Total Artificial Heart: A Retrospective Multiple-Case Analysis of Occupational Therapy in a Quaternary Hospital

PURPOSE: The primary aim of this retrospective analysis was to investigate the role of occupational and physical therapy with patients with a Total Artificial Heart (TAH; Syncardia, Tucson, AZ). A TAH is a biventricular, pneumatic, pulsatile pump implanted in a patient after removal of native heart ventricles and all four valves. A secondary aim was to define the frequency, duration, and course of therapy during the postoperative period.

DESIGN: The study was a retrospective multicase analysis. The research was descriptive in nature for population demographics. The inclusion criteria included patients implanted with a TAH in an acute care setting. Patients were all men diagnosed with New York Heart Association Class IV heart failure with the goal of a bridge to heart transplantation. All participants were referred by cardiac surgery providers for functional decline. The institutional review board granted research approval in 2015.

METHOD: Researchers analyzed therapy evaluation and treatment documentation of 10 patients participating in occupational and physical therapy while implanted with a TAH in acute care from 2012 to 2014. Demographics were obtained from electronic medical records. Mobility and activity outcomes were measured using the Activity Measure for Post-Acute Care (AM–PAC) 6 Clicks form, a standardized patient outcome measure designed to evaluate functional activities and mobility (Boston University School of Public Health, 2017). Cognition was measured using the Montreal Cognitive Assessment (MoCA). The Functional Oral Intake Scale (FOIS) was completed on patients with dysphagia.

RESULTS: Occupational therapy was provided on average in 4.8 interventions including facilitation of self-care; energy conservation education; functional mobility training; upper-extremity therapeutic exercises; cognitive retraining; coping, stress, and relaxation training; home safety and fall prevention education; and adaptive equipment instruction. Inpatient daily activity AM–PAC scores increased by 32.5% from time of evaluation to discharge, demonstrating improved daily activity function. Similarly, AM–PAC functional mobility scores improved by 33%, showing improved functional mobility. These improved scores met the minimally detectable change (MDC) level for patients receiving therapy services. The MDC for daily activities was 5.49 and for basic mobility was 4.74. The MoCA Version 7.1 was completed with four patients prior to implantation with scores averaging 24.5 out of 30, which indicated cognitive impairment. The MoCA Version 7.2 was completed with six patients with scores averaging 21.5 out of 30, also indicating impairment.

Five patients received occupational therapy services for evaluation of dysphagia. All five patients completed a clinical bedside evaluation, with two patients proceeding to video fluoroscopic swallow studies. Dysphagia interventions included diet modification and progression, swallowing exercises, education on compensatory strategies, and aspiration precautions. Time to consult ranged from 2 to 13 days post TAH implantation. Average initial FOIS score was 4.2 (range = 1–7), which increased to 6.6 (range = 5–7) at dismissal.

CONCLUSION: Based on the findings of this analysis, occupational therapy has a key role providing care to patients implanted with a TAH. Occupational therapy had an impact in improving functional daily activity and basic mobility performance with this complex medical population. Results support the need for a consistent occupational therapist and use of a standardized outcome measure to validate functional changes. This study identified the need for occupational therapy to address the psychosocial needs of patients living with a mechanical cardiac implant. Future research is needed to identify the most effective interventions for this population during the continuum of care.

References

Boston University School of Public Health. (2017). Activity Measure for Post-Acute Care. Retrieved from http://www.bu.edu/bostonroc/instruments/am-pac/

Cameron, J., Worrall-Carter, L., Page, K., Stewart, S., & Ski, C. F. (2013). Screening for mild cognitive impairment in patients with heart failure: Montreal Cognitive Assessment versus Mini Mental State Exam. European Journal of Cardiovascular Nursing, 12, 252–260. https://doi.org/10.1177/1474515111435606

Jette, D. U., Stilphen, M., Ranganathan, V. K., Passek, S. D., Frost, F. S., & Jette, A. M. (2014). Validity of the AM–PAC “6-Clicks” inpatient daily activity and basic mobility short forms. Physical Therapy, 94, 379–391. https://doi.org/10.2522/ptj.20130199