Preoperative OT Evaluations of Left Ventricular Assist Device Candidates: Outcomes & Impact on Practice

PURPOSE: Over 25k US adults with heart failure have left ventricular assist devices (LVAD) (Molina et al., 2021). LVADs involve complex self-care demands (Spielmann et al., 2021) and are challenging for clients with frailty and cognitive deficits. Yet, programs do not consistently do pre-op functional screens and there is scarce evidence on these needs (Clancy et al., 2019). To address this gap, an OT department developed a protocol for LVAD candidates. Aims: Describe feasibility of pre-op OT evals as standard care. Characterize functional needs of this complex, growing population.

DESIGN: IRB-approved descriptive study of an OT protocol for LVAD candidates at an urban hospital (2019-22).

METHOD: Medical records data from pre-op OT evals were entered into a secure database. Coders had high inter-rater reliability (>0.9). Measures: Montreal Cognitive Assessment and Allen Cognitive Level Screen for cognition. Dynamometer for grip strength, a marker of frailty (Chung et al., 2014). Activity Measure for Post-Acute Care for ADL. Performance-based ordinal scale for LVAD self-care. Nominal coding of OT notes for LVAD self-care prognoses.

RESULTS: Of n=161 OT consults, 86% were evaluated (n=139), 73% inpatient and 27% outpatient, with mean length of 63 min in 1.2 sessions. Cognitive scores were below norms (MoCA M=23.3, SD=4.1; ACLS M=4.8, SD=0.5). Mean GS was 61.8 lb (SD=26.3) for R hand and 62.1 (SD=25.9) for L. AM-PAC was M=21.6 (SD = 4.0). 87% required cueing or physical assist on LVAD self-care. OT predicted 36% would need no assist, 39% some assist and 24% 24/7 supervision to manage LVADs post-op.

CONCLUSION: OT pre-op evals provide rich insight to the medical team on candidates’ functional needs and prognosticated LVAD self-management. This protocol was feasible in clinical care.

IMPACT: LVAD candidates are an emerging area of OT practice with anticipated increased volume and complexity. These data advocate for LVAD programs to routinely consult OT pre-op to optimize care.

References

Chung, C. J., Wu, C., Jones, M., Kato, T. S., Dam, T. T., Givens, R. C., ... Schulze, P. C. (2014). Reduced handgrip strength as a marker of frailty predicts clinical outcomes in patients with heart failure undergoing ventricular assist device placement. Journal of Cardiac Failure, 20(5), 310-315. https://doi.org/10.1016/j.cardfail.2014.02.008

Clancy, M. J., Jessop, A. B., & Eisen, H. (2019). Assessment of pre-operative psychosocial function among people receiving left ventricular assist devices: A national survey of US LVAD programs. Heart & Lung, 48(4), 302-307. https://doi.org/10.1016/j.hrtlng.2019.02.003

Molina, E. J., Shah, P., Kiernan, M. S., Cornwell III, W. K., Copeland, H., Takeda, K., Fernandez, F. G., Badhwar, V., Habib, R. H., Jacobs, J. P., Koehl, D., Kirklin, J. K., Pagani, F. D., & Cowger, J. A. (2021). The Society of Thoracic Surgeons INTERMACS 2020 annual report. Annals of Thoracic Surgery, 111(3), 778–792. https://doi.org/10.1016/j.athoracsur.2020.12.038

Spielmann, H., Seemann, M., Friedrich, N., Tigges-Limmer, K., Albert, W., Semmig-Könze, S., Spitz-Köberich, C., & Kugler, C. (2021). Self-management with the therapeutic regimen in patients with ventricular assist device (VAD) support – A scoping review. Heart & Lung, 50(3), 388–396. https://doi.org/10.1016/j.hrtlng.2021.01.019