Early and Frequent Mobilization After Minimally Invasive Mitral Valve Repair with Mitral Clip

Abstract

Background/purpose: Traditionally, mitral valve regurgitation was treated with open heart surgery. In 2013, mitral valve clipping, a transcatheter procedure, was approved as an alternative procedure for mitral valve repair for individuals who were not viable candidates for open heart surgery. Due to the recent nature of the procedure and the high risk status of patients, performing and documenting physical therapy services after mitral valve clipping is limited. The purpose of this case report is to demonstrate that physical therapy services are safe and effective for older, high-risk patients with multiple comorbidities who have received mitral valve clip surgery. Case Description: The patient was an 87-year-old female s/p elective mitral valve clip, referred for physical therapy for evaluation and treatment. The patient’s past medical history included: mitral valve regurgitation, subdural hematoma, hypertension, hyperlipidemia, atrial fibrillation, pulmonary hypertension, and a history of smoking. Previously, the patient was independent and high functioning, but recently experienced worsening symptoms including shortness of breath and decreased activity tolerance. The patient reported that prior to admission, she lived in a private single level home with a part time aide to assist with activities of daily living. Clinical Impression: The patient presented with impairments that include: pulmonary dysfunction, decreased strength, balance, bed mobility, transfer skills, gait skills, functional activities, endurance and overall limited activity tolerance. The patient was a strong candidate for a case report because she was motivated, cooperative and presented with unique high risk medical conditions which made her a candidate for mitral valve clipping. The findings from the examination led to a physical therapy diagnosis of functional decline and cardiac impairment consistent with the patient's post-surgical status, age and comorbidities. Based on the patient’s age, comorbidities and severe medical condition the prognosis was determined to be fair and that the patient would benefit from physical therapy services in order to meet discharge goals related to functional improvement. The plan for this patient was daily physical therapy services to address impairments and the treatment plan included ambulation, balance training, breathing exercises, education regarding pacing and safety, and implementation of home exercise program. Outcome: The Acute Care Index of Function (ACIF) has emerged as an accurate outcome measure to quantify functional mobility improvements in patients in the ICU. ACIF scores allow physical therapists to objectively document improvements in physical function of patients in the ICU and also can be used to show patients their progress in a quantifiable manner.10 At the time of initial evaluation, the patient’s ACIF score was 18.3, at the time of discharge bed mobility was not able to be tested so total ACIF scores cannot be directly compared, but the patient showed the most improvements in transfers, with her transfers score improving from 24 to 60. The patient also showed improved pace and increased her gait speed to 1.6 feet/second (.487 m/s) by time of discharge. It is stated that in the geriatric population a change of 0.05 m/s is small meaningful change or MCID and a change of 0.13 m/s is a substantial meaningful change for gait speed, although the patient falls just short of this at 0.12 m/s, it can be stated that there is a meaningful increase in her gait speed after physical therapy. Discussion: The results of this case report suggested that physical therapy intervention following a Mitral Valve Clip in a high risk patient is safe and beneficial for improving functional mobility. Further research is needed with a larger sample size and longer duration to investigate the outcomes of other high risk patients, as well as to determine long-term effects of early physical therapy intervention in the acute setting.