|Year : 2019 | Volume
| Issue : 1 | Page : 71-75
Functional outcomes in a patient with a total artificial heart
Peter Chia Yeh1, Ashley L Michael1, Viola Hysa2, Craig DiTommaso2
1 H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
2 H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine; Baylor St. Luke's Medical Center, Houston, Texas, USA
|Date of Web Publication||22-May-2019|
Dr. Peter Chia Yeh
Baylor College of Medicine, Houston, TX
Source of Support: None, Conflict of Interest: None
A patient with biventricular heart failure received a total artificial heart (TAH) as a bridge to transplant. He had a complicated hospital course including postoperative bleeding, subarachnoid hemorrhage, and adjustment disorder. After participating in 6 months of a rehabilitation program, his Berg balance score progressed from 8 to 41 and his endurance improved from ambulating 75 feet with a rolling walker and requiring moderate assistance in his activities of daily living on admission to ambulating several times up to 200 feet with modified independent and modified independent with setup for his basic activities of daily living. Since few patients have undergone inpatient rehabilitation with a TAH, this case illustrates significant functional gains that a comprehensive rehabilitation team can provide and major considerations to be aware of to optimize care when working with patients with TAH.
Keywords: Acute inpatient rehabilitation, cardiac rehabilitation, SynCardia, total artificial heart
|How to cite this article:|
Yeh PC, Michael AL, Hysa V, DiTommaso C. Functional outcomes in a patient with a total artificial heart. J Int Soc Phys Rehabil Med 2019;2:71-5
|How to cite this URL:|
Yeh PC, Michael AL, Hysa V, DiTommaso C. Functional outcomes in a patient with a total artificial heart. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2021 Jun 14];2:71-5. Available from: https://www.jisprm.org/text.asp?2019/2/1/71/254174
| Introduction|| |
Cardiovascular disease is recognized as a leading cause of death in the world, with heart disease as the primary subset. Since 2002, the number of heart transplants performed in the US increased 10.0%, from 2188 to 2407 in 2012. From 2008 to 2012, 14,524 new candidates were added to the waiting list. As the number of people requiring heart transplant increases, the demand rises for alternative treatment options such as mechanical circulatory support. In 2012, 41% of patients required mechanical circulatory support to bridge to heart transplant. While most patients use the left ventricular assist device (LVAD) as the predominant circulatory support systems, there has been a rise in total artificial heart (TAH), with over 1600 SynCardia TAH implants to date.
The SynCardia TAH [Figure 1] and [Figure 2] is made up of three components: (1) independent right and left blood pumping chambers or ventricles, (2) drivelines that connect the ventricles to an external pneumatic driver system, and (3) housing unit with driver and batteries. Both ventricles and all native cardiac valves are removed and replaced with the TAH artificial ventricles, which are spherical chambers that allow pulsatile blood to be pumped to the body. TAH's major benefits include reducing problems commonly seen with other devices such as right heart failure, arrhythmias, ventricular clots, and low blood flows.
|Figure 1: Total artificial heart, consisting of the driver system, the drivelines, and the left and right ventricles|
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Studies demonstrate that a refined cardiac exercise regimen for patients with LVADs can result in significant improvements. One study, including 90 participants with LVADs who were admitted to an inpatient rehabilitation unit, with a mean length of stay 31.1 days with standard deviation (SD) of 20.7, found a significant improvement in functional independence measure (FIM) score (28.4 with SD of 12.3). It is notable that the majority of participants were discharged home. While similar exercise progression, positioning, and monitoring strategies exist for patients with LVADs or TAHs, innate mechanical differences between LVADs and TAH lead to distinctive parameters and considerations.
One case study evaluated the post-TAH transplant rehabilitation progression of a 49-year-old participant who eventually received a heart transplant. The authors noted that common parameters such as heart rate and rhythm are no longer applicable and even blood pressure responses for patients with TAH differ from patients with ventricular assist devices. This case study emphasized attempts to optimize the patient's condition and rehabilitation course after the initial TAH, including having SynCardia staff provide additional training to all therapists, who also all had previous cardiovascular ICU experience. Factors that were constantly assessed in this case included hypotension, pain, and various laboratory values such as hemoglobin and platelet count. In this report, after 2 weeks of physical therapy intervention, the patient was ambulating 335 feet with contact guard/minimal assistance without an assistive device. We present a unique case that focuses on a patient who was admitted to inpatient rehabilitation 7 months after receiving his TAH and highlight the functional improvements as well as major parameters and other considerations to be aware of to optimize care when working with patients with TAH.
| Case Report|| |
A 60-year-old gentleman with nonischemic biventricular heart failure was evaluated for cardiac transplant. He received a TAH (SynCardia 70 cc) in January 2017 and had a complex hospital course which included postoperative bleeding and cardiac tamponade, subarachnoid hemorrhage (SAH), multiple deep venous thrombosis, renal failure, gout exacerbation, acute cholecystitis requiring open cholecystectomy, nesiritide dependency, and adjustment disorder. Seven months after his TAH, the participant was admitted to inpatient rehabilitation with an initial Berg balance score of 8 and low exercise tolerance, only ambulating 75 feet with a rolling walker on admission and requiring moderate assistance in most of his basic activities of daily living (ADLs).
Multiple issues were considered when rehabilitating a patient with a TAH [Table 1]. All team members underwent a brief training class on the basic principle and function of the artificial heart, including training in regard to the alarm system, batteries, and precautions for the device. Due to the fact that his artificial heart creates a systolic and diastolic blood pressure, regular blood pressure readings were obtained before, during, and after each therapy session. In addition to blood pressure monitoring, each therapist conducted a conversational assessment of the patient's exertion level. The device had a battery life of about 2 h, which logistically was important to plan for showers and therapies. He was admitted with a plan to have daily assessments by a cardiologist familiar with the device, and a technical team was on call in the building for any emergencies. Circulatory support initially saw the patient daily, then progressed to assessing him three times a week, but generally accompanied the patient if he ever had to leave the rehabilitation unit. In the patient's initial post-TAH course, 3–4 additional staff members, including his nurse and a circulatory support staff, would be present for all therapy sessions; however, the amount of additional support needed decreased to 1–3 personnel after 2 months and then to 0–1 extra support staff after 4 months. Naturally, as his strength and balance progressed, his equipment could be carried on an intravenous (IV) pole held by the patient. Daily collaboration occurred among the participant's team of physicians, nurses, physical and occupational therapists, and technicians to ensure a safe environment, which including monitoring the power source, alarms, controller changes, as well as cardiac output and ventricular fill volumes.
|Table 1: Considerations and parameters to optimize safety and effectiveness when working with TAH patients|
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Despite prior evaluation and planning, several issues arose during his rehabilitation. The driveline for the artificial heart was approximately 4 feet; thus, special precautions were made to ensure that the housing unit stayed dry during showers. Due to the weight of the device and the patient's initial balance difficulties, a backpack was impractical. The team discovered that pushing a wheelchair like a walker with the battery and motor on the seat was the best initial setup for mobility. Of note, no settings needed to be changed specifically when working with therapy. The patient continued to require cardiovascular support with a nesiritide drip during his rehabilitation and close attention to optimal fluid balance was necessary due to his chronic renal and heart failure. He required a new driver for the SynCardia device during his rehabilitation course. Obvious changes in energy, fluid status, and cognition were present after device exchange that returned to baseline within 1 week. In addition, the patient required close monitoring of his anticoagulation status due to his prior SAH. The patient benefited from such close monitoring of his cardiovascular and renal statuses, pain, anticoagulation, and mental and physical stamina. Extra caution was taken to minimize the risk of falling as he was on anticoagulation. The patient was monitored for anemia, and blood transfusions were used judiciously to avoid a strong autoimmune response in expectation of the patient receiving a heart transplant in the future. Laboratory draws were kept to a minimum.
An important part of the participant's rehabilitation stay was also focused on his mental stamina and coping mechanisms during a prolonged hospitalization. The patient frequently expressed difficulty accepting his underlying heart problems and medical complications during his hospitalization. The participant expressed frustration regarding the inexactness of medical care in general. The psychiatry team was consulted and diagnosed an adjustment disorder. Regular discussions with the psychiatry team as well as the rehabilitation physicians and therapists were essential as he was often separated from his family members. Inclusion in events, such as birthday parties for various staff members, was important for his psychological well-being. The need for psychological care has been found in many transplant patients as they face many psychosocial challenges throughout the different phases of the transplant process.
The therapists focused on proprioceptive techniques, core strengthening, traditional balance exercise, safety, transfers, gait training, bed mobility, and ambulation. His Berg balance score improved to 41 after 6 months of inpatient rehabilitation, accompanied by significant improvement in his function and independence. Initially, his exercise tolerance was limited by profound weakness, persistent IV line management, and the weight of his mechanical device (around 6 kg). By week 6, he was ambulating up to 290 feet by assist with IV pole and was modified independent or set up for most of his basic ADLs. After 3 months, he was walking 200 feet with modified independent with IV pole and was modified independent with most of his functional mobility and modified independent with setup for his basic ADLs [Table 2].
| Conclusion|| |
This case illustrates the significant functional gains a participant with a TAH can make while in acute inpatient rehabilitation. While rehabilitation with patients with TAH warrants future studies, the dearth of the patient population makes it challenging. We hope that this case study provides a foundation for future physicians and teams to optimize care and to establish goals and improve independence for the unique needs of this patient population.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]