Cardiac transplantation involves surgically transplanting a donor heart into a recipient with end-stage heart failure. It has significantly improved survival rates compared to conventional treatments, with one-year survival rates over 80%. Both donors and recipients undergo extensive evaluation and selection criteria to ensure transplant success and survival. Post-transplant, recipients progress through three phases of cardiac rehabilitation - initial recovery in the hospital (Phase I), monitored exercise at a rehabilitation facility (Phase II), and long-term independent exercise maintenance (Phase III) - in order to promote heart health and maximize the benefits of their transplant.

1. Cardiac
Transplantation
By Dr. Ayesha Anwer Ali

2. Introduction
• Cardiac transplantation, first performed in 1966 by Christian Barnard
in South Africa, remained relatively uncommon until the development
of more effective antirejection drug regimens in the 1970s and 1980s,
leading to an increase in the number of centers that performed the
procedure.
• Less common forms of heart disease that have been treated with
transplantation include viral cardiomyopathy, infiltrative
cardiomyopathy, post partum cardiomyopathy, valvular heart disease,
and congenital heart disease.

3. Results of heart transplantation
• Treatment of patients with end-stage heart failure by heart
transplantation is based on the assumption that their survival and
quality of life after surgery are better than with conventional
treatment. The prognosis of patients with congestive heart failure
generally is poor, with the 5-year survival reported in one study to be
less than 30%.
• As a result, the heart transplant waiting list mortality has decreased
from 432 per at the same time, there has been an expansion in the
selection criteria for donors to increase the number of organs
available.

4. Recipient selection
• Heart transplant recipient selection is based on an extensive
multidisciplinary evaluation intended to assess the patients’ disability
and prognosis without transplantation and their ability to survive the
procedure and comply with the required postoperative management.
• Heart transplant candidates are evaluated for significant pulmonary
disease (including severe, irreversible pulmonary hypertension, which
is considered a contraindication to heart transplantation), renal
dysfunction, hepatic dysfunction, and active infectious disease before
being listed for transplantation. A candidate selected for
transplantation is placed on the list to wait for an appropriately sized
and ABO type donor organ that matches the recipient.

5. Donor selection
• Candidates who donate their hearts for transplantation must fulfill
the criteria for brain death. They should have no known serious
cardiac disease or refractory ventricular arrhythmias. Usually
candidates are less than 55 years of age, but older hearts are
occasionally used because of the shortage of hearts available for
transplantation. Donors should not have evidence of an active
infectious process or malignancy and should not have had a
prolonged cardiac arrest or required resuscitation.
• Donors should not have evidence of an active infectious process or
malignancy and should not have had a prolonged cardiac arrest or
required resuscitation.

6. Anesthetic preparations
• Because the timing of heart transplants is determined by donor availability,
the procedures occur on an emergency basis.
• When evaluating the recipient, key points include the patient’s feeding
status (may need rapid sequence induction if full stomach), the current
level of support needed for the cardiovascular system (drugs taken,
infusions running, mechanical assist devices), and the presence and current
status of implanted devices such as pacemakers or defibrillators.
• Preparing for heart transplantation is similar to preparing for any cardiac
case involving CPB, with a few special considerations. Sterile technique is
particularly important because the patient will be immunosuppressed
postoperatively.

7. Contd…
• Many anesthesiologists prefer when possible to place the arterial
cannula and pulmonary artery catheter before induction so that a
complete hemodynamic assessment can be made before and during
induction of anesthesia.

8. Goals of post operative care:
-Promote
CVS function and tissue perfusion.
Respiratory- Renal and Neurological function.
Fluid- Electrolytes and nutritional balance.
Rest, comfort and relief from pain.
Early movement and mobilization.
Psychological adjustment.
-Prevent
Post operative complications.

9. Post-Transplant Cardiac Rehabilitation
• Regular exercise should become a new permanent feature of your life
as you seek to fulfill the promise of your transplant. Your donor made
the ultimate sacrifice for you to have this second chance.
• Cardiac rehabilitation is generally divided into three phases:
{I, II and III}.

10. Phase I
• This phase begins in the hospital. Phase I begins as soon as the
second day after your transplant surgery when you were asked to sit
in a chair or stand and walk around the ICU. That was the first step in
taking action, tailored to your capabilities, to restore your mobility.
The time in the hospital is very valuable and should be used to make
sure that when you go home, but before phase II starts, you remain
active. During phase I, it is not how much you do, but that you begin a
consistent and frequent pattern of paced (exercise and rest) activity.
You are, after all, recovering from major surgery.

11. Phase II
• This phase usually takes place at a rehabilitation facility staffed by
trained personnel where you can be monitored (connected wirelessly
to a central station where your heart -- rate and rhythm-- can be
observed) and where physical activity can be augmented with
information about nutrition, medications, how to exercise safely,
special information about post-transplant health risks and
psychological factors.
• Your goal should be to regain all of your capabilities for the activities
of daily life and eventually recreation. Phase II for a heart transplant
usually lasts about three months.

12. Contd…
• A general comment about exercise, at this point, is appropriate. If you
exercised regularly before becoming ill and ultimately receiving your
transplant, that will be amazed at you restored capabilities and
excited to return to an exercise regime. But if patient have never
exercised regularly, the patient will need to accept the need at first
and then build the motivation to continue as patient see capabilities
return that you thought were lost forever.

13. Phase III
• This phase begins at the completion of Phase II and should continue for the
rest of your life. The transition to Phase III is an important decision point.
Some people decide to end their formal exercise program. However, most
people realize that in order to take advantage of the remarkable second
chance, exercise must become a daily part of their lives. You should receive
help and support from your Phase II facility contacts and the post-
transplant team at Stanford to make the right decision.
• For many people the beginning of a Phase III program coincides with going
home and finding a qualified Phase III facility is part of the decision. If you
are remaining in the local area, most phase II facilities will allow you to
continue with a Phase III program at the same place. You are familiar with
the staff and the surroundings and probably have developed meaningful
relationships with your fellow patients. You will no longer be monitored
regularly, but the staff will observe and supervise you during every session.

14. Resources
• The California Society of Physical Rehabilitation (CSPR) maintains a
website that includes a roster of rehabilitation facilities and services
offered in California.