- 87 year old female admitted on 6/4/14 for aortic stenosis, regurgitation, mitral and tricuspid regurgitation, coronary artery disease, and atrial fibrillation. She underwent MAZE procedure, transcatheter aortic valve replacement, mitral valve repair, tricuspid valve repair, and coronary artery bypass grafting x3. - She required reintubation post-op and had a slow recovery, beginning to ambulate on POD #10. The physical therapy goals were for the patient to regain independence in bed mobility, transfers, and household ambulation. - Over 16 physical therapy sessions, the patient improved from ambulating 2 steps to over 100 feet with a

1. N A T H A N D U G A N
C O L U M B I A U N I V E R S I T Y
7 / 1 1 / 1 4
Patient Case Presentation:
Inpatient Cardiopulmonary PT

2. Patient Introduction
— 87 y/o female
— Admitted on 6/4/14
— Pre-op diagnoses:
¡ AORTIC STENOSIS AND REGURGITATION
¡ MITRAL AND TRICUSPID REGURGITATION
¡ CORONARY ARTERY DISEASE
¡ ATRIAL FIBRILLATION

3. History of Present Illness
— c/o SOB (lasting seconds to minutes) at rest and with
exertion, beginning early 2013
¡ Symptoms increased in frequency over past year
¡ Limited to 1 flight of stairs and a couple of blocks of ambulation
— Associated diaphoresis, edema, palpitations
— Orthopnea and occasional PND
— Developed Afib in 2013
— Abnormal TEE on 8/23/13
¡ LVEF 65%-75%
¡ AVA: 1.1 cm2
¡ Mitral/Aortic insufficiency
¡ Bi-atrial enlargement
¡ Mild pulmonary HTN (42mmHg)

4. Past Medical History
— Aortic Stenosis (with AVA=1.1cm2)
— Aortic Insufficiency
— Mitral Regurgitation
— Atrial Fibrillation (on coumadin) s/p DC cardioversion
x2
— Pulmonary Hypertension (42 mmHg)
— CAD
— Hypertension
— Hyperlipidemia
— IBS
— Glaucoma
— Cataracts

5. Medications List
Medication Class Relevant Side Effects
Piperacillin Tazobactam &
Vancomycin
Antibiotic Hypotension, anemia,
hypoglycemia, hypokalemia
Amiodarone Antiarrhythmic Hypotension, arrhythmias
Amlodipine & Diltiazem Calcium channel blocker -
Antihypertensive
Arrhythmias, bradycardia,
tachycardia, postural hypotension
Metoprolol Tartate B1 selective receptor blocker –
decreases contractility/HR/O2
demand
Arrhythmias, dyspnea
Ipratropium Bromide Bronchodilator Hypotension, arrhythmias,
dyspnea, worsening of narrow
angle glaucoma
Heparin & Warfarin Anticoagulant Increased risk of bleeding,
hyperkalemia, hyponatremia
Simvastatin Cholesterol lowering agent Angina, cognitive impairment
Docusate Sodium & Senna Stool softeners/laxatives None
Esomeprazole Proton pump inhibitor – antacid Hypertension, arrhythmias,
hyponatremia
Brimonidine Tartate A2 receptor agonist – reduces
intraocular pressure
Hypertension, syncope

6. Social and Functional History
— Married and lives with 91 yo husband in private
home with stairs
¡ Sons and other family live nearby and are available to help as
needed
— Retired
— Independent in all ADL and IADL prior to admission
— Did not use AD for mobility prior to admission
¡ Enjoyed walking prior to illness

7. Hospital Course
— 6/4/14: Surgery performed
— 6/5/14: Extubated
— 6/6/14: Re-intubated, suspected cardiac tamponade, chest re-
opened bedside (1L fluid drained), transferred to OR
— 6/8/14: Chest closed
— 6/10/14: PT initial evaluation in CTICU
¡ Seen for 16 sessions between 6/10-6/25
— 6/12/14: Extubated
— 6/13/14: Transfer to 5GN, CTSDU
— 6/16/14: First time I saw patient
— 6/17/14: Chest tubes removed
— 6/22/14: Converted to NSR
— 6/23/14: NG feeding tube removed
— 6/25/14: Discharge to acute rehab

8. Surgical Procedures Performed
¡ MAZE, tAVR, tMVR, TV Repair, CABG x3
÷ LIMA->OM
÷ RIMA->LAD
÷ SVG from aorta->PDA

9. CABG Visualization

10. MAZE Visualization

11. Physical Therapy Initial Evaluation: POD #6
— Very limited
¡ Intubated, +CT x3 to low wall suction, +SGC, +RIJ with
multiple drips, +R radial A-line
¡ Pt lethargic but able to follow simple directions, unable to
respond to questions
— Interventions performed:
¡ Patient education: Benefits of exercise, PT intervention, use of
call bell, sternal precautions
¡ PROM x10 BUE & BLE
— Assessment:
¡ Pt has an excellent support network and is a good candidate
for cardiac rehab with good prognosis

12. Physical Therapy Goals-IE
— Short Term Goals (3 sessions):
¡ Rolling Mod A
¡ Scooting Mod A
¡ Sup<->Sit Mod A x2
¡ Sit->Stand Mod A x2
¡ Bed<->Chair Mod A x2
— Long Term Goals (by d/c)
¡ Bed Mobility Independent
¡ Transfers Independent
¡ Household Ambulation Independent

13. Physical Therapy Plan
— Continue goal-oriented physical therapy, 5-7x/week
¡ Patient and family education
¡ Gait training
¡ Therapeutic activities
¡ Therapeutic exercise
¡ Cardiac rehabilitation

14. Treatment Sessions 2-3: POD #7-8
— Slow start to rehab
— Session 2:
¡ PROM x10 BUE & BLE
¡ Rolling
¡ STGs remain
— Session 3:
¡ Extubated, SGC remains
¡ Rolling @ max A, sup<->sit @ mod A x2 & HOB elevated
¡ Able to sit EOB for ~5 minutes
¡ STGs remain

15. Treatment Session 4: POD #9
— Slow start continues
¡ Better evaluation as patient able to converse
¡ SGC removed
¡ 5LO2 via NC
— Interventions:
¡ Rolling @ max A, sup<->sit @ mod A x2 & HOB elevated
÷ No improvement over previous session
¡ Able to sit EOB for ~5 minutes
÷ No improvement over previous session
— Previous STGs remain

16. Treatment Session 5: POD #10
— Standing!
¡ 3LO2 via NC
— Interventions:
¡ Rolling @ max A, sup<->sit @ mod A & HOB elevated,
sit->stand @mod A (performed 2 times)
¡ Standing x2 trials
— STGs revised:
¡ Sup<->Sit Min A
¡ Sit->Stand Min A

17. Treatment Session 6: POD #11
— Ambulation!
— Interventions:
¡ Rolling @ max A, sup<->sit @ mod A & HOB elevated,
sit<->stand @ mod A (performed 4 times)
¡ Ambulation: 2 steps @ min A
¡ Standing x4 trials
— Previous STGs remain

18. Treatment Session 7: POD #12
— First time I worked with patient
¡ Eager to participate and then very reluctant to perform any activities
— Interventions:
¡ Sup->Sit @ min A & HOB elevated, sit->stand @ min A, bed->chair @ min A
¡ Standing ~4 minutes
— STGs revised:
¡ Rolling CS
¡ Scooting Min A
¡ Sup<->Sit CG, Sit->Stand CG, Bed<->Chair CG
¡ Ambulation: 20’ RW/CG
¡ IS to 500cc
— LTGs revised (2-4 weeks):
¡ Bed mobility, transfers, household ambulation: independent
¡ Community ambulation, stair climbing CS
¡ IS >/= 1000cc

19. Treatment Session 8: POD #13
— Back to ambulation
¡ Pt on room air, SpO2 >/=96% throughout
— Interventions:
¡ Seated scooting @ I, sup->sit @ CG & HOB elevated,
sit->stand CG/min A (from low chair)
¡ Ambulation: 5’ RW/CG
¡ Standing ~2 minutes
¡ Incentive spirometry 500cc
— Assessment: Pt had goal to make it to sink to wash her
hands, unable to accomplish. Concerned with being
independent, states “don’t touch me” during activities

20. Treatment Session 9: POD #14
— Minor regression
¡ Chest tube and foley removed
— Interventions:
¡ Sup->Sit @ min A x2 & HOB elevated, sit->stand @ min A
¡ BLE AROM
÷ Ankle pumps x20
÷ Long arc quads x20
÷ Seated hip flexion x20
— Assessment: Pt stood for ~5s before sitting and
refusing to participate further, education given. Low
motivation 2/2 c/o lack of sleep.

21. Treatment Sessions 10-12: POD #15-17
— Session 10:
¡ Interventions:
÷ Sup->Sit CS HOB elevated, sit->stand min A x2
÷ Ambulation: 25’ x 2 RW/CG
¡ Assessment: Pt self-motivated to make it to bathroom
— Session 11:
¡ Interventions:
÷ Sit->Stand @ CG/min A, toilet transfer @ min A x2
÷ Ambulation: 30’ x 2, 50’ x 1 RW/CG
¡ Assessment: Bathroom motivation still paramount
— Session 12 (w/e):
¡ Interventions:
÷ Sit->Stand @ min A/mod A
÷ Ambulation: 50’ x 2 RW/CG->min A

22. Treatment Sessions 13-16: POD #18-21
— Session 13 (w/e)
¡ Sit->Stand @ min A, bed->chair @ min A
¡ Ambulation: 50’ x 4 RW/CG
— Session 14
¡ Sit->Stand @ min A
÷ Continues to require many cues for technique
¡ Ambulation: 50’ x 2, 100’ x 1
— Session 15
¡ Sit->Stand CS
¡ Ambulation: 100’ x 2 RW/CS
— Session 16
¡ Sup->Sit @ I & HOB elevated, sit->stand @ CS
÷ Able to perform transfers correctly with vague cues
¡ Ambulation: 70’ x 1, 100’ x 1 RW/CS

23. Graphic Representation of Sessions
2 0
5
0
50
110
100
200 200 200
170
15-Jun 16-Jun 17-Jun 18-Jun 19-Jun 20-Jun 21-Jun 22-Jun 23-Jun 24-Jun 25-Jun
Ambulation Distance (Feet) vs Time

24. Why Rehab?
— Patient’s attitude of wanting to be independent
although she is not
— Significant weakness, especially in LEs
— Patient was completely independent prior to
admission
— Patient did not use an assistive device prior to
admission
— Lives with 91 yo spouse and has stairs in her home

25. Questions?

26. References
— "Atrial Fibrillation Surgery - Maze Procedure."
The Society of Thoracic Surgeons. 10 July 2014.
http://www.sts.org/patient-information/
arrhythmia-surgery/atrial-fibrillation-surgery
— "Cardiac Tamponade: MedlinePlus Medical
Encyclopedia." U.S National Library of
Medicine. U.S. National Library of Medicine. 08
July 2014. http://www.nlm.nih.gov/
medlineplus/ency/article/000194.htm
— Meinke, Laura. "Pulmonary Hypertension for
Internists.” American College of Physicians. 10
July 2014. http://www.acponline.org/
about_acp/chapters/az/mtg10_meinkepul.pdf
— "Aortic Valve Area in Aortic Stenosis."
UpToDate. 19 May 2014. Web. 10 July 2014.
http://www.uptodate.com/contents/aortic-
valve-area-in-aortic-stenosis