Rehabilitation considerations for cardiac transplantation patients

1. JAMIA MILLIA ISLAMIA
PHYSIOTHERAPY IN CARDIOPULMNARY CONDITIONS (BPT 402)
TOPIC: CARDIAC REHABILITATION
CONSIDERATIONS FOR HEART TRANSPLANT
PATIENTS
SUBMITTED TO: DR. JAMALALI MOIZ
SUBMITTED BY: ANKUSH
BPT 4TH YEAR
ROLL NO. 17BPT0O5
CENTER FOR PHYSIOTHERAPYAND REHABILITATION SCIENCES

2. PRE TRANSPLANT EXERCISE TESTING
CONSIDERATION:
• In patients undergoing transplant evaluation, measurement of peak oxygen
consumption (O2) during cardiopulmonary exercise testing provides an
objective assessment of functional capacity and is more useful than NYHA
classification, ejection fraction, or other markers of heart failure severity, for
assessing prognosis and determining the optimal timing of listing for
transplantation.
• Patients with a peak O2 of more than 14mL/kg/min have 1-and 2-year survival
rates that are comparable or better than those achieved with transplantation,
and patients should be medically managed and undergo serial exercise testing.

3. • Patients with a peak O2 between 10 and 14 mL/kg/min constitute an intermediate
risk group in which continued medical therapy may offer asurvival benefit
similar to heart transplantation among selected patients that are able to tolerate
beta blockers, have low-risk Heart Failure Survival Scores (HFSS's).
• In patients tolerating beta blockers, a peak O2 of <12 mL/kg/min has been
suggested as an appropriate threshold to identify individuals that are likely to
derive a survival benefit from transplantation.
• Patients with a peak O2 of 10 mL/kg/min, regardless of beta blocker use, have
significantly reduced survival rates with medical therapy compared to cardiac
transplantation, and these patients should be listed for transplantation.
• Based on the results of the exercise test, an ET prescription may be developed with the
goal of maintaining or even improving cardiorespiratory fitness.

4. CONTRAINDICATIONS FOR PRE TRANSPLANT
EXERCISE TESTING:
• Irreversible severe pulmonary arterialhypertension
• Advanced age (>70 years)
• Active systemic infection
• Active malignancy or recent malignancy with high
• risk of recurrence
• Diabetes mellitus with:
• End-organ damage (neuropathy, nephropathy, proliferative
retinopathy)
• Poor glycemic control(HbA1c >7.5)

5. NEED OF EXERCISE IN HT PATIENTS:
• To deal with;
a. Pre-HT syndrome of chronic HF with poor exercise capacity due to central and
peripheral circulatory abnormalities.
b. Skeletal muscle pathology.
c. Generalized deconditioning.
d. The healing process with open heart surgery.
e. Post-HT use of corticosteroid medications with resultant skeletal muscle atrophy and
weakness.

6. AEROBIC EXERCISE TRAINING IN HT PATIENTS:
• HT recipients respond to aerobic training similarly to other cardiac patients.
• Following are the effects of aerobic training seen in HT patients:
a. Peak VO2 improves by an average of 24% after 2 to 6 months of ET
b. It improves mitochondrial oxidative capacity but apparently does not increase skeletal
muscle capillary density as it does in healthy subjects.
c. Improved submaximal exercise endurance
d. Increased peak treadmill exercise workload or peak cycle power output
e. Increased maximal heart rate
f. Decreased exercise heart rate at the same absolute submaximal workload

7. a. Increased ventilatory (anaerobic) threshold
b. Decreased submaximal exercise minute ventilation
c. Reduced exercise ventilatory equivalent for CO2
d. Lessened symptoms of fatigue, dyspnea, or both
e. Reduced rest and submaximal exercise systolic and diastolic blood pressure
f. Decreased peak exercise diastolic blood pressure
g. Reduced submaximal exercise ratings of perceived exertion
h. Improved psychosocial function
i. Increased lean body mass
j. Reduced body fat mass
k. Increased bone mineral content

8. RESISTANCE TRAINING IN HT PATIENTS:
• Resistance ET partially reverses corticosteroid-related myopathy and improves skeletal
muscle strength.
• Fifty days of isokinetic strength training substantially increased muscle mass and strength
in patients with corticosteroids after transplantation. (Horber and coauthors )
• In addition, strength training has been shown to improve bone density and to reduce the
potential development of osteoporosis (also caused by prednisone) in HT recipients.

9. INTERVENTIONS IN HT PATIENTS DURING
REHABILITATION:
• Education to patients and families:
i. Medications: purposes, potential side effects, importance of strict compliance with
recommended dosing.
ii. Risk of rejection, infection, and allograft vasculopathy.
iii. Postoperative management schedule: tests, appointments.
iv. Nutrition: reduced fat, caloric intake, and sodium to help prevent weight gain related
to prednisone use and to help control blood pressure

10. • Psychosocial interventions:
• Goals:
a. To develop the coping skills,
b. stress management techniques, and
c. practical skills to deal with the multiple issues involved in posttransplant life.
d. To provide ongoing emotional support and encouragement.
• Intervention:
Group interactions or support sessions that include the patient, family members, and group
facilitators to assist patients in rebuilding family relationships and responsibilities as well as
with interactions with friends and business or professional contacts.

11. EARLY MOBILIZATION AND INPATIENT
EXERCISE TRAINING( 7-10 DAYS POST OP.):
a. After surgery, patients are extubated expeditiously, usually within 24 h.
b. Passive range of motion exercises for both the upper and lower extremities, sitting up in
a chair, and slow ambulation may begin and progress gradually after extubation.
c. Walking or cycle ergometry for up to 20 to 30 min may be implemented as tolerated.
d. Exercise intensity is guided using the ratings of perceived exertion 11 to 13 (“fairly
light” to “somewhat hard”) while maintaining a respiratory rate below 30 breaths per
minute and arterial oxygen saturation above 90%.
e. Exercise frequency is two or three sessions per day.

12. OUTPATIENT EXERCISE TRAINING
CONSIDERATIONS:
a. Continuous monitoring of the ECG during the first few supervised ET sessions is
standard practice.
b. It is not necessary to perform graded exercise testing before beginning the outpatient
exercise program; however, performance of a 6-minute walk test is helpful in assessing
functional capacity.
c. Target HR is not used for Exercise prescription unless the patient exhibits a partially
normalized HR response to exercise.
d. The typical denervated heart increases in rate slowly during submaximal exercise, and
the HR may either drift gradually higher during steady-state exercise or plateau after
several minutes.

13. • The rating of perceived exertion scale is useful for prescription of exercise intensity.
• After 6-8 weeks of sternal recovery following surgery, aerobic activities including arm
involvement may be introduced.
• The sternal incision requires special emphasis on upper extremity active range of motion
exercises.

14. RESISTANCE EXERCISE FOR OUT PATIENT:
• Progressive resistance exercise programshould be incorporated into the ET program.
• Precaution:
a. For the first 6 weeks after surgery, bilateral arm lifting is restricted to less than 10 lb
(4.5 kg) to avoid sternal nonunion.
b. Because HT recipients are likely to require antihypertensive medications, periodic
blood pressure measurement during both aerobic and strengthening ET is
recommended.
• Strength gains of 25% to 50% or greater commonly occur after 8 weeks of resistance ET
in these patients.
• Performance of the strengthening exercises immediately following the aerobic portion of
the exercise prescription (after the cool-down) is recommended.

15. • Frequency : Two or three sessions per week on nonconsecutive days
• Intensity: First 6 to 8 weeks after surgery: <10 lb for upper extremities, otherwise RPE
12 to 16
• Duration: One to three sets, 8 to 15 slow repetitions per set
• Type: Free weights, weight machines, elastic bands; include exercises for major muscle
groups

16. POSTTRANSPLANT GRADED EXERCISE
TESTING:
• It is done to facilitate the prescription of ET, and counseling of patients regarding the timing of
return to work or school or resumption of avocational pursuits.
• To evaluate the patient’s response to exercise, including ECG findings which frequently
demonstrate right bundle branch block and nonspecific repolarization abnormalities at rest.
• However, the sensitivity of the exercise ECG in detecting ischemia due to the presence of allograft
vasculopathy is poor (less tha 25%) unless combined with imaging.
• Best if done, 6 to 8 weeks after surgery before performing graded exercise testing to maximal
effort.

17. • Treadmill or cycle ergometer protocols with continuous exercise (2 or 3 min stages or
ramp tests) may be used.
• Arm cranking protocols may also be employed, after adequate sternal healing, for a
specific upper extremity fitness evaluation or an arm cranking exercise prescription.
• The initial exercise intensity during the test should be approximately 2 METs, with 1 or
2 MET increments in intensity per stage.
• Continuous multi-lead ECG monitoring with assessment of blood pressure and rating of
perceived exertion for each stage is recommended.
• For precise determination of aerobic capacity, direct measurement of VO2 and associated
variables is highly desirable.
• The end points of the graded exercise test should be maximal effort (symptom-limited
maximum) or standard signs of exertional intolerance.

18. AEROBIC EXERCISES FOR HT PATIENT:
• Frequency : Five to seven sessions per week (three supervised, two or more independent)
• Intensity: RPE 12 to 16 (if HR response to exercise has normalized, 50% to 80% of HRR)
• Duration: Begin with 5 to 10+ min per session; increase to 5 min per session; progress to 30
to 60 min per session; may use intermittent, continuous, or interval approaches
• Type:
a. First 6 weeks after surgery: walking (treadmill, indoors, outdoors), cycle ergometer (upright,
recumbent)
b. At 6 weeks, include combination arm and leg ergometer, elliptical, rower, arm ergometer,
jogging (treadmill, track, outdoors), water-based exercise.

19. • Note:
a. During inpatient rehabilitation, as well as during the outpatient phase, episodes of
rejection of a moderate or greater severity may require alteration of the ET plan. If the
rejection episode is graded as moderate, activity may be continued at the current level
but should not progress until after the rejection has been adequately treated. Severe
rejection necessitates suspension of all physical activity with the exception of passive
range of motion exercises.
b. Warm up and cool down session has to be added daily in ET program with RPE less
than 11 and for 10 + minutes, which includes ROM exercises, stretching and mild
aerobic activity.

20. SUMMARY:
• Both exercise testing and exercise training including aerobic and strength training are
critical components of care for HT patients.
• Encouragement to continue a lifelong exercise program should be a consistent message
from the HT team and the primary health care provider.
• Patients should continue in a supervised ET program indefinitely, exercise independently,
or use a combination of supervised and unsupervised ET.

21. REFERENCES:
I. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs Fifth
Edition.
I. Cash textbook of cardiopulmonary and vascular physiotherapy.
II. Kisner and colby textbook of exercise therapy.

22. THANKYOU!!
ANY QUERY?