Physical Therapist Management of Patients With Ventricular Assist Devices: Key Considerations for the Acute Care Physical Therapist

Chris L. Wells

C.L. Wells, PT, PhD, CCS, ATC, Department of Physical Therapy & Rehabilitation Sciences, School of Medicine, University of Maryland, 100 Penn St AHB, Suite 101, Baltimore, MD 21201 (USA), and Department of Rehabilitation Services, University of Maryland Medical Center, Baltimore, Maryland.

Address all correspondence to Dr Wells at: cwells{at}som.umaryland.edu.

Abstract

This article provides an overview of the utilization of ventricular assist devices (VADs), reviews the common features of VADs and management of VAD recipients, discusses clinical considerations in the rehabilitation process, and describes the role of the acute care physical therapist in the care of VAD recipients. With more than 5 million people in the United States with heart failure, and with a limited ability to manage the progressive and debilitating nature of heart failure, VADs are becoming more commonplace. In order to prescribe a comprehensive and effective plan of care, the physical therapist needs to understand the type and function of the VADs and the goals of the VAD program. The goals for the physical therapist are: (1) to deliver comprehensive rehabilitation services to patients on VAD support, (2) to develop an understanding of the role of functional mobility in recovery, and (3) to understand how preoperative physical function may contribute to the VAD selection process. The acute care physical therapist has an increasing role in providing a complex range of rehabilitation services, as well as serving as a well-educated resource to physical therapists across the health care spectrum, as more VAD recipients are living in the community.

In 2010, it was estimated that 5.8 million people in the United States had heart failure.^1–3 Heart failure is the primary cause of death in approximately 60,000 people annually and contributes to an additional 270,000 deaths in people over 45 years of age.^2,4 Of the individuals with heart failure, approximately 50,000 to 150,000 would benefit from heart transplantation, but only about 2,200 annually receive transplants.⁵ As the US population ages and medical care advances, there will be increasing demand for alternatives to heart transplantation.

The mechanical ventricular assist device (VAD) is an advance in medical management of heart failure. In the 1990s, VADs served as a bridge to transplantation for patients with severe heart failure waiting for a heart transplant. These early VADs had large pumps that mimicked the diastole and systole phase of heart functions and had high rates of bleeding and stroke. The newer VADs are smaller and have fewer complications, increasing patient eligibility and duration of VAD support.⁶ Ventricular assist devices became legitimate options for management of heart failure in 2001 when Rose et al⁷ reported an increase in survival rates for patients on VAD support (52%), improvements in quality of life, and decreased depression compared with patients receiving optimal medical management. This study led to Food and Drug Administration approval of the HeartMate XVE VAD (Thoratec Corporation, Pleasanton, California) for management of heart failure for individuals who were not candidates for heart transplantation.^7,8

With the increased use of VADs for management of heart failure, physical therapists are increasingly involved in treating these patients with medically complex conditions. The purposes of this article are: (1) to provide an overview of the utilization of VADs, (2) to review the common features of VADs and management of VAD recipients, (3) to discuss clinical considerations in the rehabilitation process, and (4) to describe the role of the acute care physical therapist in the care of VAD recipients.

Indications for VAD Implantation

The goal of VAD implantation is to relieve the stress on the heart before complications of heart failure lead to irreversible end organ dysfunction, including pulmonary hypertension, renal failure, liver dysfunction, and cardiac cachexia.^8–10 There are currently 4 indications for VAD implantation: bridge to transplantation, bridge to candidacy, destination therapy, and bridge to recovery (eTab. 1). Ventricular assist devices are primarily utilized as a bridge to transplantation, but there has been a significant rise in the number of patients receiving VADs as a bridge to candidacy. Used as a bridge to candidacy, the VAD allows time for the patient to become eligible for cardiac transplantation by, for example, decreasing body mass index, achieving a required cancer-free period, or securing financial and family support.⁸ Destination therapy is the third indication for VAD implantation. Patients in this category are not candidates for heart transplantation, and the VAD serves as their final intervention for heart failure. Patients using VADs for destination therapy tend to be older and have more comorbidities than patients using VADs for other purposes.⁸ Although age alone is not a factor related to postoperative complications, normal age-related changes may complicate the rehabilitation plan of care for these patients.^8,11 The final indication for VAD implantation is bridge to recovery. In this medical scenario, a VAD can be used to temporarily support a patient with acute heart failure with the purpose of assisting the native heart until there is sufficient functional recovery to allow the explant of the device.¹²

Patient Selection Criteria

General inclusion criteria for VAD implantation are cardiac output under 2 L/min, reversible organ dysfunction, and ability to restore physical function. Appendix 1 presents more specific medical criteria for implantation. As an active member of the VAD team, the physical therapist can contribute to patient selection by using quantitative outcome measures to document function, including gait speed, walking tolerance, functional mobility, and balance (eTab. 2).¹³ Physical therapists can intermittently assess these outcome measures to determine the VAD candidate's functional improvement or decline and provide the VAD team with preoperative rehabilitation recommendations.

Preimplant medical status and functional mobility directly affect the hospital course and the patient's rehabilitation needs after VAD implantation. Boyle et al¹⁰ reported that 70% of patients who are critically ill, defined as those in cardiogenic shock at time of implant, survived to discharge compared with 93% of patients who were medically stable at the time of implant. Medically stable patients also had an increased survival rate at 36 months. Implantation of a VAD in patients who are critically ill results in prolonged stays in the intensive care unit, pulmonary insufficiency, renal failure, and skin care issues^10,14,15 and increases the demand for subacute and acute rehabilitation services in the acute care setting.¹⁶ These outcomes have led surgeons to re-examine implanting VADs when patients are critically ill and started a trend of implanting VADs earlier in management of heart failure.^10,14,17,18

Description of VADs

Ventricular assist devices are complex devices with 5 major components: pump, cannula, driveline, controller, and power source. The pumps are implanted via a sternotomy or a thoracotomy and can be either internal or external to the body. The function of the pump is to circulate the blood. Depending on the type of internal VAD, the surgeon may place the pump within the abdomen or thorax, or in a pump pocket created in the abdominal wall. Each VAD has a distinct sound when operating properly; changes in sound may be an indication of VAD complications, including pending pump failure.

The cannulas connect the pump to the cardiovascular system. There are common cannula sites based on the ventricle being assisted by the VAD. For most VADs that are designed to support the left ventricle, the inflow cannula is inserted into the apex of the left ventricle and the outflow cannula is inserted into the ascending aorta, although the cannula can be inserted into the descending aorta. To support the right ventricle, the inflow and outflow cannulas are implanted in the right atria and the pulmonary trunk, respectively. For internal VADs, the cannulas will be placed within the body, but with external VADs, the cannulas will exit the body to connect to the pump.

The remaining 3 components of the VAD—driveline, controller, and power source—are external. The cannulas connect the pump to the cardiovascular system, and the driveline connects the pump to the controller and a power source that will operate the pump. The physical therapist will need to stabilize the cannula for pumps that are external to the body and stabilize the driveline for pumps that are internal. For most VADs, the controller contains the computer software that operates the pump and displays pump speed, power utilization, and output. The VAD team sets the controller to achieve an adequate cardiac output. Commonly, devices operate on AC power or portable battery.

Types of VADs

Devices are classified as pulsatile or nonpulsatile, based on how the device interacts with the recipient's circulation. Ventricular assist devices also are classified based on whether they provide short-term, medium-term, or long-term support. eTable 3 presents a description of types and characteristics of VADs.

Pulsatile VADs

Pulsatile devices have a diastolic phase, when the pump fills with blood, and a systolic phase, when the pump ejects blood into circulation. Although pulsatile devices are not used frequently because of their relatively larger size, lower durability, and higher complication rates, they still have a role in management of heart failure. Pulsatile VADs can be external or internal, and are most commonly used for medium-term (1–2 years) or long-term (more than 2 years) support. The cannulas exit the body just inferior to the costal margin to connect the pumps and other hardware (Fig. 1).

Figure 1.

Thoratec pVAD. This illustration shows the position of the ventricular assist device for right, left, or biventricular support. The cannulas will connect the pumps to the dual drive console or TLC II portable driver. Image courtesy of Thoratec Corporation, Pleasanton, California.

Clinical considerations with pulsatile VADs.

There are several clinical issues to consider when working with a patient on a pulsatile device. For internal pulsatile VADs, there is a risk that pronounced thoracolumbar flexion may obstruct the cannulas, and the physical therapist should address posture and proper body mechanics during activities such as sit-to-stand transfers. For external pulsatile pumps, the physical therapist must attend to the cannula and pump position because there is a risk of disrupting healing around the cannulas and of thrombosis formation within the pump if the outflow is obstructed. After repositioning or mobilizing the patient, inspection of the pump should be done to ensure proper pump emptying. The pumps can be heavy, and once the patient begins upright activity, the effects of gravity and movement may cause pain and ventricular arrhythmias. The physical therapist should collaborate with the VAD team to determine the optimal abdominal binder or anchoring system to support the cannulas and external pumps, or driveline for the internal VADs. The physical therapist should reinforce with the patient and caregivers the importance of use of the binder or anchors to protect the cannula sites to allow for healing. Finally, the physical therapist should be mindful of the maximum estimated pump output, which may limit the activity tolerance of the patient with higher functioning, and adjust the exercise prescription accordingly.

Nonpulsatile Long-term and Short-term VADs

Advances in VAD design and operation have led to increased use of nonpulsatile devices for long-term left ventricle support. Examples of nonpulsatile devices include the HeartMate II (Thoratec Corporation), the HeartWare (HeartWare Inc, Framingham, Massachusetts), and the Jarvik 2000 (Jarvik Heart Inc, New York, New York) (Fig. 2). Nonpulsatile pumps are internal, with the driveline exiting the right abdominal wall. Nonpulsatile devices move blood via an axial flow or centrifugal force. Depending on the speed of the pump and the intrinsic function of the heart, a palpable pulse and an ausculatory or palpable blood pressure may no longer be appreciated because there is no true diastolic or systolic phase. The physical therapist may obtain a blood pressure measurement using Doppler techniques; however, it is not a true systolic or mean pressure, but an estimate of mean arterial pressure.¹⁹ An arterial pressure tracing will show a dampened waveform, a narrow pulse pressure, and a higher than normal mean arterial pressure (70–85 mm Hg). Pulse oximetry readings may be inaccurate because of the lack of pulsatility.

Figure 2.

Nonpulsatile ventricular assist devices (VADs). (A) HeartMate II (image courtesy of Thoratec Corporation, Pleasanton, California). Besides illustrating the position of the HeartMate II, this picture also identifies the various components of VADs. (B) HeartWare (image courtesy of HeartWare Inc, Framingham, Massachusetts). (C) Jarvik 2000 (image courtesy of Jarvik Heart Inc, New York, New York). LVAD=left VAD, LVAS=left ventricular assist system.

Although nonpulsatile VADs are most commonly used for long-term left ventricular support, more recently devices have been developed for short-term use as a bridge to recovery or a bridge to candidacy in patients who are critically ill (eTab. 3, Fig. 3). Short-term VADs are intended to support a patient for days to 2 to 3 weeks. Commonly, short-term VADs are used to temporarily support the right ventricle when right heart failure develops acutely due to an unstable ventricular septum following implantation of a nonpulsatile left VAD. The need for short-term right ventricular support occurs in up to 40% of patients receiving a left VAD.^18,20 Unfortunately, patients have a 50% mortality rate at 3 months after implant and a 20% decrease in 1-year survival.^4,17,21

Figure 3.

Short-term ventricular assist devices. (A) Impella (image courtesy of Abiomed, Danvers, Massachusetts) and (B) Centrimag (image courtesy of Thoratec Corporation, Pleasanton, California). The Centrimag is supporting the right ventricle in the presence of HeartMate II supporting the left ventricle.

Clinical considerations with nonpulsatile VADs.

The ability to monitor vital signs for a nonpulsatile VAD recipient will depend upon whether the left ventricle is supported and the speed of the pump. If the VAD speed is sufficient, the majority of the blood will be going through the nonpulsatile pump as opposed to being ejected by the left ventricle. The result is the inability to monitor blood pressure and heart rate in the traditional manner. Therefore, besides monitoring blood pressure via the Doppler method, the physical therapist should teach the patient how to accurately use a subjective (patient-reported) scale, such as the Borg Rating of Perceived Exertion or Dyspnea Scale, to assess activity tolerance. The intensity and duration of the prescribed exercise program should elicit a mild to somewhat hard perception of effort for the patient.²² Beyond assessing exercise tolerance, the physical therapist should monitor pump function and signs of complications associated with nonpulsatile pumps, such as suckdown (see next section for description). The physical therapy intervention and assessment of the patient's exercise tolerance and functional progression assist the VAD team in managing the VAD and developing an appropriate medical plan of care.

With nonpulsatile VADs, red blood cells can be damaged as they flow through the pump, causing hemolysis at an increased rate when compared with pulsatile VADs,^8,19,23 and may result in hematuria and decreased exercise tolerance. The physical therapist is in a unique position to assess the progress of exercise tolerance and determine whether the patient's tolerance is correlated with hemoglobin and hemocrit levels.

Frequently, the cannulas and drivelines are short; therefore, organizing the environment is very important. For short-term nonpulsatile VADs, the physical therapist needs to verify with the surgeon that the sternum is closed enough to allow for mediastinal stability and the cannulas are surgically secure prior to mobilizing the VAD recipient.

The VAD speed is set to achieve a normal cardiac index, obtain normal ventricle size with a stable interventricular septum, and relieve signs and symptoms of heart failure. The physical therapist can contribute to the identification of the appropriate VAD speed setting by assessing exercise tolerance and progression, along with monitoring for signs and symptoms of heart failure and suckdown. Any unexpected findings should be reported to the VAD team for further medical investigation. Table 1 provides guidelines on resting parameters that depict medical stability.

View this table:

Table 1.

Resting Physiological Parameters Consistent With Medical Stability^{^a}

Key Factors in VAD Management

The physical therapist should be aware of several key factors when working with a VAD recipient and detect and manage these significant issues appropriately. Table 2 presents a general outline of key factors, associated signs and symptoms, and management.

View this table:

Table 2.

Key Factors in Ventricular Assist Device (VAD) Management^{^a}

Preload

All VADs are preload dependent. Preload is the volume of blood returning to the heart or VAD. The VAD needs sufficient blood volume to effectively fill the pump and to support the failing ventricle. Sufficient preload also is important to assist blood flow through the right ventricle to prevent right heart failure in the presence of left VAD support. Hypovolemia increases the risk of thrombosis formation and stroke.²³ Preload can be acutely measured by monitoring the central venous pressure (CVP). The basic trend in the early postoperative period is to have a mean CVP range from 12 to 15 mm Hg to ensure sufficient filling and forward circulation. If the patient experiences orthostatic hypotension, there will be a decrease in CVP and mean arterial pressure. If hypotension persists, the physical therapist should place the patient in a supine position and elevate the lower extremities to increase preload, continue to monitor vital signs and VAD function, and notify the bedside nurse and VAD team. Orthostatic hypotension may lead to the VAD alarming due to insufficient filling and suckdown, if not addressed.²⁴

Suckdown

Adequate blood volume in a nonpulsatile pump is critical to prevent suckdown, in which a collapsed ventricle prevents the pump from filling, causing a decrease or loss of cardiac output. Suckdown is a critical situation that must be quickly recognized and corrected. It commonly occurs in the acute care setting because the medical team is adjusting medications, VAD speed, and fluid balance to achieve hemodynamic stability.^24,25 The patient may experience suckdown during therapy due to a reduction in venous return associated with decreased muscle mass and vascular tone and with mechanical ventilation; therefore, the physical therapist must constantly examine vital signs, ventricular arrhythmias, changes in mental status or syncope, and changes in the sounds of the VAD. Typically, the VAD sounds like a smooth oscillatory hum, but suckdown produces an irregular, knocking sound. If the physical therapist suspects suckdown, the physical therapist should place the patient in a supine position with the lower extremities elevated to improve venous return and contact the VAD team. The common intervention for suckdown is to decrease VAD speed and administer fluids and medications to resolve the issues.

Afterload

Afterload is the resistance within the vascular system that the heart or the VAD has to overcome to move blood into circulation. All VADs are afterload sensitive. Hypertension is more commonly a clinical issue in the later postoperative phase but may be an issue in the acute phase of recovery. Hypertension can cause a low flow alarm and can lead to decreased VAD output. The patient may experience the common signs and symptoms of low cardiac output, including decrease in exercise tolerance, light-headedness, dizziness, and possible syncope. The physical therapist needs to monitor vital signs, adjust the exercise program, and secure the patient in a safe position to avoid falls.^24,25

Arrhythmias

Cardiac arrhythmias can adversely affect VAD function by changing ventricle or pump filling. The consequence of an arrhythmia in the presence of an LVAD depends on how much the arrhythmia affects the right ventricle's ability to fill the pump.²⁴ For example, if the CVP is low and the patient experiences an arrhythmia, such as atrial fibrillation with rapid ventricular rate or ventricular tachycardia, an impaired right ventricle would likely be unable to compensate with an effective contraction. This failure would lead to an insufficient volume to fill the LVAD and could result in decreased pump or cardiac output, and possibly suckdown. On the other hand, if the CVP is elevated, sufficient volume may reach the left VAD for proper function with sufficient cardiac or pump output. For right VAD support, the concern is how the arrhythmia affects the left ventricle's ability to fill and circulate blood. If the arrhythmia prevents the left ventricle from ejecting sufficient blood volume into systemic circulation, there would be a decrease in preload and insufficient right VAD filling. This insufficiency may lead to suckdown and further decline in cardiac output. Finally, cardiac arrhythmias are irrelevant for circulation when a patient is supported with biventricular assist device (BiVAD) because the VADs are totally responsible for pulmonary and systemic circulation and the heart is acting as a conduit for blood flow. The VAD team may attempt to manage any new arrhythmia to prevent thrombus formation within the heart.¹⁴

Thrombus

Anticoagulation and antiplatelet protocols (Tab. 1) are critical parts of medical management for VAD recipients. The protocols will vary depending upon the type of device and institutional preference. It is common to address both the coagulation cascade and platelets, with the ultimate goal to prevent thrombosis formation and avoid bleeding. There is a 20% risk of thrombosis formation within the pump or ventricle, and there can be as high as a 45% incidence of transient ischemic attacks (TIAs) or stroke, depending upon the device.^21,23,26 The postoperative bleeding risk can be as high as 50%.^21,23,26 Thrombosis can develop because of poor pump placement, insufficient anticoagulation, or insufficient pump speed that does not allow the aortic valve to open periodically to wash out the ventricle. With a thrombosis, the VAD gives off a grinding sound.

A physical therapist examination of VAD candidates and recipients should include identification of the presence or risk of deep vein thrombosis, TIAs, bruising, or hematomas. It is recommended that a neuromuscular assessment include appropriate outcome measures that are assessed preoperatively and reassessed postoperatively to monitor functional status and monitor for signs and symptoms of TIAs and stroke.²⁷ The physical therapist should routinely monitor the power the device uses at a given speed and output and be familiar with the VAD sound; both points should be part of the patient's discharge education.²⁸

Management of VAD Recipients

Infection

Infection rates for individuals with VADs have been reported to be as high as 42%.²³ Driveline infections carry a high mortality rate.¹⁷ A driveline infection can migrate to the pump and result in removal from the transplant active waiting list, VAD removal, and death. The VAD team should have detailed protocols for securing the driveline and completing dressing changes to protect the driveline from infections.

The physical therapist has a significant role in minimizing risk of infection for the VAD recipient. The physical therapist secures the driveline prior to mobility training, collaborates with nursing staff on proper hand hygiene education and patient positioning, prescribes bed surfaces and chair cushions, and promotes functional mobility to reduce risk of decubitus ulcers. Finally, the physical therapist performs airway clearance techniques to prevent pulmonary infections, which have been reported to be as high as 18% in VAD recipients.²³

Issues With Mobility

Because most devices are implanted via a median sternotomy, there is a risk of wound dehiscence and mediastinitis. Risk factors associated with sternal wounds include obesity, diabetes mellitus, smoking, and prolonged mechanical ventilation.²⁹ Awareness of these risk factors will guide the physical therapist to modify functional use of the upper quarter during functional training in order to protect the sternum in accordance with the institution's sternal precaution protocol. The physical therapist should assess sternal stability routinely in the postoperative period. Functional training also should include strategies to decrease stress at the superior insertion of the abdominal muscles and incorporate ventilatory strategies.^30,31

The physical therapist is the key professional to secure the cannulas and driveline during mobility and to instruct the patient how to modify functional activities, including rolling and supine-to-sit task, and where to place the VAD external equipment to prevent damage during mobility.

Managing the VAD and facilitating the patient's movement to prevent obstruction of blood flow are critical skills for the physical therapist. Obstructions most commonly occur when the patient is moving from a supine to a sitting position, sitting with poor posture, and transitioning to a standing position for VADs with a pump pocket or external pumps. Patients who are debilitated have a tendency to present with significant spinal flexion and posterior pelvic tilt, which may obstruct flow into or out of some VADs, during transfers and sitting. Postural control and balance with ventilation, proper body mechanics during transfers, and strength and endurance of the trunk musculature are important components in the physical therapy plan of care.

Right VAD and BiVAD Support Concerns

There are special considerations for the physical therapist when working with a patient on right VAD support regardless of the type of VAD implanted. It is important to recognize the signs and symptoms of left heart failure in the presence of right VAD support, which may occur if the right VAD is circulating more blood into pulmonary circulation than the left ventricle or the left VAD can manage (BiVAD). The physical therapist needs to monitor for interstitial pulmonary edema with inspiratory rales, dyspnea and oxygen desaturation, and decreased cardiac output with a decrease in exercise tolerance. If the patient has a pulmonary arterial catheter in place, the physical therapist may notice spikes in pulmonary arterial pressure. To prevent such spikes in pressure, the right VAD is commonly set at a pump ejection rate 10 bpm lower, and the pump output at least 0.5 L/min less, than the output of the left ventricle or the left VAD.²³

Postoperative Management

Recovery begins in the early postoperative period. Soon after left VAD implantation, pulmonary capillary wedge and right ventricular pressures decrease acutely and systemic blood pressure improves due to the increase in cardiac index and increase in blood flow. Within the first 2 months, oxygen capacity, quality of life, and walking tolerance improve. More than 80% of patients return to a New York Heart Association classification I or II.^4,12,32

Physical therapy may begin as early as postoperative day 1 even for those patients who have surgical complications, including bleeding and respiratory or renal failure. In the presence of surgical complications, the physical therapy intervention focuses on airway clearance, positioning, skin care, and maintaining joint function. Table 3 and eTable 4 present general guidelines for rehabilitation based upon the patient's functional status and general parameters for various VADs, respectively. The patient's strength and level of independence with basic functional tasks such as bed mobility, transfers, and gait may aid the VAD team, nursing, and family in understanding the focus and progression of rehabilitation. Patient progress will vary based upon medical stability (Tab. 1), degree of dysfunction, and pulmonary needs.

View this table:

Table 3.

Guidelines in the Rehabilitation Progression for Ventricular Assist Device (VAD) Recipients^{^a}

The physical therapist should evaluate the 4 major systems as delineated in the American Physical Therapy Association's Interactive Guide to Physical Therapist Practice: cardiovascular and pulmonary, musculoskeletal, neuromuscular, and integumentary.³³ The patient's medical status changes will require constant adjustment of priorities for addressing needs in each system. Initially, integumentary and pulmonary needs may be the primary focus of care for a patient who has sustained intraoperative or postoperative complications, or who was critically ill prior to implantation.

In the ICU, the physical therapist must manage the environment to safely mobilize the patient with equipment such as a pulmonary catheter, continuous hemodialysis, chest tubes, and arterial lines,^34,35 with the goals to progress muscular function, minimize the effects of immobility, and progress function.

The physical therapist will initially monitor vital signs, self-reported scores from a subjective scale, and VAD function during physical therapy. It is important to monitor the mean arterial pressure in patients on nonpulsatile VAD support because hypertension will make it difficult for the pump to circulate blood forward, while hypotension may lead to suckdown. Therefore, it is important to constantly monitor VAD function in order to provide a safe exercise prescription. The physical therapist should consult with the VAD team if the mean pressure is less than 70 mm Hg or greater than 90 mm Hg, especially when accompanied with a VAD alarm (eTab. 4).¹⁹ For the short-term VADs, the physical therapist should document patient tolerance with progressive functional training, which may aid the surgical team in determining the parameters for weaning or when to explant a temporary VAD, or ascertain the need for a long-term VAD.

Rehabilitation should focus on restoring functional mobility and improving activity tolerance, with the goal to prepare for discharge home, because it is often difficult to discharge these patients to another facility for rehabilitation.³⁶ Table 3 gives guidelines on physical therapist intervention based upon functional ability and strength. The physical therapist should begin training to adjust for the biomechanical changes that occur because the patient has to carry or manage the VAD, batteries, and controller once the patient becomes safe with transfers and ambulation. Ventricular assist device education with the patient and family needs to be incorporated as early as possible and should include driveline protection, changing the power sources for mobility, and addressing any alarms.

The frequency of intervention will vary based upon the patient's needs. Commonly, physical therapy treatment frequency is 5 to 7 days a week until the patient can safely walk the halls independently or with supervision from family or nursing staff. Once the patient is an independent ambulator, therapy can be advanced to facilitate a smooth admission to outpatient physical therapy and community re-entrance.³⁷ Then the frequency of physical therapy may be decreased to 2 to 3 days a week and focus on more traditional cardiac rehabilitation goals, including aggressive functional strengthening, muscle endurance training, and increased aerobic training.^36,38

Finally, prior to discharge, it is recommended that the patient complete a few discharge-related activities. The patient should be taken outside to assess community safety with walking across streets and variable surfaces. The physical therapist also should assess the patient's ability to manage the VAD independently. The physical therapist should complete functional testing to document outcomes, provide a home exercise program, and make the referral to outpatient rehabilitation services.

Staff Training and Competency

As the number of patients implanted with VADs increases, bioengineers can no longer supervise all of the patients. Consequently, a new model has emerged to increase the competence for VAD management. Many VAD centers have adopted the train-the-trainer model. At the University of Maryland Medical Center, a multidisciplinary team, called the SuperUsers, addresses staff training and competency and develops patient care protocols and educational materials.³⁹ The SuperUser committee comprises nurses, physical therapists, and bioengineers. Education is provided by Intranet modules, classroom lectures, handouts, and hands-on practice with training VAD models. The SuperUser committee also mentors staff who routinely work with VAD recipients to become clinical resources to support the bedside staff with daily patient care. All staff undergo written and practical competency testing annually. This practical competency is based on a clinical scenario and focused on clinical decision making and critical components of VAD management. Appendix 2 lists the general key testing areas for a VAD competency. Although the staff training module is nursing focused, physical therapy involvement is important. The success of this model centers on multidisciplinary contribution.

Conclusion

This is an exciting and challenging time for physical therapists across the health care model. Physical therapists are faced with providing quality care to increasing numbers of clients with heart failure and VAD recipients. The VAD should be viewed as an aid to improve the rehabilitation potential for the client, not as a barrier. To decrease the fears that may accompany delivering care, the physical therapist needs to be trained in VAD management. With competency in managing patients with VADs, physical therapists are able to provide early interventions, including mobility that will enhance a patient's functional recovery. Although this article focused on acute care therapy, more and more patients will be community living with VAD support, and the acute care physical therapist may serve an important role in mentoring physical therapists across the health care spectrum.

Appendix 1.

Appendix 1.

Eligibility Criteria for Ventricular Assist Device Implantation^a

^a These are the common medical inclusion criteria for ventricular assist device implantation. Modified from Leitz,⁸ Drakos et al,¹⁴ and Miller.²⁰

Appendix 2.

Appendix 2.

General Key Staff Competency Areas

Footnotes

The author acknowledges Dr Erik Sorensen for his constant resource of information as a bioengineer at the University of Maryland Medical Center, Dr Erika Feller for her commitment to enhancing the rehabilitation process for patients served by the VAD program at the University of Maryland Medical Center, and Dr Fran Huber for her editorial skills and professional recommendations.

Received November 15, 2011.
Accepted September 27, 2012.

References

Centers for Disease Control and Prevention. Heart failure fact sheet. Division of Heart Disease and Stroke Prevention website. Available at: http://www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_heart_failure.htm. Accessed August 12, 2012.
1. Roger VL,
2. Go AS,
3. Lloyd-Jones DM,
4. et al
; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics, 2011 update: a report from the American Heart Association [erratum in: Circulation. 2011;123:e240, and Circulation. 2011;124:e426]. Circulation. 2011;123:e18–e209.
Disease statistics. National Heart Lung and Blood Institute website. Available at: http://www.nhlbi.nih.gov/about/factbook/chapter4.htm#4_5. Accessed October 12, 2011.
1. Caccamo M,
2. Eckman P,
3. John R
. Current state of ventricular assist devices. Curr Heart Fail Rep. 2011;8:91–98.
US Department of Health & Human Services. 2011 Annual Report of the United States Organ Procurement and Transplantation Network website. Available at: http://optn.transplant.hrsa.gov/data/. Accessed October 10, 2011.
1. Mitter N,
2. Sheinberg R
. Update on ventricular assist devices. Curr Opin Anaesthesiol. 2010;23:57–66.
1. Rose EA,
2. Gelijns AC,
3. Moskowitz AJ,
4. et al
. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001;345:1435–1443.
1. Lietz K
. Destination therapy: patient selection and current outcomes. J Card Surg. 2010;25:462–471.
1. Slaughter MS,
2. Meyer AL,
3. Birks EJ
. Destination therapy with left ventricular assist devices: patient selection and outcomes. Curr Opin Cardiol. 2011;26:232–236.
1. Boyle AJ,
2. Ascheim DD,
3. Russo MJ,
4. et al
. Clinical outcomes for continuous-flow left ventricular assist device patients stratified by pre-operative INTERMACS classification. J Heart Lung Transplant. 2011;30:402–407.
1. Stepanenko A,
2. Potapov EV,
3. Jurmann B,
4. et al
. Outcomes of elective versus emergent permanent mechanical circulatory support in the elderly: a single-center experience. J Heart Lung Transplant. 2010;29:61–65.
1. Rogers JG,
2. Aaronson KD,
3. Boyle AJ,
4. et al
. Continuous flow left ventricular assist device improves functional capacity and quality of life of advanced heart failure patients. J Am Coll Cardiol. 2010;55:1826–1834.
1. Fritz S,
2. Lusardi M
. White paper: “walking speed—the sixth vital sign.” J Geriatr Phys Ther. 2009;32:46–49.
1. Drakos SG,
2. Janicki L,
3. Horne BD,
4. et al
. Risk factors predictive of right ventricular failure after left ventricular assist device implantation. Am J Cardiol. 2010;105:1030–1035.
1. Lietz K,
2. Long JW,
3. Kfoury AG,
4. et al
. Outcomes of left ventricular assist device implantation as destination therapy in the post-REMATCH era: implications for patient selection. Circulation. 2007;116:497–505.
1. Jette DU,
2. Brown R,
3. Collette N,
4. et al
. Physical therapists' management of patients in the acute care setting: an observational study. Phys Ther. 2009;89:1158–1181.
1. Kirklin JK,
2. Naftel DC,
3. Kormos RL,
4. et al
. Third INTERMACS annual report: the evolution of destination therapy in the United States. J Heart Lung Transplant. 2011;30:115–123.
1. Feller E
. Patient Selection for Ventricular Assist Devices. Baltimore, MD: University of Maryland Medical Center; 2011.
1. Slaughter MS,
2. Pagani FD,
3. Rogers JG,
4. et al
. Clinical management of continuous-flow left ventricular assist devices in advanced heart failure. J Heart Lung Transplant. 2010;29(4 suppl):S1–S39.
1. Miller LW
. Patient selection for the use of ventricular assist devices as a bridge to transplantation. Ann Thorac Surg. 2003;75(6 suppl):S66–S71.
1. Osaki S,
2. Edwards NM,
3. Velez M,
4. et al
. Improved survival in patients with ventricular assist device therapy: the University of Wisconsin experience. Eur J Cardiothorac Surg. 2008;34:281–288.
1. Thompson WR,
2. Gordon NF,
3. Pescatello L
. ACSM Guidelines for Exercise Testing and Prescription. 8th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2010.
1. Genovese EA,
2. Dew MA,
3. Teuteberg JJ,
4. et al
. Incidence and patterns of adverse event onset during the first 60 days after ventricular assist device implantation. Ann Thorac Surg. 2009;88:1162–1170.
1. O'Shea G
. Ventricular assist devices: what intensive care unit nurses need to know about postoperative management. AACN Adv Crit Care. 2012;23:69–83.
1. Christensen D
. Physiology of contrinuous flow pumps. AACN Adv Crit Care. 2012;23:46–54.
1. Kirklin JK,
2. Naftel DC,
3. Kormos RL,
4. et al
. Third INTERMACS annual report: the evoluton of destination therapy in the United States. J Heart Lung Transplant. 2011;30:115–123.
American Physical Therapy Association, Neurology Section. StrokEDGE taskforce report. Available at: http://www.neuropt.org/docs/stroke-sig/strokeedge_taskforce_summary_document.pdf. Accessed November 7, 2011.
1. Amir O,
2. Bracey AW,
3. Smart FW,
4. et al
. A successful anticoagulation protocol for the first HeartMate II implantation in the United States. Tex Heart Inst J. 2005;32:399–401.
1. Cahalin LP,
2. Lapier TK,
3. Shaw DK
. Sternal precautions: is it time for change? Precautions versus restrictions—a review of literature and recommendations for revision. Cardiopulm Phys Ther J. 2011;22:5–15.
1. Kauffman TL,
2. Barr JO,
3. Moran ML
. Geriatric Rehabilitation Manual. 2nd ed. Philadelphia, PA: Elsevier; 2007:576.
1. Massery M
. Enhancing geriatric functional motor performance by utilizing effective ventilatory strategies. Canadian Physiotherapy Gerontology Division Newsletter. 1993;27:6–7.
1. Corra U,
2. Pistono M,
3. Mezzani A,
4. et al
. Cardiovascular prevention and rehabilitation for patients with ventricular assist device from exercise therapy to long-term therapy; part I: exercise therapy. Monaldi Arch Chest Dis. 2011;76:27–32.
American Physical Therapy Association. Interactive Guide to Physical Therapist Practice online. Available at: http://guidetoptpractice.apta.org. Accessed January 11, 2013.
1. Leditschke IA,
2. Green M,
3. Irvine J,
4. et al
. What are the barriers to mobilizing intensive care patients? Cardiopulm Phys Ther J. 2012;23:26–29.
1. Stiller K
. Safety issues that should be considered when mobilizing critically ill patients. Crit Care Clin. 2007;23:35–53.
1. Ueno A,
2. Tomizawa Y
. Cardiac rehabilitation and artificial heart devices. J Artif Organs. 2009;12:90–97.
1. Kennedy MD,
2. Haykowsky M,
3. Humphrey R
. Function, eligibility, outcomes, and exercise capacity associated with left ventricular assist devices. J Cardiopulm Rehabil. 2003;23:208–217.
1. Laoutaris ID,
2. Dritsas A,
3. Adamopoulos S,
4. et al
. Benefits of physical training on exercise capacity, inspiratory muscle function, and quality of life in patients with ventricular assist devices long-term postimplantation. Eur J Cardiovasc Prev Rehabil. 2011;18:33–40.
1. Lindsay M,
2. Agarwal P,
3. Lovelace S,
4. et al
. SuperUsers: meeting the needs of our VAD program. Paper presented at: Trends in Critical Care Nursing; October 27–29, 2009; King of Prussia, Pennsylvania.
1. Enright PL,
2. Sherrill DL
. Reference equations for the six-minute walk in healthy adults. Am J Respir Crit Care Med. 1998;158(5 pt 1):1384–1387.
1. Shumway-Cook A,
2. Baldwin M,
3. Polissar NL,
4. Gruber W
. Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997;77:812–819.
1. Bohannon RW
. Reference values for the five-repetition sit-to-stand test: a descriptive meta-analysis of data from elders. Percept Mot Skills. 2006;103:215–222.
1. Bohannon RW
. Reference values for the timed up and go test: a descriptive meta-analysis. J Geriatr Phys Ther. 2006;29:64–68.
1. Hayes K,
2. Johnson M
. Measure of adult general performance tests. Arthritis Care Res. 2003;49(5 suppl):S28–S42.
1. Adams HP Jr,
2. Davis PH,
3. Leira EC,
4. et al
. Baseline NIH Stroke Scale score strongly predicts outcome after stroke: a report of the Trial of Org 10172 in Acute Stroke Treatment (TOAST). Neurology. 1999;53:126–131.
1. Frownfelter D,
2. Dean E
1. Frownfelter D,
2. Massery M
. Facilitating ventilation patterns and breathing strategies. In: Frownfelter D, Dean E, eds. Cardiovascular and Pulmonary Physical Therapy: Evidence and Practice. 4th ed. St Louis, MO: Elsevier; 2012:848.
1. Voss DE,
2. Ionta MK,
3. Myers BJ
. Proprioceptive Neuromuscular Facilitation: Patterns and Techniques. Philadelphia, PA: Lippincott Williams & Wilkins; 1985.