Inpatient rehabilitation outcomes for patients receiving left ventricular assist device

Outcomes of Patients Referred for Cardiac Rehabilitation After Left Ventricular Assist Device Implantation

A single-center continuous-flow left ventricular assist device (LVAD) cohort (n = 503) was reviewed for patients with information on cardiac rehabilitation (CR) participation (n = 273) over a 13-year period. The analysis was then limited LVAD recipients who fit into three main CR categories: those who graduated CR (n = 138), those who were able to but declined participation (n = 61), and those who were too sick to complete or start CR (n = 28). To assess the association between CR categories and mortality and hospitalizations on LVAD support, multivariate cox regression and negative binomial regression analyses were performed, respectively. Among those who started CR and had the opportunity to finish (enough follow-up time, insurance coverage), 79% graduated. Those who graduated CR had a 96% survival at 1 year (95% confidence interval [CI], 91-98). Compared with the graduated group, those in the too sick group had an increased hazards rate of mortality (hazard ratio, 2.85; 95% CI, 1.49-5.44; p < 0.01) and an increase in the incidence rate of hospitalizations (incidence rate ratio, 1.74; 95% CI, 1.14-2.66, p = 0.01). This study is the largest to date to report outcomes of LVAD recipients referred for CR. The lower readmission rates and high survival in the group that graduated CR provides further evidence for the safety of CR in LVAD recipients.

The Future of Exercise-Based Cardiac Rehabilitation for Patients With Heart Failure

Cardiac rehabilitation (CR) is a comprehensive program that includes exercise training, titration of medical therapy, lifestyle modification, educational support, and psychosocial assessment. All these components are safe and beneficial resulting in significant improvements in quality of life, functional capacity, mortality, and hospital readmission. Current guidelines support its use in a broad spectrum of cardiac disease. This review focuses on exercise-based CR for heart failure (HF) patients in whom CR is a recommended treatment. Exercise should be prescribed according to a personalized approach, optimizing, and tailoring the rehabilitative program to the patient's characteristics. Specific CR programs are dedicated to older patients, those with HF and preserved ejection fraction, and recipients of cardiac implantable electronic devices or left ventricular assistance device. Telemedicine may increase CR participation and overcome some of the barriers that limit its utilization.

Cardiac Rehabilitation in German Speaking Countries of Europe-Evidence-Based Guidelines from Germany, Austria and Switzerland LLKardReha-DACH-Part 2

Background: Scientific guidelines have been developed to update and harmonize exercise based cardiac rehabilitation (ebCR) in German speaking countries. Key recommendations for ebCR indications have recently been published in part 1 of this journal. The present part 2 updates the evidence with respect to contents and delivery of ebCR in clinical practice, focusing on exercise training (ET), psychological interventions (PI), patient education (PE). In addition, special patients’ groups and new developments, such as telemedical (Tele) or home-based ebCR, are discussed as well. Methods: Generation of evidence and search of literature have been described in part 1. Results: Well documented evidence confirms the prognostic significance of ET in patients with coronary artery disease. Positive clinical effects of ET are described in patients with congestive heart failure, heart valve surgery or intervention, adults with congenital heart disease, and peripheral arterial disease. Specific recommendations for risk stratification and adequate exercise prescription for continuous-, interval-, and strength training are given in detail. PI when added to ebCR did not show significant positive effects in general. There was a positive trend towards reduction in depressive symptoms for “distress management” and “lifestyle changes”. PE is able to increase patients’ knowledge and motivation, as well as behavior changes, regarding physical activity, dietary habits, and smoking cessation. The evidence for distinct ebCR programs in special patients’ groups is less clear. Studies on Tele-CR predominantly included low-risk patients. Hence, it is questionable, whether clinical results derived from studies in conventional ebCR may be transferred to Tele-CR. Conclusions: ET is the cornerstone of ebCR. Additional PI should be included, adjusted to the needs of the individual patient. PE is able to promote patients self-management, empowerment, and motivation. Diversity-sensitive structures should be established to interact with the needs of special patient groups and gender issues. Tele-CR should be further investigated as a valuable tool to implement ebCR more widely and effectively.

Role of Cardiac Rehabilitation After Ventricular Assist Device Implantation

Patients with heart failure suffered by a complex syndrome, where the filling of the ventricle or ejection of the blood is impaired. In this setting, the exercise capacity decreases for many reasons, one of them being the insufficient oxygen transfer due to reduced cardiac output and anemia. Ventricular assist device has emerged as a durable and safe therapy for patients with end-stage heart failure. The benefits of cardiac rehabilitation in ventricular assist device patients are enormous: the first aim is to progressively reduce the physical and functional impairments of these patients, so that they will be able to resume meaningful daily activities.

Characteristics, Therapeutic Needs, and Scope of Patients With a Continuous-Flow Left Ventricular Device Entering Cardiac Rehabilitation: A RETROSPECTIVE ANALYSIS

BACKGROUND

With an increasing number of left ventricular assist devices (LVADs) being implanted, the need for adequate cardiac rehabilitation (CR) regimens meeting the special needs of these patients arises. Only a few studies have reported experience gained on this topic. Structured CR strategies are poorly implemented. The aim was to evaluate the characteristics, therapeutic needs, and scope of LVAD patients at admission to CR within a greater cohort in order to identify their special CR needs.

METHODS

Retrospective single-center study; 69 LVAD patients (50.7 ± 13.6 y; 59 male; 48 HVAD; 21 HeartMate II) who completed first inpatient CR were included. Patient records were used to document relevant medical information (including the results of a 6-min walk test and a maximal isometric strength test for quadriceps femoral muscles in both legs) and the International Classification of Functioning, Disability and Health for classification of health and health-related domains.

RESULTS

Patient characteristics demonstrated a heterogeneous group: CR was started 44 ± 38.6 d after implantation; CR duration was 28 ± 9.7 d. Despite similar etiology, physical and psychological condition was diverse, although, overall a high degree of impairment was present, especially in the body function (79.7%) and activity and participation (95.7%) domains. The results demonstrated the need for a highly individualized approach in the somatic and also in the education, psychosocial, and social therapeutic regimes.

CONCLUSION

The results demonstrate a heterogeneous group with a high level of impairment and special needs in many CR domains. The development and evaluation of a special highly individualized approach of CR, which meets the special needs of these patients, is needed.

Outcomes of Acute Inpatient Rehabilitation After Ventricular Assist Device Placement

OBJECTIVE

The aim of the study was to compare outcomes of inpatient rehabilitation after ventricular assist device placement with outcomes for other cardiac diagnoses.

DESIGN

This was a retrospective review of the electronic health records of 265 patients admitted to inpatient rehabilitation: 166 patients were admitted after ventricular assist device placement and 99 were admitted for other cardiac disease. Data collected included functional independence measure score on admission and discharge, dates of admission and discharge, and disposition.

RESULTS

Patients admitted after ventricular assist device placement had a mean functional independence measure gain of 25.7 and length of stay of 8.7 days. Patients admitted for other cardiac diagnoses had a mean functional independence measure gain of 25.9 and length of stay of 9.4 days. These differences were not statistically significant. Change in functional independence measure from admission to discharge was statistically significant within each group (P < 0.001). Most patients were discharged home, and the proportions who returned to acute care or home were not different between groups.

CONCLUSIONS

Both the ventricular assist device and nonventricular assist device groups had significant and equivalent improvements in functional outcomes after inpatient rehabilitation. This study found that ventricular assist device patients benefit from inpatient rehabilitation with similar disposition rates as patients with other cardiac diagnoses. Inpatient rehabilitation is the appropriate setting for this group.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Describe the role of rehabilitation in the care of individuals after ventricular assist device (VAD) placement; (2) Compare the outcomes of inpatient rehabilitation for individuals after VAD placement to those admitted for other cardiac reasons; and (3) Recognize potential complications that may occur during the course of a VAD patient's inpatient rehabilitation stay.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Association of Cardiac Rehabilitation With Decreased Hospitalizations and Mortality After Ventricular Assist Device Implantation

OBJECTIVES

This study characterized cardiac rehabilitation (CR) use in ventricular assist device (VAD) recipients in the United States and the association of CR with 1-year hospitalization and mortality by using the 2013 to 2015 Medicare files.

BACKGROUND

Exercise-based CR is indicated in patients with heart failure with reduced ejection fraction, but no data exist regarding CR participation after VAD implantation.

METHODS

The study included Medicare beneficiaries enrolled for disability or age >65 years. The investigators identified VAD recipients by diagnosis codes and cumulated CR sessions occurring within 1 year after VAD implantation. Multivariable-adjusted Andersen-Gill models were used to evaluate the association of CR with 1-year hospitalization risk, and Cox regression was used to evaluate the association of CR with 1-year mortality.

RESULTS

There were 1,164 VADs implanted in Medicare beneficiaries in the United States in 2014. CR use was low, with 348 patients (30%) participating in CR programs. The Midwest had the highest proportion of VAD recipients who began CR (38%), whereas the Northeast had the lowest proportion of CR participants (25%). Each 5-year increase in age was associated with attending an additional 1.6 CR sessions (95% confidence interval [CI]: 0.7 to 2.5; p < 0.001). CR participation was associated with a 23% lower 1-year hospitalization risk (95% CI: 11% to 33%; p < 0.001) and a 47% lower 1-year mortality risk (95% CI: 18% to 66%; p < 0.01) after multivariable adjustment.

CONCLUSIONS

Approximately one-third of VAD recipients attend CR. Although it is not possible to account fully for unmeasured confounding, VAD recipients who participate in CR appear to have lower risks for hospitalization and mortality.

Outcomes of Acute Inpatient Rehabilitation of Patients With Left Ventricular Assist Devices and Subsequent Stroke

OBJECTIVE

The aim of the study was to examine the functional outcomes and medical complications of patients with left ventricular assist device implantation and subsequent stroke during comprehensive inpatient rehabilitation.

DESIGN

Retrospective cohort study of 21 patients admitted to an inpatient rehabilitation facility between 2009 and 2015. Main outcome measurements include admission and discharge Functional Independence Measure, length of stay, and Functional Independence Measure efficiency.

RESULTS

The study included 17 male and 4 female patients aged 32-75 yrs. Eleven patients (52%) required transfer to an acute care hospital for evaluation. Fifteen patients completed inpatient rehabilitation with median [interquartile range] length of stay 26 [13.5-34] days (range = 7-59 days), median [interquartile range] Functional Independence Measure gain of 18 [12.5-32], and median [interquartile range] Functional Independence Measure efficiency of 1.0 [0.6-1.44]. Patients who required transfer to acute care during their course but ultimately completed inpatient rehabilitation (n = 5) demonstrated larger median [interquartile range] Functional Independence Measure gain (40 [23-42]) and longer median [interquartile range] length of stay (35 [35-42]) compared with patients who completed inpatient rehabilitation without transfer (Functional Independence Measure gain = 15 [9.25-26.5]; length of stay = 14.5 [11.5-26.25]).

CONCLUSIONS

Patients with left ventricular assist device implantation and subsequent stroke demonstrate functional gains during acute inpatient rehabilitation programs. A large percent of patients required transfer to acute care.

Ventricular Assist Device Patients Have Different Clinical Outcomes and Altered Patterns of Bleeding with Intracranial Hemorrhage

Intracranial hemorrhage (ICH) is one of the most feared complications of left ventricular assist device (LVAD) support. However, outcomes in this group have not been well described. We therefore sought to examine clinical outcomes in this patient population in comparison to those with heart failure (HF) and no LVAD, as well as those without HF or LVAD. The National Inpatient Sample database, years 2002-2012, was queried to classify patients into 3 groups: any ICH (group 1), any HF with any ICH (group 2), and any LVAD with any ICH (group 3). Clinical outcomes, hemorrhage type, neurosurgical intervention rates, and hospital factors were collected and analyzed. Group 1 consisted of 419,264 patients, group 2 had 41,186, and group 3 had 118 patients. Group 3 patients were more likely to be in large, academic medical centers, with longer length of stay and higher hospital charges. Inpatient mortality was highest in this group at 39%; however, 46.2% were ultimately discharged to home. Patients in group 3 were more likely to have a subarachnoid or intracerebral hemorrhage versus a subdural or epidural hemorrhage. Neurosurgical intervention rates did not differ between the groups. Although LVAD patients with ICH have worse clinical outcomes, the majority survived their event and nearly half were able to be discharged home. Left ventricular assist device patients also have a distinct pattern of bleeding with ICH. Additional study is required to understand risk factors for the development of ICH in this population and ideal management strategies.

The Rehabilitation of Patients With Advanced Heart Failure After Left Ventricular Assist Device Placement: A Narrative Review

Because more patients with advanced heart failure are receiving a left ventricular assist device (LVAD) as destination therapy or a bridge to transplantation, there is increasing attention on functional outcomes and quality of life after LVAD implantation. Rehabilitation providers in the acute inpatient rehabilitation setting increasingly will treat patients with an LVAD and should understand the exercise physiology, medical management, rehabilitation considerations, and outcomes after rehabilitation for patients with an LVAD. The purpose of this article is to provide the physiatrist with a comprehensive understanding of the rehabilitation of patients with advanced heart failure and LVAD implantation. Changes in relevant organ system physiology and exercise physiology after LVAD are summarized. Safety of rehabilitation and program considerations for acute inpatient rehabilitation are reviewed. Recommendations for medical management and prevention of secondary complications seen in patients with an LVAD are outlined. A discussion of outcomes after acute inpatient rehabilitation, the dual diagnosis of stroke and LVAD placement, and long-term cognitive, functional, and quality-of-life outcomes after LVAD placement is presented.

Does a Comprehensive Inpatient Rehabilitation Program Improve Patients' and Caregivers' Emotional State in LVAD Patients?

Few studies evaluated the effect of cardiac rehabilitation programs on perceived emotional and health status of left ventricular assist device (LVAD) patients, and none explored their effect on caregivers' strain. We enrolled 119 adult LVAD patients, together with their caregivers (n = 91), in two Rehabilitation Institutes that provided inpatient multidisciplinary activities. At admittance and prior to discharge they completed questionnaires evaluating patient emotional state and subjective perception of health status, caregiver strain, and patient and caregiver perception of the VAD. Six months after discharge, patients and caregivers were contacted again and asked specific questions about their quality of life. Patients' state anxiety and depression symptoms significantly diminished at discharge (0.000), whereas their perception of general health status rose (0.000). Caregivers' perceived strain also significantly decreased (0.001) and the perceived device management skill grew both for patients and caregivers (0.000). A substantial amount (36%) of psychologically frail patients and caregivers, although improving their emotional condition, never reached that of the less frail subjects. At the 6-month follow-up, both patients and caregivers appeared stable in evaluating respectively their general health and their caregiving-related strain, compared to discharge. Our data show that a comprehensive inpatient rehabilitation program improves the emotional state of LVAD patients and of their caregivers, even in psychologically frailer subjects. Team approach makes patients and caregivers self-confident about device management, increasing their knowledge, clarifying their doubts, and encouraging them to handle the difficulties met during the rehabilitation period, suggesting strategies to cope with daily life at home.

Exercise Performance During the First Two Years After Left Ventricular Assist Device Implantation

Exercise performance of patients with left ventricular assist devices (LVADs) improves after postimplant cardiac rehabilitation (CR). Few studies assess the effectiveness of a CR and its long-term effect of exercise performance. For this purpose, we retrospectively analyzed data from LVAD patients, who underwent a stationary CR twice after pump implantation. Data from exercise training and cardiopulmonary exercise tests (CPETs) were analyzed. Fifteen patients (age: 57 ± 10 years, male 87%) were admitted to the rehabilitation clinic twice 39 ± 18 and 547 ± 197 days after LVAD implantation. An improvement from the beginning to the end of the second CR was observed in bicycle ergometer training (14.0 ± 8.8 vs. 35.7 ± 14.7 W; p < 0.001), in muscular strength (e.g., leg press: 41 ± 10 vs. 53 ± 14 kg; p < 0.001), and in 6 minute walk distance (421 ± 126 m vs. 480 ± 133 m; p = 0.040). Between the first and the second CR, improvement in all the training modules was observed as well as an increase in CPETs peak workload (56 ± 24 vs. 83 ± 26 W; p < 0.001) but not in peak oxygen consumption (12.3 ± 3.2 vs. 12.2 ± 4.0 ml/min/kg; p = 0.906). Thus, over long implant periods, patients showed improvement of their exercise performance in the submaximal load range, but no change in the aerobic capacity was observed.

Post-acute Care Trajectories in the First Year Following Hospital Discharge After Left Ventricular Assist Device Implantation

INTRODUCTION

Patients with advanced heart failure who undergo left ventricular assist device (LVAD) implantation are heavy users of post-acute care services. We sought to better describe the post-acute trajectories and burden of care transitions for this patient population.

METHODS AND RESULTS

We conducted a retrospective cohort study of 227 patients who were discharged after index hospitalization for LVAD implantation. Of these, 162 (71%) were discharged home, and 65 (29%) were discharged to a facility, including long-term acute care hospitals (n = 50), inpatient rehabilitation facilities (n = 11), and skilled nursing facilities (n = 4). Follow-up extended to 1 year, with censoring at date of heart transplantation, LVAD removal, death, or loss of follow- up. In the first year post-discharge, those patients initially discharged home spent a mean 265 days at home, 0.5 days in a facility, and 13 days in the hospital as result of readmission. Those initially discharged to a facility spent a mean 241 days at home, 37 days in a facility, and 19 days in the hospital as result of readmission. Patients initially discharged home experienced fewer care transitions, 4.2 vs 5.2 transitions per patient, compared with those initially discharged to a facility.

CONCLUSIONS

In the first year following index hospitalization for LVAD implantation, patients initially discharged to a facility have an increased burden of care transitions, as well as time spent in the hospital and in a facility, compared with patients initially discharged home. Specialized models of care are needed in facilities caring for patients with LVADs.

Use of Post-acute Care Services and Readmissions After Left Ventricular Assist Device Implantation in Privately Insured Patients

BACKGROUND

Very little is known about health care resource utilization, including post-acute care use and hospital readmissions, after left ventricular assist device (LVAD) implantation.

METHODS AND RESULTS

Administrative claims from a database of multiple United States health plans were used to identify patients that received an LVAD (ICD-9 code 37.66) and survived to hospital discharge from January 1-2006, through September 30-2013. Post-acute care use was defined as a skilled nursing facility or rehabilitation stay within 90 days after hospital discharge. Patients were censored at heart transplantation or end of coverage through December 31-2013. Of 583 patients (mean age 55 years, 77% male), 223 (38.3%) used post-acute care services, more commonly in patients with diabetes, who required hemodialysis, and who had LVADs implanted at hospitals in more populated areas, with more beds, and in the northeast region (P < .05 for each). The most common reasons for readmission were device complications, heart failure, and arrhythmia. Readmission risk was higher in patients who had diabetes, peripheral vascular disease, and longer hospital length of stay, but it did not differ by post-acute care use.

CONCLUSIONS

Use of post-acute care services varies based on hospital characteristics. We found no association between post-acute care use and readmission risk after LVAD implantation.