cardiac transplantation.pptx...surgeries

1. CARDIAC
TRANSPLANTATION

2. introduction
 Cardiac transplantation is an accepted therapy for an end stage heart
disease.
 Impressive improvements in survival, refinement of immunosuppressive
therapy,and improvements in monitoring techniques have prompted many
new centers to initiate cardiac transplantation programmes.
 A heart transplant removes a damaged or diseased heart replaced with a
healthy one.
 Although heart transplant surgery is a life saving measure, it has many
risks.
 Careful monitoring,treatment,and regular medical care can prevent or help
manage some of these risks.

3. definition
 Cardiac transplantation is a therapeutic procedure whereby the heart of
a suitable donor is implanted into a recipient
- TEXTBOOK OF CARDIAC NURSING
 Heart transplant is a surgical procedure performed to remove the
damage heart from a patient and replace it with a healthy one from an
organ donor
- MOSER AND RIEGELS

4. HISTORY[global]
 Carrel and Guthrie first reported successful heterotopic cardiac
transplantation in dogs in 1905 .
 1913 Mann and colleagues at Mayo Clinic reported successful
transplantation of the heart into the neck of dogs.
 Medawar was the first to develop concepts of immunology applicable to
Transplantation.
 Lower and Shumway first reported successful experimental orthotopic
cardiac transplantation in 1960.
 Orman Shumway is widely regarded as the father of heart
transplantation although the world's first adult human heart transplant
was performed by a South African cardiac surgeon,Christiaan Barnard,
utilizing the techniques developed and perfected by Shumway and
Richard Lower.
 In 1964, Hardy and colleagues performed the first heart transplant into
a human, using a chimpanzee heart.
 The first human-to-human heart transplant (allograft) was performed in
Cape Town, South Africa, by on December 3, 1967.
 The recipient was Louis Washkansky, a 53-yearChristiaan Barnard -old

5. Cont’d
 Three days after the Cape Town operation, Adrian Kantrowitz
performed the second human heart transplant in Brooklyn.
 The recipient was an 18- day-old neonate with Ebstein anomaly,
refractory heart failure, and previous aorticpulmonary shunt for severe
cyanosis.
 Barnard performed the third human heart transplant on Philip Blaiberg,
a 46-year-old dental surgeon with refractory heart failure, severe
coronary artery disease, and a large left ventricular aneurysm.
 He became the first long-term survivor, living for 18 months. Norman
Shumway performed the fourth heart transplant 4 days later, and this
patient died 2 weeks later.

6. History [india]
 At KEM Hospital, Mumbai, Dr PK Sen and his team performed
the first heart transplant in India in February 1968.
 The Organ Transplant Bill 1994 was passed in the Indian
Parliament in May 1994 which cleared the way for organ harvest
from brain-dead patients.
 Successively, Dr P Venugopal and his team performed the first
successful heart transplant on August 3, 1994. Hyderabad first
transplant was done in global hospital.
 The full extent of the law and notification happened in 1995 after
which other centres in India performed the surgery successfully.
 6 heart transplants have been done in NIMS ,INDIA .
 Collectively, 129 heart transplants have been performed in India
since 1994 with 82 in Chennai, 33 at AIIMS and 14 at other
centres in India.

7. INDICATIONS
 The ACC/AHA guidelines include the following indications for cardiac
transplantation:
 Refractory cardiogenic shock requiring intra-aortic balloon pump
counter pulsation or left ventricular assist device (LVAD) .
 Cardiogenic shock requiring continuous intravenous inotropic therapy
(i.e., dobutamine, milrinone, etc.).
 Peak VO2 (VO2max) less than 10 mL/kg per min.
 NYHA class of III or IV despite maximized medical and
resynchronization therapy.
 Recurrent life-threatening left ventricular arrhythmias despite an
implantable cardiac defibrillator, antiarrhythmic therapy, or catheter-
based ablation.
 End-stage congenital HF with no evidence of pulmonary hypertension.
 Refractory angina without potential medical or surgical therapeutic

8.  Severe symptoms, with dyspnoea at rest or with minimal exertion
(NYHA class III or IV)
 Episodes of fluid retention (pulmonary or systemic congestion,
peripheral edema) or of reduced cardiac output at rest (peripheral
hypoperfusion)
 Objective evidence of severe cardiac dysfunction (at least one of the
following). Left ventricular Ejection fraction less than 30%, •
 Pseudonormal or restrictive mitral inflow pattern on Doppler
echocardiography.
 High left and/or right ventricular filling pressure .Severely impaired
functional capacity demonstrated by one of the following
 Inability to exercise, 6-minute walk test distance less than 300 m (or
less in women or patients who are age 75 and older), or peak oxygen
intake less than 12 to 14 mL/kg/min
 One or more hospitalizations for HF in the past 6 months

9. Absolute contraindications
 Systemic illness with a life expectancy 2 year despite HT, including
Active or recent solid organ or blood malignancy within 5 y (eg.
leukemia, low-grade neoplasms of prostate with persistently elevated
prostate-specific antigen) .
 AIDS with frequent opportunistic infections.
 Systemic lupus erythematosus, sarcoid, or amyloidosis that has
multisystem involvement and is still active .
 Irreversible renal or hepatic dysfunction in patients considered for
only HT.
 Significant obstructive pulmonary disease (FEV1 1 L/min)
 Fixed pulmonary hypertension • Pulmonary artery systolic pressure
60 mm Hg . Mean transpulmonary gradient 15 mm Hg .Pulmonary
vascular resistance 6 Woods units.

10. REFERRAL AND EVALUATION OF POTENTIAL
CANDIDATES
 Patient with advanced persistently symptomatic heart failure despite
optimal medical therapy may be refferred for cardiac transplantation.
 Referral can be initiated by a primary Cardiologist,Internist,Family
practitioner,The patient and the family member.
 Referral usually made up to nearest heart transplant centre with the
beneficial insurance companies.

11. EvALuation protocol for cardiac transplantation
General
 Complete history and physical examination
 Nutritional status evaluation
 Blood chemistry evaluation
 Hematology and coagulation profile
 Lipid profile
 Urine analysis
 24 hour urine for creatinine clearance test
 Nuclear renal scan with measurement of effective renal plasma flow
 PFT and ABG
 Ventilation perfusion scan
 Mammography
 Prostate specific antigen

12.  Abdominal USG, Carotid USG
 Social evaluation
 Psychiatric evaluation
 dental evaluation
 X-Ray PNS
CARDIOVASCULAR
 ECG
 Chest X-ray PA and lateral view
 Two dimensional ECHO with Doppler study
 Exercise testing
 Cardiac catheterization
 Myocardial Biopsy
 Holter monitor
 Radionuclide Angiogram
 Nuclear imaging study

13.  IMMUNOLOGY
 ABO blood type and Antibody screen
 Panel reactive antibody screen
 Human leukocyte antigen typing
 INFECTIOUS DISEASE SCREENING
 Serology for HepatitisA,B,C,Herpes
virus,HIV,Toxoplasmosis,Varicella,Rubella,Ebstein Barr
virusVDRL,Histoplasmosis,
 Throat swab
 Urine culture and sensitivity
 Stool for Ova and parasites
 purified protein derivatives skin test with control

14. Listing patient for cardiac transplantation
 Once evaluation completed the information are compiled and
presented to the team meeting to decide whether or not placed on
the waiting list
 Candidates are listed as per UNOS
It depends upon three factors
 The severity of a patient’s heart disease
 Absence of absolute contraindications to transplantation
 Exclusion of other surgical therapeutic options

16. MANAGEMENT OF PATIENTS AWAITInG CARDIAC
TRANSPLANTATION
 Regular follow up
 Unstable heart failure patient may require hospitalization until
transplantation
 Management by pharmacological and non pharmacological
theraphy.

17. Donor selection
 Donor-Recipient Size Matching
 Matching Donor and Recipient
 Donor-Recipient Size Matching Because ischemic time during cardiac
transplantation is crucial
 donor recipient matching is based primarily not on HLA typing but on the
severity of illness
 ABO blood type (match or compatible)
 response to PRA, donor weight to recipient ratio (must be 75% to 125%),
 geographic location relative to donor
 length of time at current status

18. Cardiac donor criteria
 Brain death
 Consent
 Age generally less than 55
 ABO blood type compatibility
 Compatible donor recipient weight
 Absence of active infection
 Absence of malignancy except primary brain tumour
 Absence of pre existing heart disease or cardiac tumour
 Negative serology test
 Acceptable left ventricular function

19. Criteria For Determining Brain Death Clinical
Evaluation
 Mechanism of brain injury is sufficient to account for irreversible loss of
brain function
 Absence of reversible causes of CNS depression
 CNS depressant drugs
 Hypothermia (<32°C [85°F]) ,Hypotension (MAP <55 mmHg)
 Absence of neuromuscular blocking drugs that may confound the results
of the neurologic exam
 No spontaneous movements, motor responses, or posturing

20.  No gag or cough reflexes
 No corneal or pupillary light reflexes
 No oculovestibular reflex (cold calorics) Confirmatory Tests
 Apnea test for minimum of five minutes showing
 No respiratory movements
 PCO2 >55 mmHg
 pH <7.40

21. Principles in donor management
 Restoration and maintanence of adequate hemodynaemic stability
 Maintenance of adequate oxygen perfusion
 Treatment of brain death related complication
 Donor Selection And Management
 Acceptance of the concept of irreversible brain death, both legally and
medically.
 Patients with irreversible brain injury accompanied by the intent to
withdraw life support are considered to be potential organ donors.

22. ORGAN PROCUREMENT

24. Preoperative nursing care
Psychological Preparation
 The patient may tensed about his surgery because of ignorance, feet, etc. the
nurses should give psychological support to the patient.
 Discuss with the patient to give feel information about the surgery such as:
 Type of surgery
 Consequence of surgery
 The problems to be faced
 Expected duration of hospitalization
 Expected time of resuming duty
 Cost of surgery
 Treatment done before surgery and if purpose

25. Eradicate Fear of Operation from the Patient
 The means surgery operation itself make fear to the patient so for reducing that fear
the nurses should
 Allow the patient to ask questions and clear all his doubts
 Introduce the patient to some ones who has similar surgeries and successfully
recovered from the symptoms
 Explain how to get rid of pain after surgery
 Tell the patient when he can have meals
 Answer all questions soaked by the patients in a language he can understand
 Let the patient see the persons, places and equipment involved in the operation
 Always short the procedures with an example
 For many patients, their admission to the hospital is an experience in their times. In
such situation, the nurses should make them feel at home in by eradicating their fear

26. OBTAIN INFORMED CONSENT
The nurses should get an informed consent from patient/guardian for each
operation
 Never compel them to give their consent
 They should understand the language used in the consent form
 Explain the complications that may occur in the period of anaesthesia
BUILD UP THE GENERAL HEALTH OF THE PATIENT AND
CORRECTION OF THE DISEASE PROCESS FOR SPEEDY
RECOVERY
 Assist the doctor to carry out thorough physical examination
 Collect all baseline dates
 Arrange for the blood donors
 Diet may be adjusted to correct underweight/overweight of the patient

27. PREOPERATIVE TEACHING
We should teach the patient to increase his health by giving advices like
 (a) stop smoking,
 (b) maintain personal hygiene,
 (c) deep breathing and coughing exercises
 [d]active and passive exercise
SURGICAL PREPARATION OF THE SKIN
 Skin preparation helps reduce the number of microorganism present on skin
and thus reduce the possibility of wound infection.
 Shave the area and clean the area with antiseptic lotion/swab

28. PREPARATION OF THE PATIENT ON THE EVENING
BEFORE OPERATION
 Remove the lipstick and nail polish
 Remove all jewelry and hand over them to the relatives
 shave the area to be operated
 Ask shaving, ask the patient to have a through bath and dress in clean
clothes
 The patient should be reassured to prevent anxiety and fear of operation

29. PREPARATION OF THE PATIENT ON THE DAY OF
SURGERY
 Help the patient for eliminaton and for mouth care
 Remove hair pins, clips, ornaments, false teeth, etc
 Comb and tie hair with a ribbon
 Remind the patient and his relative about the fasting before surgery
 Check the orders for bowel preparation
 Clean the operation site with soap and water thoroughly, dry the area with clean towel
 Cover the site with sterile towel and fix it by means of bandages
 Introduce nasogastric tube, urinary catheter if ordered
 Stop all medications unless specifically ordered by the surgeon

30. SENDING THE PATIENT TO OPERATING ROOM
 Administer the premedication to the patient one hour before surgery
 Check the vital signs
 Write the patients name, age, sex, ward, bed no, diagnosis, hospital number
etc., on a identification card and fasten it on to the dress or as on arm to
prevent mistaken identify
 Ask the patient on to void just before sending to operating room
 Transfer the patient on to a patient trolley and cover him with clean sheets to
prevent draught
 Never leave the patient alone on trolley
 Always send the patients charts with all reports
 Always send the patient with an attended up to the operation theater

31. Pre operative nursing diagnosis
 Ineffective Breathing Pattern related to end stage heart failure
 Fear/Anxiety related to Change in health status; threat of death
 Risk for Injury related to complications of drug therapy
 Risk for Infection related to Presence of pathogens/contaminants,
environmental exposure, invasive procedures
 Risk for Imbalanced Body Temperature related to Exposure to cool
environment
 Deficient Knowledge about surgical procedures related to lack of
exposures
 Altered Sensory/Thought Perception related to Therapeutically restricted
environments; excessive sensory stimuli
 Risk for Deficient Fluid Volume related to Restriction of oral intake

32. The heart transplant process
 The heart transplant process starts when doctors refer patients with end-
stage heart failure to a heart transplant center for evaluation.
 Patients found to be eligible for a heart transplant are placed on a
waiting list for a donor heart.
 Heart transplant surgery is done in a hospital when a suitable donor
heart is found.
 After the transplant, patients are started on a lifelong health care plan
involving multiple medicines and follow up.

34. Cardiac transplantation procedure
 It is important to carefully plan the entire operation to attempt to limit the
donor ischemic time to less than 6 hours and preferably less than 4 hours.
 Ischemic times should also be limited to around 4 hours or less in situations
where the donor heart is marginal (older donor) as well as in recipients with
increased pulmonary vascular resistance.
 Both the bicaval and the biatrial technique can be safely performed with
excellent long-term outcomes in patients with endstage heart failure.
 Numerous studies have been performed comparing both these techniques
with varied results.
 The bicaval technique preserves normal atrial morphology, sinus node
function, and valvular function.

35.  As a result, it has consistently been associated with a decreased incidence of atrial
arrhythmias and the need for pacemaker implantation.
 However, potential disadvantages include an increased ischemic time and the
possibility of narrowing of the caval anastomosis.
 Standard median sternotomy is Performed The vena cavae are also cannulated
(preferably with right-angled metal tip cannulas) as distally as possible
 Recipient cardiectomy the aorta is cross-clamped cavo-atrial junction incision is
ideally made : medially through the ostium of the coronary sinus and laterally
through the floor of the fossa ovalis cuff of posterior left atrial tissue.
 BIATRIAL TECHNIQUE The SVC is doubly ligated and the right atrium is
opened from the lateral IVC toward the right atrial appendage, to avoid the sinus
node
 Donor heart The left atrial cuff Connecting incisions between each of the 4
pulmonary veins The superior vena caval cuff is trimmed at the level of the
azygous vein opening and more if adequate recipient cuff is present

36.  Orthotopic heart transplantation: bicaval anastomosis technique Suturing the LA
Superior and inferior vena caval anastomosis Pulmonary artery and aortic
anastomosis.
 Orthotopic heart transplantation: biatrial anastomosis technique The right atrial
anastomosis is initiated at the superior end of the atrial incision. A long 3-0
Prolene suture is used and the suture ends are carried both inferiorly and
superiorly to first complete the septal anastomosis, and then they are joined at
the lateral wall of the septum.
 Completed orthotopic heart transplantation Reperfusion Look for LA
anastomotic site bleed RA RV site
 If need Inotropic support Vasodilators

37.  CPB separation ,May develop bradyarrythmias – Require direct
acting sympathomimetics, pacing
 Most grafts recover normal ventricular function – Dysfunction
secondary to ischemia – Concern with early recognition of right
ventricular failure
 RV failure – PVR > 4 Woods units with little or no reversibility
preop – Low CO with elevated CVP (> 15) and elevated PAP (> 40).
PCWP may be low.
 The most common reason for failure to wean a heart transplant
recipient from cardiopulmonary bypass is right-sided heart failure,
evidenced by a low cardiac output despite a rising central venous
pressure.

38.  Heterotopic heart transplantation Heterotopic heart
transplantation involves a donor heart being connected in parallel
with the recipient heart. The end result involves four surgical
anastomoses: at the levels of the right atria, left atria, aortas, and
pulmonary trunks.
 Advantages to the heterotopic technique compared with the
traditional orthotopic approach.The native heart basically functions
as an “assist device” and usually can maintain circulation during:
 recovery of donor heart function from ischemia sustained during
transplantation.
 severe rejection episodes.
 The period of adaptation of a small donor heart to the demands of
the circulation.
 The period of adaptation during which the PVR decreases after
transplantation and
 A period of chronic rejection, while the patients awaits

39.  There are, however, a few distinct disadvantages inherent in
heterotopic transplantation that cannot be ignored.
 These include:
 I. the continuing risk of embolic episodes originating from thrombi
in the poorly contracting native left ventricle;
 2. angina, which may be secondary to persistent ischemia in the
native myocardium, and
 3. functionally significant right lower lobe atelectasis secondary to
the position of the heterotopic heart.
 This can be a source of persistent pulmonary dysfunction and
recurrent pneumonia.

40. Post transplant physiology
 Cardiac denervation is an inevitable consequence : a denervated
donor heart.
 The atrial remnant of the recipient remains innervated, but no
impulses will cross the suture line.
 As a result, the donor atrium is responsible for heart rate generation.
 The transplanted heart has a higher intrinsic rate and reduced rate
variability.
 Resting heart rates range from 90 to 110 beats per minute.
 Normal responses to changes in position, e.g. orthostatic changes,
are lost as are the variations in response to stimuli such as the
Valsalva manoeuvre, carotid sinus massage.

41.  Intrinsic functions such as cardiac impulse formation and conduction are
intact.
 In the innervated heart, the normal acute response to a sudden reduction in
intravascular volume is a simultaneous increase in both heart rate and
contractility.
 In the denervated heart, however, the initial response via the Frank-
Starling mechanism is an increase in stroke volume dependent on an
adequate left ventricular end diastolic volume.
 The increased contractility secondary to heart rate is a secondary effect
and is dependent on circulating catecholamines.
 The transplanted heart is, therefore, critically preload dependent; higher
filling pressures are needed.

45. Bicaval,biatrial approach

48. HETEROTOPIC TYPE

49. HETEROtropic

51. orthotropic

53. Post operative nursing care
Haemodynamics monitoring
 Maintenance of a heart rate of 100-110bpm is an important aspect of
early postoperative care that enables optimal cardiac output and
adequate renal perfusion to be achieved.
 reduction of pulmonary vascular resistance is beneficial for right
ventricular function.
 Isoprenaline is administered to achieve both of these, although
temporary pacing via epicardial wires may be required.
 Additional inotropes/vasodilators such as milrinone/adrenaline or
glyceryl trinitrate may be used, depending on the patient.

54.  If the patient’s cardiac function is satisfactory and adequate
hydration is achieved.
 Maintaining adequate blood pressure is not usually a problem in the
early postoperative period.
 Hypertension is common following cardiac transplant; this is often
drug-induced and generally caused by anti-rejection therapy.
 ACE inhibitors and calcium channel blockers are common
treatments.
 Life-threatening arrhythmias are rare postoperatively, even during
acute rejection episodes .
 Atrial flutter/fibrillation is occasionally seen in patients and, if
problematic, can be treated with overdrive atrial pacing, amiodarone
or, more rarely, DC cardioversion.

55. Respiratory care
 Patients rarely experience respiratory problems.
 Intense physiotherapy, observation of respiratory rate, oxygen saturations,
and regular chest X-rays will allow early identification of pulmonary
atelectasis.
 Precise fluid management will help prevent pulmonary oedema.
 Oxygen therapy will be weaned as the patient’s clinical condition allows.
 Fluid balance/renal function
 The assessment and management of a patient’s fluid balance following
heart transplant can be challenging.
 It is essential to keep a fluid balance record, to check the patient’s weight
daily, as well as make regular checks of their urea and electrolyte levels,
and do clinical examinations.
 Patients are often oedematous, and this is caused by a combination of fluid
overload and having low albumin levels preoperatively.
 Diuretics are frequently used but care must be taken not to cause
hypovolaemia.

56.  Most patients will present with renal dysfunction at the time of transplant,
secondary to heart failure. The insult of surgery, potential hypotensive episodes
perioperatively and nephrotoxic anti-rejection therapy usually worsens renal
function in the early days.
 Regular monitoring of urea and electrolyte levels, maintenance of optimal fluid
balance and avoidance of unnecessary nephrotoxic drugs will help.
 Dialysis may, occasionally, be necessary. Renal-dose dopamine is no longer
used routinely for all patients, as many studies have questioned its value
Organ rejection
 Rejection following cardiac transplant is most common in the first six to 12
weeks, although it can occur at any time.
 Triple therapy anti-rejection treatment consisting of cyclosporin, azathioprine
and prednisolone is most commonly administered postoperatively, but the drug
regimen will vary from centre to centre.
 Agents such as tacrolimus, and mycophenolate mofetil can also be used.

59. Acute rejection biopsy grading

60. All anti-rejection therapy has side-effects that include:
 Nephrotoxicity
 Abnormal liver function
 Hypertension
 Diabetes
 Osteoporosis
 Bone-marrow suppression
 Post-transplant lymphoproliferative disease
 Increased incidence of skin cancer/malignancies
 Acne/moon face/facial hair
 Shakiness/tremor

61. Signs and symptoms of rejection may include:
 Weight gain
 Low grade temperature
 Lethargy/general malaise
 Palpitations
 Shortness of breath
 Soft heart sounds/S3 gallop
 Balancing the dose of anti-rejection drugs is crucial both to minimise
rejection and avoid a high level of side-effects

62.  The most accurate way of determining rejection remains endomyocardial
biopsy .
 This is initially carried out at weekly intervals and gradually reduced in
frequency, according to individual need.
 Biopsy specimens are examined and graded according to the International
Society of Heart .
 Forty per cent of patients will require treatment for rejection in the first six
weeks, through intravenous administration of methyl prednisolone 10mg/kg
for three days.

63. Infection
 Patients taking immunosuppressive drugs are inevitably at risk of infection.
 All patients are initially nursed in cubicles with restricted visiting.
 The focus of care to minimise infection risk is early extubation, the removal of
lines and ambulation.
 Antibiotic therapy of flucloxacillin 500mg four times a day is given for 48
hours.
 In addition, short-term anti-infective treatment will include nystatin suspension
(antifungal mouthwash); acyclovir 200mg three times a day (antiviral); and
sulfamethoxazole trimethoprim 480mg once a day (to prevent Pneumocystis
carinii infection).
 Any signs and symptoms of infection including pyrexia and raised white-cell
count will be investigated and, where possible, an organism identified before
further antibiotics are commenced; broad-spectrum antibiotics are rarely used.
Patients are taught to take their own temperature and recognise signs and
symptoms of common infections.

64. Pain control
 Good pain control is essential to aid recovery from transplant and facilitate
cooperation with physiotherapy (Coleman and Bucker-Milburn, 1996).
 Although all patients are assessed individually, patient-controlled analgesia
(morphine) is commonly used, followed by oral dihydrocodeine and
paracetamol.
 Patients are encouraged to express their needs.
 Referral to the specialist pain team.
Mobility
 All patients are assessed for the risk of deep-vein thrombosis and will
usually be prescribed low molecular weight anticoagulants once a day until
they are mobile.
 Patients who develop thromboembolic problems may require formal
anticoagulation therapy. n be made, if necessary.

65.  Mobility and independence are encouraged as the patient’s condition and
confidence .
 They are encouraged to sit out of bed on day two, start walking around at
four to five days postoperatively and attend the gym on day eight,
following a satisfactory cardiac biopsy result.
 Each patient will require an individual exercise plan tailored to his or her
needs .
Nutrition and hydration
 As soon as adequate gastrointestinal function is established, patients are
encouraged to eat and drink, and intravenous fluids are discontinued.
 A good fluid intake of 2L in 24 hours is optimal.

66.  In the early postoperative period, a diet high in protein and calories is
encouraged to aid recovery and tissue repair .
 Early dietetic input is established, as patients may require advice on low-
potassium, low-sugar or high-magnesium needs.
 Long-term advice will recommend patients adhere to a low-saturated fat
diet, to prevent obesity and raised lipid levels.
 Constipation will be treated with basic interventions.
 he focus of care will shift to education and rehabilitation. It is often around
this time that a patient’s emotional and psychosocial needs increase.

67. Postoperative psychological issues
 Although successful transplantations have much to do with advances in
surgical technique, physical management and immunosuppression, a
patient’s emotional and behavioural responses contribute significantly to
long-term survival and progress following transplantation.
 The education process starts as soon as the patient is able to cope with it
(three to seven days postoperatively).
 This is a structured programme that covers self-medication, awareness of
side-effects, self-monitoring of signs and symptoms of rejection and
infection, checking temperature and weight, and general health advice.
 Teaching is relaxed and informal and continues in the outpatient clinic.
Donor guilt
Social and marital problems
Stress
Body image and compliance

68. Side-effects from medication
 All patients will initially be started on a regimen of high-dose steroids which in
themselves can result in depression even before the occurrence of side-effects such as
obesity and excessive hair growth.
Changes in body image
 It can affect the patient’s recovery and subsequent drug compliance.
 Non-compliance with drug therapy/clinic attendance can result in transplant
rejection.
 Younger recipients often perceive themselves as victims, whereas older
recipients are grateful for a second chance.
 Many adolescents have difficulty in coping with the altered body image
caused by the medication.
 Multidisciplinary interventions used to improve compliance and patient
recovery include:
e

69. Rehabilitation and outpatient care
 Rehabilitation and education are ongoing processes following the operation,
culminating in discharge into hospital accommodation or home within two to three
weeks of transplantation
 Outpatient visits are frequent in the early post discharge period, and medications,
investigations and follow-up are adjusted on an individual basis.
 Within three months, the majority of patients will be able to lead a normal lifestyle
and many consider returning to work.
 In this time of surgical and medical miracles, it is important to recognise that for the
well-being and long-term survival of transplant patients, the multidisciplinary input
of transplant coordinators, nurses, social workers, psychologists, physiotherapists,
chaplains and even ward domestics is paramount.

70. Rehabilitation Management And Treatments
 A multidisciplinary approach should be used in the treatment, management
and rehabilitation of this population.
 Heart transplant candidates should initiate an exercise routine prior to
surgery.
 Post transplant, patients will be deconditioned, with impaired functionally
capacity, decreased cardiac output, and decreased maximal oxygen capacity.

71. At different disease stages
Pretransplant stage
 Left ventricular assist devices (LVADs) can serve as a viable bridge before
transplantation, allowing an opportunity to recondition through aerobic
training that can include treadmill or free ambulation.
New onset/acute
 Physical conditioning should begin during the inpatient phase, once
hemodynamic stabilization has been achieved.
 Exercise programs should include aerobic exercises in cycle-ergometer or
walking with progressive increase on duration and intensity and articular
mobility, flexibility, and resistance of large muscular groups. Monitoring
should include HR and blood pressure, and subjective fatigue with the
Borg Scale. The six-minute walk test measures functional exercise
capacity.
 The Borg Rate of Perceived Exertion Scale determines the perceived
exertion during various levels of exercise intensity.

72. Sub-acute19
 Programs can begin as early as 2 weeks post-surgery.
 Structured-supervised programs demonstrate superior outcomes over
home-based programs in a physical work capacity and activities of daily
living.
 Walking is recommended on alternate days
 Closed-chain resistive activities (bridging, half squats, toe raises),
abdominal exercises (curl ups and pelvic tilts), flexibility exercises (chest
expansion and thoracic mobility, side stretch, trunk twist, scapular
squeezes, shoulder rolls), and aerobic exercises (treadmill walking or
pedaling on bicycle ergometer).
 The duration and intensity shall progressively increase to meet the
patient’s tolerance with a goal of 30 minutes of continuous aerobic
exercise at moderate intensity for each session.

73. BICYCLE ERGOMETRY

74. SCAPULAR SQUEEZES

75. SHOULDER ROLLS

76. Trunk twist

77. FLEXIBILITY EXERCISE

78. ABDOMEN EXERCISE

79. TOE RAISE

80. HALF SQUAT

81. CURL UPS

82. AEROBIC EXERCISE

83. BRIDGING

84. PELVIC TILT

85. Chronic/stable:
 Cardiac transplant patients may survive for more than 25 years.
 Chronic immunosuppression may lead to infections, malignancy, and renal
deterioration.
 Exercise routines should be adopted daily.
 Exercise must be halted if organ rejection is suspected.
Preterminal or end of life care
 An interdisciplinary approach is used to address patient and family needs.
 Providers need to educate patient/family about disease progression,
functional decline, advanced care planning, and end of life decisions.
 Goals are targeted to maximize quality of life, focusing on symptoms
management.
 These include pain relief, affirming life and regarding dying as a normal
process, and offering a support system to help patients live as actively as
possible.

86. Patient & family education
 Education to the patient and family is core to the short- and long-term
process.
 After the heart transplant, the patient must monitor signs of infection,
weight changes, pulse, changes in blood pressure and sugar levels.
 Patients must adhere to nutritional recommendations, medications and the
exercise routine.
 Adjustment to the post-transplant process can require psychosocial support

87. HEALTH EDUCATION
• Eating plenty of fruits and vegetables each day
• Eating whole-grain breads, cereals and other grains
• Drinking low-fat or fat-free milk or eating other low-fat or fat-free dairy
products, to help maintain enough calcium in your body
• Eating lean meats, such as fish or poultry
• Maintaining a low-salt diet
• Avoiding unhealthy fats, such as saturated fats or trans fats
• Avoiding grapefruit and grapefruit juice due to its effect on a group of
immunosuppressant medications (calcineurin inhibitors)
• Avoiding excessive alcohol
• Staying hydrated by drinking adequate water and other fluids each day
• Following food safety guidelines to reduce the risk of infection

88. POST OPERATIVE NURSING DIAGNOSIS
 Decreased cardiac output related to blood loss and cardiac
transplantation.
 Impaired gas exchange related to trauma of extensive chest surgery
 Risk for deficient fluid volume and electrolyte imbalance related to
alterations in blood volume
 High risk for impaired tissue integrity related to multiple drains,
Hypothermia.
 Risk of infection related to invasive procedure and exposure to
pathogens.
 Risk for injury related to chemical, physical, and electrical hazards.
 Risk for alteration in fluid and electrolyte balance related to abnormal
blood loss and NPO status.