INTRODUCTION:
In 1967 the first successful heart transplant was achieved in South Africa (Barnard, 1968), although research had been taking placed duringthe previous years in America as well as South Africa. Thef firstpatient survived for 18 days; the second operation was performed in January 1968, also in South Africa, and the patient lived for 18 months. Between then and the middle of 1969, 135 further cardiac transplants were carried out in 60 centres throughout the world. Unfortunately, due to the immense problems of infection and rejection, the survival record did not improve as fast as had been hoped. The programme therefore suffered a lack of confidence, and only five centres continued with their clinical research programmes; Dr Shumway of Stanford performed the greatest number of operations using the orthotopic technique (heart of recipientreplaced by heart of donor).
In 1974, Barnard and his associates in South Africa started to concentrate on the heterotopic technique (heart of donor placed to the right of recipient’s heart in ‘piggy-back’ fashion) (Wolpowitz et al, 1978). Since then the life expectancy of survival following heart transplantation has steadily improved, and graft survival rates have become comparable with those achieved in cadaveric kidney transplantation.
Clinical heart transplantation re-started in Britain in 1979 at Papworth Hospital (English et al, 1980), and in January 1980 at Harefield Hospital. It is interesting however to note that the longest surviving heart transplant recipient is a Frenchman who underwent his operation in 1968.
THE
RECIPIENT
The main indication for heart transplantation is end-stage heart disease which is totally incapacitating and may be secondary to widespread coronary disease or to idiopathic or rheumatic cardiomyopathy (Russell and Cosimi, 1979). These conditions cannot be remedied by any further conventional medical or surgical treatment. Patients with incorrectable congenital abnormalities may also benefit.
In order to undertake transplantation it is essential that the recipient be assessed before acceptance into the transplant programme. In addition to this assessment other criteria must be taken into account:
1. There is no upper or lower age limit when considering a patient for heart transplantation even those aged over 60 years.
2. The patient should have no active infection (nor recent pulmonary infarction, although this is not an absolute contra-indication).
3. The patient should have a strong motivation to survive, be psychologically stable, and, if possible, be from a supportive background.
4. A raised pulmonary vascular resistance is an absolute contraindication for an orthotopic heart transplant, although in this situation a heterotopic transplant, or heart/lung transplant, would be appropriate.
5. With the advent of cyclosporin A, insulin dependent diabetes mellitus is no longer a contra-indication but such patients should be free from other complications of diabetes.
THEDONOR
Any potential donor must have suffered irreversible brain damage - this is due usually to an intracranial haemorrhage or may be the direct result of a road traffic accident. The diagnosis of brain death is made by doctors who are independent of the transplant team.
Other
points to be considered include:
1. Any donor over 35 years of age must undergo coronary angiography to preclude any possibility of undetected coronary disease (De Bakey, 1969).
2. Compatability of size of the heart may be a consideration between recipient and donor, but smaller hearts may be used for heterotopic transplantations in adults.
3. ABO
blood group compatibility is essential.
4. Cross-matching of donor lymphocytes and recipient serum is necessary only in patients with cytotoxic antibodies (detected at assessment).
5. Tissue typing is performed on all recipients and donors but a match is not essential.
6. There must be no history of heart disease, systemic infection, or malignancy other than a primary cerebral tumour. The donor should not have been on long-term medication which could adversely affect the performance of the heart.
TRANSPORTATION OF THE DONOR HEART
Quick and easy transportation is essential for a successful operation. The donor heart is phmged into ice-cold Hartmann’s solution to cool it from the outside. The aorta is clipped and a Medicut is inserted into the aorta and connected to a litre of Hartmann’s containing 1 ampoule of Cardioplegia Infusion (St Thomas’s Hospital Formula).
This is infused into the aortic root causing the heart to stop suddenly. The heart is then examined. The donor heart is transported in Hartmann’s solution, packed in three sterile bags, and put into a cool box filled with ice. Rapid transportation to the recipient hospital then takes place in order to keep the total ischaemic time as short as possible.
TECHNIQUES FOR CARDIAC TRANSPLANTATION
Orthotopic technique :
The patient is placed on to cardiopulmonary bypass. Cardectomy of the recipient heart is carried out by division of the atria at their midlevel plane and of the great vessels immediately above the semilunar valves. This leaves the walls of the recipient’s right and left atria and intra-atrial septum in situ, and they are anastomosed to the correspondingly prepared structures of the donor heart. The sinuatrial node in the recipient’s right atrium is retained and care is taken to preserve the integrity of the donor’s sinuatrial node.
The orthotopic technique for heart transplant: (a) large cuffs of atria are left after most of the recipient’s heart is removed; (b) the left atria are joined; (c) the two aortas and atrial septa are joined; (d) the right atria and pulmonary trunks are joined
Heterotopic technique (‘piggy-back’)
The recipient’s heart is left in situ and the donor heart is placed to the right of it, within the right pleural cavity. The superior and inferior venae cavae of the donor heart are ligated, and the pulmonary artery is anastomosed to that of the recipient heart. An end-to-side anastomosis is performed between the aorta of the donor and the aorta of the recipient, and the donor left and right atria are anastomosed to the respective atria of the recipient. Haemodynamically the heterograft assists the failing left ventricle of the recipient.
IMMEDIATE
POSTOPERATIVE CARE
This differs little from that received routinely by cardiac surgical patients except for the use of immunosuppressive drugs and reverse barrier nursing techniques. Due to the failing heart and circulator deficiencies the desperately ill patient undergoing transplantation is prone to pulmonary infections and the use of immunosuppressive drugs increases the high risk of postoperative infection. It is mandatory therefore to provide an atmosphere as free as possible from bacteria. Nursing is considered in three stages and the length of time each patient spends at each stage depends on the individual’s postoperative progress.
In some patients mechanical respiratory assistance is required for several days but most patients are extubated less than 12 hours after the operation. Orthotopic patients will have the usual pericardial and mediastinal drains but a heterotopic transplant patient will have a right pleural drain also. These patients may also have undergone -repair of their own heart at the same time, for example an aneurysmectomy or bypass grafts, in which case the l^ng saphenous vein will have been removed from one or both legs to provide the grafts. Most of the other peri-operative attachments are much the same as for any cardiac surgery except that all heart transplant patients have pacing wires in situ on return from the theatre.
Orthotopic patients have three wires (two atrial, and one ventricular) and heterotopic patients have six wires (two atrial wires and a ventricular wire for the donor heart, and the same for the recipient’s own heart). These pacing wires are connected to a pacemaker which works on demand.
First stage barrier nursing
The patient is returned from the operating theatre into an isolation room which is self-contained, individually ventilated, and has temperature controlled filtered air at a positive pressure. Before entering the cubicle the staff must, in the airlock, put on a plastic apron, cap, mask, and sterile gown and overshoes as they pass
through the sliding doors into the room. Hands must be washed prior to donning sterile gloves, and then the patient may be approached. This stage may last only 24 hours.
Second stage barrier nursing
Only a plastic apron, mask and overshoes are required with washing of hands prior to treating the patient.
Third stage barrier nursing
No barrier nursing techniques are required and by this time the patient is usually in an ordinary single hospital room.
PHYSIOTHERAPY MANAGEMENT:
Pre-operative physiotherapy
When the patient attends the hospital for assessment for cardiac transplant surgery he will be seen by a multidisciplinary team including the physiotherapist. Her role is:
1. To gain the patient’s confidence and to explain the reasons for the course of postoperative physiotherapy.
2. To teach correct breathing control and effective coughing in order to improve and maintain efficient ventilation and to clear the lung fields if necessary.
3. To reinforce the general pre-operative routine, with regard to infusions and drains, given by the nursing staff.
Many patients may be assessed at other hospitals or in other countries, so it is difficult for the unit physiotherapist to see every patient before operation. Once accepted on to the list for transplant surgery, an explanatory pre-operative booklet is sent to each patient.
This does help the patient to become familiar with the likely pre- and postoperative routine, but does not replace the direct contact between patient and therapist. Additionally, some patients are admitted at night for the operation and in such cases pre-operative physiotherapy will not be possible.
Postoperative physiotherapy
Individual programmes are designed depending on the patient’s age, pre-operative condition and postoperative progress, but the aims of treatment are consistent throughout:
1. To clear and maintain the lung fields in order to prevent pulmonary infection.
2. To
prevent circulatory complications.
3. To encourage and improve exercise tolerance, range of movement, and muscle power.
4. To
achieve early independence and a return to normal life.
DAY OF OPERATION
If the period of ventilation of the patient is to be continued then treatment will be given as and when requested, similar to other ventilated patients; but in general the patient only requires to be ventilated for less than 12 hours after surgery. Physiotherapy treatment commences within an hour of extubation of the patient.
1. Breathing exercises, especially diaphragmatic and unilateral basal, are encouraged. The latter are important in all patients but particularly for the right side of ‘heterotopic’ patients as the new heart may cause some compression of the right base.
2. The patient will be encouraged to cough, the physiotherapist supporting in the mid-axillary line (as all drains are still in situ). The patient can support himself around the lower chest.
3. Active leg exercises: (a) plantar and dorsiflexion of feet; (b) knee flexion and extension; and (c) isometric quadriceps exercises.
Due to the pre-operative condition of most patients it is unlikely that they will have been able to manage more than a small amount of exercise or mobility. Early mobilization, therefore, is of the utmost importance. On the first treatment only three of each exercise may be possible. Assistance may be necessary at first.
The number of treatments on the operation day is dependent upon the condition of the patient. Routine evening treatments are not required but emergency physiotherapy should be available.
FIRST POSTOPERATIVE DAY
The mediastinal and pericardial drains are removed during the first day, and breathing and leg exercises continue as before with an increase in the latter to five or eight times depending on the individual patient. The patient will be treated two or three times during the day.
Under normal circumstances breathing exercises are continued twice a day, but may be modified if the patient is producing sputum, or the blood gas measurements, radiographic appearances or lung expansion are unsatisfactory. Leg exercises continue to be increased according to the patient’s exercise tolerance until he is allowed out of bed.
SECOND POSTOPERATIVE DAY
If most of the infusion lines, drains, and other attachments have been removed the patient is allowed out of bed to sit in a chair for short periods.
1.
Breathing exercises may be given either in the bed or in a chair.
2. The use of a ‘pedal machine’ is started for 1 or 2 minutes to stimulate the patient’s circulation and encourage gentle mobility. This machine can be used a number of times during the day and the time will be increased as the patient is able.
3. If the patient is unable to stand from a chair without using his hands on the sides, the first short-term goal is to encourage this activity. Knee flexion in a standing position and heel raises encourage general leg muscle movement. These three exercises (stand-ups, knee-bends and heel-raises) plus the breathing and leg exercises are recorded on an exercise progression chart which is filled in during the patient’s stay in hospital.
PROGRESSION FROM THE THIRD DAY
As soon as all attachments are removed the patient starts to walk within the room. Once all heart support (dopamine) is discontinued the exercycle programme commences in place of the ‘pedal machine’. Breathing and general exercises continue.
At first no resistance is used and the patient builds up to 4 minutes at I5kph or 35 revs per minute (rpm) depending on the exercycle used.
This constitutes the ‘warm-up’ and ‘cool-down’. A work load is then introduced at 2okph or 5orpm. The first treatment with a work load would be:
warm-up
2 minutes at I5kph
work
load 1 minute at 2okph
cool-down
2 minutes at I5kph
The warm-up and cool-down are kept constant but as the patient becomes stronger the work-load time is increased or resistance may be added, the aim being to encourage both the endurance and strength without overtaxing the patient. When barrier nursing is no longer required the patient may walk, wearing a mask while in the hospital corridor or attending departments such as x-ray or cardiology.
At about five days postoperatively the patient will be able to go for short walks in the grounds accompanied at first by a member of staff and a relative. He is encouraged to negotiate stairs as soon as his physical condition allows, and should be able to climb a flight of about 17 stairs with ease by the time of discharge.
Note: If the patient is having an infusion of HATG or RATG he will only have breathing exeitises if indicated, as exercises at this time tend to increase muscle pains which are one of the sideeffects of these drugs.
A chart showing the rate of perceived exertion (RPE) is introduced to the patient at about seven days postoperatively so that the patient is able to gauge at what level he is to work at his exercise programme. After any walk, set of exercises, or exercycle session, the patient slmuld feel that the exercise has been fairly light, that is between 11 and 12. The numerical scale used allows for easy transfer lo the Toronto Rehabilitation Research Project where this scale (8- 20) is also used.
8
9 VERY LIGHT
10
11 FAIRLY LIGHT
12
13 SOMEWHAT HARD
14
15 HARD
16
17 VERY HARD
18
19 VERY VERY. HARD
20
Relatives should be involved at all times and should be made aware of how important it is for the patient to reach successive short-term goals. This not only stimulates the patient but also increases the confidence of both patient and relative by the time comes for discharge and a return to their normal environment, away from the constant attention of the hospital staff. In order to continue the exercise programme and walking routine, home advice will be given. At about 10 days postoperatively, if the patient shows no signs of rejection, is coping well and lives locally, he will be discharged home. If he lives a long distance away from the unit at which the author works, he is moved to one of the half-way flats in the village for two or three weeks.
THOSE ABOVE ARE
COLLECTED FROM SOME BOOKS AND WEBSITES..
(CASH'S TEXTBOOK)
THANK YOU,
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