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ORGAN TRA:'\ISJ>U\NTATIO�

725

pur, pcnphcml edcma, pulmonary crackles, and jugular vein distennon.IO-1l Suo)ccrively. recipients may report vague symptoms of decrca!oicd exercisc rolerance, fatigue, lethargy, or dyspnea. However,

the mOSt reli"ble technique to diagnose rejection is by performing

periodIC endomyocardial bIopsy. The initial biopsy is performed 5-

10 days after transplantation. Under local anesthesia, a bioptome

catheter is advanced through the right internal jugular vein into the

right ventricle Linder fluoroscopy. Because rejection usually occurs in

small areas throughout the heart, three to five tissue specimens are

obt.tincd from different sites for histologic and immunologic studles."·" The presence of lymphocytic infiltration, polymorphonuclear leukocytcs, inrerstitial hemorrhage, and myocytic necrosis is an IIldic3ror of cardiac rejcction, the latter being the most severe.12

The frequency of surveillance endomyocardial biopsies varies

between transplant institutions. They are usually performed weekly

for the first month, biweekly for the second and third months,

monthly for the next 6 months, every 3 months up to the first 2

years, �lIld then annually.ILI] If rejection is identified, immunosuppressIve a!lents are intensified by administration of high-dose oral or intravenous corticosteroids, antilymphocyte antibodies, or both. I" If

the cardIac transplant reCIpient has frequent arrhythmias (which

often IIldlc.tc ischemia), periodic coronary angiography IS performed to deteer allograft coronary disease.lo.1!

Clinical Tip

• The panenr is placed in a protccnve isolation room.

Posinve-pressure now rooms are recommended to limit the

transfer of airborne pathogens. The usc of a face mask and

strict hand washing are required.)"

• In the initial postoperative period, mediastinal drainage

IS promoted by elevating the head of the bed to a 30-

degree angle and turning the patient every 1-2 hours.5

• Phase I cardiac rehabilitation usually begins 2-3 days

postoperatively, once the patient is hemodynamically Stahle. r,ercise is progressive and based on the patient'S

activity tolerancc. Exercise is progrcssed from active

SUpll1C exercises without resistance to ambulation and stationary biking. Vital signs are monitored before, during,

and immediately after exercise.

726

ACUTE CARE HANDBOOK FOR I'HYSICAL THERAPISTS

• The cardiac transplant recipient has a resting heart rate

that is higher than normal, owing to the absence of parasympathetic nervous system or vagal tone that would normally

slow the heart rate.' The rate is usually between 90 and 110

beats per minute, and it does not vary with the recipient's respirations. The transplanted heart is denervated because the extrinsic nervous supply to the donor heart was severed during the procurement surgery." Therefore, it no longer has autonomic nervous system connection to the recipient's body.

Consequently, it is unaffected by the recipient's sympathetic

and parasympathetic nervous system, which normally controls the rate and contractiliry.S.9

• Patients should gradually increase and decrease demands

on the transplanted heart by extending their warm-up and

cool-down periods to 5-10 minutes,,·11,3' In the absence of

neural regulation, heart rate increases during exercise, but the

increase at the onset of exercise is delayed by 3-5 minutes.'·40

The denervated heart depends on circulating catecholamines

to increase the rate and force of contractions.s With exercise,

heart rate and cardiac output increase gradually over 3-5

minutes and remain elevated for a longer period of time at

the completion of activity.' As well, after cessation of exercise, there is a slower-than-normal return to pre-exercise heart rate level. 1,9-1 I

• The peak heart rate achieved during maximal exercise is

significantly lower in cardiac transplant recipients than in agematched patients. As a result, exercise prescriptions that are based on target heart rate are not recommended. II instead,

the Borg scale, which uses the rate of perceived exertion

(RPE), is frequently used during exercise for self-monitOring.

The recipients exercise at an RPE between 1 1 and 13."

• Physical therapists should monitor blood pressure before,

during, and after activity. At rest, systolic and diastolic blood

pressures of heart transplant recipients arc higher than nor·

mal."·40 The systolic blood pressure should be between 80

and 150 mm Hg, and the diastolic blood pressure should be

less than 90 mm Hg]'

• Orthostatic hypotension is common in the early postoperative phase, owing to the absence of compensatory reflex tachycardia.' Allow the patient time to change position

slowly and adapt to the new position."