CardioPulm Exam 2 - Thoracic Organ Transplantation Heart and Lung

Who Qualifies for a Heart or Lung Transplant

• People w/ severe, progressive, life-threatening heart or lung disease
• Disease getting worse & limits life expectancy
• Pts often:
  → Have very poor heart or lung function
  → Need many meds or O₂ support
  → Struggle w/ ADLs (walking, cooking, dressing, etc)
  → Can't go to school or work full-time anymore

Common Reasons for Needing a Heart Transplant

Under age 39:

• Nonischemic cardiomyopathy (top reason, 64% of those cases)
• Congenital heart disease (heart defect present since birth, 11%)
  Ages 40-69:
• Nonischemic dilated cardiomyopathy (49% of cases, heart becomes enlarged & weak but not due to blocked artery)
• Ischemic cardiomyopathy (35% of transplants in this age group; caused by reduced blood flow to heart, e.g. CAD)
  Age ≥ 70:
• Ischemic cardiomyopathy (most common reason for transplant, overtaking nonischemic)

Common Reasons for Needing a Lung Transplant

Emphysema

• Most common reason
• Form of COPD
• Damages air sacs in lungs (alveoli)
  Idiopathic pulmonary fibrosis
• 2nd most common reason
• Causes scarring in lungs

Single vs. Double Lung Transplant

Single lung transplants

• May be acceptable & help conserve donor organs (ongoing shortage, esp lungs)
• Very valid option in many cases
  Double lung transplants
• Offer better long-term survival
• Esp for pts < 65
• 2 healthy lungs provide stronger overall respiratory function
• Reduces risk for complications
• Preferred for:
  → Young pts
  → Cases w/ less-than-ideal donor lungs

Contraindications for Cardiac Transplantation

• Can be absolute or precautionary → depends on pt & situation
• Active or recent organ or blood malignancy w/in 5 yrs
• Current or recent (w/in 6 months) abuse of tobacco, alcohol, or other active substances abusers
• Any active infection
• Severe DM w/ end organ damage
• ABI < 0.7
• Morbid obesity

Contraindications for Lung Transplant

• Active malignancy w/in past 2 yrs
• Continued abuse of alcohol, tobacco, or narcotics
• Infection w/ HIV
• Morbid obesity
• Absence of consistent support system

Decision to Refer for Transplantation Evaluation

Primary physician must:

• Assess pt's health trend (steady decline?) vs. average wait time for transplant (too early may stress pt, too late may miss window for transplant)
• Balance treatment options
• Present all medical txs while introducing transplant as last resort (pt needs to be mentally & physically ready)
  Once referred:
• Pt undergoes outpt eval
  → Lab tests & procedures
  → Screening for contraindications
  → Team assessments: medical, psychological, & social evals
  → Social support & adherence checks
• Reassessment every 6 months recommended

Listing and Allocation - If accepted:

• Pt added to United Network of Organ Sharing (UNOS) national
• Matching & ranking depends on:
  → Age, blood type, tissue match, wait time, immune status, & distance from donor

Physical Therapy Evaluation

PTs assess:

• Cardiopulm limitations, MSK condition, exercise capacity, & airway clearance
• 6-min walk test → most common (practical measure of endurance)
  → Full cardiopulm stress tests rarely used b/c most pts needing transplant cannot tolerate
• VO2 max → if below 14 mL/min indicates higher risk of death in stronger case for transplant referral

Physical Therapy Evaluation - Frailty Assessment

Frailty linked to poor outcomes & part of transplant criteria:

• Defined by symptoms like unintentional weight loss, fatigue, slow gait, low activity
• Frailty Index & Fried Frailty Phenotype → validated tools
• Helps guide rehab & early mobility strategies

Preoperative Rehabilitation: What it is and Why it Matters

Before transplant surgery, pts can benefit from rehab
Goal:

• Improve exercise tolerance
• Boost confidence & self-management
• Help pts get in best physical shape possible to handle stress of surgery
• Reduce risk of dying while waiting for transplant
  Typically includes:
• Edu for pt & family
• CV endurance training
• Strength & flexibility exercises
• Breathing retraining

Heart Transplant Candidates

• Encouraged to stay active w/in safe limits
• Participation in formal cardiac rehab
• Many can only do light activity or daily tasks
• Common issues include:
  → Low BP: reduce blood flow to vital tissues
  → Reduced lung function: poor oxygen exchange
  → High pulmonary resistance: pt needs to breath faster & harder
  → Exercise may exacerbate these symptoms so must be careful monitored
• Rehab may start in hospital

Lung Transplant Candidates

• Exercise often required before transplant
• Some centers require pts to relocate (closer to facility) to ensure consistent participation
• Pts may need to maintain min 6MWD to stay eligible
• Oxygen levels must be monitored during exercise to stay above 90% (due to high risk of exercise-induced hypoxemia)

Exercise Guidelines

• Most pts can do 30-40 min of endurance exercise (walking, cycling, or swimming)
• 3-5x/wk
• At 70-80% of predicted max HR
  → Improves cardio fitness w/out overexerting pt
  → While keeping oxygen levels stable

Hospitalized Patients

• Some pts too sick to leave hospital before transplant
• Despite condition, exercise still important to help them survive surgery
• Pts may need:
  → Advanced oxygen systems
  → Circulatory support devices
  → Close monitoring by PT
  → Knowledgeable care teams familiar w/ critical meds & equipment

Factors that may determine that a patient is unsuitable for transplantation

• Pt did not meet criteria of organ system failure
• Presence of contraindications limits potential success of surgery
• Pt unable to meet psychosocial requirements
• ↓ overall benefits for pt from transplantation procedure
• Pt opted for more conservative surgical or medical management
• Pt deemed too frail & would benefit from pre-rehab before reeval

Lung Volume Reduction Surgery (LVRS)

• Surgical procedure that removes 20-35% of each lung's volume
  → Usually from upper lobes (diseased)

Lung Volume Reduction Surgery (LVRS) - How it helps

• Improves breathing mechanics & chest wall movement
• Can double FEV1 (key measure of lung function)
• Reduces CO₂ retention
  → May no longer need supplemental oxygen
• Improves exercise capacity, dyspnea, & quality of life

Lung Volume Reduction Surgery (LVRS) - Why it works

• Less lung hyperinflation allows respiratory muscles to work better (e.g. emphysema)
• Improved cardiac filling (helps heart function better)
• Better V/Q matching (how well air & blood matched in lungs)

Zephyr Endobronchial Valve (EBV)

• Non-surgical device for emphysema
• Tiny (about size of pencil eraser)
• Uses brochoscope so no incision is needed

Zephyr Endobronchial Valve (EBV) - How it works:

• Valve closed: Blocks air from entering damaged lung areas during inhalation
• Releases trapped air during exhalation
• Reduces lung hyperinflation & pressure

Zephyr Endobronchial Valve (EBV) - Benefits:

• Similar improvements to LVRS but less invasive
• Enhances lung function, exercise capacity, & quality of life
• Can be removed if needed

BiPAP (Bilevel Airway Pressure)

• Noninvasive ventilation device that uses nasal mask to deliver air pressure during both inhalation & exhalation
  Used for:
• Pts w/ respiratory failure who are not responding to meds or oxygen therapy
• Avoiding intubation
• Improving sleep, energy levels, & exercise tolerance
  Especially helpful for:
• Pts awaiting lung transplant
• Those w/ severe respiratory failure needing symptoms relief & rehab support

CPAP vs. BiPAP - Alternative therapy to lung transplant

Mechanical Circulatory Support Devices (MCSDs) - Alternative therapy to heart transplant

• Electrically powered devices implanted surgically or through blood vessels to help heart pump blood (unable to do on own)
  Types:
• Temporary MCSDs: short-term, typically in hospitalized pts who need stabilization
• Durable Continuous-Flow LVADs: long-term devices that support L ventricle
  Purposes:
• Bridge to recovery
• Bridge to transplant
• Bridge to decision
• Destination therapy

Home IV Drug Therapy - Alternative therapy to heart transplant

Pts receive IV inotropic meds to improve heart pumping & blood flow
Who it's for:

• Pts awaiting transplant
• Pts not eligible for transplant, but needing symptom relief
  Limitations:
• Improves symptoms but does not extend life beyond about 1 yr
  Goals:
• Reduced heart's oxygen demand
• Improve blood flow to heart
• Slow rapid HR
• Restore normal heart size & shape
• Support heart & blood vessel repair

Four main surgical methods used in heart transplantation

• Heterotopic Transplantation
• Total Transplantation
• Biatrial Technique
• Bicaval Technique

Heterotopic Heart Transplantation "Piggyback"

What it is

• Native heart not removed
• Donor heart connected to recipient's heart through median sternotomy (central chest incision)
• Atria & major vessels joined so both hearts work together
  When it's used
• Size mismatch between donor & recipient
• High pulmonary vascular resistance in recipient

Heterotopic Heart Transplantation "Piggyback" - Why it's rarely used now

Better survival w/ standard (orthotopic) transplantation
Complications include:

• Lung compression
• Blood clots due to poor flow
• Valve problems in native heart
• Dangerous arrhythmias
• Recurrence of angina

Total Transplantation

• Complete removal of recipient's atria
• More complex surgery
• Full replacement of heart w/ separate connections for:
  → Superior & inferior vena cava
  → Pulmonary veins

Advantages of Total Transplantation

• Full anatomical replacement

Disadvantages of Total Transplantation

• Requires 6 separate connections (↑ surgical time & risk of complication
• Potential for bleeding & pulm vein complications (twisting or narrowing)

Biatrial Technique (Orthotopic Transplantation)

• Recipient's atrial cuffs left intact
• Donor atria sewn directly to recipient's atria
• Recipient's SA node remains functional, though disconnected from donor heart

Biatrial Technique - Unique Feature

2 P waves appear on ECG

• 1 from recipient's SA node
• 1 from donor's SA node

Biatrial Technique - Pros & Cons

Pros

• Simpler & faster surgery
  Cons
• Can lead to
  → Atrial dysfunction
  → Sinus node issues
  → Valve problems
  → Blood clots

Bicaval Technique (Modern Standard)

What it is

• Separate connections made for superior & inferior vena cava
• More precise anatomical reconstruction than biatrial
  Benefits
• Better atrial function (fill & contract more effectively)
• Fewer arrhythmias
• Less need for pacemakers
• Reduced tricuspid valve leakage

Lung Transplantation

Used to replace 1 or both diseased lungs w/ healthy donor lung
2 main types:

• Single-lung transplantation
• Double-lung transplantation
  → Bilateral sequential transplantation

Double-Lung Transplantation - Early Technique

• Used tracheal anastomosis
  → Connecting donor trachea to recipient's
• Performed as double-lung block (both lungs transplanted together as single unit)

Double-Lung Transplantation - Current standard

• Uses mainstem bronchial anastomoses (large airway leading into each lung)
  → Connecting donor & recipient bronchi
• Performed through:
  → Bilateral anterior thoracotomies
  OR
  → Clamshell incision (better surgical exposure; more efficient & safe)

Double-Lung Transplantation - Surgical Sequence

• Least functioning lung removed & replaced 1st
• Remaining lung ventilated during procedure
• After both lungs transplanted
  → 2 chest tubes placed in each pleural space

Single-Lung Transplantation

• Typically done through posterolateral thoracotomy
• Common procedure for advanced lung disease or pt who only needs 1
• Posterolateral thoracotomy
  Surgical sequence:
• Atrial anastomosis (connect lungs veins & arteries to heart)
• Pulmonary artery anastomosis
• Bronchial anastomosis

Postoperative Management and Support - ICU

• Hemodynamic monitoring (arterial lines, pulm artery catheters)
• Fluid & meds control (IV)

Postoperative Management and Support - ECMO (Extracorporeal Membrane Oxygenation)

• Used to support pts w/ early graft dysfunction
• Oxygenates blood outside of body when lungs not functioning well
• Especially beneficial for pts w/ pulmonary artery HTN
• Pt may be positioned in prone to improve V/Q match, esp posterior part of lungs (during covid); gives lungs chance to rest

Patient's Response to Activity Post-Transplant - Key Physiological Changes

• Transplanted heart denervated
  → Heart no longer receives direct signals from body (autonomic NS)
  → Heart responds differently to exercise & stress (doesn't immediately ↑ HR)
• Hemodynamic function improves significantly
  → Heart pumps more effectively & blood flow better regulated

Impact on PT

• Improvements allow for greater aerobic endurance & better activity tolerance
• PTs must understand these changes to adjust exercise plans safely & monitor responses carefully
• Aerobic training after surgery can help max these gains

Cardiovascular Changes After Transplantation - Denervation

• After a heart transplantation, donor heart initially denervated
  → Lacks nerve connections

Cardiovascular Changes After Transplantation - Reinnervation

• In some pts, sympathetic nerves may reconnect to donor heart over time (

Heart Response to Activity after Transplantation - Heterotopic heart transplantation

• Denervated heart responds slower to physical activity compared to normal heart
• In heterotopic heart transplantation:
  → Donor heart behaves like denervated heart
  → Native heart still responds normally to activity
• Monitoring
  → Use ECG or peripheral pulse checks to observe how both hearts respond during treatment
• Decisions about exercise & tx should be based primarily on donor heart's response

Blood Pressure Concerns after Transplantation

• HTN common
  → ↑ risk of heart ischemia
• To reduce risk
  → Position pts upright rather than lying flat
  → Avoid long isometric exercises

Pulmonary Changes After Heart and Lung transplantation

• Pts often show significant improvement in VO2 max (max oxygen body can use during exercise)
• Even w/ these gains, exercise performance still falls below normal predicted levels for healthy individuals

Why Exercise Limitations Persist

Ongoing limitations in exercise ability often due to factors outside lungs themselves:

• Exercise-induced HTN
  → High BP during activity
• Ms atrophy
• Pre-existing changes in ms oxidative capacity
  → How well muscles use oxygen, often reduced before transplant
• Poor nutrition or general deconditioning

Acute Postoperative Inpatient Phase - Initial Eval

After surgery

• Pts typically eval by PT in ICU (99% of time) once medically stable
• Usually w/in 12-24 hrs
• Pts placed in protective isolation to prevent infection

Acute Postoperative Inpatient Phase - Infection Control Measures

• Pts must wear masks when leaving hospital room
• Hand hygiene
• Visitors or staff w/ respiratory infections not allowed to interact w/ pt
• People who have received live vaccine should also avoid contact for at least 6 wks

Acute Postoperative Inpatient Phase - Postoperative Setup

Transplant recipients initially:

• Intubated & on mechanical ventilation
• Receiving multiple IV meds
• Equipped w/ chest tubes, pacemaker wires, urinary catheter, & monitoring devices (still will mobilize pt; need multiple people assisting)

Sternal Precautions

Traditionally, surgeons recommended limited use of arms for 6-8 wks after:

• Sternotomy (heart transplant)
• Bilateral thoracosternotomy (bilateral lung transplant)
  Updated Evidence
• New research show using arms in functional, WBing activities safe & does not ↑ risk of wound problems (keep ADD to body)

Physical Therapy in ICU - Initial evaluation focuses on:

• Gas exchange (how effectively oxygen moves)
• Airway clearance
• Effects of prolonged immobility
• P! management
• Mobility limitations

Goals in the ICU Phase

Pulm hygiene & chest wall mechanics

• Help pt clear secretions & improve breathing to support weaning off ventilator & O₂
  Strength & ROM
• Focus on improving movement in upper body & chest area
  Exercise tolerance
• Begin light activity using ADLs & low-to-mod intensity exercise
  → MET levels 1-4
  → Borg scale

Progression After ICU

Once pt stable & moved out of ICU

• Can be placed in step-down unit (less critical 4-5 pts/nurse) or regular room (6-7 pts/nurse)
  → In ICU, 1-2 pts/nurse
• Independence in mobility & ADLs
• Endurance training
  → Stationary cycling, stair climbing, walking longer distances
• MSK rehab
  → Strengthen prox muscles affected by steroids
  → Use WBing exercises to prevent bone loss

Complications in the Acute Phase

Common issues in 1st 30 days:

• Primary graft failure (27% deaths in this period)
• Acute rejection
• Bacterial infection

Complications in the Acute Phase - Infection prevention

• Use PPE
• Practice strict hand hygiene
• Administer antibiotics (nurses)

Complications in the Acute Phase - Acute rejection

• Caused by immune system activation despite immunosuppressive therapy
• Leads to myocyte damage, reduced cardiac output, & risk of ischemia
• Exercise intolerance
• Confirmed through biopsy
• Tx: adjust dosage for immunosuppressive therapy; recognize & manage early

Initial Therapy Goals After Lung Transplantation

Eval & improve pulmonary hygiene

• Use optimal positioning
• Encourage mobilization
• Enhance cough effort (clear secretions)
  Use combo of airway clearance techniques
• Postural drainage
• Percussion & shaking
• Active cycle breathing
  Teach directed coughing
  Begin breathing retraining

Post-ICU Rehabilitation

Begins 2-4 days after surgery

• Step down unit or regular room
  Focuses on
• Ventilation & airway clearance
• Mobility training
• Thoracic mobility exercises
• Breathing exercises
  Use stationary bike or treadmill
  Hospital-specific guidelines for UE
• May include 5-10 lb weight restriction for 4-6 wks (depends on surgical incision & facility's policies)

Common Complications

Infection

• Most frequent complication & leading cause of death
  → 35% of deaths in 1st yr
  → 20% thereafter
  Primary Graft Dysfunction (PGD)
• Form of acute lung injury w/
  → Diffuse opacities on imaging
  → Low oxygen levels
• Caused by:
  → Donor lung injury before or during transplant
  → Reperfusion injury
  → Ventilator-induced trauma

Vital Signs in Normal Patients VS Patients Post Heart Transplantation Charr

Be familiar w/

Activity Levels for Inpatient PT after Cariac Transplantation Chart

Be familiar w/

• Levels of progression

Guidelines for Determining the Appropriateness of Exercise & Progression Chart

Be familiar w/