39 year old Male
 Single, no children
 Lives in a 2 story home alone?
 Lives in a 1 story home with brother?
 Lives in a 3 story home with sister?
 Father lives close by
 Already owns a Rollator and a cane

Physical therapy diagnosis: Middle
cerebral artery stroke in April
 Past Medical History: Emergency LVAD
placement in February for non-ischemic
cardiomyopathy
 Hypertension, obesity, congestive heart
failure, renal failure, respiratory failure

Before LVAD placement patient
ambulating at home independently with
a Rollator
 Before MCA stroke patient ambulating in
parallel bars & transferring with
moderate assistance

Cognition: Impulsive, easily distracted,
follows 1 step commands 90% of the time
 Sensation: Diminished in Left extremities
 ROM: Within functional limits
 Strength: 3-/5 in left extremities
 Supine to sit Max x 1
 Sit to stand Mod x 1
 1 step to chair Mod x 1
 Left side neglect

Impairments: Decreased strength,
endurance, mobility, sensation
 Functional limitations: Unable to walk
independently, unable to transfer
independently, unable to perform ADLs
 Disabilities: Unable to return home,
unable to work

Fair-good
 Positive: young age, family support
 Negative: many co-morbidities, patient
attitude, lack of motivation, limited
cognitive functioning

By discharge the patient will…
 Perform supine to sit with mod. assist
 Perform sit to stand with min. assist
 Perform bed to chair with min. assist
 Sit unsupported static with supervision
assist for 5 minutes
 Ambulate 25 feet with least restrictive
device with mod. assist

Discharge to inpatient rehab
 Physical therapy 5x a week
 Focus on: therapeutic exercise, transfer
training, endurance activities, balance
and gait training

Transfer training:
supine to sit and sit to
stand ranged from
dependent to
minimum assist
 Ambulation with
ARJO platform walker
up to 30 feet.

LVAD training:
changing device to
portable battery pack
 Balance training: sitting
edge of bed with
reaching tasks required
moderate assist x1






Pt. supine to sit with mod. assist ✔ (min.
assist)
Pt. sit to stand with min. assist ✖ (mod. assist)
Pt. bed to chair with min. assist ✖ (mod.
assist)
Pt. sit unsupported static with supervision
assist for 5 minutes ✔ (10 minutes
unsupported while changing battery pack)
Pt. will ambulate 25 feet with least restrictive
device with mod. assist ✔ (30 ft. with ARJO
& mod. assist)

Do continuous flow LVAD devices have
less incidence of stroke than pulsatile
LVAD devices?


Mark S. Slaughter, M.D., Joseph G. Rogers, M.D., Carmelo A. Milano, M.D.,
Stuart D. Russell, M.D., John V. Conte, M.D., David Feldman, M.D., Ph.D.,
Benjamin Sun, M.D., Antone J. Tatooles, M.D., Reynolds M. Delgado, III, M.D.,
James W. Long, M.D., Ph.D., Thomas C. Wozniak, M.D., Waqas Ghumman,
M.D., David J. Farrar, Ph.D., and O. Howard Frazier, M.D.
2009 Randomized Controlled Trial in the New England Journal of Medicine
200 patients; 133 received continuous, 59
received pulsatile device
 Age range 26-81; mean age of 62
 Inclusion factors: Ejection fraction <25%,
ineligible for heart transplant, and NY
Heart Association class III or IV symptoms
 Exclusion factors: active infection,
irreversible renal, pulmonary, or hepatic
dysfunction

Positive outcome was considered surviving
without having a disabling stroke or device
replacement
 62 patients (46%) from the continuous flow
group achieved this; only 7 patients (11%)
of the pulsatile group did
 17% from continuous group suffered a
disabling stroke; 14% from pulsatile group
 Continuous group did have less incidence
of infection, renal failure, respiratory failure,
cardiac arrhythmia & right heart failure

Overall the continuous flow group did
better
 Occurrence of stroke was higher in
continuous group, but this difference
was not statistically significant

Large age range; most participants older
than my patient
 Limited surgeon experience
 Patients not blinded



Leslie W. Miller, M.D., Francis D. Pagani, M.D., Ph.D., Stuart D. Russell, M.D.,
Ranjit John, M.D., Andrew J. Boyle, M.D., Keith D. Aaronson, M.D., John V.
Conte, M.D., Yoshifumi Naka, M.D., Donna Mancini, M.D., Reynolds M.
Delgado, M.D., Thomas E. MacGillivray, M.D., David J. Farrar, Ph.D., and O.H.
Frazier, M.D.
2007 Observational Clinical Study in the New England Journal of Medicine
133 patients receiving a continuous flow
device
 Age range 37-63 ; average age of 50
 Inclusion factors: NY Heart Association class
IV symptoms and eligible for a heart
transplant
 Exclusion factors: active infection, severe
renal, pulmonary, or hepatic dysfunction, or
the presence of mechanical circulatory
support

Positive outcome was considered
survival, still eligible for transplant, or
already received a transplant at 180
days post-op
 100 (75%) patients achieved this
 25 patients died; remaining 8 had severe
medical complications making them
ineligible for transplant
 11(8%) patients suffered strokes

Compared their study to 3 previously
written studies regarding pulsatile
devices
 Both types had the same overall survival
rate
 Pulsatile had twice the incidence of
stroke

Study subjects healthier than my patient
 Subjects older than my patient
 Not a direct comparison

The risk for stroke is low, but it does still
happen
 Important to monitor patients very
closely after this surgery
 Overall, continuous devices seem to be
more beneficial with less adverse events
 Would I do anything different?
