Safety and Feasibility of an Early Mobilization Protocol for Patients with Femoral Intra-Aortic Balloon Pumps as Bridge to Heart Transplant

Weakness acquired in the cardiac intensive care unit: still the elephant in the room?

Over the past two decades, the cardiac critical care population has shifted to increasingly comorbid and elderly patients often presenting with nonprimary cardiac conditions that exacerbate underlying advanced cardiac disease. Consequently, the modern cardiac intensive care unit (CICU) patient has poor outcome regardless of left ventricular ejection fraction. Importantly, delayed liberation from organ support, independent from premorbid health status and admission severity of illness, has been associated with increased morbidity and mortality up to years post-general critical care. Although a constellation of several acquired morbidities is at play, the most prominent enactor of poor long-term outcome in this population appears to be intensive care unit acquired weakness. Although the specific burden of ICU-acquired morbidities in CICU patients is yet to be clearly defined, it seems unfathomable that patients will not accrue some sort of ICU-related morbidity. There is hence an urgent need to better establish the exact benefit and cost of resource-intensive strategies in both short- and long-term survival of the CICU patient. Consequent and standardized documentation of admission comorbidities, severity of illness indicators, relevant ICU-related complications including weakness, and long-term post-ICU morbidity outcomes can help our understanding of the disease continuum and how to better care for the CICU survivor and their families and caregivers. Given increasing budgetary pressure on healthcare systems worldwide, interventions targeting CICU patients should focus on improving patient-centred long-term outcomes in a cost-effective manner. It will require a holistic and transmural continuity of care model to meet the challenges associated with treating critically ill cardiac patients in the future.

Tailored Approach to Temporary Mechanical Circulatory Support for Cardiogenic Shock: Strategies to Facilitate Patient Mobilization

PURPOSE OF REVIEW

This article discusses a tailored approach to managing cardiogenic shock and temporary mechanical circulatory support (tMCS). We also outline specific mobilization strategies for patients with different tMCS devices and configurations, which can be enabled by this tailored approach to cardiogenic shock management.

RECENT FINDINGS

Safe and effective mobilization of patients with cardiogenic shock receiving tMCS can be accomplished. Appropriate patient selection, tailored device management, and dynamic multidisciplinary approaches to mobilization are critical to success. Cardiogenic shock is a heterogeneous condition characterized by end-organ dysfunction due to hypoperfusion and low cardiac output. Temporary mechanical circulatory support (tMCS) is an increasingly valuable tool in managing these patients, with various devices and configurations available. Critically ill patients receiving tMCS are at risk for complications and deconditioning associated with prolonged bed rest, making it essential to implement strategies that promote mobility when feasible. We advocate for a tailored approach to the selection and management of tMCS in patients with cardiogenic shock. This approach focuses on the early identification of patients who may benefit from tMCS before further deterioration, alongside the selection of devices that provide ventricular-specific support and facilitate upper-body cannulation to enhance mobilization while also considering patients' potential exit strategies from tMCS. Understanding this approach is vital to appropriately facilitating safe and effective mobilization.

Ambulation in patients with peripheral veno-arterial extracorporeal membrane oxygenation and concomitant femoral intra-aortic balloon pump support

INTRODUCTION

The mobilization and ambulation of patients with severe cardiogenic shock supported with peripheral veno-arterial extracorporeal membrane oxygenation (pVA-ECMO) and concomitant femoral intra-aortic balloon pump (IABP) support is not well-described. This technical paper describes an ambulation protocol to prevent deconditioning in this critically ill patient population.

METHODS

A protocol for the ambulation of patients with pVA-ECMO and concomitant IABP support was created in December 2022 and implemented at a single center. To initiate ambulation, patients were initially placed in a vertical position utilizing the VitalGo Total Lift Bed (VitalGo Systems, Miramar, FL) with mechanical circulatory support device monitoring performed by a critical care multidisciplinary team. Retrospective analysis of successfully ambulated patients was performed from December 2022 to January 2024.

RESULTS

A total of 35 patients out of 112 patients with ECMO support were ambulated in the study period. Four of these patients had pVA-ECMO with concomitant IABP support with this cohort completing a total of 11 sessions during the study period. Patients ambulated an average of 200 feet per session without any adverse events, including cannula and balloon pump migration or displacement. Three of the four patients studied were either bridged to an advanced therapy including orthotopic heart transplant or durable left ventricular assist device or were discharged.

CONCLUSION

A protocol for ambulation of CS patients with pVA-ECMO support and concomitant femoral IABP support is feasible and can safely be implemented in this critically ill patient population. Further multicenter studies are necessary to determine the overall impact of ambulation on patient outcomes.

The Effects of Exercise on Cardiogenic Shock with an Intra-Aortic Balloon Pump: A Case Report

This case report describes the exercise program on a hospitalized 54-year-old male patient with cardiogenic shock waiting for a heart transplant assisted by an intra-aortic balloon pump, a temporary mechanical circulatory support device. The temporary mechanical circulatory support device, an intra-aortic balloon pump, was placed in the left subclavian artery, enabling the exercise protocol. Measurements and values from Swan-Ganz catheter, blood sample, brain natriuretic peptide (NT-proBNP), and high-sensitivity C-reactive protein (hs-CRP), as well as the six-minute walk test (6MWT) and venous oxygen saturation (SvO2) were obtained before and after an exercise protocol. The exercise training protocol involved the use of an unloaded bed cycle ergometer once a day, for a maximum of 30 minutes, to the tolerance limit. No adverse events or events related to the dislocation of the intra-aortic balloon pump were observed during the exercise protocol. The exercise program resulted in higher SvO2 levels, with an increased 6MWT with lower Borg dyspnea scores (312 meters vs. 488 meters and five points vs. three points, respectively). After completing the ten-day exercise protocol, the patient underwent a non-complicated heart transplant surgery and a full recovery in the ICU. This study showed that exercise is a feasible option for patients with cardiogenic shock who are using an intra-aortic balloon pump and that it is well-tolerated with no reported adverse events.

Cardiac rehabilitation after cardiac surgery: An important underutilized treatment strategy

Physical inactivity remains in high levels after cardiac surgery, reaching up to 50%. Patients present a significant loss of functional capacity, with prominent muscle weakness after cardiac surgery due to anesthesia, surgical incision, duration of cardiopulmonary bypass, and mechanical ventilation that affects their quality of life. These complications, along with pulmonary complications after surgery, lead to extended intensive care unit (ICU) and hospital length of stay and significant mortality rates. Despite the well-known beneficial effects of cardiac rehabilitation, this treatment strategy still remains broadly underutilized in patients after cardiac surgery. Prehabilitation and ICU early mobilization have been both showed to be valid methods to improve exercise tolerance and muscle strength. Early mobilization should be adjusted to each patient's functional capacity with progressive exercise training, from passive mobilization to more active range of motion and resistance exercises. Cardiopulmonary exercise testing remains the gold standard for exercise capacity assessment and optimal prescription of aerobic exercise intensity. During the last decade, recent advances in healthcare technology have changed cardiac rehabilitation perspectives, leading to the future of cardiac rehabilitation. By incorporating artificial intelligence, simulation, telemedicine and virtual cardiac rehabilitation, cardiac surgery patients may improve adherence and compliance, targeting to reduced hospital readmissions and decreased healthcare costs.

Heart transplantation and the role of inpatient rehabilitation: A narrative review

Heart transplantation is a definitive treatment option for patients with end-stage heart failure. Medical and functional complications are common after this procedure, and rehabilitation is often needed postoperatively. Physiatrists caring for persons who have received a donor heart must appreciate the surgical background, the physiologic changes expected, as well as the potential medical complications for which they are at risk after heart transplantation. This review summarizes various topics in heart transplantation including the history of the procedure, exercise physiology and functional outcomes, postoperative medical therapy, medical complications, and special considerations for inpatient rehabilitation in this patient population.