Transcript Document

Physical Therapy in Heart
and Lung Transplantation
and Mechanical Assist
Devices
Kim Dosch, PT
Tina Fields, PT, CCS
06/20/2013
Heart Transplantation
Statistics
UM=60 a year
 Demographics

Gender: 3males : 1 female
 Age: <65, typical 50-65
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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
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
Operative
Procedure
• Median Sternotomy
• Implication for PT:
sternum approximated
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)
Operative Procedure
Techniques
 Orthotopic
heart transplant:
removed most of the pt’s heart
and replaced it 95% of the donors
heart.
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.
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

http://www.pbs.org/wg
bh/nova/eheart/transpl
antwave.html
Lung Transplantation
Statistics
 UM:
40-45 year,
nationally 1500
 Demographics
 Gender:
1:1
: 50-64
most, rare >65
 5yr survival
50%
 Age
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
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 Clearance
 Splinted Cough Technique: pressure on
incision to help decrease pain
 Teach volitional coughing
 Bed Mobility (thoracotomies vs. clamshell:
either side.

Open Clamshell Incision
Heart OR Lung
Transplant: Post
Operative Course
Post-Operative Issues
Medications/Side effects
Rejection
Return to Independent Function
Exercise
Lifestyle Modification

Pregnancy, decrease risk of heart disease
(ex: diet, exercise)
Medications
Anti-rejection
Cyclosporine:
increase
potasium,
tremour
 Tacrolimus
 Mycophenolate
 Prednisone:
cortico-steroids,
steroid induced
myopathy

Anti-Infection
Acyclovir
 Gancyclovir
 Bactrim
 Nystatin
 Sporanox

Medication Side Effects
Side Effects of Steroids
Anabolic Versus Corticosteroids
 Side Effects of Corticosteroids


Corticosteroid Induced Myopathy

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Proximal muscle weakness, 2 female: 1 male
Other Symptoms

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Hyperglycemia
HTN
Myalgias
Osteoporosis
Medication Side Effects
Corticosteroid Induced Myopathy

Implications for PT ?
Focus on strengthening
 Education
 Home Exercise Program for continued
strengthening
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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 exercise
 Monitoring for:
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Muscle weakness
Tremors
Flaccid paralysis
Slow pulse/EKG changes
Oliguria
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
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Pets: not allowed to clean litter boxes
Gardening: need to wear gloves
Crowded environments, visitors, masks
Construction
Hand-washing
Group exercise