By Serena Agusto-Cox | News & Views

Approximately 22.7% of heart transplant patients experience rejection in the first year after surgery, according to the National Institutes of Health. Melissa Lyle, MD, FACC, FHFSA, associate professor at the Mayo Clinic College of Medicine, and Wendy Cawley, BSN, RN, CCRP, in the cardiopulmonary rehabilitation clinic at Mayo Clinic Florida, say advances in heart failure and heart transplantation care, coupled with the practical management of these patients in cardiovascular rehabilitation (CR), can mitigate rejection and improve patient outcomes.

According to Dr. Lyle, certain clinical advancements for heart failure and transplant patients have led to a greater need for CR — starting with the proliferation of donors. “Utilization of hepatitis C organs has increased the donor pool,” she explains. “The number of donors after circulatory death also has increased. As a result, every year we see higher numbers of heart transplant patients, and as we increase the number of transplant patients, the need for CR post-transplant increases.”

Additionally, the landscape for monitoring transplant patients for rejection has improved, thanks in part to the use of noninvasive blood tests. “Typically, transplant patients were sent for biopsies to monitor for signs of rejection, but with these noninvasive approaches to rejection monitoring, our need for biopsies is reduced,” says Dr. Lyle. In the CR setting, staff need to be aware of rejection signs and be able to act with the help of the transplant recipient’s care team.

Prehabilitation and CR

Many transplant patients are in advanced heart failure before they receive a donor heart, and every transplant recipient will be referred to CR to continue their recovery. According to Dr. Lyle and Cawley, prehabilitation in CR is an important part of the journey. To be listed for transplant, patients are evaluated and given a status of one through six. Patients who are listed as one through three often await their transplants in the hospital.

Dr. Lyle says, “Once a patient is found to be in advanced heart failure, it is important that we begin a transplant evaluation as soon as possible. We want to couple their medication therapy with CR to ensure they are at their strongest before the transplant occurs.” She adds, “Frailty and decreased functional capacity will lead to worse outcomes post-transplant.” Even those patients awaiting transplant in the hospital undergo prehabilitation as much as possible.

According to Cawley, through prehabilitation, CR programs can set patient expectations for the post-transplant experience. “One of the most important teaching points for transplant patients is self-monitoring,” she explains. “Patients and caregivers who recognize signs of rejection are better equipped to self-monitor at home after the CR program. CR staff need to set the tone early in the process.” With the ability to recognize rejection signs early, they also are in a position to  teach those skills to patients.

Care Coordination Is Key to Catching Rejection Early

Care coordinators assigned to transplant recipients meet weekly with CR staff, according to Cawley. “Our CR staff can reach out to them at any time when possible signs of medication complications or organ rejection are observed,” she adds.

Some common signs of rejection are:

• Fatigue
• Shortness of breath
• Peripheral edema
• Low-grade fever
• Swelling of the legs and feet
• Significant weight changes
• Changes in electrocardiogram readings

“One of the biggest things we teach our patients is about exercise and tolerance,” says Cawley.

Dr. Lyle calls CR the front line in transplant recipients’ recoveries. “They see patients more regularly than the transplant team,” she adds. “Oftentimes, Cawley’s team is the first to alert us with concerns about possible organ rejection. Arrhythmias are of particular concern, which is why her team will send us the ECG strip if it appears outside normal parameters for that particular patient.”

CR staff who understand the signs of rejection and how to monitor these recipients during the program are integral to successful patient outcomes. “Heart transplant patients lack sympathetic and parasympathetic innervation (their new hearts are denervated) so some transplant patients will have a resting heart rate of about 100 beats per minute or a sinus tachycardia at baseline. CR staff are familiar with this higher heart rate in transplanted patients,” says Dr. Lyle. CR staff must be trained to recognize that higher rate as normal for transplant patients and to identify atrial arrhythmia or ventricular arrhythmia through the monitoring process.

Patients with left ventricular assist devices (LVADs) also have different care teams and devices that have to be monitored. LVADs are electrically powered through a percutaneous driveline, which comes out through the abdomen to connect to the controller and power sources. The power sources are often battery packs that are carried in bags or in pockets of special vests. According to Cawley, these batteries and controllers are large and heavy, but they must be carried at all times. “These devices provide continuous flow, meaning they are not pulsating devices. Patients with LVADs may not have a pulse, making it difficult to get a blood pressure reading in a traditional way,” says Dr. Lyle.

Cawley explains, “Our staff have a yearly competency they must complete to familiarize themselves with the LVAD, such as the alarms it puts out, how to handle emergencies, and how to screen the patient about their driveline site and other factors that could impact their health.” CR staff need to be able to take blood pressures with a doppler. They must be able to teach patients about their LVAD device, what activities they can’t do because of their device and the driveline, and how to adjust not only their diet and exercise but also how they operate on a day-to-day basis. Tugging or pulling of the driveline during exercise, for example, can leave patients susceptible to infection and disrupt the integrity of the device.

“For our transplant patients, we need to talk about things like infection control and ways that they're not just making heart-healthy choices, but how to do that in a way where they're thoroughly washing their foods and eating fully cooked foods,” she adds. “There are some nuances that must be understood when caring for patients with LVADs and transplant recipients.” CR staff and patients also need to monitor daily weights, sodium compliance, medication compliance, and fluid restrictions. Cawley emphasizes that CR staff need to be educated about all aspects of their care and be able to help patients understand their own care responsibilities and where to find the resources they need.

“If patients are reporting alarms or having them in the clinic, high or really low MAPS, weight gains, or signs of infection, CR staff need to report that to their care coordinator,” says Cawley. “Then the physicians can adjust treatment from there.”

Additionally, heart transplant patients often struggle with hypertension because their donor heart functions as it should. “A lot of the medications we use to suppress the immune system can increase their blood pressure,” says Dr. Lyle. “CR staff can help alert us about hypertension, and we can make medication adjustments more quickly.”

Steroid-induced hyperglycemia is another area of concern for transplant recipients who receive steroids. “Transplant patients often end up being prescribed short- or long-acting insulin, even if they did not have diabetes before,” says Cawley. “This adds another layer to their care in CR and to the education they need on caring for themselves at home. They need to know how to check their blood sugar levels and how to take their insulin.” Higher glucose levels can interfere with the recovery process and lengthen recovery times. “A drop in blood sugar during exercise also can be dangerous, which is why having a diabetic exercise protocol is important for transplant patients,” she adds.

According to Dr. Lyle, “these protocols are even more critical for those patients who had diabetes before their transplant. They may know the protocols for checking their blood sugar levels, but their course of steroids makes management harder, especially during exercise.” Having an endocrinologist on the team can help tremendously with these types of transplant recipients. “At CR, we’re very goal-focused,” says Cawley. “One of the goals of many of our transplant recipients is to get off of insulin.”

Front Line of Transplant Patients’ Recovery

CR programs are uniquely positioned to monitor transplant patients closely and teach each patient the skills they need to self-monitor their recovery. “These patients will need to exercise and self-monitor indefinitely,” explains Cawley. “They need to be able to recognize the signs of rejection at home.” Dr. Lyle agrees that CR staff are a key part of the transplant patient’s recovery. “CR is where transplant patients make friends, see their own progress, and visualize getting back to their lives post-surgery,” she says. “It’s not just about increased exercise capacity. It’s about the education they receive on how to care for their new heart, their LVAD, and themselves.” CR teams are on the front lines of transplant patients’ care, but patients are in the driver’s seat.