All right. Good morning, everyone. Thank you for coming. I'm just a few housekeeping announcements. Please either turn off your cell phones or silence them for the duration of the talk. They are recording the session. At the end of today's session, please remember to complete your evaluation forms and claim your CME. Okay. So, rehab considerations for patients with advanced heart failure. Our objectives this morning will be to identify rehab precautions necessary for individuals with very low ejection fractions, including those with left ventricular assist devices or LVADs and those with wearable defibrillators, to describe key elements of an interdisciplinary inpatient rehab program for persons with LVADs, review therapy considerations for those who have undergone heart transplantation, and to identify safety issues with the chronic use of IV milrinone in post-acute and home settings. I'm Lauren Shapiro. I'm an Associate Professor of PM&R and the Vice Chair for Quality, Safety, and Compliance at the University of Miami Miller School of Medicine. And I'll be speaking first about wearable defibrillators. I will introduce our speakers in greater detail just prior to their talks, but I'm very excited to introduce them briefly now. Following my talk, Dr. Nicole Ponti, one of my colleagues at the University of Miami, will be discussing the rehabilitation of patients with ventricular assist devices. She'll be followed by Dr. Leslie Breidberg from the Shirley Ryan Ability Lab at Northwestern University Department of PM&R, who will be describing the care of patients on milrinone therapy and those with remote heart monitoring. And last but not least, Dr. Sarah Eichmeier from the University of Kansas School of Medicine Department of PM&R will be reviewing the rehabilitation of patients with heart transplants. The prevalence of heart failure is rising over time as the population is aging. It's estimated that over 6 million American adults currently have heart failure. And it is somewhat more common among the patients typically cared for physiatrists. Many of us care for a patient population that is largely over age 65, in whom there's a greater prevalence of heart failure. The risk of ischemic stroke is two to three times higher among those with heart failure. Many of us also care for persons with anoxic brain injury following cardiac arrest. And many physiatrists are caring for those with COVID-19 sequelae. And it's important to note that nuance at heart failure in hospitalized COVID-19 patients may be as high as one in four. And we are seeing more so-called cardiac cases in IRFs. When you look at the cardiac rehab impairment category data from UDS from 2010 to 2020, there was a pretty significant increase during that time. With a slight decrement in 2020, which some of you will remember was a somewhat unusual year. And heart failure, of course, is not just a cause of disability, but a very common comorbidity among the patients that we see. So while some of these patients who come to inpatient rehab facilities may be coded as cardiac, we do know that heart failure is common in our other patient populations. And they may come in under a stroke impairment category or a non-traumatic brain injury or some other category as well. So physiatrists are really being increasingly called upon to care for patients receiving interventions for heart failure that were either not available or perhaps not as widespread in their use 20 years ago. So this will not be your typical cardiac rehab talk. We will not be discussing metabolic equivalents. We will not be calculating optimal heart rates, although these are very important things, of course. But we will be reviewing what physiatrists need to know when caring for patients who have received or are using these newer, although some of these have been around for quite some time, interventions. And with a real focus on what we need to know with regards to therapy precautions and some considerations for safe discharge planning. So with that, I'm going to jump into our first talk on wearable cardioverter defibrillators. So what are they? Well, these are devices worn by patients at risk for sudden cardiac death. They detect life-threatening heart rhythms and can deliver a shock in the event of V-fib or V-tach. Most of you are probably familiar with the LifeVest by Zoll, which has been around for about 20 years now. Last year, the Assure WCD system from Kestra Medical was approved as well. This here is a picture of the LifeVest. And when someone rents a LifeVest, they get a box and it has multiple components within it. This is the garment, this little vest here, and that's fit to the patient's body habitus. And it contains electrodes to sense the rhythm, as well as self-gelling defibrillator pads. The patient also gets a rechargeable battery pack, which contains a monitor, which can display an alert. It also contains response buttons. The battery pack is typically kept in place with a shoulder strap or waist holster. Within the box, they also receive a battery charger and a modem device. If a ventricular arrhythmia is detected, the patient receives multiple alerts. They get an audible alarm, the garment vibrates, and they receive a message on the monitor pack. If the patient is conscious, they have the opportunity to abort the shock by pressing buttons on the monitor. If the shock is not aborted, gel is released onto the defibrillator pads and shocks are delivered up to five per episode. The time from onset of arrhythmia to shock is about 45 to 50 seconds. There are some interesting features of the devices as well that can be helpful in a rehab setting, beyond the potentially aborting a life-threatening arrhythmia, of course. They are able to store and transmit data, including EKG recordings and compliance. The patient can initiate a recording. If, for example, your therapy gym is on another floor and the patient's working with therapy, they have a brief episode of dizziness or palpitations, they can initiate a recording very quickly, which may give you an opportunity to capture an abnormality. It also contains an accelerometer, which can be really useful to monitor a patient's physical activity remotely while in a cardiac rehab program. Indications. These are used when there's a risk for life-threatening arrhythmia, primarily when someone has had an implanted defibrillator that has had to be removed, perhaps due to infection, and when there's a contraindication for device implantation. It is also commonly used when there's a risk for a life-threatening arrhythmia, but that risk is expected to improve over time, as is often the case with viral myocarditis and peripartum cardiomyopathy. We're increasingly also getting patients with life vests following myocardial infarction. So, patients with low ejection fractions following MI are at high risk for sudden cardiac death, but there is some data from the cardiology literature showing that implanted defibrillators should not be implanted until 40 to 90 days post-MI. So, there was this potential that the vest could kind of play a really important role in that time period. The vest trial included persons hospitalized with acute MI and an ejection fraction less than 35%, and it was very successful in converting ventricular tachyarrhythmias when shocks were administered, but it did not achieve its primary endpoint goal in that it did not lead to decreased deaths due to arrhythmia during the 90-day period. They did, however, find that this was largely likely due to compliance with wear, which was very suboptimal, and very few deaths occurred in that trial while actually wearing the vest. Vest usage is associated with some not-ideal quality-of-life measures. So, anxiety and depression are very common, although it does improve over time. More than a third experience pain or discomfort, and that is more common in obese individuals. Some patients report restricted mobility and or impairments in self-care, but it's nearly always rated as mild, and sleep disturbance is very common. So, what precautions must we abide by? It's very important that we avoid putting patients in situations where there may be vibration and or significant noise, which may interfere with their ability to perceive the warning alerts. The vest is worn at all times, except it must be removed when they're taking a shower or a bath. There is a risk for electromagnetic interference. So, our therapists, particularly if they're a stroke patient and they have come over with a life vest, they want to do vital stim for their dysphagia, they want to do bioness, but these are absolutely contraindicated while wearing the device. With anti-theft safety gaits, there is a potential for interference as well. It is considered safe if they walk a normal pace through the gait, but if you have a patient who is perhaps walking very slowly, there is that potential. So, it is important that we work on gait speed within their therapy sessions to maintain their safety. In the event you need to use an external defibrillator on one of these patients, you do need to remove the device or at the very least the battery pack in the front of the garment. And of course, it needs to be removed before an MRI. So, there are some challenges with bringing these patients to rehab settings. Delivery, of course, may delay admission to rehab and it is really up to you and your facility whether you feel safe bringing patients over before their vest is delivered. And I think a lot of that will depend on the resources you have available like telemetry and what is your response time in the event of a code. We personally, we wait. Our therapists very frequently take our patients outside and we're not following them with a crash cart. So, if they were to have a sudden cardiac event, it would be horrible. Our response time would be terrible. Now, for those of you who might be doing consults in acute care, it usually is okay for them to do some mobility while awaiting the life vest. And I found this on a Facebook group, so not very scientific, but it made me chuckle and I think some of you will kind of laugh a little too, but tales of the hospitalist. Patient needs a PT eval to discharge. Patient needs a life vest before we can discharge. PT won't exert the patient without said life vest and life vest company won't deliver until we have a discharge order. So, you know, it's only funny because I've heard this happen many times, so it's very relatable. But if you're on an acute care, you know, hospital unit with a physical therapist and someone were to have a cardiac arrest, it would be a witnessed arrest and your time to defibrillation would be very short. So, probably not significantly different from the 45 to 50 seconds that is typical with the life vest. Now, we're increasingly also getting patients who come over with the vest who are agitated and or confused. And this has been a real challenge for us. And you have to ask the question, can they abort a shock if needed? We recently had a patient on my service who had a left MCA stroke and was still globally aphasic. He had a MI as well and a really low ejection fraction of 5 to 10%. And many of my team members were absolutely horrified that they did not fit this gentleman with the life vest before coming over. But due to his global aphasia, it was actually the right choice in that there was no way if he received any of these responses or alerts that he would be able to abort a shock. And due to his history of non-sustained VTAC, you know, he was at high risk of potentially getting that alert. We've also had patients damage their device. We do take patients with anoxic brain injury and stroke very commonly. Fortunately, you just reach out to Zoll and they've been very good about replacing them when that occurs. And of course, many of our patients aren't particularly compliant. And particularly at night when many patients sundown, it is important that these devices are worn while they're sleeping. These patients and their caregivers need education. In addition to general heart failure education like daily weights and diet, they need to learn to don and doff and clean the garment. They need to charge the battery every 24 hours. They need to be instructed that no one else should wear the device. The detection of rhythm is based on the patient's baseline EKG recordings. So you know, it is important to say it because you know it's only in the warnings because someone probably did it. It's important they recognize sirens and alarms. And caregivers need to be instructed that they do need to clear the patient in the event of a two-tone siren or they risk receiving some of that shock themselves. And if a shock is delivered, they need to know that they need to seek immediate medical evaluation and they will need either a new vest itself or new electrodes. I am now a Floridian, so I am obliged to talk about emergency preparedness. Any time a patient goes home on an electrically powered device for life or function, including LVADs, LifeVests, Milrinone drips, it is really important that we consider what will happen in the event of a power outage. So these are patients I always make sure are registered with their utility companies for medically essential services. In Florida, our utility company, FPL, has a nice little priority turn-on service form. Very quick signature by a physician and it gets them priority turn-on service in the event of an outage. We should review with them that they should consider purchasing a generator or portable power station if that's within their means. And these are our patient population that should really consider registering for medical shelters and or evacuation assistance in advance of a storm approaching in the forecast. We're gonna save questions for the end and I'm gonna turn things over next to Dr. Nicole Ponte. Dr. Ponte is an assistant professor of clinical PM&R at the University of Miami. She completed a residency in internal medicine prior to pursuing a second residency in PM&R and is actually double boarded with internal medicine. She currently serves as the medical director for our medically complex inpatient rehab service at the Christine Lynn Rehabilitation Center, again, in Miami. So please welcome Dr. Ponte. All right. Thank you, Dr. Shapiro. Good morning. So, today I'm gonna be reviewing some of the indications for LVAD placement, some of the basic components, precautions, and medical concerns that may arise in the rehab setting as well as developing an individualized plan of care for patients in the rehab setting. Oh, there we go. Okay. So, the Society of Thoracic Surgeons, in the 2020 report, released the 10-year data of the Intermax Registry, which is the interagency registry of mechanically assisted circulatory support. That data showed that 25,000 patients were implanted over that 10-year period, each year being the record-breaking number of LVADs per year. More recently, even as recent as September of last year—oh, sorry, excuse me—September of this year, the data from the Momentum 3 trial released its five-year update showing that HeartMate 3, which is the most dominant LVAD being implanted at this time, showing improved survival risks as compared to older models. So all of this is to say is that we're seeing increased LVAD implantations that are making their way into the rehab setting and increased improvement in safety profiles. However, this is not to say that they are risk-free. The LVAD implantation is associated with significant adverse event profiles, so there are various things that rehab clinicians should be aware of going forward. So before delving in, I'd like to just review a little bit of the history of the LVAD. Starting in the 1950s, there was a race in North America to perfect the technique for cardiopulmonary bypass. This paved the way for open-heart surgeries, intracardiac surgeries, and going forward, the advancement of mechanical circulatory systems that support patients with advanced heart failure. The first commercial success we see is in 1998 with a HeartMate XVE. This is by maker Thoratec, later acquired by Abbott. This was something that was being implanted in patients with advanced heart failure, and the idea was for portability and durability for this machine. Then the question arose, what had better outcomes, optimal medical management at the time versus a HeartMate XVE? And that's what the landmark rematch trial demonstrated was better outcomes and better survivorship with a HeartMate. However, the HeartMate XVE was of a pulsatile flow design as a way of mimicking the innate heart pulsatility, and the study, while it showed improved survivorship, also highlighted a lot of the mechanical complications and device-related complications that you can see as related to the pulsatile flow devices. That led to the development of continuous-flow LVADs being present on the market, and most notably the HeartMate II, which is a continuous-flow LVAD with an axial design, axial being the long axis of the rotor being parallel to the direction of the flow. So given these new advances in technology, they compared that with a pulsatile flow with continuous flow, again showing improved outcomes with newer generations of LVAD. However, because of this long axis flow, the rotor is supported on two ruby bearings, which were blood-immersed and caused friction and were a source of thrombogenesis. So that led to the development of the centrifugal flow design of the HeartMate III and the HVAD, also known as HeartWare by maker Medtronic. So these utilized a rotor that was suspended within the casing. In the case of HeartMate III, fully magnetically levitated and frictionless, as opposed to the HVAD, magnetically and hydrodynamically levitated. So as we saw in the Momentum III trial, the outcomes for the HeartMate III, as compared to II, are ever-increasing and ever-improving over time. So that led to a shift towards more centrifugal LVAD placements over time. Until 2021, in June, the FDA issued a Class I recall of the HVAD, citing increased adverse neurologic events, as well as pump malfunctions and failure to restart. So while HVAD is no longer commercially available, Medtronic continues to be available for technical support and in all, the HeartMate III reigns supreme, for now. So with all this advancement in technology, who gets an LVAD? So this is just a quick review of how we get to the stage of implanting a person with an LVAD. The ACC AHA guidelines in 2022 demonstrated four stratifications of heart failure classifications, ranging from at-risk down to advanced heart failure. This is a way of capturing patients who might be on that slippery slope on their way down to symptomatic stage C and advanced stage D heart failure. This is not to be confused with the New York Heart Association class I through IV. This is a descriptor of the symptomatology that you would get in stage C and D heart failure, stage IV being severe dyspnea at rest. To further complicate it, there is further stratification of patients by the intramax profiles. This lists I through VII, VII being a placeholder, all the way down to sliding on inotropes and crashing and burning, critical cardiogenic shock. This is as they are described. The idea of this is to identify patients that are sick enough to warrant requiring an LVAD, generally in that intramax III profile. But from that 10-year data recently released, it's showing at least 50% of patients more recently are being implanted at that level II and level I. So very critically ill patients, and that is to say we're getting patients that are at a functional baseline that's very debilitated and very low. So Medicare coverage database, again, it meets the criteria for meeting coverage. LVAD, left ventricular ejection fraction of less than 25% with symptomatic heart failure either inotrope dependent or with severe cardiogenic shock requiring ICU level care, failing goal directed medical therapy, and requiring circulatory support from either intra-aortic balloon pump or comparable temporary mechanical support systems. Patients will be typically designated either bridge to transplant or destination therapy. This kind of lets you know the intention and duration of the LVAD use. So bridge to transplant being a shorter term in order to get them ready for and optimized for surgery for transplant while they wait on the list. Some other terminology as well as bridge to recovery and bridge to decision have also emerged to also capture those populations as well. So let's take a look at the internal components of the LVAD. We have the inflow cannula made by coring the apex of the left ventricle. This draws blood from the left ventricle into the pump with the impeller and out again through the outflow graft that is connected to the aorta. There's a tunnel driveline that allows access to the percutaneous portion of the LVAD and that's connected to the controller and the battery power. So the controller includes an emergency backup energy source but the main source of energy is coming from the batteries or the wall source that the patient might be hooked up to providing up to 17 hours on battery but more durability on the long term wall source. Here you can also see the modular driveline. This is an exchangeable external portion of the driveline. If there's damage that occurs to that, that then facilitates exchange of that portion of the external part of the driveline as opposed to requiring surgery to replace. Other equipment that you may encounter in the rehab setting along with the batteries and controllers. There's other mobile units, portable mobile units to facilitate mobility and a variety of different wearables to customize for patient use as well as notably the shower bag and travel bag that patients will have to learn how to use once they're discharged from rehab. You also may see patients with parameters on the monitor. There are four main parameters of the LVAD. So there is the power, the speed, flow, and pulsatility index. Power is straightforward. This is measured in watts. It ranges between 5 and 10 watts and it's directly related to speed and flow. The more power you put in, the more flow you will get. There's changes to this parameter that might suggest something clinical is happening. An increase in power may indicate that thrombus has formed within the pump which is a very feared complication. A gradual decrease may mean there's an obstruction downstream. Speed again directly related to power is specific per LVAD maker. So HeartMate 3 ranges from 3,000 to 9,000 revolutions per minute with an average around 5,000. Flow also taking into account speed, power, but also the patient's hematocrit. As speed increases, flow increases. But if there's downstream obstruction with increased blood pressure, that could cause a decrease in the flow. There's a low flow alarm that is set at 2.5 liters per minute that will alarm if you cross that threshold. And pulsatility index is a unitless measure that is a surrogate of left ventricular contraction. The more the LV contracts, the more variability there is in the power introduced into the system. So how do these patients behave in terms of their physical exam? They act a little differently. Patients may or may not be pulseless. It depends on the flow out of the LVAD and the innate heart function natively. So that's not a good measure of how patients are clinically, and it shouldn't be used as a sole measure of clinical assessment. Blood pressure, as you may notice, they have a narrow pulse pressure, and this is due to the constantly unloading left ventricle into the system, which prevents the end systolic pressure from building. A better measure is the MAP, the mean arterial pressure, which should aim to be in the 65-85 range. Some sources say 70 to 90, but it shouldn't exceed 90 because that is associated with adverse events. And O2, because it's pulse dependent, you may have variable effects in obtaining a pulse in ox reading. So in order to measure a MAP noninvasively, you can inflate a blood pressure cuff and use a Doppler ultrasound. You find the brachial artery and measure, and the first sound that you hear, whether it's pulsatile or continuous, is the opening pressure, and there's good correlation between this and an invasive arterial MAP reading. On exam, you'll hear the classic LVAD hum, which can complicate your full assessment of the patient's volume status and perfusion while you're trying to listen to the lungs and assessing for good capillary refills, but it is something present. Other medical concerns, these patients are prone to both clotting and bleeding. Because of this hardware, they require anticoagulation with warfarin. As mentioned before, there's areas of friction within the system that can be thrombogenic, leading to issues like pump thrombosis and ischemic stroke. However, ischemic stroke and hemorrhagic stroke occur in approximately equal frequency between each other. It is proposed that now that we are using continuous flow LVADs, there's changes to the endothelial function. Infections are always a feared complication as well, especially driveline infections. If patients are persistently getting driveline infections, that may necessitate lifelong use of antibiotics to suppress whatever pathogen is present to avoid the feared need to explant the LVAD. And arrhythmias. Arrhythmias, so patients with advanced heart failure typically have ventricular arrhythmias and are already implanted with defibrillators. This, while they're less susceptible to cardiogenic shock and cardiac arrest, these patients may have changes in their hemodynamics due to ventricular arrhythmias, and that should be addressed by their primary cardiology team. So in an emergency, what can you do? The two main things to take away from this is that in an LVAD patient that's unresponsive, you do want to assess for the function of the LVAD and the perfusion of the patient. If neither one is happening, then it is possible to consider compressions on a patient with an LVAD, although the risk for dislodgement is great and clinical judgment is advised in these particular scenarios. So this is a lot for patients to take in. So what can they do is something that patients will want to know. So the idea of this is that patients can go back to doing their regular activities after a course of rehab and getting back to their functionality. So patients can safely rehab in our settings and then be transitioned. What they cannot do and things that they do have to accommodate are no contact sports for fear of damaging the devices, no swimming or submerging in water for risk of damaging, again, the electrical components, and they cannot be away from power sources. Pregnancy is not advised. So sternal precautions, six to eight weeks move in the tube for screenotomies. MRIs are also contraindicated. Any workup needs to be pursued with CT or ultrasound imaging. Anticoagulation is another thing to be considered. The goals can be varied and adjusted based on their bleeding risk. So they might have narrower or lower target INRs. And hemodynamics, fluid is very important in these patients. They're preload dependent. If they do run dry, they can result in suction events, which is when the endocardium gets sucked over into the inflow, and in which case the machine is smart enough to know to rev down to release that to prevent left ventricular failure and collapse. And in general, it's not advised to pursue devices like electrical stimulation just for risk of interference and of course aqua therapy. So going forward, how do we exercise these patients? We wanna make sure that they have no new symptoms when they're starting their exercises and to abort if there's any concern for overexertion. The guidelines from Europe suggest that early mobilization and early bed mobility is correlated with better clinical outcomes. Things like transferring to bed, to chair, to commode and pre-gait activities are highly beneficial in these patient populations when you're trying to build them up from their very disabled, for their very low debility states from immediately post-surgery. It's important to consider their premorbid function and their post-morbid intention in order to risk stratify them and to develop individualized cares and plans of care in rehab. You wanna avoid any intensive exercises or things that would affect the blood pressure. So gradual warmups and cool downs with low to moderate intensity exercises being advised for these patients until they're showing that they can tolerate greater and to assess all alarms. So there is a very nice review article by my esteemed co-panelists who wrote a article in 2019 published in the Journal of PM&R, which I highly recommend. It's a very comprehensive review of everything that we talked about as well as physiology down to how to better tailor the experience for the LVAD patient in rehab. And this includes speech therapy, patients being able to learn and recite back steps of safely transferring from power to wall and being able to understand all of the components of the LVAD. Occupational therapy, teaching them how to take a shower without getting the driveline wet, learning how to coordinate themselves without getting tangled in their lines, physical therapy, advancing themselves with LVAD, ambulating and shifting to the carry bags and battery sources, as well as nursing goals for patient education, medication management, including Coumadin education and safe battery changes as well. So this is all to say that there's a lot of changes that these LVAD patients are undergoing and they have to learn their new baselines, their new ADLs. And it's always a buddy system. It's never one person alone. It has to be paired with at least one other family member or friend who's able to be there and to support them in this process. And this is to say, it's a lot for these patients and you're there at a crossroads. So it's very important to be attentive to the changes that they're undergoing and to utilize resources like pastoral care and rehab psychology when necessary. And if you're not already acquainted with your local representatives who can help with engineering support, here's some numbers. Thank you. Thank you so much, Dr. Ponzi. Please, if you have questions, hang on to them. We will answer them at the end. Our next speaker is Dr. Leslie Rydberg who currently serves as an attending physician as well as the Henry and Monica Batts Medical Student Education Chair at the Shirley Ryan Ability Lab where her practice focuses on medically complex rehabilitation, LVAD rehabilitation, neurorehab and electrodiagnostic testing. She is also an associate professor of PNR as well as medical education at Northwestern University Feinberg School of Medicine. All right, thanks everyone for coming. I am glad to see so many of you in the audience who have a great interest and passion about heart failure rehabilitation. I was worried we were not gonna have anyone here because all of the residents in my program seem to have other very important sessions to attend at 10 o'clock this morning. So I'm not sure what that is because I think obviously every physiatrist should know about heart failure. So I'll talk about Milrinone, intravenous Milrinone in the post-acute setting and a little bit about remote heart monitoring. But how did I get here to being a physiatrist who works with heart failure in medically complex patients? So I went into PMNR planning to do non-surgical orthopedic, sports medicine, all of that. And I found that I didn't love it. I didn't feel like I was making the kind of impact on people's lives that I really wanted to do. And so of course my residency program director said, well, what are you gonna do with your life then? I said, I don't know. And he said, you're gonna do inpatient rehabilitation. I said, I am? He said, yeah, and you're gonna do medically complex rehabilitation. And so here I am. So that's how I found this path. And I started working at the Rehabilitation Institute of Chicago and he said, how would you like to run our LVAD rehab program? I said, we don't have an LVAD rehab program. And he said, exactly. And so I've started, I've been working with patients with LVAD since about 2009, 2010. And so it's been really fun to see the evolution. And so what I actually really enjoy is what are the innovations that all of those brilliant cardiologists and medical scientists are making and how can we as rehabilitation providers and physicians really provide that support so that our patients have the rehabilitation that they need. So anytime something new comes up, they circle back to me and say, hey, how would you like to? And I raise my hand. So that's how I ended up running our COVID rehab unit. That's how I got involved with Milrin On Drip. We actually were accepting for a while a novel device that was a portable intra-aortic balloon pump. So that is a story for another day since that's not commercially available at this point. But I'll start talking about Milrin On. And so Milrin On Drips are certainly something that our acute care colleagues and our internal medicine colleagues are very comfortable with using and not something seen as commonly in patient rehabilitation. And so it is an advanced life support medication. It's classified as a presser. And so we don't usually, we usually say, okay, if you need that, you're leaving rehab. You're not coming to rehab. But the mechanism of action, the way that it works is it's a bipurity and phosphodiesterase inhibitor that affects the cardiac tissue. And so it affects the C-AMP and the C-GMP levels. So the C-AMP actually works on that cardiac excitation contraction coupling. So it actually helps to increase the contractility at the level of the heart. And the C-GMP leads to vasodilatory effect in arteries and veins. So it actually works to change the peripheral vasculature with increased vasodilation. My sister-in-law, the pharmacist, could probably explain it better. But basically it's helping to support the underlying cardiac function. And so it's really used as a short-term IV therapy for patients with acute decompensated heart failure with reduced ejection fraction in need of inotropic support. So usually that's in the ICU. That is our perioperative patients who are in there for transplant valves, CABG procedures. It has also been used for severe heart failure retrofractory to optimal medical therapy. And so this is where we come in because they're using it now for more chronic heart failure conditions. And so it is used ideally as a bridge to definitive transplant, or excuse me, bridge to definitive treatment. But as we know, what is definitive treatment for end-stage heart failure? I mean, LVAD, but really heart transplant. And that is a whole different talk for another day in that many of our patients won't qualify ever or may not qualify currently. So milrinone is delivered as a weight-based treatment and it does require a continuous infusion. So what equipment and access do we need to provide this care to our patients? So first and foremost is they need a central line in order to get this treatment. A peripherally inserted central catheter is adequate, but they must have some form of central line that they're able to get this continuous infusion. It cannot be given through a peripheral IV. So number one, that's what they need. Number two is they have to have the infusion pump in the room. And because if the treatment is interrupted, even shortly, it could have dire consequences. We have a backup pump in the room. So an infusion pump, a backup infusion pump, obviously the appropriate IV tubing to connect everything. And then we keep a 24-hour supply of the medication on the floor so that at all times we have enough and we don't have to worry about shortage or not getting the medication from pharmacy. And then what are the cautions that we have to think about in our patients on milrinone? So if there is, again, a peripheral IV, if it extravagates into the surrounding tissue, it can actually cause tissue necrosis. So that's why the central line is so important. The common side effects are really from that peripheral vasodilatory effect that I mentioned. So headaches, syncope, severe hypotension. And the main thing we're looking at is that the hemodynamic changes. So our patients with heart failure come in with baseline blood pressures relatively low, and that's where they live because of their underlying cardiac dysfunction. So what we're looking for is, are they having a change in their blood pressures? Are they now developing new symptoms that are attributed to that vasodilatory effect? And then worst case scenario is ventricular tachyarrhythmias, not something we like to deal with in rehab. So thinking about, many of these patients have end-stage heart failure, so they may have an implantable defibrillator, they could have a life vest. So thinking about how we're gonna manage any arrhythmias if they show up. And then platelet dysfunction is another thing to look out for in our routine lab monitoring for our patients on milrinone. And so what are we looking at, or how are we monitoring these patients? So any of our patients with severe heart failure and inpatient rehabilitation, we get daily weights. I don't know how your institutions do it, but we get daily bed weights, which means it's kind of a general estimation of their weight. I had a patient with heart failure who also had an amputation, and so some days they weighed him with his leg and some days without. And so it's hard to know if that was fluid or prosthetic. So we do have some challenges there. But ideally, following weights is our best option in rehab to look for fluid shifts. In's and out's not super easy to get in many of our patients as well. So we're looking for changes in blood pressure, new onset angina or palpitations, or significant dyspnea. So we're really looking for a change in our patient's cardiovascular functioning. And then consideration for inpatient rehabilitation. So in order to safely deliver this, number one, we need to make sure we can maintain that continuous infusion. And so these patients, again, have to have all the equipment, the backups, the medication, but they must get it continuously. And so that includes during therapy and rehabilitation. So you have to have nurses who are well-trained in administering the medication and therapists who are comfortable walking someone around the gym hooked up to their Miller & Owen drip. And it's really a great translation thinking about how we're going to do things functionally, getting dressed, going to the bathroom, ambulation, while dealing with this continuous infusion. Off-unit activity. So if anyone's going to leave the immediate surroundings of the floor, they must have a nurse with them in case there's a problem with the Miller & Owen. And then ongoing vital sign monitoring, especially during therapy. And then for dose adjustments. As a physiatrist, I don't feel like it's my role to decide what dose someone should be on with Miller & Owen. So you must have that close communication with the cardiologist who's prescribing it. And then thinking about when we may need to adjust a dose. So I said it's weight-based, right? So if someone's weight changes dramatically, we have patients who weren't eating and start eating in rehab. So they start gaining weight. We have patients who are very fluid overloaded or aren't eating and are losing weight in inpatient rehabilitation. So thinking about weight-based dosing. So we do have that issue come up sometimes. And then how do we think about discharge planning? So someone's going to go home with this continuous infusion. So we set that up early with the company to make sure that they have everything that they need in terms of the supplies, the education, the continuous medication. We coordinate with cardiology. We make sure they know what date they're being discharged, what dose they're being discharged on. They have to have that follow-up appointment to make sure that there's that continuity of care. Patient and family have to have all of the emergency numbers of who to call. And so that's kind of the great thing about them being in inpatient rehabilitation is we can do that education over and over again. But then I don't want to get the phone call 24 hours after discharge saying, oh, there's a problem with the Milrinone. That's the worst possible phone call to get. First of all, I want there to be no problem. Second of all, I shouldn't be your emergency contact for Milrinone, basically, is what I think about it. All right. So that's Milrinone. And I think we've been relatively successful about integrating that into our rehabilitation workflow. As Dr. Shapiro said, many of our patients with heart failure do have stroke or other neurologic sequela. And so we have mapped out specific areas of our rehabilitation hospital that take patients with LVADs, that take patients with Milrinone drip so that we have a specific group of nurses and therapists who are comfortable working with that diagnosis. And same with comfort with physicians and comfort with the care managers and social workers so that we're not reinventing the wheel every time we have these patients. So we kind of have a center or a group of people that are most comfortable with that. So the other things I'm gonna talk about are kind of the remote cardiac monitoring. And because there's not really a device that we have to titrate or things we have to measure, these patients can actually go to any service or any floor because there's just fewer specifics that we have to know from an educational standpoint. So the CardioMEMS is a heart failure system, and it's an implantable wireless pulmonary artery pressure sensor. And so I've started getting patients with these, and this is really cool. They measure the pulmonary artery pressure, which is a surrogate measure for fluid retention in the lungs caused by worsening heart failure. So this is a monitoring system, and we see that pulmonary artery pressure goes up in hemodynamic congestion. So it's placed in the distal pulmonary artery via a right heart catheterization procedure. So it's relatively low risk. It's not an open procedure. But it is, in theory, a way to catch early indicators of worsening heart failure. So what do we think of as rehabilitation professionals? We see that weight change. We see the symptoms on that far end on the right. So if we're seeing weight changes, that may be a little bit too late for us to intervene. And so what this is seeing is that early time, they're starting to see in that green and yellow the change in filling pressures. And so if we can catch those changes earlier, can we make medication changes, do interventions earlier, and prevent that symptomatic decompensation, hospitalization end of the picture there? And so it's implanted in people with Class 2 or Class 3 heart failure who have been hospitalized in the past year for heart failure exacerbations. And the other criteria is that they do have elevated BNP levels that go along with their clinical picture. And so, like I said, it's placed via femoral venous access. And it's this really tiny device. You can see the picture next to the dime. I always do better if I have money to kind of give me a sense of how big or important something is. And so it is just kind of stuck in there really pretty easily. And so it's contraindicated in patients who can't take dual antiplatelet or anticoagulant therapies in the short term after the procedure, because there are some adverse events of the implantation procedure itself, bleeding, infection, air embolism, kind of all of the things you would expect with any sort of procedure. But of course, like the bad things, stroke, thrombus, cardiovascular injury, cardiac perforation, myocardial infarction. So it's not a low risk, not a un-risky procedure. But there are things to kind of watch out for with the procedure. But the really cool part is the data acquisition. So the patient initiates a sensor reading. The readings are wirelessly transmitted to the secure website, and then the clinicians can access and review the website. So they come over and they've got this patient electronic system. All they have to do is like say, hey, give me a reading. And it gets sent over to the cardiologist. Not to me. I don't have access to the data. So they can't send it to me, because I'm not involved in the patient care network and the monitoring system. But this is information that we can collect. And so our normal pulmonary artery pressures, it's usually 20 millimeters of mercury or less. And target PA pressures in this patient population are about 18 to 25. So if you know the patient's baseline, and then you can follow over time, are these going up? That would be an indication to kind of look at their heart failure regimen. And so they can use their own mobile devices to transmit information about this. But why this is, I think, really cool is that there's no activity restrictions. They can shower. They can bathe. They can do all their therapies. We can use our regular heart failure guidelines. But it is this advanced tool for additional heart failure monitoring. So one example, I had a patient who we just kind of had a hard time figuring out, should we be giving her diuretics? Should we be giving her fluids? Like we had a really hard time knowing where she was from a fluid status standpoint. And so we had her send kind of every other day. We had her trigger this, send it to her cardiologist, and we called her cardiologist. And the cardiologist was like, oh, well, actually her pulmonary artery pressures are going up. So we were able to use that to guide her diuretic therapy. So I think it was actually really helpful for us in a way that we are sometimes guessing a little bit in rehabilitation. All right. And then really quickly, just the ZioPatch. So we do, as rehabilitation professionals, we get patients with these kind of little devices. And this is kind of the latest generation that I've been seeing in Chicago. There are different brands. There are different types. But it's basically just ambulatory EKG monitoring. The ZioPatch is nice because it sticks on really well. It's kind of like right over the patient's chest. It's water resistant. It doesn't bother them with therapy. These don't fall off. I've not had them fall off a lot. So this has been a really great innovation to get kind of that continuous 14-day EKG monitoring. So our patients come over with their box, and they place it right when they leave. And then all we have to do is take it off, stick it in the box, and stick it in the mail. So the hardest part is remembering when to take it off. And so I put it in the note, and I write in Sharpie on the box. And I figure it's okay if it's a little extra, you know, a couple extra days, and we don't get it off on the exact right day, it's okay. But this has been something that doesn't help us in the immediate moment during rehabilitation, but it can certainly help the referring team in the workup of patients who have had stroke or syncope are probably the two biggest reasons that the company states and that I've seen it for. So for patients with palpitation, shortness of breath, dizziness, lightheadedness, presyncope, fatigue, anxiety, which many of our patients have one of these or all of these. And so this can be a really good way for the referring teams to get information. I don't place them myself, but a lot of our referring teams do. So many patients come over, and I don't even know they're there until I'm doing the physical exam. I'm like, oh, hey, you got one. And in terms of inpatient rehabilitation, like I said, this is easy, fine. They can shower after it's been on 24 hours. You shouldn't take a bath. We're not really doing baths in inpatient rehab. Keep lotions away. There is a button that the patient can press if they feel symptomatic. So there's a little check, and it says, okay, it was 12.30, and the patient had some symptoms. And that lets the people interpreting the study look at their EKG tracings at that time. And then they can log their symptoms as well. All right. And there are my references. Thank you very much. I actually learned a... I shouldn't sound surprised. I learned a lot from that talk. And our final speaker is Dr. Sarah Eichmeier, who is an associate professor and serves as the residency program director in the Department of Rehabilitation Medicine at the University of Kansas, where she also serves as the medical director for acute inpatient rehabilitation. And she has triple boarded in PM&R, brain injury medicine, and electrodiagnostic medicine. All right. So I'm going to finish out our talk with talking about heart transplantation and to pick up where Leslie's story dropped off. I also had a meeting with our program director in my fourth year, and he said, what are you going to do? And I said, I think I like inpatient rehab. I think I like medically complex rehab. And he went, hmm, have you talked to Leslie? So that was the beginning of my journey. And I do want to say that I am at University of Kansas. We have a 29-bed general inpatient rehab unit, and we have successfully been able to take these patients with advanced heart failure interventions, as well as our strokes, our brain injuries, and our spinal cord injuries. So last week alone, on my service, I had one LifeVest, one dobutamine drip waiting for a VAD, two VADs, and a heart transplant, and a half a dozen stroke patients. So you can do this. You don't have to be a freestanding, huge rehab hospital. You can kind of do this wherever you land. So the objectives are to look at medical needs during inpatient... cardiac rehabilitation, but I really. throughout their continuum. They are so deconditioned. this process through home health, outpatient, and possibly even outpatient cardiac rehab once they're transplanted. So if you have done some transplant rehab in the inpatient rehab setting, you will know these things, but I just want to bring them up because this is true of all transplant, not just heart, but liver, kidney, lung, bone marrow. Close communication with the transplant team is key, and your key person in this part of your equation is the transplant coordinator. When you're setting up a program like this, you need to know who your coordinator is because they are like the savior person. They are the person who knows all the things. They're the person you can ask questions of. They are very key in this communication with taking care of these patients on your rehab unit. Another key component is immunosuppression monitoring. So when you get to transplant, of course they're going to be on chronic immunosuppression. These drugs are going to have to be very closely monitored for drug troughs, and you have to work very closely with your transplant pharmacist to make sure that they are having the right doses, and you're monitoring those levels appropriately. And then the final kind of key transplant consideration is to just be aware of the signs of organ rejection. For each population of transplant that you care for, you need to know what it looks like when that organ isn't working because it might be subtle, and it's going to be different, and you have to be able to monitor that as the physician caring for these patients. So for heart transplant, it's very important to be aware of that. These patients are going to need serial right heart catheterizations and biopsies, usually weekly, and then it'll spread out a little bit later on. And you have to be able to decide as a program, can you manage that? Can you get the patient to their biopsy every week? How is that going to interrupt their program? So those are kind of three big things to be aware of before we go. So for maintenance immunosuppression, there's three main categories of drugs that I think you should be aware of because your patients are going to be on all of them. The first one is glucocorticoids. There's usually a prednisone taper, very prolonged prednisone taper, and of course the side effects of prednisone, as we all know, are listed. I think I highlighted a weakness because a lot of times, depending on how high dose of steroids these patients are on, they may develop a steroid myopathy, which can be difficult to distinguish from just their overall very deconditioned picture. But it's important to be aware of it so you can work with the transplant team to potentially adjust the dose of steroids if needed. The next class is calcineurin inhibitors. Usually these patients are on either taquilimus or cyclosporine. This is the drug that you have to monitor the trough levels, and this is something you have to work with your nursing staff and your phlebotomist to get the timing right because it does have to be a trough level. These drugs need to be given twice a day, 12 hours apart, no matter what, and so it has to be done at the same time every day. This was one of the biggest challenges when we were getting our transplant rehabilitation program off the road, on the road, was getting these trough levels done appropriately and then giving the medications give at the same time every day. So that took a lot of interdisciplinary work with pharmacy and nursing and phlebotomy. The side effects of taquilimus in particular can be weakness, but also tremor. And so if you're taking care of transplant patients, you may notice, depending on what their taquilimus levels is, they get a very kind of large tremor in their hands. Depending on how bad it is, it can interfere with their activities and daily living, grooming, dressing, eating. When it gets to be the point where they can't pick up their fork and feed themselves breakfast, that's probably a little bit too late. You probably already should have been calling the transplant team, but you might need to adjust the dose so that they can get through their ADLs without that interfering tremor. The last class is antimetabolites, so mycophenolate or azathioprine. Side effects, just to be aware of, are listed here. Sometimes if they do have a concurrent infection, this is a drug that might be held. So if they had a post-operative sepsis or UTI or something like that, the mycophenolate might be held because it does have side effect increasing risk of infection. So then, of course, you have to be aware of infection prophylaxis in transplant patients. And so, in general, for PCP prophylaxis, these patients are going to be on Bactrim, usually, unless there's some sort of like a lab issue, and then they might be switched to Dapsone or Tovaquan. So here's some side effects listed. Again, rashes, hyperkalemia, cytopenia. For CMV prophylaxis, valgaine cyclovir or acyclovir are typically used. And again, a lot of these drugs have a side effect of cytopenias, and so you are monitoring their labs very closely, maybe more often than some of your other patients on your rehabilitation unit. Most of our transplant patients get daily labs throughout their entire stay. We're not really able to cut back on those for all the reasons I'm mentioning. And then, oral candidiasis. These patients are on usually a nystatin switch and spit for at least four weeks post-transplant. When we started doing this program, we didn't maybe understand that this was kind of a unique thing for our heart transplant patients. We were very comfortable with liver and kidney and didn't realize that this nystatin was intentionally part of the protocol. We learned very quickly, do not discontinue the nystatin. They need to be on it. So, medical complications for your transplant patient. Of course, rejection, right? That is the most feared complication. It is important to know that half of heart transplant rejection occurs within the first six weeks. That is when they're with you on your rehab unit. Some of the symptoms might be an increase in fatigue. It might be weight gain or signs of volume overload. It might just be exercise intolerance. Frank heart failure is really a late sign. And so, your index of suspicion needs to be very high, very high for these. Because of the high rate of rejection for heart transplant, this is the serial right heart catheterization with biopsy. So, it usually is weekly for several weeks. They are progressively spaced out as the patient does better. But, this is pretty much almost a whole day process where they have to be medically excused from their three hours of therapy. At our institution, they are transported over to the cardiac cath lab. They get their biopsy. Cardiology meets with them. The surgeon meets with them. The whole transplant team meets with them. It's a whole day missed of therapy every single week. And so, we put our patients on a modified schedule so that they get the makeup therapy over the weekend. So, they don't lose too much time. So, other medical complications, of course, are infections. So, within the first month of heart transplant, it's usually nosocomial infections, upper respiratory infections, pneumonia, UTI, cellulitis. They are also immunosuppressed, right, because of their drugs. And so, opportunistic infections do exist, but that's why they're on the prophylaxis as well. And the symptoms of infection may be masked by immunosuppression. So, they may not mount the fever or the white count. So, you have to have a very high index of suspicion for these complications. Just listed a whole bunch of other things that can happen. I don't want to talk about all of them in detail, but you can kind of read through them here. I think that of these, we have a lot of critical illness, polyneuropathy, myopathy, depending on how their pre-op and post-op course went. They're very critically ill and they're very weak. We also get a lot of encephalopathy and delirium. And so, that is challenging, too, because you're managing not only a very medically complex patient, but a cognitively impaired patient who needs to learn a lot of new things about how to take care of this heart. And so, it can be very challenging to manage these patients in your program. So, I did want to mention a little bit about heart transplant precautions. So, we mentioned earlier the move in the tube precautions. Classically, sternal precautions were pretty limiting as far as not extending back with your arms or lifting, abducting over 90 degrees overhead. Individualized sternal precautions slowly replaced those very prohibitive precautions because it was hard to do activities of daily living if you couldn't use your arms very much. But more recently, the move in the tube precautions have become more widely accepted and are actually very conducive to activities of daily living. So, the idea is you just have to kind of keep your arms close to your side as if you're in a tube for six to eight weeks. And within that restriction, you can do your ADLs. So, if you need to push up a little bit to get out of bed to do a transfer, it's fine. If you need to use a walker to get around, it's fine. You just have to maybe avoid, you know, kind of coming out of the tube. So, it's been, I think, really helpful for our patients. They're able to do their ADLs and not worry so much that they're going to disrupt their sternum. So, cardiac monitoring during therapy. So, as you know, this is a classic SAE board question, the denervated heart physiology, right? We teach it to our residents every year. But it's important because there is no parasympathetic vagal tone to the transplanted heart. So, at baseline, you're going to have a resting tachycardia. You're going to have a little bit of an elevated blood pressure at rest. And then that heart relies on their circulating catecholamines to have this ramp up to activity. And so, you're going to need a slow ramp up, a gradual increase for exercise. They're not going to be able to mount an appropriate response because of their new physiology. Their peak heart rate will be 25% lower than expected for age. And their VO2 max will be 33% of predicted. So, they're going to... Basically, you can't rely on their targeted heart rate for your exercise prescriptions. And so, most people use the Borg rate of perceived exertion, which is shown here on the slide. You want to target kind of that moderate intensity, right? That's somewhat hard, that 13 on your Borg scale. There is a modified Borg scale and you can use something called a dyspnea index as well. And so, this is the one part of the lecture that is still true from your classic cardiac rehab lecture. It's just a little different after you have a heart transplant. So, I did want to list out the therapy goals by discipline because I think it can be helpful when you're talking to your team and you're thinking about adding this to your program. What are all the therapists going to do? Because you're going to have to work with them to understand how this patient population might be a little different and what are the goals. Luckily, they're not that different from kind of what our therapy colleagues typically do. PT's working on mobility and endurance training. A lot of times, they're pretty much independent for mobility when they show up. They're just very, very weak. They can only walk a couple feet. And so, we spend a lot of time working on endurance. Occupational therapy, of course, ADLs. But also, if they do have that tremor from the tachylimus, trying to find some adaptive equipment that might make it easier. Some weighted utensils for eating and grooming. And then, we talk a lot about energy conservation and pacing strategies because they're still, you know, recovering from just their very overall weakened deconditioned state. Speech therapy, depending on if they were critically ill and have some dysphagia or dysphonia, or if they had the encephalopathy or delirium, speech therapy is very often involved in these patients. Psychology, there is, you know, a decent amount of depression and anxiety afterward. And again, if there's some cognitive changes, you might get psychology involved. We have our dietician see every single one of these patients because most of them are malnourished. And nutrition is very important as they start to build their bodies back up after transplant. And then for a social work case management team, looking at kind of navigating through the murky waters of their insurance approvals and what they can get afterwards. And of course, just overall discharge planning. So, patient education. So, this is, I think, where physiatry really has a role to sit down with your patients and make sure they understand what comes next. The acute hospitalization is such a whirlwind of activity, and most of times my patients are too overwhelmed to even understand what the heck they learned when they were in the hospital. So, we spend a lot of time talking about, this is what comes next. This is your rehab plan. This is your exercise plan. This is what it looks like if you start to have signs of rejection or side effects from your medications. This is all the things that you're gonna have to take with your new immunosuppression regimen. We spend a lot of time with our pharmacists teaching the family and the patient the importance of adherence to that program. We do address their anxiety and depression because now that they've come through this huge life-changing milestone, it's exciting, right? They're ready to move on, but there's a lot of conflicting emotions there. So, we spend a lot of time just chatting. And of course, the transplant medications. So, for discharge planning, it gets tricky because depending on where you get these patients from and if they're still at your institution for their transplant cardiology follow-up, they have to have ongoing laboratory monitoring of those immunosuppressant drugs. You have to have coordination with the transplant team for education and teaching. In our program, what that looks like is that the day of discharge, we do rehab education and then the transplant coordinator comes over and does discharge education and then the transplant pharmacist brings a big bag of drugs and does all the teaching and then they get to go. So, it's a very busy day. It could look different. You could discharge them from your rehab hospital and then they would have a same-day appointment in the transplant clinic to get all that discharge education and teaching done. So, you have to make sure you coordinate with your cardiology colleagues what you want your program to look like. Cardiac rehabilitation is recommended for most of these patients, but it kind of depends how weak they are and how much assistance they need when they leave your program. A lot of our patients need kind of traditional therapy first and then they go to cardiac rehab to really work on that endurance when they've graduated. So, I did include a table and the references are also included in this presentation. There's a handful of studies out there that have shown outcomes after inpatient rehab for heart transplant. Not a lot. We need more. If anybody wants to do another study, let me know. Leslie, I'm looking at you. But the good news is they do well. So, you can see FIM gains are pretty good here in the middle column. There may be a little lower than your general rehab population, but they're pretty good. They still make functional changes. They still have a pretty high discharge-to-home rate. They still make changes on your six-minute walk test, your timed up-and-go, your Berg balance, all our regular rehab outcomes. These patients make improvements. The one thing to be aware of is they're going to have a higher acute hospital readmission rate because they're a medically complex patient population and they might have a little bit longer length of stay, too. So, you have to figure out, is this population right for your program or not? I would encourage you to think about it if you're not taking these patients. They've been a wonderful addition to our program. They really help with the complexity, right, the CMI mix in your group. They're a huge service to our organization and it helps that we have kind of a wraparound care for the heart transplant patients so that they can get everything I'd like to thank all of our fantastic panelists for very, very nicely, briefly reviewing a very complicated topic, and we're going to open things up for questions, and Dr. Harvey, you're up first. Thanks. Is this on? It's on now? Okay. Well, you can hear me. I do want to thank you all. Not having been blessed as a parent, three of you up there are my surrogates, and I'm so proud of you guys. So this question is actually for Leslie. If you go home on Miller Roan, are there like portable pumps that you can like carry in a backpack so you can actually go out of your house and do things? Is this one on? Yeah. Okay. Yeah. So we can set them up with a portable home device, similar to someone who's on home oxygen. So they do not have to walk down the street with an IV pole. So ideally, we get that set up with the home infusion company so that they're actually given the device and can work with it immediately prior to discharge. So they can't have, we don't have access to that for during inpatient rehabilitation, but there are better devices for a community. Yes. Hi. Excellent presentations all around. And my side gig is medical ethics, and there's been a lot of concern in the ethics community about people getting stuck on these ventricular assist devices without even people talking about them. They say, here, this is just what you need. And I know in a lot of the cancer rehab lectures we've had earlier in the week, they've talked a lot about sitting down and having the talk with the patient, where you really go over their functional prognosis that we're very good at, but also with their life prognosis and how that all fits together. And I'm wondering if that's part of the rehab, particularly, for many of these conditions, particularly these left ventricular device, because, I mean, to me, it looks like their prognosis is probably as bad or worse than many of our cancer rehab patients. And how do you deal with that? Do you want to take that? You actually have a good example. So we were actually chatting amongst ourselves right before the session on that very topic. And several of us have had kind of disaster cases, because too often, physiatrists are not involved in those discussions prior to implantation. And I can share an interesting example, and Dr. Eichmeyer actually had an interesting one as well, if she wants to share. But I had a woman on my service for about 60 days following a right brain stroke. And she had come to the hospital in progressive heart failure, and they had the conversation with her while she had capacity. And she said, no, I don't want to live with an LVAD device. And at that time, it is my understanding, she had that ability to make that decision. I, of course, met her after her stroke. After she had a right brain stroke on the acute care service, she no longer had decision-making capacity. And she said to her mother, who had low health literacy, didn't really understand the situation well. And they did implant the device, and the family was completely unable to care for it. The patient became profoundly depressed, because she didn't want to live that way. So we are seeing these situations arise. Would you be able to talk about your case as well? Yeah. We had a patient this last year who was not a good LVAD candidate, was denied for an LVAD several times by the committee, because he didn't have social support. Finally found some friends who were going to be his supports, and we know how that goes. So they implanted the device, and then the next day, he had a post-operative bilateral MCA stroke with global aphasia. So that was kind of a mess. We ended up bringing him to inpatient rehab, because he did start to improve, and it was frustrating. It was frustrating for everybody. He ended up spending six months in our unit, which is not great, because where are you going to send a globally aphasic patient? still texts my OT every other week and says, I'm doing fine, although it's mixed up in aphasic still. But he's doing really well. So yes, those things happen all the time. Because of that case and several other stories, which I will not share, I raised my hand because I do that a lot. And we are in the works of getting a physiatrist on the VAD selection committee because we need to be at those conversations for our institution. I think that we have a therapist on the committee, a physical therapist and an ethicist. I'm Michael Leonard McAllen. I was asking about the Millerone. When they go home, it seems like they're so careful while they're in the hospital. Gotta have a nurse with them all the time. But suddenly they go home and they're on this Millerone therapy, which we normally wouldn't have been given if they didn't have a nurse with them. How is that possible? And how often are there complications? And what's the life expectancy of those people? I had another question after that. In terms of Millerone, you're right. We are very cautious in the inpatient setting and they have all the resources. The nice thing is is that the infusion pumps that patients are given are much easier to navigate than setting up all the tubing and the pumps and everything. So it should be relatively easy for patients and families to manage that pump. And they do get training from the company and they do get support from the company. And we do set them up with home health nursing to have that additional support. We honestly do see that these patients end up back in acute care hospitals with some regularity just because they have end-stage heart failure that requires Millerone. So their rate of hospital readmissions is pretty high. And some of these patients, we can end up getting off the Millerone because of improvement in cardiac function with inpatient and intensive outpatient rehabilitation. Some people do end up getting that definitive management or more advanced management, LVAD heart transplant, things like that. And the life expectancy is useful. I don't have that data. I have one other question. I've been taking care of cardiac patients for over 30 years. And I guess my experience is we followed the road treatment that the cardiologists or the thoracic surgeons give us, you know, not to use the upper extremities. But to me, it never made any sense. We don't have, you know, if you're using your arms to press down, I don't see how it affects the sternum. And using your arms, except for maybe butterfly exercises, I'm not sure how it causes sternal dehiscence. But that's always what they've been afraid of. And they want to attribute any complications to something that they did actively. When the only ones I've ever seen having more problems have been patients that have an infection in that area. So has there been any studies that show that if we use the upper extremities to normal activities, that it would have an increase in complications? Yeah, so there is a paper that looked at classic sternal precautions compared to the move in the tube, the updated ones, and found no increased complications with kind of moving towards, you know, the move in the tube, which you get to use your arms. So I don't know if I have the reference in here, but that does exist. It'd be nice if we were able to treat them normally. Because all of them end up with atheist capsulitis in the shoulders. And of course, probably some increased falls because they can't use their arms to balance themselves. Thank you. Thank you so very much. It's so exciting to know that there's young people who can take care of us. Gosh, I'm, you know, like totally proud. Thank you very much. Two questions, and Sarah, you started answering one. There are a number of people who are undomiciled or have unstable housing situations. And so bringing them to rehabilitation is a problem because the skilled facilities won't accept a patient with an LVAD, with no renown. So I'm just curious, you know, how you've navigated that. And the second question, of course, is related to what appears to be the Medicare-managed care companies now all of a sudden deciding that, well, they have low exercise tolerance. Well, they're not appropriate for acute inpatient rehabilitation. And it seems to be newer this year. I didn't know if there's any tricks you had in terms of speaking to the pediatric urologists who are doing the rehabilitation reviews. Yeah. Thanks. I can take the first one. Yeah, I'm happy to answer the second. Perfect, okay. So I can just tell you what we've done in Kansas City for that very issue is, you know, we were one of the first acute inpatient rehab units that would take VADs and no renown drips and heart transplants. And then what happens if they can't go home? And so what we have done, honestly, is worked within our metro area with our preferred provider network for our institution to say, listen, if we are going to provide comprehensive care from beginning to end for these patients, we need in this area a couple of skilled nursing facilities that will be able to manage these patients appropriately. And so we have identified two skilled nursing facilities in our area and with rehab and cardiology working together have kind of trained their staff to be able to manage these patients. So that is what we did because that was such a need because you want to be able to provide them the rehab services that they deserve, but you don't want to exclude them if they don't have a discharge plan, right? Like that is such a conundrum in our industry. We do have a couple skilled nursing facilities in the Chicagoland area that are LVAD trained. Could you just comment that LVAD training is the most in Medicare? So we sort of have a very similar situation where our LVAD team has gone out and trained a number of skilled nursing facilities, but we have this difficulty in that they're not contracted mostly with the Medicare Advantage plans locally. We are very, very cautious bringing these patients in after some experiences, but some very much do need the rehabilitation. We do kind of tentatively, you know, go on paper with an earlier discharge day than we actually think they'll need. And we start that appeal process very, very early on. Nava Health in particular, which oversees a lot of local plans, I see some nodding, has been really, really problematic and they will deny all the time. We're pretty good at getting initial authorization for acute rehab because there's like legitimately very few places that can safely manage these patients. But for those with really bad endurance who just are gonna need more time, for those whose social situation may be not ideal, it is really, really challenging, but we get on it right away. And we do eventually, we will get SNF coverage eventually if we appeal enough, but it is not uncommon for me to do three or four appeals both over the phone and in writing. I have like a template I've been using of late and it's successful. And I've gone to Twitter, not with any protected information and just like stop Nava Health. And then miraculously, I get off. I encourage others to use that hashtag. I'm currently the only one, but. Say that again. Hashtag stop Nava Health. If you have a patient with a Medicare Advantage plan for which Nava Health is the third party vendor, they're really difficult with Medicare Advantage and getting patients to skilled nursing facilities after IRF. It's a problem like we discussed it in the inpatient rehab group the other day, but keep fighting. You will, if it's a really strong case, you'll get there. It's exhausting. But yes, I've gone to three and four levels of appeal and I've always eventually gotten what the patient needs, but start early. Yeah, you gotta fight hard, right? Excellent, thank you. I'm Dr. Lisa Merritt, practice between Sarasota and Florida and a lot of places, Sacramento and Sarasota, Florida, a lot of places in between. And recently was upstate New York and had a case of a woman who actually came after brain surgery for a brain tumor. And on exam, I found that she actually had a loop monitor that somehow didn't quite get mentioned in everything that had gone on and had to do a lot of investigative reporting to figure it out. Couldn't find anybody to interrogate or what was it connected to. And apparently she had been lost to follow up for six years with this in place and was about to start chemo radiation. And so it was a bit of a conundrum. And my point is that we have to also look at follow up and care coordination on these cases. By that point, the battery was dead, but she was actually going in and out of a fib still. And it was a bit of a situation, as we say. Anyway, we got all that straight and she got stronger by the time we went home, got her all good. However, she then came back and had some challenges probably because of seizures and things because they weren't following up on the new medications that she had been placed on. So it's a whole idea of continuity of care, is my point. I had another case that actually was another type of transplant. However, she was a sacroilamnus. And I was trying to figure that one out and had to go back to the original team that transplanted her. Because we were in a rural hospital somewhere in her own home setting now, only to find out that they were tracking trough levels and that that should be done. And so I had to go through all kinds of steps to figure out how to get that done and have that cook in so when we got her out, lost to follow up confusion or whatever. And she bounced back in with a fall and a seizure and probably related to the fact that she was super therapeutic at the time that I got the records back four days later after we had done it, after she had been discharged. So my point is, is the patient is your patient until you really hand them off and we have to all work closely together. And I wanna just add with a simple solution that I've used over the years, it's a scale. Sometimes I will even buy them. You can get them really cheap at Bed Bath and Beyond and instruct patients about weighing themselves. And it's a really simple intervention that people can be educated on and it's really very important to give them some sense of empowerment because heart issues can be extremely challenging. And then one last question, has anybody looked at the whole use of chelation therapy, which was part of the trial to assess chelation therapy was a national study done like 2006 to eight or something like that based out of Miami in which they were able to show a positive impact on the subset of patients with diabetes and history of myocardial infarction. I know we say chelation, everybody like goes all whatever, but it definitely showed improvement as a conservative management in helping people with congestive heart failure and MI. Thank you. I'm not personally familiar with chelation therapy for this patient population, but it sounds interesting and I will look into it. That's what I wanted to encourage you to do. All right, but thank you for those important points. You know, and a really good reminder to always examine patient's anterior chest wall because we do have that come up quite a bit where suddenly there's a Zio patch we didn't know about or a loop recorder that clearly has just been implanted. So any other questions? If not, we thank you very much for coming today. Thank you.

rehab considerations

advanced heart failure

low ejection fractions

interdisciplinary rehab programs

LVADs

therapy considerations

heart transplant patients

safety issues

IV milrinone

wearable defibrillators

sternal precautions

gait speed precautions