Exercise Therapy for Cardiac Transplant Recipients

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Abstract

Heart transplantation (HT) is an attractive treatment for patients with terminal heart failure from a variety of causes. Survival at 1- and 5 years after HT averages 90% and 70%, respectively. The physiologic response to exercise is abnormal after HT presumably because the transplanted heart is surgically denervated, although a minority of patients demonstrate signs of partial cardiac reinnervation several months after surgery. The heart rate response to exercise is typically blunted, and exercise capacity is below average for most HT recipients. Multiple studies have demonstrated the benefits of exercise training (ET) after HT. Peak exercise oxygen uptake improves by an average of 24% after 2 to 3 months of ET. Resistance training results in increased skeletal muscle mass and strength. Early mobilization and low-level ET may begin in the hospital after extubation. Outpatient ET, ideally in a supervised environment for at least several weeks, should begin immediately after hospital dismissal. Exercise prescription for HT patients is similar to that for other patients who have undergone cardiothoracic surgery, with the exception of a target heart rate. Ratings of perceived exertion are useful for prescribing exercise intensity. Exercise training does not affect the frequency or severity of episodes of acute rejection. There are no data regarding the effect of ET on survival after HT.

Section snippets

Background information

The first successful human heart transplantation (HT) was performed by Barnard1 in Cape Town, South Africa, in 1967. Although the patient lived only 18 days, the resulting publicity and enthusiasm spurred a number of surgical centers to perform the operation. Long-term survival was poor, and the procedure did not enjoy widespread application during the 1960s and 1970s. Developments at Stanford University, including improved techniques for preservation of the donor organ, the transvenous right

Responses to exercise

The responses of HT recipients to acute exercise is unique and related, in part, to the following factors7, 8, 9:

  • 1.

    The transplanted heart is surgically denervated and receives no direct efferent input from the autonomic nervous system and provides no direct afferent signals to the central nervous system. Months after HT, some patients demonstrate signs of partial cardiac reinnervation. This will be discussed later.

  • 2.

    During organ harvesting and with transplantation, the donor heart has experienced

Graded exercise testing

Exercise testing after HT is helpful in determining the exercise capacity, prescribing exercise training (ET), and in counseling patients regarding the timing of return to work or school, or resumption of avocational pursuits. The electrocardiogram (ECG) of HT recipients commonly demonstrates right bundle-branch block and nonspecific repolarization abnormalities. The sensitivity of the exercise ECG in detecting ischemia due to the presence of allograft vasculopathy is poor (<25%), unless

Responses to ET

Recipients of HT are excellent candidates for progressive ET for several reasons: pre-HT syndrome of chronic HF with poor exercise capacity due to central and peripheral circulatory abnormalities, skeletal muscle pathology, deconditioning, the healing process with open-heart surgery similar to that observed with coronary or valvular surgery, and post-HT use of corticosteroid medications with resultant skeletal muscle atrophy and weakness.

Pretransplant graded exercise testing and training

As part of the evaluation process for HT, ambulatory patients undergo cardiopulmonary exercise testing. Peak VO2 is a powerful prognostic indicator: patients with an aerobic capacity of 14 mL kg−1 min−1 (4 METs) or below experience a markedly reduced 1-year survival, independent of left ventricular ejection fraction.47

Based on the results of the exercise test, an ET prescription may be developed for the patient with the goal of maintaining or even improving cardiorespiratory fitness while

Statement of Conflict of Interest

The author declares that there is no conflict of interest.

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    Statement of Conflict of Interest: see page 435.

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