Physical Therapy in Heart and Lung Transplantation and

Mechanical Assist Devices

Kim Dosch, PT

Tina Fields, PT, CCS

06/20/2013

Heart Transplantation

StatisticsUM=60 a yearDemographics

Gender: 3males : 1 femaleAge: <65, typical 50-65

Heart TransplantationCommon 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

The Transplant ListStatus1A: 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 transplant7: took off the list temporarily, for infection, etc

Tissue Match: antigen, antibody reaction

Time to transplant

Operative Procedure

• Median Sternotomy• Implication for PT:

sternum approximated

Median Sternotomy: Implications for PT

Facility Dependent10# lifting restriction until sternum

heals Includes lifting/pushing/pulling Implications for mobility?

Full shoulder range as tolerated to pain (no ROM restrictions)

Operative Procedure

Techniques

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

Post Operative ChangesDenervation of HeartLoss 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.

Post Operative ChangesDenervation of Heart Implications for PT

Loss of Vagus Nerve Prolonged warm up and cool down neededElevated resting heart rateBlunted HR response to exercisePredicted HR formulas no longer appropriate for

useLack of cardiac ischemia sensation

http://www.pbs.org/wgbh/nova/eheart/transplantwave.html

Lung Transplantation

StatisticsUM: 40-45 year,

nationally 1500Demographics

Gender: 1:1Age: 50-64

most, rare >655yr survival

50%

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

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

Operative Procedure

• Thoracotomy Incision

• Single Lung Transplant

• Loss of Vagus Nerve: lose sensory of lungs filling and need to cough

Operative Procedure• Clamshell

Incision• Double Lung

Transplant• Loss of

Vagus Nerve

• Loss of carina

Operative Procedure

Thoracotomy incision

Clamshell incision Implications for PT

10 lb. lifting restriction on involved side for thoracotomy (bilateral for clamshell)

Airway ClearanceSplinted Cough Technique: pressure on incision

to help decrease painTeach volitional coughingBed Mobility (thoracotomies vs. clamshell:

either side.

Open Clamshell Incision

Heart OR Lung Transplant: Post Operative Course

Post-Operative IssuesMedications/Side effects

Rejection

Return to Independent Function

Exercise

Lifestyle ModificationPregnancy, decrease risk of heart disease

(ex: diet, exercise)

MedicationsAnti-rejectionCyclosporine:

increase potasium, tremour

TacrolimusMycophenolatePrednisone:

cortico-steroids, steroid induced myopathy

Anti-InfectionAcyclovirGancyclovirBactrimNystatinSporanox

Medication Side Effects

Side Effects of Steroids Anabolic Versus CorticosteroidsSide Effects of Corticosteroids

Corticosteroid Induced Myopathy Proximal muscle weakness, 2 female: 1 male

Other Symptoms Hyperglycemia HTN Myalgias Osteoporosis

Medication Side Effects

Corticosteroid Induced Myopathy Implications for PT ?

Focus on strengtheningEducationHome Exercise Program for continued

strengthening Self Targeting/Monitoring Self Progression

Medication Side Effects

Elevated Potassium: 3.5 to 5 is normal Implications for PT ?

Aware of lab values and effects on exerciseMonitoring for:

Muscle weakness Tremors Flaccid paralysis Slow pulse/EKG changes Oliguria

Medication Side EffectsImmunosuppression Implications for PT ?

Not treat if ill, good caregiver hand-washingAttempt to see isolation patients afterEducation for lifestyle changes

Pets: not allowed to clean litter boxes Gardening: need to wear gloves Crowded environments, visitors, masks Construction Hand-washing Group exercise