May 5, 1996 - transplantation model. A year later, Goldberg and col-. HS Sadowsky, RRT, PT, CCS, is Associate Professor, Department of Physical Therapy, ...
Cardiac Transplantation: A Review Cardiac transplantation is now an accepted treatment for end-stage cardiac disease. To ameliorate the deconditioning that results from the preoperative disease state and to counteract o r lessen the severity of the sequelae of postoperative imn~unosuppression,physical therapists are active participants in the rehabilitation of cardiac transplant recipients. This involvement requires a level of knowledge and understanding of the surgical procedures, pharmacology, and postoperative management with which the therapist may have, heretofore, been unexposed. This article reviews the development of cardiac transplantation and presents an overview of the current state of the art, with emphasis on preoperative considerations, surgical and immediate postoperative care, and the effects of complications on selected exercise-related responses. [Sadowsky HS. Cardiac transplantation: a review. Phys Ther. 1996;76:498-515.1
Key Words: Cardiac, general; Cardiovascular diseases; Cardiovascular system; Immunosup~ession; Transplantation.
H Steuen Sadowsky
498
Physical Therapy . Volume 7 6 . Number 5 . May 1996
ardiac transplantation has grown from a scientific curiosity into an accepted medical intervention for a broad spectrum of patients with end-stage heart disease. Cardiac transplantation is taking place at a great number of facilities, and a great Inany physical therapists are participating in the rehabilitation of transplant recipients. This article reviews the development of cardiac transplantation and then presents an overview of the present state of the art, with emphasis on preoperative considerations, surgical and immediate postoperative care, complications, and transplantation effects on selected exercise-related responses.
Proximal Left Carot~d
Prox~malExternal
Historical Review Carrel and Guthriel were the first to describe cardiac transplantation (using a canine model) in their 1905 discussion of surgical anastomotic techniques. Carrel was awarded [he Nobel Prize for Medicine and Physiology in 1912, in large part for this work, but little more occurred with regard to cardiac in any model until 19339 when Mann and colleagues' refined the technique for cervical cardiac transplantation sufficiently to permit limited circulatory loading of the right ventricle of the heterotopically (ie, in other than the normal or usual position) transplanted heart. From the 1930s through the 1950s, cervical anastomosis of the "donor" heart was considered the most feasible means of accomplishing cardiac transplantation in the dog model (Fig. 1). Mann e t a12 can be credited with clarifying several technical aspects of the surgical procedure, and they astutely observed that failure of the transplanted heart is likely due "to some biologic factor" and not always to flawed surgical technique. There were few important developments regarding cardiac trar~splantationuntil the 1950s. In 1951, Marcus
Figure 1. Cervical (heterotopic)placement of the transplanted "donor" heart in the experimental canine model (after Balkin, in Marcus et 013).
and coworker9 described circulatory loading of both ventricles of a transplanted canine heart (Fig. 1). This achievement led them to speculate on future prospects for application in human cardiac transplantation. In 1953, Downie4 decried the dismal record of cardiac transplant survival and called for a concerted effort to expand the understanding of what is now called immunology. In 1957, Webb and Howard-eported that myocardial viability could be maintained for u p to 8 hours with a combination of cardioplegic arrest and surface cooling in a heterotopic intrathoracic cardiac transplantation model. A year later, Goldberg and col-
HS Sadowsky, RRT, PT, CCS, is Associate Professor, Department of Physical Therapy, School of Health and Social Work, -246.
43 Ventur;~HO, L.;rvic. (J, Stapleton DD, Price HL.. Cardiac trans1)l;tntalion: how recipirnts arc selected. Pnc/,qwad :\fvd. I991;90:13l-132, 1.75-138. 44 Cahl-ol (:, Gar~djbakhch I , Pavic A, etal. Heart and heal-t-lung transplantatio~~ in the 1990s. IJo.si,~rrrd M P ~ J1992;ii8(~1rppl . 1):S78-S80.
5 12 . Sadowsky
63 Stevenson L,W, Miller LW. C:ardiac tmnspl;lntatior~as ther;~pyl i ~ r heart failure. ( : I I I'~rnrohl . Cttr(lio1. 199 1 ;16:217-305. 64 E:dw;rrds EB, Guo T, Brcer~TJ. et al. T l ~ eLIKOS OPTN waiting list li-orn 1988 to 199.1. (;/in 7ion\pl. 1993:71-8.1.
65 Potter CD, Wheeldon I)K. MJallworkJ . Functional assrsyment and rnanap11e11tof heart dono1 s: a I-ationitle for charactel-imtion and a g ~ ~ i to d r tl~rl-apy.J Heor1 I.ung 7ic1~1cl1l~1nl. 1!195;14:59-(i5.
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66 Kirh;~~-tls PS, &(.Ison KA, Fra/ir~.O H , et al. Why referred potential h(,;~rtd o n o ~ s211.c.n't~lsed.l > x Ik~crrlI71tl,/. 1!)93;20:218-222. 67 Young.jB, Naftel D(:, Bourge KC, et al. Matching the hc;~rtdonor ant1 I~(.ilrtt ~ ~ r l s p l a nrecipient: t clues for successfi~lexpansion of the report. The (hrdiac donor pool-a mlrltiv:~ri:~ble,m~~lti-institutional I ' I - . I I I SKesearcl~ ~ ~ ~ I I Databac I~ ( ; r o ~ ~ p,/. H P I I I1.nrlfi I 7 ' 1 1 1 n . s ~ ~ 1994; l~~nl. 13::-15:-1-96 1;disc~~ssion: 3ti4-365. 68 Uoroshow KW. Asliw;~lS, S , r ~ ~ kGM' r l . Availability and selection of donol-s [Or 1)rtliatric I~earttr;~nsplantation.,/ Hrrl-t Lung 'lionsplont. 1!l95: 14:.52-38. su~.~ic;ll considerations and 69 MrGregor (:
