Heart

Transplantation

(HT)

Introduction

More than 5000 HT occur each year

around the world, although it is estimated

that up to 50,000 people are candidates

for transplantation.

According to the British Heart Foundation,

there were 145 HT at 7 hospitals around

the UK in 2013.

Conventional criteria for HT

(Banner et al, 2011)

Indications for urgent

inpatient referral

(Banner et al, 2011)

Risks factors and

contraindications

Related to heart failure (HF)

Cardio-renal syndrome

Hyponatraemia

Liver dysfunction

Secondary pulmonary hypertension

Anaemia

Comorbidity

Age

Diabetes

Obesity

Sepsis and active infection

Recent pulmonary embolism

Autoimmune Disorders

Psychosocial factors

Substance abuse

- Excessive alcohol consumption

- Smoking

Non-adherence to follow-up

Poor family or social support

Factors determining heart

allocation

(Banner et al, 2011)

Outcomes after first HT

Survival

Approximately 85% - 90% of HT patients

are living 1 year after their surgery, with

an annual death rate of approximately 4

percent thereafter.

The 3 year survival approaches 75%.

Prognosis

Recipient Factors Donor Factors

• Pre-operative need

for artificial breathing

support

• Pre-operative need for

heart function

assistance with a VAD

• Second heart

transplantation

• Heart conditions other

than CAD or

cardiomyopathy

• Being female

• Being underweight or

obese

• Female donor

• Increased age

• Left ventricular

hypertrophy

• Elevated blood levels

of Troponin I and T

Early Mortality

50% – 80% of people experience at least 1

rejection episode.

Average of 1 to 3 episodes of rejection in

the first year after transplantation.

Acute rejection is most likely to occur in

the first 3 – 6 months.

Causes of death

Acute rejection

Infections

Artery disease in the transplanted heart

vessels

Lymphoma and other malignancies

Clinical problems post-HT

Physical deconditioning

Muscular atrophy

Muscle weakness

Lower maximal aerobic capacity

Recommendations for exercise

and physical rehabilitation after

HT

Class I:

The routine use of cardiac rehabilitation with performance of aerobic exercise training is recommended after HT. The short-term benefits of this approach include improvement in exercise capacity and possible modification of cardiovascular risk factors such as obesity, hypertension, and glucose intolerance. There is currently no information on potential long-term benefits.

Level of Evidence: B

Class I:

Resistance exercise is also strongly encouraged in HT recipients to restore BMD and prevent the adverse effects of corticosteroid and CNI therapy on skeletal muscle. Resistance exercise should be additive to other therapies for bone mineral loss and muscle atrophy.

Level of Evidence: B

Note: Do not start arm exercises until 3 months after HT

Benefits of post-HT physical

conditioning

(Guimaraes et al, 2004)

Effects of physical training on

HT pathophysiology

Exercises considerations for

HT patients

During exercise and activity, the transplanted

heart is regulated by the humoral system.

The humoral system relies on circulating

catecholamines to elevate the HR in response

to the higher demands of activity.

This lengthens the time between the onset of

activity and the increase in HR.

There is also a prolonged HR recovery after

exercise.

Therefore, patients should extend their warm-up and

cool-down periods to 5-10 minutes.

Exercises considerations for

HT patients

In a normally innervated heart, the vagus

nerve at rest works by depressing the intrinsic

rate of the heart set by the SA node.

However, in the transplanted heart, the SA

node paces the allograft heart resulting in a

higher resting HR.

It is not possible to use your HR as a guide as it is no

longer regulated by the nervous system. To measure the

exertion levels during exercise, the Borg Scale is used.

Conclusion

There are many factors to consider before

patients undergo HT.

The first year after HT is the most crucial

period when mortality rate is the highest

secondary to acute rejection and infections.

Aerobic training and resistance exercise are

beneficial to patients after HT.

Longer warm-up and cool down sessions

should be incorporated into treatment

regime and use of Borg scale to measure

exertion levels during exercise.

References

Banner, N. R., Bonser, R. S., Clark, A. L., Clark, S., Cowburn, P. J., Gardner, R. S., et al. 2011, “UK guidelines for referral and assessment of adults for heart transplantation”, Heart, Vol. 97, no. 18, pp. 1520-1527.

British Heart Foundation. 2014, Heart transplant, [internet]. Available at: https://www.bhf.org.uk/heart-health/treatment/heart-transplant.aspx[Accessed 16th February 2014].

Costanzo, M. R., Costanzo, M. R., Dipchand, A., Starling, R., Anderson, A., Chan, M., et al. 2010, “The International Society of Heart and Lung Transplantation Guidelines for the care of heart transplant recipients”, The Journal of Heart and Lung Transplantation, Vol. 29, no. 8, pp. 914-956.

Eisen, H. J. 2014, Patient information: Heart transplantation (Beyond the basics) [online]. Wolters Kluwer, Philadelphia. Available at: http://www.uptodate.com/contents/heart-transplantation-beyond-the-basics [Accessed 16th February 2014].

Guimaraes, G. V., Moraes d’Avila, V., Chizzola, P. R., Bacal, F., Stolf, N. & Bocchi, E. A. 2004, “Physical rehabilitation in heart transplantation”, Rev Bras Med Esporte, Vol. 10, no. 5, pp. 412-415.