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Annals of Physical and Rehabilitation Medicine 57 (2014) 138–142

Clinical case / Cas clinique

Rehabilitation of a hemiplegic patient with cardiac assistive device
Rééducation d’un patient hémiplégique porteur d’une assistance ventriculaire gauche
N. Bradai a,*, C. Andriantsifanetra a, A. Charlanes a, C. Scouarnec a, C. Cleophax b,
P. Leprince c, A. Yelnik a
a

Service de médecine physique et de réadaptation, AP–HP, groupe hospitalier Saint-Louis–Lariboisière–F.-Widal, université Paris Diderot,
UMR 8194 Paris Descartes, 200, rue du Faubourg-Saint-Denis, 75010 Paris, France
b
Service d’anesthésie-réanimation, AP–HP, groupe hospitalier Saint-Louis–Lariboisière–F.-Widal, université Paris Diderot, 1, rue Ambroise-Paré,
75010 Paris, France
c
Service de chirurgie cardiaque, institut de cardiologie, hôpital Pitié-Salpêtrière, 91, boulevard de l’Hôpital, 75113 Paris, France
Received 26 July 2013; accepted 19 December 2013

Abstract
Introduction. – Possible admission to a PRM unit of a hemiplegic patient equipped with a left ventricular assistance device (LVAD) may constitute
a cause for concern. We are reporting our observation on the subject.
Observation. – A 30-year-old hemiplegic patient presented with left hemiparesis secondary to a right middle cerebral artery (MCA) ischemic stroke
having occurred during cardiopulmonary arrest. Persistence of major left ventricle dysfunction necessitated installation on 8 November 2011 of a
mono-ventricular HEART-MATE II assistive device. Possible later recourse to cardiac transplantation would depend on clinical development. When
admitted to a PRM unit on 18 January 2012, the patient presented with left hemiparesis and cognitive disorders. Virtually all members of the attendant
medical and paramedical team were given instruction on the functioning of electrical power assistance systems. In spite of the complexity of the
logistics, and notwithstanding the difficulty of managing potentially worrisome medical problems, multidisciplinary rehabilitation efforts were
successful. The patient’s improved condition led to the decision to undertake heart transplantation, which was carried out on 27 October 2012.
Discussion and conclusion. – This observation illustrates the undeniable role of PRM in decision-making and, more generally, in the opportunities
that may arise in sensitive and challenging situations.
# 2014 Elsevier Masson SAS. All rights reserved.
Keywords: Hemiparesis; Ventricular assistance; Multidisciplinary rehabilitation; Heart transplant

Résumé
Introduction. – L’éventualité d’admettre un patient hémiplégique porteur d’une assistance ventriculaire gauche embarquée en service de MPR
peut inquiéter. Nous en rapportons l’observation.
Observation. – Un patient âgé de 30 ans présentait une hémiplégie gauche secondaire à un infarctus sylvien droit survenu au décours d’un arrêt
cardiorespiratoire. En raison de la persistance d’une dysfonction majeure du ventricule gauche, l’implantation d’une assistance mono-ventriculaire
gauche de type HEART-MATE II a été effectuée le 8 novembre 2011. L’éventuel accès à une greffe cardiaque était suspendu à l’évolution. À son
admission en MPR le 18 janvier 2012 le patient présente une hémiparésie gauche et des troubles cognitifs. L’essentiel de l’équipe médicale et
paramédicale a été formé au fonctionnement de l’assistance à alimentation électrique. Malgré l’aspect logistique, la complexité dans la gestion des
problèmes médicaux et l’inquiétude initiale que cela a pu susciter au sein de l’équipe, une rééducation multidisciplinaire a pu être menée à bien.
L’évolution de l’état du patient a contribué à la décision d’une greffe cardiaque et celle-ci a eu lieu le 27 octobre 2012.
Discussion et conclusion. – Cette observation illustre la place indiscutable de la MPR dans des prises de décisions et dans les chances qui peuvent
être offertes dans certaines situations délicates.
# 2014 Elsevier Masson SAS. Tous droits réservés.
Mots clés : Hémiparésie ; Assistance ventriculaire ; Rééducation pluridisciplinaire ; Greffe cardiaque

* Corresponding author.
E-mail address: nacerabradai@hotmail.com (N. Bradai).
1877-0657/$ – see front matter # 2014 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.rehab.2013.12.001

N. Bradai et al. / Annals of Physical and Rehabilitation Medicine 57 (2014) 138–142

1. English version
1.1. Introduction
Ventricular assistance is a form of therapy that is currently
widely used as a means of mitigating cardiac insufficiency,
whether it be temporary, prior to a heart transplant, or
permanent. To date, approximately 10,000 left ventricular
assistance devices (LVAD) have been installed in the world
taken as a whole, including 1000 in France and 82 in Europe in
2011.
We are reporting here on our observation of a hemiplegic
patient equipped with this type of apparatus. Possible later
recourse to cardiac transplantation would depend on clinical
development. Hospital objectives consequently consisted not
only in his recovering maximal autonomy, but also in his
acquiring eligibility for a heart transplant.
1.2. Observation
On 9 October 2011 Mr. G., 30, single, a night watchman,
suffered refractory cardiopulmonary arrest (no flow: 0 minute;
low flow: 60 minutes) due to anterior myocardial infarction. He
received an angioplasty with installation of a metallic stent on
the anterior interventricular artery (AIA) and two stents on the
right coronary artery. Left ventricular ejection fraction (LVEF)
was lower than 20%. On cessation of sedation, left hemiplegia
caused by right middle cerebral artery infarct was discovered.
Tracheotomy was necessary. Persistent major dysfunction of
the left ventricle led to installation on 8 November 2011 of a left
mono-ventricular HEART-MATE II assistive device (LVAD).
In order to function, the apparatus had to receive a permanent
power supply originating in either two batteries or the local
electrical grid. When admitted to a PRM unit on 18 January
2012, it was essentially for the following reasons that Mr. G.
had not been selected as a heart transplant candidate: He
presented with predominantly brachiofacial left hemiparesis,
generalized hypoesthesia of the left hemicorpus, temporospatial disorientation, psychomotor retardation, attentional and
memory disorders, dysexecutive syndrome and left visuospatial
neglect. He was using a tracheostomy tube and receiving mixed
texture oral nutrition, and did not suffer from bladder or bowel
dysfunction. Supervised walking was possible. On admission,
his functional independence measure (FIM) was 57/126.
During meetings with a representative of the LVAD
manufacturer, virtually all members of the medical and
paramedical team, including members of the night shift, were
given instructions on the functioning of the electrically
powered LVAD and on the manipulations through which
power could be transferred from the electrical grid to batteries.
Nurses were entrusted with responsibility for this series of
gestures, which were necessary in view of rehabilitation and
ambulation. Information sheets and lists of precautions to take
were placed in the patient’s room, as were the phone numbers to
be dialed in case of emergency. Prior to the admission of Mr. G.,
the medical staff had been instructed on how to proceed with
the power transfer.

139

In spite of the logistical complexity (transfer of power to the
batteries in the morning and back to the grid at the end of the
day), and notwithstanding the initial worries of the teams, they
managed to adapt to an unusual situation, and their
multidisciplinary rehabilitation efforts were successful. No
complication was related to the apparatus, but an infection of
the abdominal orifice constituting the cable entry point was
discovered in the context of a persistent infectious syndrome
and necessitated surgical drainage as well as use of vacuum
assisted closure (VAC) for 3 weeks. Only on 11 May 2012 was
the tracheostomy tube withdrawn on account of granuloma
necessitating first local, and then surgical treatment.
Mr. G. benefited from rehabilitation consisting in physiotherapy, occupational therapy and speech therapy according to
the methods usually applied for a patient recovering from a
stroke. While he did not carry out a full-scale and structured
cardiac retraining program similar to the one that was recently
described in other patients equipped with a LVAD [1], effort
retraining was nevertheless progressively given in accordance
with his degree of tolerance. In conjunction with the
cardiologist and given the fact that blood pressure and pulse
rate were not reliable indicators, perception of tolerance was
based on the occurrence of sweating. In his physiotherapy
sessions, Mr. G. engaged in articulation flexing and motor skill
recovery; he also counteracted spasticity and gradually
readapted himself to effort through use of a cyclometer for
his lower limbs and a cycle ergometer; he also ambulated on
different surfaces and, towards the end of his hospital stay,
walked with steadily increasing velocity on a treadmill. On
arrival at the PRM unit his walking perimeter had been limited
to 25 m; prior to the heart transplant, it had become unlimited.
Since it remained possible that there would be no transplant,
technical support had been drawn up and tested with the aim of
rendering the patient autonomous with regard to the
manipulations needed to transfer LVAD power supply to the
batteries. However, this type of assistance had to be given up,
partially on account of the non-functionality of his paralyzed
upper limb, and partially due to the persistence of a number of
neuropsychological disorders associating slight slackening of
the pace, difficulty remaining attentive during complex tasks,
working memory disorder and some degree of visuospatial
neglect.
Even though they were not major, the preceding neuropsychological disorders did not allow Mr. G. to achieve autonomy
in manipulation and management of his ventricular assistance
apparatus. On the other hand, autonomy in walking and in the
basic activities of daily life was reacquired. On 1 October 2012,
his FIM stood at 109/126. A return home was nonetheless
totally impractical as long as the patient was carrying a LVAD,
of which the use would have necessitated permanent human
assistance on account of his neuropsychological disorders.
With this in mind, the satisfactory medical condition of the
patient, his age and his wishes represented arguments in favor
of his eligibility for a heart transplant, which at that point
constituted the one means of enabling him to regain actual
autonomy. And so, on 27 October 2012, Mr. G. received a heart
transplant. The aftermath of the surgery was marked by acute

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rejection of the transplant that was mastered through
immunosuppressive treatment. After 6 weeks in the cardiology
ward followed by 2 weeks of preparation in the unit, a return
home could be organized and indeed took place (three and a
half hours a day of home assistance: a nurse to monitor the
treatment, and housekeeping help).
Several follow-up consultations took place subsequent to the
transplant and discharge from hospital. It was shown that the
patient was not only largely autonomous at home with regard to
basic activities of daily life, but also in relation to more
complex activities such as shopping, budget management and
paperwork. He has resumed social life and uses public
transportation.
In addition to the PRM follow-up, he undergoes monthly
cardiac monitoring. His LVEF has reached 60%, and he shows
no signs of cardiac insufficiency. He is awaiting a decision by
the French maison departementale des personnes handicapées
that may lead to daytime medical care aimed at facilitating his
occupational rehabilitation.
1.3. Discussion
Hospitalization in a PRM unit allowed the patient to achieve
optimal progress, which was evidently a key consideration in
decision to undertake a heart transplant in spite of the
neurological deficits. Paradoxically, it was the persistence of
dysexecutive disorders that constituted our main indication
for the transplant, which offered the only possible guarantee
of a return to autonomy. In the future, the PRM unit is likely to
be called upon anew, given not only the proven benefits of
structured physical training for LVAD-equipped patients and
heart transplant recipients [1,3], but also the incidence of
stroke following installation of the device, incidence
estimated at 14 to 47% [2,4]. Laoutaris et al. [3] have
reported improvement following structured physical training
in the VO2 peak of LVAD-equipped patients, in the distance
they cover in 6 minutes and in their overall quality of life.
English and Speed have likewise reported FIM improvement
in similarly equipped patients following their stay in a PRM
structure.
To our knowledge, there have been no studies on the
rehabilitation of hemiplegic patients carrying these types of
devices.
1.4. Conclusion
This observation illustrates the role of PRMs in the
rehabilitation of patients with multiple deficiencies and also
their importance, in conjunction with cardiologists, in sensitive
decision-making. Their role is likely to be amplified on account
of progress in cardiology technology and, concomitantly, due to
organ donor penury.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.

2. Version française
2.1. Introduction
L’assistance ventriculaire constitue une thérapie aujourd’hui
largement utilisée pour pallier à une insuffisance cardiaque,
qu’elle soit un moyen transitoire avant une greffe cardiaque ou
portée de manière définitive. À ce jour, environ 10 000 assistances ventriculaires gauches (AVG) ont été implantées dans le
monde, 1000 en Europe et 82 en France en 2011.
Nous rapportons l’observation d’un patient hémiplégique
porteur d’une AVG implantée. L’éventuel accès à une greffe
cardiaque était suspendu à l’évolution. Ainsi, les objectifs
d’hospitalisation étaient outre la récupération d’une autonomie
maximale, l’éligibilité à une greffe cardiaque.
2.2. Observation
M. G. âgé de 30 ans, célibataire, gardien de nuit, avait été
victime le 9 octobre 2011 d’un arrêt cardiorespiratoire
réfractaire (no flow de 0 minute et low flow de 60 minutes)
sur infarctus du myocarde antérieur. Il avait bénéficié d’une
angioplastie avec mise en place d’un stent nu sur l’IVA et deux
stents sur la coronaire droite. La fraction d’éjection du
ventricule gauche (FEVG) était inférieure à 20 %. À l’arrêt
de la sédation, il avait été découvert une hémiplégie gauche sur
infarctus sylvien droit. Une trachéotomie avait été nécessaire.
La persistance d’une dysfonction majeure du ventricule gauche
avait conduit à l’implantation d’une assistance mono-ventriculaire gauche de type HEART-MATE II le 8 novembre
2011. Cette AVG devait être alimentée en permanence par deux
batteries ou par le secteur. À son admission en MPR le
18 janvier 2012, M. G. n’avait pas été retenu comme candidat à
une transplantation cardiaque : il présentait une hémiparésie
gauche à prédominance brachio-faciale, une hypoesthésie de
l’hémicorps gauche à tous les modes, une désorientation
temporo-spatiale, un ralentissement psychomoteur, des troubles attentionnels, des troubles mnésiques, un syndrome
dysexécutif et une négligence visuospatiale gauche. Il était
trachéotomisé, alimenté par voie orale avec texture mixée et
n’avait pas de troubles vésico-sphinctériens. La marche sous
surveillance était acquise. La mesure d’indépendance fonctionnelle (MIF) d’entrée était de 57/126.
Lors de réunions avec la représentante du fabriquant de
l’appareil d’AVG, l’essentiel de l’équipe médicale et paramédicale incluant l’équipe de nuit a été formé au fonctionnement de l’AVG à alimentation électrique ainsi qu’aux
manipulations pour les transferts de l’alimentation du secteur
vers des batteries. La responsabilité de cette manipulation
nécessaire à la rééducation et à la déambulation a été confiée
aux infirmier(e)s. Des fiches d’information et de précautions
ainsi que les numéros de téléphone à joindre en cas d’urgence
ont été placés dans la chambre du patient. Avant son admission,
des membres de l’équipe médicale s’étaient rendus dans le
service d’origine afin d’apprendre les gestes nécessaires.
Malgré l’aspect logistique (transfert de l’alimentation du
secteur aux batteries tous les matins et retour vers le secteur en

N. Bradai et al. / Annals of Physical and Rehabilitation Medicine 57 (2014) 138–142

fin de journée) et l’inquiétude initiale des équipes, celles-ci ont
su parfaitement s’adapter à cette situation inhabituelle et la
rééducation multidisciplinaire a pu être menée à bien. Aucune
complication liée à l’appareil n’est survenue, mais une
infection de l’orifice abdominal d’entrée du câble découverte
devant un syndrome infectieux persistant a nécessité une mise à
plat chirurgicale ainsi qu’un vacuum assisted closure (VAC)
durant 3 semaines. La canule de trachéotomie n’a pu être retirée
que le 11 mai 2012 en raison d’un granulome nécessitant un
traitement local puis chirurgical.
M. G. a bénéficié d’une rééducation comportant kinésithérapie, ergothérapie et orthophonie selon les méthodes
habituellement utilisées pour un patient après AVC. Il n’a
pas été réalisé un véritable programme de réentraı̂nement
cardiaque structuré tel qu’il a été décrit chez des patients
porteurs d’AVG [1] cependant, le réentraı̂nement à l’effort
s’est fait de manière progressive, basé sur la tolérance du
patient. En accord avec le cardiologue celle-ci était basée sur
l’apparition de sudations, puisque la tension artérielle et le
pouls n’étaient pas fiables chez ce patient. Ainsi, en
kinésithérapie, il a bénéficié outre d’un travail articulaire et
d’éveil de la motricité, de lutte contre la spasticité, d’un
réentraı̂nement progressif à l’effort utilisant le cyclomètre
pour membres inférieurs, le cycloergomètre, la marche sur
différents terrains et, en fin d’hospitalisation, d’une marche à
vitesse progressivement croissante sur tapis roulant. À son
arrivée en MPR, son périmètre de marche était de 25 m, il est
devenu illimité avant la greffe. Dans l’éventualité d’une nongreffe, des aides techniques avaient été confectionnées et
testées dans l’objectif de rendre le patient autonome pour les
manipulations du transfert de l’alimentation de l’AVG du
secteur vers les batteries. Elles ont dues être abandonnées en
raison, d’une part, de la non-fonctionnalité du membre
supérieur plégique et, d’autre part, de la persistance de
certains troubles neuropsychologiques associant un ralentissement modéré, des difficultés attentionnelles lors de tâches
complexes, des troubles de la mémoire de travail et des
éléments de négligence visuospatiale.
Sans être majeurs, ces troubles neuropsychologiques étaient
suffisamment présents pour que M. G. ne soit pas autonome
dans la gestion de l’appareil d’assistance ventriculaire.
L’autonomie à la marche et pour les activités de base de la
vie quotidienne était acquise. Au 1er octobre 2012, la MIF était
de 109/126. Le retour au domicile était inenvisageable tant que
le patient portait une AVG car cela aurait nécessité en
permanence une aide humaine en raison des troubles
neuropsychologiques. Le bon état médical, le souhait du
patient, son jeune âge ont constitué des arguments pour
l’éligibilité à la greffe qui constituait le seul moyen de lui
rendre une véritable autonomie. M. G. a pu bénéficier d’une
greffe du cœur le 27 octobre 2012. Les suites opératoires ont été
marquées par un rejet aigu de greffe maı̂trisé par le traitement
immunosuppresseur. Après 6 semaines en cardiologie puis
2 semaines de préparation dans le service, le retour au domicile
a pu être organisé (trois heures et demie d’aides humaines
quotidiennes : infirmière pour le contrôle du traitement et aideménagère).

141

Plusieurs consultations de suivi ont eu lieu depuis la greffe
et la sortie. Elles ont montré que le patient est autonome au
domicile pour les activités de base de la vie quotidienne mais
également pour certaines activités plus élaborées, telles que
les courses, la gestion de son budget et de ses papiers. Il
reprend une vie sociale et se déplace par les transports en
commun.
Outre le suivi MPR, il bénéficie d’un suivi cardiologique
mensuel. Sa FEVG est de 60 % et il ne présente pas de signes
d’insuffisance cardiaque. Il est en attente d’une décision de la
maison départementale des personnes handicapées (MDPH)
pour un accueil de jour dans l’objectif d’une réinsertion
socioprofessionnelle.
2.3. Discussion
L’hospitalisation en service de MPR a permis au patient des
progrès optimaux, ce qui a été un élément clé dans la décision
de greffe cardiaque malgré les déficits neurologiques. Paradoxalement, c’est la persistance de troubles dyséxécutifs qui
constituait pour nous l’indication principale à la greffe, seule
garantie de la reprise d’une autonomie. Les services de MPR
seront probablement mis à contribution à l’avenir en raison du
bénéfice prouvé d’un entraı̂nement physique structuré chez les
patients porteurs d’AVG et les patients greffés [1,3] mais aussi
en raison de l’incidence de survenue d’accident vasculaire
cérébral après mise en place d’un tel dispositif, incidence
estimée entre 14 et 47 % [2,4]. Ainsi, Laoutaris et al. [3]
rapportent une amélioration de la VO2 Peak, de la distance
parcourue en 6 minutes et de la qualité de vie chez des patients
porteurs d’une AVG après un entraı̂nement physique structuré.
English et Speed [1] montrent une amélioration de la MIF après
séjour en structure de MPR de patients implantés.
À notre connaissance, il n’y a pas de travaux sur la
rééducation de patients hémiplégiques porteurs d’une telle
assistance.
2.4. Conclusion
Cette observation illustre la place de la MPR pour la
réadaptation de patients porteurs de déficiences multiples et son
rôle, ici aux côtés des cardiologues, dans la prise de décisions
délicates, place qui prendra probablement de l’ampleur en
raison des progrès en matière de technologie cardiaque et de la
pénurie de donneurs d’organes.
Déclaration d’intérêts
Les auteurs déclarent ne pas avoir de conflits d’intérêts en
relation avec cet article.
References
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