heart and lung transplant and vads and ecmo

what are ventricular assist devices?

used for end stage heart failure that is unresponsive to medical intervention

• VADs can perform the work of the LV and/or RV

• LVAD

• RVAD

• BiVAD

what are the clinical indications for ventricular assist devices?

• bridge to transplant

• destination therapy

• bridge to recovery

• bridge to decision/bridge to candidacy

what is bridge to transplant?

reduces mortality rates for patients awaiting transplantation

what is destination therapy?

permanent solution for patients NOT eligible for cardiac transplant

what is bridge to recovery?

allows the myocardium to recover and then the device is removed

what is bridge to decision/bridge to candidacy?

implanted as a short term stabilizing measure when a patient is critically ill and a final determination regarding transplant eligibility cannot yet be made or if the patient has some potentially modifiable barriers that would allow for transplantation

what is patient criteria for LVADs?

• NYHA class 3B or IV despite optimal medical therapy

• ejection fraction less than or equal to 25%

• VO2 < 12 or < 50% of predicted value

• more than 3 HF related hospitalizations

• inotrope or mechanical circulatory support dependence

• worsening renal and/or hepatic function due to reduced perfusion

what are complications of LVADs?

• bleeding (GI bleeding)

• infection (drive line)

• RV failure

• malignant arrhythmias

• failure of device (varies)

• thromboembolism/CVA

• renal failure

• multi-organ failure

what is an LVAD?

• blood is continuously flowing from the ventricle through the pump and into the aorta

  • DECREASES LV WORK AND MYOCARDIAL DEMAND

  • INCREASES MAP, CAO AND SYSTEMIC PERFUSION AND CORONARY FLOW

• NO PULSES

  • unable to palpate HR or obtain manual BP readings

what is functional status post LVAD?

exercise capacity REMAINS LOW after LVAD placement

what are exercise guidelines for LVADs?

• BORG RPE 11-13 (6-20 SCALE)

• dyspnea less than 5 (0-10 scale)

• MAP between 70-90 mmHg

• LVAD FLOW GREATER THAN 3 L/MIN

• EKG changes (ST shifts no more than 1 mm and or increasing ventricular arrhythmias

• decreased SpO2

• WATCH FOR SYMPTOMS OF EXERCISE INTOLERANCE

when should exercise with LVADs be stopped?

• new symptoms or signs are elicited (fainting, headache, SOB, chest pain, thoracic pressure, fever , supraventricular or ventricular arrhythmias)

• VAD alarms or related problems occur

• unexpected changes detected in VAD parameters (flow, speed, watt operation)

what is the acute phase (wk 1-6) of PT intervention post LVAD?

• management of acute care factors

• progressive mobilization

• education

what is management of acute care factors in the acute phase?

• wound and skin integrity

  • driveline and use of abdominal binder

• pulmonary hygiene

  • IS/deep breathing/coughing

• ROM/strengthening exercises for neck/UE/LE

what is progressive mobilization in the acute phase?

• need for hemodynamic monitoring

  • monitor flow rate, MAP, HR, RPE

  • watch for signs of exercise intolerance

• use of interval training to improve aerobic conditioning

what is education in the acute phase?

how to tether and untether LVAD to/from batteries

what does cardiac or outpatient therapy look like for LVADs?

• more than 3-5 days a wee

• RPE 11-13

• goal: 20-60 min

• strength training after 4-8 weeks

what is extracorporeal membrane oxygenatiion (ECMO)?

• used to temporarily support patients with sever cardiopul dysfunction that is unresponsive to conventional treatment

  • cardiogenic shock/failure

  • respiratory failure

    • ARDS

    • COVID

  • bridge to heart and or lung transplant

what are the 2 types of ECMO?

• veno-venous: support pulmonary function

• veno-arterial: supports cardiac function

what comes from the medical complexity of ECMO patients?

prolonged bed rest leading to significant weakness and lower levels of mobility

is rehab and mobilization safe on ECMO?

• yes!

• decreases delirium, mech vent, ICU/LOS and mortality

• increases functional ability, exercise capacity and QoL

what are the 3 things to think about with mobility on ECMO?

• determine

  • medical stability and obtain order

• gather

  • team (RN, perfusionist, RT, if needed) additional help to secure lines

• progress

  • slowly progress mobility as tolerated (vitals and flows and cannulas)

what are wait times for heart transplants?

varies from days to a year or more

what are indications for a heart transplant?

accepted treatment of choice for patients with end stage heart disease

• age less than or equal to 69

• NYHA stage 3 or 4

• EF < 20 %

• cardiac index <2.0

• Vo2 max < 14 or <50% age predicted value

• increased risk of mortality within next year

what are contraindications for heart transplants?

• active uncontrolled systemic infection

• severe pulm HTN

• severe non-reversible end organ failure or damage (not heart)

• malignancy with limited life expectancy

• documented nonadherence to med treatment

• inadequate social support

• morbid obesity

what is an orthotopic transplant?

• done > 95 % of the time

• performed via median sternotomy

• recipients native heart is removed and donor heart is inserted

what is heterotopic “piggy back” transplant?

• donor heart is attached to the recipients heart

• done <5% of the time

  • size mismatch

  • severe pulmonary HTN

• poor survival

• 2 separate EKGS

what are immunosuppression drugs used for heart transplant?

• cyclosporine A (CSA)

• tacrolimus

• azathioprine (imuran)

• corticosteroids

• mycophenolate (cellcept)

what are common side effects of immunosuppression drugs?

• high BP

• high cholesterol

• bone loss

• elevated blood sugar

• weakness

what antibiotics and antivirals should heart transplant recipients be on?

• sulfamethoxazole-trimethoprim (bactrim, septra)

• vsalganciclovir (valcyte) or valacyclovir (valtrex)

what are complications of heart transplants?

• organ rejection

• primary graft failure

• infection

• cardiac allograft vasculopathy

  • accelerated form of CAD

• cardiovascular kidney metabolic sydnrome

  • often develop HTN, DM, CKD, high chloesterol and increased triglycerides and LDL levels

• malignancy: skin cancer and lymphomas

what happens post tranaplant?

HEIDI SAID KNOW THIS

• heart is DENERVATED

  • loss of autonomic nervous system modulation

  • increase adrenal release of norepinephrine

  • resting HR 95-115 bpm

  • response to exercise is DELAYED AND BLUNTED

    • LOWER PEAK HR

  • usually no angina

what is heart rate response in the transplanted heart?

delayed onset of raising, lower peak and HR stays high longer

NEED WARM UP AND COOL DOWN

what are common impairments pre transplant?

• dyspnea

• reduced exercise capacity/physical function

  • high levels of frailty

  • difficulty performing ADLs

• muscle weakness

• edema

• cognitive impairment

what should PT intervention be pre transplant?

• exercise training in patients with advanced HF has been shown to be beneficial

• obtain medical clearance

• individualized exercise plan

  • aerobic/mobility training

    • low intensity, may benefit from interval training

  • strength

    • low weights

  • balance training as needed

  • monitor vital signs and watch for exercise intolerance

• education

what does PT intervention look like post transplant?

• address any pulmonary issues

• gradual progress patient’s mobility/activity tolerance

  • supine to sitting to standing to walking

  • WARM UP AND COOL DOWN

• monitor HR but also watch BP, RPE and symptoms of fatigue

  • delayed and blunted = use RPE

• provide education

  • sternal precautions

  • deneverated heart response

  • HEP

what level on the rejection scale should you withhold activity?

level 3: moderate rejection

what are signs and symptoms of rejection?

• DECREASEDE EXERCISE TOLERANCE

• fever

• arrhythmias

• SOB

• edema

• hypotension

• syncope

what is the outpatient aerobic FITT for heart transplants?

• frequency: min 3 days/week, prefer 5

• intensity:

  • with an exercise test use 50-80% exercise capacity

  • without an exercise test, use talk test, RPE and clinical judgement

• time: 20-60 min a day

• type: overground or TM walking, bike, UE ergometry

what is the outpatient resistance FITT for heart transplants?

• frequency: 2-3 days a week, non consecutive

• intensity: 10-15 reps at 60-70% of 1 RM

• time: 1-2 sets

• type: weight machines or free weights

what is done at OP cardiac rehab?

• aerobic training

• strength training

• address any MSK problems

• education/HEP/self monitoring

what are tips for exercising a patient after a heart transplant?

• need a prolonged warm up and cool down

• initial intensity 40-50%

• monitor vitals and watch for inappropriate responses

• no exercise when rejection reaches a level 3

• sternal precautions for 4-6 weeks

• alternate between UE and LE exercises

what are the benefits of exercise training after heart transplant?

• greater improvement in exercise capacity, exercise time and the ability to rise from sitting

• restored the subject’s bone mineral density to 1-3.6% the pre treatment levels

what are additional benefits of cardiac rehab post heart transplant?

• improve muscle strength

• reduce complications

  • CVAs, hospital readmissions, and cardiovascular events

• reduces anxiety and depression

• improved long term survival

what is the composite allocation score for lung transplants?

• determines a priority for receiving a lung transplant

  • scored 0-100

  • based on medical urgency, likelihood of survival at 5 years (makes up 50% of scale)

  • used on patients 12 and older

• if younger than 12 the patient is listed as priority 1 or 2 based on medical illness

what are indications for lung transplants?

• end stage pulmonary disease

  • COPD, adults with CF, bronchiectasis, alpha 1 antitrypsin deficiency

  • interstitial lung disease/pulmonary fibrosis

  • pulmonary artery disease

• maximal medical intervention

• high risk of death within 1-2 years without a transplant

• significant decline in physical function

what are contraindications for lung transplants?

• lack of patient willingess/acceptance of transplant

• malignancy with high risk of recurrence or death related to cancer

• kidney or liver failure (unless multi organ transplant)

• MI or CVA within 30 days

• active infection (TB or HIV)

• limited functional status with poor rehab potential post transplant

• repeated episoded of non-adherence

• active substance use (vaping, tobacco, marijuana, IV drugs)

• other severe uncontrolled medical condition expected to limit survival after transplant

what are the 3 types of lung transplant?

• single

• bilateral

• lobar

  • living donor, to kids

what are the two surgical approaches for lung transplantations?

• single/bilateral thoracotomies

• clamshell thoractomy

what are immunosuppression drugs used for lung transplant?

• cyclosporine A (CSA)

• tacrolimus

• azathioprine (imuran)

• corticosteroids

• mycophenolate (cellcept)

what are common side effects of immunosuppression drugs?

• high BP

• high cholesterol

• bone loss

• elevated blood sugar

• weakness

what antibiotics and antivirals should lung transplant recipients be on?

• sulfamethoxazole-trimethoprim (bactrim, septra)

• vsalganciclovir (valcyte) or valacyclovir (valtrex)

what are common lung transplant complications?

• primary graft dysfunction

• airway complications (ischemia, necrosis, dehiscence, bleeding and stenosis)

• rejection

• infections

• cancer

what is lung denervation?

• impaired cough reflex

• impaired mucociliary clearance

• altered airway responsiveness

how is rejection monitored in lung transplants?

• lung biopsy

• home spirometry: drop in lung function (FEV1)

• symptoms

  • falu like symptoms

  • fatigue/weakness/decrease activity tolerance

  • fever/tachycardia

  • SOB

  • decrease SpO2

what are common impairments pre lung transplant?

• dyspnea

• hypoxia

• reduced exercise capacity/physical function

  • difficulty performing ADLs

• muscle weakness (peripheral and respiratory)

• ineffecient breathing patterns

• increased fall risk

• reduced chest wall mobility

what are potential assessment techniques pre lung transplant?

• vitals

• chest wall eval

• cough/sputum

• skin color

• lung auscultation

• breathing pattern

• functional capacity/exercise tolerance

• strength

• balance

what should the pulmonary rehab/OP exercise program look like pre transplant?

• goal is to improve/prevent deterioration of physical condition pre transplant

  • aerobic exercise

  • strength

  • balance

  • inspiratory muscle training

  • airway clearance/breathing techniques

• greater 6MWT prior to transplant is associated with better outcomes post transplant

  • improved survival

  • shorter LOS post transplant

• exercise should continue up until time of transplant

what is pre lung transplant aerobic FITT?

• frequency: min2 days a week prefer 5

• intensity: moderate to vigorous (50-80% HHR or 3-5 BORG 0-10)

• time: 15-30 min continuous or 5-10 in 2-3 bouts

• type: overground or treadmill walking, bike, UE ergometry

what is pre lung transplant resistance FITT?

• frequency: 2-3 days a week, non consecutive

• intenstiy: 60-70% 1 RM for beginners, over 80% for experiences

• timeL strength 1-2 sets, 8-15 reps at 30-80% of 1 RM targeting muscle groups of UE and LE

• type weight machines or free weights

what are common impairments for post lung transplant?

• impaired secretion clearance/ineffective cough

• pain

• inefficient breathing patterns

• reduced Shoulder ROM

• reduced exercise capacity/physical function

• muscle weakness

what are potential assessment techniques post lung transplant?

• review ABGs and chest xrays

• vital signs

• pain

• lung ausc

• cough/sputum

• skin color

• breathing pattern

• functional capacity/physical function

• strength

what are post lung transplant interventions in the hospital?

• airway clearance techniques

• breathing techniques

• ROM exercises

• early progressive mobility program: progress to TM walkingw hen stable

• postural reeducation

• education

• monitor vitals and O2

• discharge to OP pulm rehab to continue exercise for 6-12 weeks after transplant

what are post lung transplant interventions OP?

• aerobic training

• strength training

• breathing techniques

• postural retraining

• flexibility

• balance

• vitals

• signs and symptoms of rejection and self monitoring

what is FITT for aerobic OP rehab post lung transplant?

• frequency: min 3 days wk perfer 5

• intensity: moderate to vigorous intensity (50-80% HHR or 3-5 on borg 0-10)

• time: continuous 20-30 min

• type: overground or TM walking, bike, UE ergometry

what is FITT for resistance OP rehab post lung transplant?

• frequency: 2-3 days a week, non consecutive

• intensity: strength 60-70% of 1 rm for beginner over 80% for experiences, targeting major muscle groups of UE and LUE

• time: continuous 20-30 min

• type: weight machines or free weights

what are benefits of exercise training after lung transplant?

• increase exercise capacity

• rebuild muscle strength

• improve CV and metabolic health

• improves bone density

• improves mental well being