2.  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

3.  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

4.  Before LVAD placement patient ambulating at home independently with a Rollator  Before MCA stroke patient ambulating in parallel bars & transferring with moderate assistance

5.  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

6.  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

7.  Fair-good  Positive: young age, family support  Negative: many co-morbidities, patient attitude, lack of motivation, limited cognitive functioning

8.  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

9.  Discharge to inpatient rehab  Physical therapy 5x a week  Focus on: therapeutic exercise, transfer training, endurance activities, balance and gait training

10.  Transfer training: supine to sit and sit to stand ranged from dependent to minimum assist  Ambulation with ARJO platform walker up to 30 feet.

11.  LVAD training: changing device to portable battery pack  Balance training: sitting edge of bed with reaching tasks required moderate assist x1

12.  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)

13.  Do continuous flow LVAD devices have less incidence of stroke than pulsatile LVAD devices?

14.  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

15.  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

16.  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

17.  Overall the continuous flow group did better  Occurrence of stroke was higher in continuous group, but this difference was not statistically significant

18.  Large age range; most participants older than my patient  Limited surgeon experience  Patients not blinded

19.  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

20.  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

21.  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

22.  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

23.  Study subjects healthier than my patient  Subjects older than my patient  Not a direct comparison

24.  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?