevalence of donor and donation images before/after heart transplants. DDI = Donor and donation images. HTX = Heart transplant.
Donor and donation images occurrence time
To identify the most prominent stages of DDI development, only participants who reported experiencing DDI were asked to select a single time frame where DDI most frequently occurs before and after HTX. As shown in Figure 2, before HTX, 27.1% of participants reported experiencing DDI just before the procedure, followed by 24.7%, 25.3%, 12.0% in the previous year, and 10.8% in the previous year, 24.7%.
After HTX, DDI was most frequently reported to occur immediately (42.7%) or several days later (38.7%). A small number of participants showed the most prominent stages at weeks (12.1%), months (5.1%), or years (1.4%). These findings suggest that DDIs gather primarily around the perioperative period and are the highest occurrence just before and after implantation.
Times of images of donors and donations before and after a heart transplant. Participants were asked to select only one time slot. The percentages reflect mutually exclusive responses, so they add up to 100% per hour. DDI = Donor and donation images. HTX = Heart transplant.
Intensity of donor and donation images
To identify the most prominent stages of DDI development, only participants who reported experiencing DDI were asked to show how often these thoughts occurred. Of the recipients whose DDI had a Pre-HTX (n = 202), a total of 164 provided responses regarding the intensity of these experiences. DDI occurred “at least once a day” in 33.5% (n = 55) and “at least once a week” in 22.6% (n = 37). DDI with slightly fewer DDIs occurring “at least once a month” (11.0%, n = 18), “infrequently” (23.8%, n = 39), or “once” (9.1%, n = 15).
Of the recipients whose DDI had a Post-HTX (n = 364), a total of 352 provided responses regarding the intensity of these experiences. Post-HTX, DDI occurred “less frequently” than most once a month (31.0%, n = 109), followed by “at least once a day” (30.4%, n = 107) or “at least once” (at least 26.4%, n = 93). DDI occurred “at least once a month” in 8.2% (n = 29) and “once once a month” in 4.0% (n = 14).
The duration of singular thinking was reported by almost half the recipients as “min” length (50.0%, n = 184, 39 responses missing), followed by “min” (28.8%, n = 106). Although less frequent, DDI was reported to follow “several seconds” (18.8%, n = 69) or “time” (2.4%, n = 9).
Avoiding donor and donation images
Sixty-two patients reported positively avoiding their donor pre-HTX ideas (19.9%, 96 responses not lost).
Post-htx, only patients who slightly avoided such thoughts were slightly more common: 22.1% (n = 88, 8 responses missing). In this case, it appeared that avoidance would likely occur immediately after HTX (5.5%, n = 22; “days”: 4.3%, n = 17; “after a few weeks”: 5.5%, n = 22, “month”: 4.8%, n = 19; “after a year”: 2.0%, n = 8).
Avoidance of Pre-HTX resulted in thought suppression in just half of patients (n = 54, 52.9% vs n = 48, 47.1%).
Feelings experienced in the context of a heart transplant
Table 2 shows the presence of various emotions in the outlook for HTX following HTX and the expected emotions when thinking about donors. The main emotions before and after HTX were hope, joy and gratitude. The most frequently reported disgust was anxiety. When I think about donors, gratitude prevailed, followed by joy.
Personal beliefs and perceptions
Table 3 provides a summary of participants' personal beliefs and perceptions, revealing a significant degree of heterogeneity. On the one hand, over 50% said that the soul was absent, but a similarly high proportion was considered the heart to be the seat of the soul. Approximately half of respondents agreed that the soul can affect the body (and vice versa).
Predictors of donor and donation images
Regarding the time point of Pre-HTX, gender (female) emerged as the sole sociodemographic predictor, and psychological burden appeared to be interrelated with Pre-HTX DDI (see Table 4). Therefore, we can confirm the second hypothesis that demonstrates the association between psychological distress and DDI. Emotions appeared to play a major role in ideas about future surgery. Both positive (e.g., hope) and disgust (e.g., guilt) are associated. Anxiety and sadness were emotions that predicted Pre-HTX DDI at all times. Furthermore, emotional recharging of the mind as the heart as the heart and soul predicted the occurrence of pre-HTX DDI.
Both psychological and physical burdens led to Post-HTX DDI (see Table 4). As a result, we can also confirm the hypothesis that asserts the association between psychological distress and DDI for Post-HTX DDI. Anxiety and sadness remained predictors of Post-HTX DDI. However, in the case of Post-HTX DDI, there is no longer any emotional responsibility in the mind for the emotional center and soul to play a predictive role.
Other variables did not produce significant results (see Supplementary Table S1).
