This document provides information on cardiac rehabilitation considerations for heart transplant patients. It discusses the transplantation procedure and potential complications. It outlines the abnormal exercise physiology findings in transplant patients and benefits of regular exercise. Exercise recommendations include initial inpatient mobilization, followed by outpatient programs incorporating aerobic exercise and strength training. The goals are to improve functional capacity and quality of life while avoiding risks to immune function or transplant rejection.

1. CENTER FOR PHYSIOTHERAPY AND REHABILITATION
SCIENCE
JAMIA MILLIA ISLAMIA
Submitted to: Dr. Jamal Moiz
Submitted by: Sumaiya Shams
Mpt (cardio)

2. SPECIAL CONSIDERATION IN CARDIAC
REHABILITATION PROGRAM FOR
HEART TRANSPLANT PATIENT

3. Introduction
• Heart transplantation is the treatment of choice for eligible
patients with advanced chronic heart failure resulting in
markedly improved survival, functional status, and quality of
life compared with alternative treatments.
• The Registry of the International Society for Heart and Lung
Transplantation’s 2015 report contained 112,521 heart
transplantations performed worldwide between 1982 and 2013
with 1- and 5-year survival of 82% and 69%, respectively.

4. • Survival is similar for both patients with and without
circulatory support with an LVAD before transplantation
• The age range of heart transplant recipients is from newborn to
the eighth decade of life. For adults, the average age at
transplant is approximately 54 years and 75% are men.
Approximately 50% of children who receive a transplant are
≤5 years of age. The average age of the donors is
approximately 35 years.

5. Orthotopic transplantation

6. Heterotopic transplantation

7. Graft Dysfunction
• The transplanted heart may fail soon after surgery due to
primary graft dysfunction, pulmonary hypertension, or
hyperacute rejection. Primary graft dysfunction is caused by
ischemia and reperfusion injury related to the transplant
procedure and results in the majority of early mortality .
• Contributing factors include brain death of the donor, ischemic
time, and hypothermia of the donor heart. The incidence is
variable but occurs in at least 5% of patients.
• The pathophysiology includes both increased pulmonary
vascular resistance and systemic inflammation.

8. Rejection
1. Hyperacute Rejection
2. Acute Cellular Rejection
3. Acute Humoral Rejection
4. Chronic (Cardiac Allograft Vasculopathy) Rejection

9. Medications
Effects Common Immunosuppressant Drugs and Associated Side
Drug
1. Tacrolimus (Prograf)
2. Sirolimus (Rapamune)
3. Mycophenolate mofetil
(CellCept)
4. Prednisone
5. Cyclosporine (Gengraf,
Neoral, Sandimmune)
6. Azathioprine (Imuran)
Potential Common Side Effects
1. Tremor, headache, diarrhea, hypertension,
nausea,renal dysfunction.
2. Skin irritation, tremor, light-headedness, weight
gain, abdominal pain, diarrhea
3. Diarrhea, leukopenia, sepsis, vomiting,
infection,edema
4. Muscle atrophy/weakness, hypertension, fluid
retention, osteoporosis, aseptic necrosis of bone,
“moon” face appearance, truncal obesity,
increased insulin resistance, cataracts, glaucoma,
mood swings, personality change, insomnia,
peptic ulcer disease
5. Renal dysfunction, tremor, hypertension,
hirsutism, gum hyperplasia, muscle cramps,
acne.
6. Nausea/vomiting, leukopenia, thrombocytopenia,
anemia

10. Common Non rejection Medical Problems
1. Infection and Malignancy
2. Hypertension
3. Obesity
4. Dyslipidemia
5. Diabetes
6. Chronic Renal Insufficiency
7. Osteoporosis
8. Depression

11. Psychological Factors
• As the period of convalescence continues, patients must
adjust to the tedium of medical appointments and
procedures. As previously discussed, the
immunosuppressant prednisone may cause mood swings
and personality change.
• The first episode of acute rejection may result in heightened
feelings of anxiety and transient depression. As the recovery
from surgery progresses and the degree of medical
surveillance decreases, patients generally shift their
attention from transplant-related activities to becoming
more independent, resuming family roles, and occupational
and avocational pursuits.
• The readjustment to life after transplantation requires
months, and the 1-year anniversary is an important
milestone in this process. Most patients are able to return to
productive and meaningful lives.

12. Graded Exercise Testing Considerations:
Pretransplant
• Peak vO2 is a powerful prognostic indicator: Patients with an
aerobic capacity of 14 mL ∙ kg−1 ∙ min−1 (4 METs) or below
experience a markedly reduced 1-year survival, independent of
left ventricular ejection fraction.
• Based on the results of the exercise test, an exercise
prescription may be developed for the patient with the goal of
maintaining or even improving cardiorespiratory fitness while
waiting for a donor organ.

13. Graded Exercise Testing Considerations:
Posttransplant
• 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 should be approximately 2 METs, with
1–2 MET increments in intensity per stage.
• Continuous multilead ECG monitoring with BP measurement and
Borg RPE for each stage is recommended. For precise determination
of aerobic capacity and the ventilatory anaerobic threshold, direct
measurement of O2 and associated variables is highly desirable.
• The endpoints of the graded exercise test should be maximal effort
(symptomlimited maximum) or standard signs of exertional
intolerance.

14. Heart Rate and Exercise
• As a result of the loss of parasympathetic innervation of the donor heart
with transplantation, heart rate (HR) at rest is elevated at approximately
95–115 bpm and represents the inherent rate of depolarization of the
sinoatrial node
• With graded exercise, for the majority of patients, the HR typically does
not increase during the first several minutes (delayed increase), followed
by a gradual rise with peak HR slightly lower than normal (approximately
150 bpm) due to sympathetic nervous system denervation.
• Many patients achieve their highest exercise HR during the first few
minutes of recovery from exercise rather than at the point of maximal
exercise intensity. HR may remain near peak values for several minutes
during recovery before gradually returning to resting levels (delayed
decrease).
• The chronotropic reserve (the difference between the maximal and
resting HRs) is less than normal.
• Regulation of HR during exercise is dependent on circulating
catecholamines.

15. Blood, Intracardiac, and Vascular Pressures
• BP at rest is mildly elevated in heart transplant patients, even
though most patients receive antihypertensive medications.
During exercise, BP generally increases appropriately,
although peak exercise BP is slightly lower than expected for
normal persons.
• Vascular resistance is elevated, and intracardiac and
pulmonary vascular pressures (particularly right-sided
pressures) are elevated.

16. Left Ventricular Function
• For most heart transplant patients, left ventricular ejection
fraction is normal at rest and during exercise. However, as
mentioned previously, left ventricular diastolic function is
often impaired, as evidenced by an elevated filling pressure for
a given end-diastolic volume.
• This impairment results in a below normal increase in stroke
volume during exercise. The impaired rise in stroke volume,
coupled with the below normal HRR, results in an impaired
exercise cardiac output.

17. Exercise Cardiac Output
• With the onset of exercise, cardiac output in transplant
recipients with complete cardiac denervation increases due to
augmentation of stroke volume via the Frank-Starling
mechanism. Later, increased HR also contributes to
augmentation of cardiac output .
• The greater increase, relative to controls, in left ventricular
end-diastolic volume index during exercise in transplant
patients that results in an enhanced Frank- Starling effect.
However, at rest and during exercise, the cardiac index is
lower for transplant recipients than for normal persons.

18. Pulmonary Function and Arterial Oxygenation
• The efficiency of pulmonary ventilation during exercise is below
normal during at least the first several months after transplantation,
illustrated by an elevation in the ratio of minute ventilation to
carbon dioxide production (the ventilatory equivalent for CO2, VE/
CO2).
• This excess ventilation results in a heightened sense of shortness of
breath during exercise. The normal increase in tidal volume during
exercise is blunted, probably as a result of respiratory muscle
weakness, deconditioning, and the effects of corticosteroid
medications. Alveolar gas diffusion impairment is present in
approximately 40% of patients. However, arterial oxygen saturation
at rest and during exercise is normal for most patients.
• A minority of patients with pretransplant diffusion abnormalities
experience mild arterial desaturation (to approximately 90%) with
exercise. Azathioprine may cause anemia in some patients, resulting
in reduced arterial oxygen content.

19. Oxygen Extraction by Exercising Skeletal Muscle
• Extraction of oxygen from the arterial blood by metabolically
active body tissues, as indicated by the arterial-mixed venous
oxygen difference, is normal at rest after transplantation.
• However, during exercise, the arterial mixed venous oxygen
difference does not increase in a normal manner and reflects
abnormalities with both the delivery of capillary blood to the
exercising skeletal muscle and impairment of the oxidative
capacity of the Muscle.

20. Oxygen Uptake Kinetics, Peak Exercise VO2
• With the onset of exercise, the rate of increase in O2 (oxygen
uptake kinetics) is slower than normal as a result of both an
impaired rise in cardiac output and a diminished oxidative
capacity of the skeletal muscle (reduced arterial-mixed venous
oxygen difference).

21. Abnormal Exercise Physiology Findings in
Cardiac Transplant Patients
• Increased resting HR
• Delayed HR increase at onset of exercise
• Blunted maximal HR
• Delayed return of HR to resting level after cessation of exercise
• Reduced HRR
• Increased exercise left ventricular end-diastolic pressure (diastolic dysfunction)
• Increased exercise pulmonary artery pressure, pulmonary capillary wedge pressure, right
atrial pressure
• Increased left ventricular end-systolic and end-diastolic volume indices
• Impaired increase in stroke volume during exercise
• Reduced exercise cardiac output
• Decreased exercise arterial-mixed venous oxygen difference
• Slowed oxygen uptake kinetics during exercise
• Decreased maximal oxygen uptake
• Reduced maximal power output during exercise testing
• Decreased ventilatory anaerobic threshold
• Increased exercise ventilatory equivalents for oxygen and carbon dioxide

22. Potential additional benefits of regular exercise for transplant
recipients:
• Improved submaximal exercise endurance
• Increased peak treadmill exercise workload or peak cycle power output
• Increased maximal HR
• Decreased exercise HR at the same absolute submaximal workload
• Increased ventilatory (anaerobic) threshold
• Decreased submaximal exercise minute ventilation
• Reduced exercise ventilatory equivalent for CO2
• Lessened symptoms of fatigue and/or dyspnea
• Reduced rest and submaximal exercise systolic and diastolic BP
• Decreased peak exercise diastolic BP
• Reduced submaximal exercise RPEs
• Improved psychosocial function
• Increased lean body mass
• Reduced body fat mass
• Increased bone mineral content

23. Resistance Exercise
• Most cardiac transplant patients require prednisone, at least during
the first several months after surgery, for immunosuppression.
Skeletal muscle atrophy and weakness are common side effects
related to prednisone use.
• Resistance exercise training partially reverses corticosteroid-related
myopathy and improves skeletal muscle strength.
• Horber and associates found definite evidence of skeletal muscle
wasting and weakness in the lower extremities of renal transplant
patients who received prednisone.
• Fifty days of isokinetic strength training substantially increased
muscle mass and strength in these patients.
• In addition, strength training has been shown to improve bone
density and to reduce the potential development of osteoporosis
(also caused by prednisone) in cardiac transplant recipients.

24. Effect of Exercise Training on Immune Function and
Longevity
• An obvious and important question concerning exercise
training in immunosuppressed cardiac transplant recipients is
the effects of training on immune function.
• Traditional, moderate-intensity training does not increase or
decrease the number or severity of episodes of acute rejection.
In addition, training does not require changes in
immunosuppressant dosage or treatment.
• Infection risk is not changed by exercise training.

25. Early Mobilization and Inpatient Exercise Training
• 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 .
• Walking or cycle ergometry may be increased in duration to 20–30
minutes as tolerated. Exercise intensity is guided using the Borg
RPE scale ratings of 11–13 keeping the respiratory rate below 30
breaths per minute and arterial oxygen saturation above 90%.
Exercise frequency is two to three sessions per day.
• Patients whose postoperative courses are uncomplicated typically
remain hospitalized for 7–10 days.
• During inpatient rehabilitation, as well as during the outpatient
phases, episodes of acute rejection of a moderate or greater severity
may require alteration of the exercise plan depending on the
preferences of the transplant team.
• In general, 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 acute
rejection necessitates suspension of all physical activity with the
exception of passive range-of motion exercises.

26. Outpatient Exercise Training
• Exercise prescription for cardiac transplant patients is similar
to methods used with patients who have undergone coronary
bypass, coronary valve, or other cardiothoracic surgery. The
one exception is that a target HR is not used, unless the patient
exhibits a partially normalized HR response to exercise as
discussed previously.
• 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 Borg RPE scale ratings of 12–14 (“somewhat hard”)
may be used to prescribe exercise intensity.

27. • The HRR (also called chronotropic response), defined as the
difference between the HR at rest and the highest value during
maximal exercise, increases during the first 6 weeks after
transplantation in many patients.
• In a subset of patients, the HRR increases further over the next 6–
12 months.
• A more rapid decline in HR from peak exercise to baseline is
observed in some patients at 1–2 years after transplantation.
• Recently, high-intensity interval training (HIIT) has been used in
exercise programs for transplant recipients and is well tolerated
with favorable effects on fitness .
• The exercise prescription should include standard warm-up and
cool-down activities, a gradual increase in aerobic exercise duration
to 30–60 minutes, and a frequency of four to six sessions per week.
• Typical modes of aerobic exercise used during the early outpatient
recovery period include walking outdoors (or in shopping centers,
schools), treadmill walking, cycle ergometry, and stair climbing

28. • Special emphasis on upper extremity active range-of-motion exercises is
required. At approximately 6 weeks after surgery, when sternal healing is
nearly completed, rowing, arm cranking, combination arm/leg ergometry,
outdoor cycling, hiking, and jogging become additional options, depending
on a patient’s fitness levels. Sports such as tennis and golf may be
performed as early as 6 weeks after surgery if patient fitness is adequate (5
METs or greater) and sternal healing is nearly complete.

29. Skeletal muscle weakness in cardiac transplant recipients is
very common
and is related to the following factors
1. Skeletal muscle atrophy due to advanced heart failure
2. Pretransplant deconditioning
3. Corticosteroid use posttransplant as part of the
immunosuppressant regimen.

30. • Muscle strengthening exercises should be incorporated into the exercise
program to counteract these factors.
• For the first 6 weeks after surgery, bilateral arm lifting is restricted to less
than 10 lb to avoid sternal nonunion.
• During this early stage of rehabilitation, light hand weights are an excellent
method of introducing resistance exercise. After at least 6 weeks of healing,
patients may be started on standard weight machines, emphasizing
moderate resistance, 10–20 slow repetitions per set, one to three sets of
exercises for the major muscle groups, with a frequency of two or three
sessions per week
• Elastic band exercises are also another excellent mode of resistance training
for these patients.
• Borg RPE scale of 12–14 to gauge the intensity of lifting. Strength gains of
25%–50% or greater commonly occur after 8 weeks of strength training in
these patients.
• Performance of the strengthening exercises immediately following the
aerobic portion of the exercise prescription (after the cool-down) is
recommended.

31. FITT RECOMMENDATIONS FOR INDIVIDUALS WITH
HEART TRANSPLANTATION
• Frequency 3–5 d ∙ wk−1
• Intensity Use RPE of 11–14 on a 6–20 scale.
• Time Progressively increase from 15–20 min ∙d−1 up to 30–60 min
∙ d−1
• Type Treadmill or free walking, stationary cycling, and dual-action
stationary bike
• Resistance Slowly increase upper body activities over several
weeks to months from 40% of 1-RM to 70% of 1-RM. Lower body
excises should begin at 50% of 1-RM. 1–2 sets of 10– 15 repetitions
for each exercise Weight machines are best, but dumbbells, elastic
bands, and body weight can be used.
• Flexibility 2–3 d ∙ wk−1 with daily being most effective Stretch to
the point of feeling tightness or slight discomfort. 10–30 s hold for
static stretching 2–4 repetitions of each exercise Static, dynamic,
and/or PNF stretching.

32. THANK YOU!!