Heart transplant is the only definitive treatment for end-stage heart failure (HF) (Dokainish et al., 2017). Each year, there are approximately 7,300 patients awaiting heart transplant in the United States with 3,200 transplantations performed annually (Sandhu et al., 2019). It is estimated that the wait-list mortality is as high as 10% (Lund et al., 2017). Therefore, optimizing pre-transplant conditions of patients awaiting heart transplant is of paramount importance.

Patients awaiting heart transplant often face significant psychological stress, and emotional well-being has emerged as an important predictor of post-transplant outcomes in several organ groups (Chen et al., 2014). Frailty is an independent predictor of mortality in heart transplant candidates and recipients (Jha et al., 2018). Therefore, the International Society for Heart Lung Transplantation endorses assessing frailty in patients who are being evaluated for heart transplant (Mehra et al., 2016).

Psychological frailty refers to an individual’s cognitive and mood resilience in the presence of stressors. In recent years, there has been growing evidence that psychological frailty is equally as important as physical frailty in transplant outcomes. One study demonstrated that pre-operative depression and social isolation were associated with increased all-cause mortality following heart transplant (Spaderna et al., 2017). Moreover, depression is a predictor of poor compliance with medications after heart transplant and leads to an increased rate of re-hospitalization (Delibasic et al., 2017). Similarly, pre-transplant psychosocial vulnerability is associated with worse post-transplant psychosocial outcomes in liver, lung, and bone marrow transplant (Goetzmann et al., 2007). On the other hand, optimism has been shown to be associated with better survival in bone marrow transplant patients, particularly in the first 2 months following transplant (Lee et al., 2003). These factors are under studied as predictors of outcomes in heart transplant candidates.

Societal guidelines recommend psychosocial evaluation of all patients being considered for heart transplant (Mehra et al., 2016). This evaluation aims to detect and optimize psychosocial factors influencing patients’ health including cognitive function, adherence, psychopathology, social support and substance abuse (Bui et al., 2019). The methods used for this assessment are few and vary by center preference but include Psychosocial Assessment of Candidates for Transplantation (PACT), Stanford Integrated Psychosocial Assessment for Transplantation (SIPAT) and Transplant Evaluation Rating Scale (TERS) (Maldonado et al., 2012; Twillman et al., 1993). However, these assessment tools do not assess factors that can affect long-term psychological frailty and well-being like adjustment, resilience or optimism.

Emotional Affect refers to an individual’s emotional response or tone, and it may be categorized as positive or negative. Positive affect (PA) is the extent that an individual experiences pleasurable engagement with the environment (Crawford and Henry, 2004). In contrast, negative affect (NA) is the extent that an individual experiences pessimism, anger, unhappiness, nervousness and sadness (Watson et al., 1988). The Positive and Negative Affect Schedule (PANAS) is a validated 20-item scale that measures PA and NA. Additionally, the Positivity Ratio (PR)—calculated as the ratio of PA to NA—is used to distinguish individuals with optimal psychological functioning. A PR greater than 2.9 is associated with high emotional resilience and flourishing psychosocial health (Fredrickson and Losada, 2005). This threshold was originally proposed by Fredrickson and Losada (2005) in their work on emotional complexity and human flourishing. The PR has since been applied in a range of psychological and medical studies as an index of emotional resilience and adaptation, including in older adults and individuals with chronic illness (Diehl et al., 2011; Zautra et al., 2005). These applications support its relevance in evaluating psychological well-being among heart transplant candidates and recipients. Therefore, the PANAS may serve as a useful tool to assess emotional functioning and mental resilience. This study aims to: (1) describe affect in heart transplant candidates, (2) assess the change of affect in heart transplant candidates over time and following transplant, and (3) evaluate the relationship of pre-transplant affect with clinical and psychological outcomes before and after transplant.

Our primary findings can be summarized as follows: (1) the majority of waitlisted heart transplant patients have a PR below the threshold for optimal emotional well-being; (2) PR decreases following heart transplant; (3) many heart transplant candidates report feeling distressed or scared; (4) baseline PANAS scores predict post-transplant QOL; and (5) affect is not associated with key physical transplant outcomes.

Interestingly, baseline PA and NA scores in our cohort were comparable to values reported in healthy college students (PA: 33.3 ± 7.2, NA: 17.4 ± 6.2) (Crawford and Henry, 2004). However, the mean PR in our cohort was 2.3—lower than the optimal threshold of 2.9 and only modestly higher than the average PR of healthy young adults (≈1.9–2.1) (Fredrickson and Losada, 2005). This suggests that although transplant candidates may not have severely elevated NA or suppressed PA, the combination of slightly elevated negative emotions with only modest positive engagement results in a suboptimal emotional balance. While standardized scoring approaches such as the sten scale offer a useful framework for classifying affective functioning, we chose to use raw PANAS scores and the positivity ratio in this analysis to align with validated methods commonly reported in transplant and psychosocial research. Norm-based transformations would require population-specific reference data stratified by clinical characteristics, which were not uniformly available across our sites. Future studies may benefit from incorporating normalized affect scores to enable trajectory-based categorization (e.g., movement from low to moderate affect) and comparison with external populations. The PR represents the balance of positive to negative emotions over time and is a predictor of psychological well-being (Fredrickson and Losada, 2005). In our cohort, the mean PR was 2.3, below the optimal threshold of >2.9, suggesting that heart transplant candidates may be less emotionally equipped to adapt to novel or stressful situations (Fredrickson and Losada, 2005). The further decline in PR post-transplant may reflect the psychological toll of transplantation or persistent gaps in psychological support following transplant. Several mechanisms may underlie the observed shifts in PA and NA following transplantation. The early post-transplant period is often marked by physical debility, high treatment burden, and uncertainty around graft function, which may contribute to elevated NA. Concurrently, immunosuppressive medications—particularly corticosteroids—can affect mood regulation and may exacerbate irritability, anxiety, or depressive symptoms. On the other hand, the decrease in PA may reflect diminished energy, loss of autonomy, or unmet expectations regarding recovery. Social isolation, changes in caregiver dynamics, or employment disruptions may also influence emotional states. These multifactorial contributors highlight the need for integrated psychosocial care during the transplant recovery period. Our findings align with prior research demonstrating increased depression and psychological distress after organ transplantation (Dew et al., 2012; Stilley et al., 1999). This is clinically significant, as post-transplant psychiatric conditions, particularly depression, have been associated with increased mortality (Dew et al., 1999).

Moreover, over a quarter of participants reported feeling moderately to extremely distressed (28%), scared (30.8%), irritable (30%), nervous (36.9%), or afraid (25.3%), consistent with prior research on high rates of anxiety and depression in patients awaiting heart transplant. For example, Schneekloth et al. (2019) found that 17 and 27% of waitlisted heart transplant patients experienced anxiety and depression episodes, respectively, in the year preceding transplant.

At baseline, a substantial proportion of participants reported experiencing distressing emotions: 28% felt moderately to extremely distressed, 30.8% scared, 30% irritable, 36.9% nervous, and 25.3% afraid. At the same time, many participants endorsed strong positive emotions: 76.3% reported feeling determined, 71.2% alert, 70.2% interested, 60.7% attentive, and 52.8% strong. This mixed emotional profile underscores the psychological complexity of transplant candidacy—patients frequently experience concurrent feelings of purpose and resilience alongside fear, anxiety, or uncertainty.

Affect was not associated with LOS, readmissions, or mortality. Prior studies have linked pre-transplant psychological factors—particularly depression—to longer hospital stays. For example, Rogal et al. (2016) found that depression in liver transplant candidates was associated with prolonged LOS during the transplant hospitalization. Similarly, patients with pre-existing mood or anxiety disorders had longer LOS during stem cell transplantation (Prieto et al., 2002). We previously demonstrated that lung transplant candidates with higher negative affect had an increased risk of waitlist mortality (Pennington et al., 2020).

Our findings also suggest that PANAS scores can predict post-transplant QOL, as they correlated closely with post-transplant KCCQ scores. QOL in transplant recipients is shaped by interactions between physiologic, social, and psychological factors (Angermann et al., 1992). Additional factors such as employment status, caregiver burden, or return-to-work capability were not captured in this study but may meaningfully influence emotional recovery and QOL. Grady et al. (1999) identified nine key predictors of post-transplant QOL at 1 year, including lower stress, better adherence to the transplant regimen, effective coping strategies, fewer functional limitations, lower symptom burden, older age, fewer complications, access to helpful healthcare information, and positive health perceptions. While some of these factors emerge only after transplant, our findings highlight the potential of pre-transplant PANAS scores to identify at-risk patients. Targeting these vulnerable individuals with pre- or post- transplant psychological interventions may enhance coping skills and improve post-transplant QOL. Furthermore, stratification by timing of post-transplant survey (3–6 vs. 7–12 months) did not reveal significant differences in affect, indicating that psychological recovery may stabilize early after transplant in many patients. While we did not conduct stratified analyses by baseline PR category, future studies with larger longitudinal samples may help determine whether individuals with higher pre-transplant positivity ratios—indicative of flourishing mental health—demonstrate more resilient emotional trajectories after transplantation.

Similar associations between psychosocial vulnerability and outcomes have been observed in other transplant populations. For example, in liver transplant candidates, pre-transplant depression has been linked to increased post-operative complications, longer hospital stays, and reduced survival (Rogal et al., 2016) likewise, kidney transplant recipients with baseline depressive symptoms report lower post-transplant quality of life and increased healthcare utilization (Griva et al., 2014; Palmer et al., 2013; Rogal et al., 2016). These findings underscore the generalizability of our results and the importance of addressing psychological well-being across transplant populations. Several evidence-based interventions have shown potential for improving post-transplant QOL. Early identification of psychological distress through routine screening tools such as the PANAS or PHQ-9 can help flag at-risk patients. Cognitive behavioral therapy (CBT) has been shown to reduce anxiety and depressive symptoms in solid organ transplant recipients (Epstein et al., 2019; Rodrigue et al., 2011; Rogal et al., 2011). Additionally, structured peer mentoring, mindfulness-based stress reduction, and multidisciplinary care models that integrate mental health providers into transplant teams have been associated with improved coping and adherence (Chida and Steptoe, 2008). Further work is needed to evaluate the scalability and long-term effectiveness of these strategies in heart transplant populations.