2. Kim Dosch, PT Tina Fields, PT, CCS 06/20/2013
Physical Therapy in Heart and Lung Transplantation and Mechanical Assist Devices
Kim Dosch, PT Tina Fields, PT, CCS 06/20/2013

3. Heart Transplantation
Statistics
UM=60 a year
Demographics
Gender: 3males : 1 female
Age: <65, typical 50-65

4. Heart Transplantation
Common Diagnoses: heart failure, myocarditis, etc
Pre-operative condition: mechanically vented, Pacemaker
Exclusion from the transplant list: cancer, drug/alcohol abuse, compliant with medical regiment, insurance coverage, pulmonary hypertension, kidney failure

5. The Transplant List Status Tissue Match: antigen, antibody reaction
1A: most critical status, increased risk of death in next 7 days, min transplant time of 59 days.
1B: ventricular assistant device >30 days, can go home, average time to transplant is 115 days.
2: everybody else on transplant list that is not 1A or 1B >365 days till transplant
7: took off the list temporarily, for infection, etc
Tissue Match: antigen, antibody reaction
Time to transplant

6. Operative Procedure Median Sternotomy
Implication for PT: sternum approximated

7. Median Sternotomy: Implications for PT
Facility Dependent
10# lifting restriction until sternum heals
Includes lifting/pushing/pulling
Implications for mobility?
Full shoulder range as tolerated to pain (no ROM restrictions)

8. Operative Procedure Techniques
Orthotopic heart transplant: removed most of the pt’s heart and replaced it 95% of the donors heart.

9. Least amount of anastomosis as possible as they are bleeding site, they will leave the R atrium with the venous return and on the L atrium will leave the Aorta, therefore should only have 4 anastomosis R atria, L atria, pulmonary artery, aorta.

11. Post Operative Changes
Denervation of Heart
Loss of Vagus Nerve
Role of Vagus Nerve: parasympathetic HR control, decreases HR when
Implications for PT: we need to be aware of HR control not adapting, elevated resting HR.

12. Post Operative Changes
Denervation of Heart
Implications for PT
Loss of Vagus Nerve
Prolonged warm up and cool down needed
Elevated resting heart rate
Blunted HR response to exercise
Predicted HR formulas no longer appropriate for use
Lack of cardiac ischemia sensation

14. Lung Transplantation Statistics UM: 40-45 year, nationally 1500
Demographics
Gender: 1:1
Age: most, rare >65
5yr survival 50%

15. Lung Transplantation
Common Diagnoses: A: Obstructive lung disease, B: Pulmonary vascular disease, pulmonary hypertension, C: cystic fibrosis and amino deficienties D: restrictive lung disease (idiopathic pulmonary
Pre-operative condition
Exclusion from the transplant list same as heart transplant

16. The Transplant List Lung Allocation Score: score 0-100
1 predicted post-op survival, 2 waitlist survival, 3 transplant benefit, 4 rare allocation. The higher the score the more critical the patient.
Tissue Match: antigen, antibodies
Time to transplant: depends on lung allocation score,< 30 days-5 years, typical is 6 monthes-2years

17. Operative Procedure Thoracotomy Incision Single Lung Transplant
Loss of Vagus Nerve: lose sensory of lungs filling and need to cough
Main stem broncus is where the anastomosis is.

18. Operative Procedure Clamshell Incision Double Lung Transplant
Loss of Vagus Nerve
Loss of carina
Anastomosis at trachea, both lungs together, takes out carina so loss of cough reflex
Anastomosis each lung at bronchi separately

19. Operative Procedure Thoracotomy incision Clamshell incision
Implications for PT
10 lb. lifting restriction on involved side for thoracotomy (bilateral for clamshell)
Airway Clearance
Splinted Cough Technique: pressure on incision to help decrease pain
Teach volitional coughing
Bed Mobility (thoracotomies vs. clamshell: either side.

20. Open Clamshell Incision

21. Blue lines are sutures, can have lack of blood flow here, so will harden and constrict.

22. Heart OR Lung Transplant: Post Operative Course

23. Post-Operative Issues
Medications/Side effects
Rejection
Return to Independent Function
Exercise
Lifestyle Modification
Pregnancy, decrease risk of heart disease (ex: diet, exercise)

24. Medications Anti-rejection Anti-Infection
Cyclosporine: increase potasium, tremour
Tacrolimus
Mycophenolate
Prednisone: cortico-steroids, steroid induced myopathy
Anti-Infection
Acyclovir
Gancyclovir
Bactrim
Nystatin
Sporanox
These medications are given to every patient following transplant. These drugs are given prophylactically to prevent the onset of rejection.
Cyclosporine acts on the T cells to suppress rejection.
Tacrolimus is similar to Cyclosporine, it also suppresses the T cell response to foreign material.
Mycophenolate is a broader drug that acts on T cells and other types of white blood cells to prevent rejection.
Prednisone-is a powerful steroid which acts as an anti-inflammatory agent to prevent rejection. Although the effects are beneficial to prevent rejection, there are some very detrimental side effects that come along w/taking this medication. Elevation of blood glucose levels which over time can cause damage to nerves and cause neuropathy, muscle wasting, and obvious concurrent effects on mobility. Steroids can also cause an increase in fluid retention which impacts mobility and aeration. It also impacts calcium levels which leads to bone loss and osteoporosis, and possible fractures.

25. Medication Side Effects
Side Effects of Steroids
Anabolic Versus Corticosteroids
Side Effects of Corticosteroids
Corticosteroid Induced Myopathy
Proximal muscle weakness, 2 female: 1 male
Other Symptoms
Hyperglycemia
HTN
Myalgias
Osteoporosis

26. Medication Side Effects
Corticosteroid Induced Myopathy
Implications for PT ?
Focus on strengthening
Education
Home Exercise Program for continued strengthening
Self Targeting/Monitoring
Self Progression

27. Medication Side Effects
Elevated Potassium: 3.5 to 5 is normal
Implications for PT ?
Aware of lab values and effects on exercise
Monitoring for:
Muscle weakness
Tremors
Flaccid paralysis
Slow pulse/EKG changes
Oliguria

28. Medication Side Effects
Immunosuppression
Implications for PT ?
Not treat if ill, good caregiver hand-washing
Attempt to see isolation patients after
Education for lifestyle changes
Pets: not allowed to clean litter boxes
Gardening: need to wear gloves
Crowded environments, visitors, masks
Construction
Hand-washing
Group exercise