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

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Heart Transplantation Statistics UM=60 a year Demographics Gender: 3males : 1 female Age:

The Transplant List Status 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

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Operative Procedure Median Sternotomy Implication for PT: sternum approximated

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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)

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Operative Procedure Techniques Orthotopic heart transplant: removed most of the pts heart and replaced it 95% of the donors heart.

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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.

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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

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http://www.pbs.org/wg bh/nova/eheart/transpl antwave.html

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Lung Transplantation Statistics UM: 40-45 year, nationally 1500 Demographics Gender: 1:1 Age : 50-64 most, rare >65 5yr survival 50%

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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

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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

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Operative Procedure Thoracotomy Incision Single Lung Transplant Loss of Vagus Nerve: lose sensory of lungs filling and need to cough

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Operative Procedure Clamshell Incision Double Lung Transplant Loss of Vagus Nerve Loss of carina

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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.

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Open Clamshell Incision

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Heart OR Lung Transplant: Post Operative Course

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

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Medications Anti-rejection Cyclosporine: increase potasium, tremour Tacrolimus Mycophenolate Prednisone: cortico-steroids, steroid induced myopathy Anti-Infection Acyclovir Gancyclovir Bactrim Nystatin Sporanox

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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

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

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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

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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