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HEART TRANSPLANT
DR. ANERI PATWARI
MPT:CARDIO-RESPIRATORY
ASSISTANT PROFESSOR
INTRODUCTION
•The human heart is an organ that pumps Blood to supplying oxygen and nutrients to the body
tissues.
•Normal heart beats 60 to 100 per minute. if the heart is not able to supply blood to the organs and
tissues, they'll die."
08-04-2024 2
DEFINITION
•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.
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HISTORY
•The first human-to-human heart transplant was performed in Cape Town on 3 December 1967 by
Christiaan Barnard; the patient died 18 days later of infective complications. Outcomes were poor
in the early years, but with the discovery of ciclosporin in the 1980s there was an improvement in
survival which led to a peak in cardiac transplant activity in the early 1990s.
• 129 heart transplants have been performed in India since 1994 with 82 in Chennai, 33 at AIIMS
and 14 at other centres in India.
• At KEM Hospital, Mumbai, Dr PK Sen and his team performed the first heart transplant in India
in February 1968, months after the first attempt at heart transplant was made by Christiaan N.
Barnard in December 1967 at South-Africa. Barnards's patient lived for 18 days while Sen's
patient died within 24 hours, this was before immuno-supressing drugs were made
08-04-2024 4
TRANSPLANT INDICATIONS:
ABSOLUTE
1. Hemodynamic compromise due to heart failure, cardiogenic shock
2. Dependence on intravenous inotropic support for adequate organ perfusion Peak V O2 <10
mL/kg/min
3. Severely limiting non revascularizable ischemic heart disease affecting activities of daily
living Recurrent symptomatic ventricular arrhythmias refractory to therapy. Relative
indications
4. Peak V.O2 11–14 mL/kg/min with major limitations affecting activities of daily living,
Recurrent unstable angina refractory to current therapy
5. Recurrently labile fluid balance or renal function in chronic heart failure despite full patient
adherence to therapy.
08-04-2024 5
TRANSPLANT INDICATIONS:
INSUFFICIENT
Indications Presence of the following without other indications for transplant:
a. Impaired left ventricular systolic function
b. Previous history of NYHA class III or IV heart failure
c. Peak V O2 >15 mL/kg/min
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CONTRAINDICATIONS
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CARDIAC TRANSPLANT
EVALUATION TEST
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CARDIAC TRANSPLANT
EVALUATION TEST
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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:
1. functional capacity is more useful than
2. NYHA classification,
3. ejection fraction,
4. or other markers of heart failure severity, for assessing prognosis and determining the optimal
timing of listing for transplantation.
5. 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.
08-04-2024 12
PRE TRANSPLANT EXERCISE TESTING
CONSIDERATION
5. Patients with a peak O2 between 10 and 14 mL/kg/min constitute an intermediate risk group
in which continued medical therapy may offer a survival benefit similar to heart transplantation
among selected patients that are able to tolerate beta blockers, have low-risk Heart Failure Survival
Scores (HFSS's).
6. 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.
7. 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.
8. Based on the results of the exercise test, an ET prescription may be developed with the goal of
maintaining or even improving cardiorespiratory fitness.
08-04-2024 13
HEART FAILURE SURVIVAL
SCORE
low (HFSS >8.10), medium (7.2–8.09), and high (≤7.19)
08-04-2024 14
CONTRAINDICATIONS FOR PRE
TRANSPLANT
1. Irreversible severe pulmonary arterial ypertension , Advanced age (>70 years)
2. Active systemic infection, Other multisystem disease with poor long-term survival
3. Active malignancy or recent malignancy with high, risk of recurrence
4. Diabetes mellitus with:
a) End-organ damage (neuropathy, nephropathy, proliferative retinopathy)
b) Poor glycemic control(HbA1c >7.5)
5. Psychosocial factors including history of non-compliance with medication,
6. inadequate support, ongoing/recent drug or alcohol abuse, current smoker.
7. Obesity (body mass index >35 kg/m2 or weight >140% of ideal body weight).
08-04-2024 15
CONTRAINDICATIONS FOR PRE
TRANSPLANT
8. FEV1, forced expiratory volume in one second; FVC, forced
9. Irreversible renal dysfunction with estimated glomerular filtration rate <30 mL/ min/1.73 m2.
10. Irreversible liver dysfunction, eg, cirrhosis.
11. Recent pulmonary thromboembolism (generally in the last 3 months).
12. Pulmonary hypertension with pulmonary artery systolic pressure >60 mm Hg,
13. If irreversible with either pharmacological manipulation or mechanical unloading of the left
ventricle, then this is an absolute contraindication to isolated heart transplantation.
14. Current or recent neoplasm: risk of recurrence should be discussed with the oncologist. •
Severe lung disease: FEV1 and FVC <50% predicted or evidence of parenchymal lung disease.
08-04-2024 16
DONOR SELECTION
•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.
08-04-2024 17
DONOR AND
RECIPIENT MATCHING
1. A potential donor must meet several criteria:
2. The donor must meet national or regional criteria for brain death.
3. Electrocardiographic and echocardiographic findings should be normal.
4. A donor older than 45 years (often considered for an older recipient) should undergo coronary
angiography to exclude significant coronary artery disease.Otherwise, the risk factor profile
for coronary artery disease should be low and there should be no evidence of untreated acute
infection or systemic malignancy.
5. Results from human immunodeficiency virus infection and hepatitis screens should be
negative.
6. Potential donors with cardiac trauma are usually excluded.
08-04-2024 18
DONOR-RECIPIENT MATCHING
DEPENDS
1. Blood type: ABO matching is mandatory. Matching of rhesus factor status is not required
since cardiac myocytes do not express the rhesus antigen.
2. Body size: Generally, the donor’s body weight should be at least 80% of the recipient’s.
3. Pulmonary hypertension: If the recipient has an elevated pulmonary vascular resistance or
pulmonary artery systolic pressure a larger donor heart is usually selected to ensure adequate
right ventricular functional reserve.
4. Geographic location of donor: Ensure the shortest possible cold
08-04-2024 19
08-04-2024 20
NEED OF PRE EXERCISE
To deal with;
1. Pre-HT syndrome of chronic HF with poor exercise capacity due to central and
peripheral circulatory abnormalities.
2. Skeletal muscle pathology.
3. Generalized deconditioning.
4. The healing process with open heart surgery.
5. Post-HT use of corticosteroid medications with resultant skeletal muscle atrophy and
weakness.
08-04-2024 21
NEED OFAEROBIC EXERCISE IN
POST TRANSPLANT
1. Peak VO2 improves by an average of 24% after 2 to 6 months of ET
2. It improves mitochondrial oxidative capacity but apparently does not increase
skeletal muscle capillary density as it does in healthy subjects.
3. Improved submaximal exercise endurance
4. Increased peak treadmill exercise workload or peak cycle power output
5. Increased maximal heart rate
6. Decreased exercise heart rate at the same absolute submaximal workload
08-04-2024 22
NEED OFANAEROBIC EXERCISE
IN TRANSPLANT
1. Increased ventilatory threshold
2. Decreased submaximal exercise minute ventilation
3. Reduced exercise ventilatory equivalent for CO2
4. Lessened symptoms of fatigue, dyspnea, or both
5. Reduced rest and submaximal exercise systolic and diastolic blood pressure
6. Decreased peak exercise diastolic blood pressure g. Reduced submaximal exercise ratings of
perceived exertion
7. Improved psychosocial function, Increased lean body mass
8. Reduced body fat mass , Increased bone mineral content
08-04-2024 23
NEED OF RESISTANCE
TRAINING IN TRANSPLANT
1. Resistance ET partially reverses corticosteroid-related myopathy and improves
skeletal muscle strength.
2. Fifty days of isokinetic strength training substantially increased muscle mass and
strength in patients with corticosteroids after transplantation. (Horber and coauthors )
3. 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.
08-04-2024 24
POST TRANSPLANT
REHABILITATION
EDUCATION
1. Medications: purposes, potential side effects,
importance of strict compliance with
recommended dosing.
2. Risk of rejection, infection, and allograft
vasculopathy.
3. Postoperative management schedule: tests,
appointments.
4. Nutrition: reduced fat, caloric intake, and
sodium to help prevent weight gain related to
prednisone use and to help control blood
pressure
PSYCHOLOGICAL
1. To develop the coping skills, stress
management techniques, and
2. practical skills to deal with the multiple issues
involved in posttransplant life.
3. To provide ongoing emotional support and
encouragement.
4. 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.
08-04-2024 25
EARLY MOBILIZATION AND INPATIENT
EXERCISE TRAINING( 7-10 DAYS POST OP.)
1. After surgery, patients are extubated expeditiously, usually within 24 h.
2. 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.
3. Walking or cycle ergometry for up to 20 to 30 min may be implemented as tolerated.
4. 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%.
5. Exercise frequency is two or three sessions per day.
08-04-2024 26
OUTPATIENT EXERCISE
TRAINING CONSIDERATIONS
1. Continuous monitoring of the ECG during the 1ST few supervise sessions is standard practice.
2. It is not necessary to perform graded exercise testing before beginning the outpatient exercise
program; performance of a 6-minute walk test is helpful in assessing functional capacity.
3. Target HR is not used for Exercise prescription unless the patient exhibits a partially
normalized HR response to exercise.
4. 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
5. The rating of perceived exertion scale is useful for prescription of exercise intensity.
6. After 6-8 weeks of sternal recovery following surgery, aerobic activities including arm
involvement may be introduced.
7. The sternal incision requires special emphasis on upper extremity active range of motion
exercises.
08-04-2024 27
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.
•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.
08-04-2024 28
POST TRANSPLANT GRADED
EXERCISE TESTING
•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.
08-04-2024 29
RESISTANCE EXERCISE FOR OUT
PATIENT
Progressive resistance exercise program should 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. b. Because HT recipients are likely to require antihypertensive medications, periodic
blood pressure measurement during both aerobic and strengthening ET is
recommended.
c. Strength gains of 25% to 50% or greater commonly occur after 8 weeks of resistance
ET in these patients.
08-04-2024 30
RESISTANCE EXERCISE FOR OUT
PATIENT
•Performance of the strengthening exercises immediately following the aerobic portion of the
exercise prescription (after the cool-down) is recommended.
• 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
08-04-2024 31
AEROBIC EXERCISES FOR HT
•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.
08-04-2024 32
AEROBIC EXERCISES FOR HT
•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.
• 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.
08-04-2024 33
08-04-2024 34
COMPLICATIONS
EARLY LATE
08-04-2024 35
SUMMARY
1. Both exercise testing and exercise training including aerobic and strength training
are critical components of care for HT patients.
2. Encouragement to continue a lifelong exercise program should be a consistent
message from the HT team and the primary health care provider.
3. Patients should continue in a supervised ET program indefinitely, exercise
independently, or use a combination of supervised and unsupervised ET.
08-04-2024 36
REFERENCES
1. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs Fifth Edition.
2. Cash textbook of cardiopulmonary and vascular physiotherapy.
3. Kisner and colby textbook of exercise therapy.
08-04-2024 37
08-04-2024 38

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PHYSIOTHERAPY IN HEART TRANSPLANTATION..

  • 1. HEART TRANSPLANT DR. ANERI PATWARI MPT:CARDIO-RESPIRATORY ASSISTANT PROFESSOR
  • 2. INTRODUCTION •The human heart is an organ that pumps Blood to supplying oxygen and nutrients to the body tissues. •Normal heart beats 60 to 100 per minute. if the heart is not able to supply blood to the organs and tissues, they'll die." 08-04-2024 2
  • 3. DEFINITION •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. 08-04-2024 3
  • 4. HISTORY •The first human-to-human heart transplant was performed in Cape Town on 3 December 1967 by Christiaan Barnard; the patient died 18 days later of infective complications. Outcomes were poor in the early years, but with the discovery of ciclosporin in the 1980s there was an improvement in survival which led to a peak in cardiac transplant activity in the early 1990s. • 129 heart transplants have been performed in India since 1994 with 82 in Chennai, 33 at AIIMS and 14 at other centres in India. • At KEM Hospital, Mumbai, Dr PK Sen and his team performed the first heart transplant in India in February 1968, months after the first attempt at heart transplant was made by Christiaan N. Barnard in December 1967 at South-Africa. Barnards's patient lived for 18 days while Sen's patient died within 24 hours, this was before immuno-supressing drugs were made 08-04-2024 4
  • 5. TRANSPLANT INDICATIONS: ABSOLUTE 1. Hemodynamic compromise due to heart failure, cardiogenic shock 2. Dependence on intravenous inotropic support for adequate organ perfusion Peak V O2 <10 mL/kg/min 3. Severely limiting non revascularizable ischemic heart disease affecting activities of daily living Recurrent symptomatic ventricular arrhythmias refractory to therapy. Relative indications 4. Peak V.O2 11–14 mL/kg/min with major limitations affecting activities of daily living, Recurrent unstable angina refractory to current therapy 5. Recurrently labile fluid balance or renal function in chronic heart failure despite full patient adherence to therapy. 08-04-2024 5
  • 6. TRANSPLANT INDICATIONS: INSUFFICIENT Indications Presence of the following without other indications for transplant: a. Impaired left ventricular systolic function b. Previous history of NYHA class III or IV heart failure c. Peak V O2 >15 mL/kg/min 08-04-2024 6
  • 12. 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: 1. functional capacity is more useful than 2. NYHA classification, 3. ejection fraction, 4. or other markers of heart failure severity, for assessing prognosis and determining the optimal timing of listing for transplantation. 5. 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. 08-04-2024 12
  • 13. PRE TRANSPLANT EXERCISE TESTING CONSIDERATION 5. Patients with a peak O2 between 10 and 14 mL/kg/min constitute an intermediate risk group in which continued medical therapy may offer a survival benefit similar to heart transplantation among selected patients that are able to tolerate beta blockers, have low-risk Heart Failure Survival Scores (HFSS's). 6. 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. 7. 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. 8. Based on the results of the exercise test, an ET prescription may be developed with the goal of maintaining or even improving cardiorespiratory fitness. 08-04-2024 13
  • 14. HEART FAILURE SURVIVAL SCORE low (HFSS >8.10), medium (7.2–8.09), and high (≤7.19) 08-04-2024 14
  • 15. CONTRAINDICATIONS FOR PRE TRANSPLANT 1. Irreversible severe pulmonary arterial ypertension , Advanced age (>70 years) 2. Active systemic infection, Other multisystem disease with poor long-term survival 3. Active malignancy or recent malignancy with high, risk of recurrence 4. Diabetes mellitus with: a) End-organ damage (neuropathy, nephropathy, proliferative retinopathy) b) Poor glycemic control(HbA1c >7.5) 5. Psychosocial factors including history of non-compliance with medication, 6. inadequate support, ongoing/recent drug or alcohol abuse, current smoker. 7. Obesity (body mass index >35 kg/m2 or weight >140% of ideal body weight). 08-04-2024 15
  • 16. CONTRAINDICATIONS FOR PRE TRANSPLANT 8. FEV1, forced expiratory volume in one second; FVC, forced 9. Irreversible renal dysfunction with estimated glomerular filtration rate <30 mL/ min/1.73 m2. 10. Irreversible liver dysfunction, eg, cirrhosis. 11. Recent pulmonary thromboembolism (generally in the last 3 months). 12. Pulmonary hypertension with pulmonary artery systolic pressure >60 mm Hg, 13. If irreversible with either pharmacological manipulation or mechanical unloading of the left ventricle, then this is an absolute contraindication to isolated heart transplantation. 14. Current or recent neoplasm: risk of recurrence should be discussed with the oncologist. • Severe lung disease: FEV1 and FVC <50% predicted or evidence of parenchymal lung disease. 08-04-2024 16
  • 17. DONOR SELECTION •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. 08-04-2024 17
  • 18. DONOR AND RECIPIENT MATCHING 1. A potential donor must meet several criteria: 2. The donor must meet national or regional criteria for brain death. 3. Electrocardiographic and echocardiographic findings should be normal. 4. A donor older than 45 years (often considered for an older recipient) should undergo coronary angiography to exclude significant coronary artery disease.Otherwise, the risk factor profile for coronary artery disease should be low and there should be no evidence of untreated acute infection or systemic malignancy. 5. Results from human immunodeficiency virus infection and hepatitis screens should be negative. 6. Potential donors with cardiac trauma are usually excluded. 08-04-2024 18
  • 19. DONOR-RECIPIENT MATCHING DEPENDS 1. Blood type: ABO matching is mandatory. Matching of rhesus factor status is not required since cardiac myocytes do not express the rhesus antigen. 2. Body size: Generally, the donor’s body weight should be at least 80% of the recipient’s. 3. Pulmonary hypertension: If the recipient has an elevated pulmonary vascular resistance or pulmonary artery systolic pressure a larger donor heart is usually selected to ensure adequate right ventricular functional reserve. 4. Geographic location of donor: Ensure the shortest possible cold 08-04-2024 19
  • 21. NEED OF PRE EXERCISE To deal with; 1. Pre-HT syndrome of chronic HF with poor exercise capacity due to central and peripheral circulatory abnormalities. 2. Skeletal muscle pathology. 3. Generalized deconditioning. 4. The healing process with open heart surgery. 5. Post-HT use of corticosteroid medications with resultant skeletal muscle atrophy and weakness. 08-04-2024 21
  • 22. NEED OFAEROBIC EXERCISE IN POST TRANSPLANT 1. Peak VO2 improves by an average of 24% after 2 to 6 months of ET 2. It improves mitochondrial oxidative capacity but apparently does not increase skeletal muscle capillary density as it does in healthy subjects. 3. Improved submaximal exercise endurance 4. Increased peak treadmill exercise workload or peak cycle power output 5. Increased maximal heart rate 6. Decreased exercise heart rate at the same absolute submaximal workload 08-04-2024 22
  • 23. NEED OFANAEROBIC EXERCISE IN TRANSPLANT 1. Increased ventilatory threshold 2. Decreased submaximal exercise minute ventilation 3. Reduced exercise ventilatory equivalent for CO2 4. Lessened symptoms of fatigue, dyspnea, or both 5. Reduced rest and submaximal exercise systolic and diastolic blood pressure 6. Decreased peak exercise diastolic blood pressure g. Reduced submaximal exercise ratings of perceived exertion 7. Improved psychosocial function, Increased lean body mass 8. Reduced body fat mass , Increased bone mineral content 08-04-2024 23
  • 24. NEED OF RESISTANCE TRAINING IN TRANSPLANT 1. Resistance ET partially reverses corticosteroid-related myopathy and improves skeletal muscle strength. 2. Fifty days of isokinetic strength training substantially increased muscle mass and strength in patients with corticosteroids after transplantation. (Horber and coauthors ) 3. 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. 08-04-2024 24
  • 25. POST TRANSPLANT REHABILITATION EDUCATION 1. Medications: purposes, potential side effects, importance of strict compliance with recommended dosing. 2. Risk of rejection, infection, and allograft vasculopathy. 3. Postoperative management schedule: tests, appointments. 4. Nutrition: reduced fat, caloric intake, and sodium to help prevent weight gain related to prednisone use and to help control blood pressure PSYCHOLOGICAL 1. To develop the coping skills, stress management techniques, and 2. practical skills to deal with the multiple issues involved in posttransplant life. 3. To provide ongoing emotional support and encouragement. 4. 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. 08-04-2024 25
  • 26. EARLY MOBILIZATION AND INPATIENT EXERCISE TRAINING( 7-10 DAYS POST OP.) 1. After surgery, patients are extubated expeditiously, usually within 24 h. 2. 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. 3. Walking or cycle ergometry for up to 20 to 30 min may be implemented as tolerated. 4. 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%. 5. Exercise frequency is two or three sessions per day. 08-04-2024 26
  • 27. OUTPATIENT EXERCISE TRAINING CONSIDERATIONS 1. Continuous monitoring of the ECG during the 1ST few supervise sessions is standard practice. 2. It is not necessary to perform graded exercise testing before beginning the outpatient exercise program; performance of a 6-minute walk test is helpful in assessing functional capacity. 3. Target HR is not used for Exercise prescription unless the patient exhibits a partially normalized HR response to exercise. 4. 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 5. The rating of perceived exertion scale is useful for prescription of exercise intensity. 6. After 6-8 weeks of sternal recovery following surgery, aerobic activities including arm involvement may be introduced. 7. The sternal incision requires special emphasis on upper extremity active range of motion exercises. 08-04-2024 27
  • 28. 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. •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. 08-04-2024 28
  • 29. POST TRANSPLANT GRADED EXERCISE TESTING •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. 08-04-2024 29
  • 30. RESISTANCE EXERCISE FOR OUT PATIENT Progressive resistance exercise program should 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. b. Because HT recipients are likely to require antihypertensive medications, periodic blood pressure measurement during both aerobic and strengthening ET is recommended. c. Strength gains of 25% to 50% or greater commonly occur after 8 weeks of resistance ET in these patients. 08-04-2024 30
  • 31. RESISTANCE EXERCISE FOR OUT PATIENT •Performance of the strengthening exercises immediately following the aerobic portion of the exercise prescription (after the cool-down) is recommended. • 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 08-04-2024 31
  • 32. AEROBIC EXERCISES FOR HT •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. 08-04-2024 32
  • 33. AEROBIC EXERCISES FOR HT •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. • 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. 08-04-2024 33
  • 36. SUMMARY 1. Both exercise testing and exercise training including aerobic and strength training are critical components of care for HT patients. 2. Encouragement to continue a lifelong exercise program should be a consistent message from the HT team and the primary health care provider. 3. Patients should continue in a supervised ET program indefinitely, exercise independently, or use a combination of supervised and unsupervised ET. 08-04-2024 36
  • 37. REFERENCES 1. Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs Fifth Edition. 2. Cash textbook of cardiopulmonary and vascular physiotherapy. 3. Kisner and colby textbook of exercise therapy. 08-04-2024 37