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Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Republic of Korea, Department of Rehabilitation Medicine1, Yonsei University College of Medicine, Seoul, Korea, Department and Institute of Rehabilitation Medicine2, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Republic of Korea, Department of Rehabilitation Medicine3 |
INTRODUCTION>
Patients with severe heart failure (HF) who are candidates awaiting for heart transplantation (HT), are at risk of cerebrovascular event. HF patients either with or without atrial fibrillation, showed 1.6% and 1.2% average annual incidence of stroke, respectively. Although, left ventricular assist devices (LVAD) are used as a bridge therapy to HT, they are associated with 9% annual incidence of stroke. We report a case of successful cardiac rehabilitation (CR) in HT recipient who had gone through upper and lower limb amputation and ischemic stroke during period of LVAD application.
CASE>
A-52-year-old man was admitted for cardiac, prosthetic and stroke rehabilitation. At initial presentation he could barely walk using a walker, aided by physical therapist since he had multi-comorbidities interfering his gait function.
Four years ago, he went through coronary intervention due to acute myocardial infarction (AMI). Compartment syndrome of right arm and left leg occurred due to iatrogenic vessel injury and suspicious vasospasm. As a result, he went through right above elbow (A-E) and left below knee (B-K) amputation. Prostheses for amputation sites were made. Meanwhile, deteriorated ejection fraction of 35% was checked and LVAD was implanted.
Two years after AMI, during period of LVAD application, right middle cerebral artery infarction occurred leaving him left side hemiplegic sequelae. One year later, LVAD was removed and went through HT. After general medical care, he was referred to our hospital for comprehensive rehabilitation.
Alongside stroke rehabilitation, he started ECG-monitored exercise training on bicycle ergometer. He could not go through treadmill exercise because his B-K stump was very short and the skin of stump was thin and fragile. We referred him to an orthopedic surgeon to take knee disarticulation and made a new knee disarticulation prosthesis.
Four months after knee disarticulation, cardiopulmonary exercise program re-started using a bicycle ergometer. Initially, the exercise intensity was set by rate of perceived exertion 13 for 30 minutes per session, daily for 8 weeks. As a result of the 8-week program, revolution per minute increased from 30 to 40 and workload of watts increased from 0 to 2. There was no adverse cardiovascular event throughout the entire exercise program. Additionally, he took prosthetic walking training and he could walk independently with prosthesis and hemi-walker.
DISCUSSION>
Ischemic stroke before and after HT represents a comorbidity with considerable impact not only on mortality but also on subse¬quent poor functional outcome. Sequelae of stroke can be a huge obstacle to CR and to gain optimal exercise capacity. In this case, right A-E and left B-K amputation left him a significant dysfunction in activity of daily living which made rehabilitation even harder. Despite all multi-comorbidities of this case, CR after HT was safe and effective for improving exercise capacity.
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