Physiotherapy and Rehabilitation Programs for Pediatric VAD Patients

Abstract

The field of mechanical circulatory support for children has evolved dramatically over the last decade. This is in part attributable to the development of smaller ventricular assist devices (VADs) which has expanded the array of support strategies in pediatrics. Extracorporeal membrane oxygenation (ECMO) was originally the cornerstone of mechanical circulatory support for children. Its ease of implantation, wide accessibility, and applicability to all patient sizes made it the first-line choice for urgent cardiopulmonary support. However, ECMO has significant limitations related to its extracorporeal design (i.e., pump external to the body with cannula inserted either in peripheral vessels or centrally similar to cardiopulmonary bypass), its thrombogenic nature, need for aggressive anticoagulation, and secondary complications. These issues limit the duration of support to weeks, with an exponential rise in complications beyond that time. Additionally, ECMO cannulation prevents easy mobilization of patients. Many patients remain heavily sedated and ventilated for the duration of support, and as such, there is no way to engage patients in active physiotherapy or rehabilitation. The advent of pediatric VADs has changed the way we approach children on mechanical circulatory support. The first pediatric VAD to gain widespread global use was the Berlin Heart EXCOR® (Berlin Heart GmbH, Germany). This paracorporeal pulsatile-flow device can be used for right, left, or biventricular support. A variety of pump sizes are available to accommodate all sized children, infants to adolescent. The more secure central cannulation technique with externalization of the cannula through the upper abdominal wall allows patients to be woken up, extubated, fed, mobilized, reconditioned, and rehabilitated. While the Berlin Heart EXCOR® is vastly superior to ECMO in terms of survival to and after transplantation, it still has a high risk of stroke [1]. The largest multicenter prospective study on the Berlin Heart was conducted in North America for the Investigation Device Exemption (IDE) Food and Drug Administration (FDA) trial [1]. This study reported a 29% incidence of stroke despite standardized anticoagulation and antiplatelet therapy. As such, a comprehensive approach to mitigating stroke risk and improving recovery post stroke through rehabilitation has evolved from the Berlin Heart experience.