Transplant patients may enter an outpatient CR program as soon as they are dismissed from the hospital. The transplant team generally requires patients to remain near the transplant center for approximately 3 months for close follow-up, and ideally, patients should exercise in both a supervised program (up to 3 sessions/week) and independently (at least 3 sessions/week).
Continuous ECG monitoring during the first few exercise sessions is standard practice. It is not necessary to perform graded exercise testing before the patient begins the outpatient exercise program. However, graded exercise testing should be performed by 8 weeks after surgery (for patients with relatively uncomplicated courses), when the patient has recovered sufficiently from surgery, to assess the cardiopulmonary response to exercise and to refine the exercise prescription.
Exercise prescription for cardiac transplant recipients is similar to the methods used with other patients who have undergone cardiothoracic surgery. The one exception is not using a target HR unless the patient has a normalized response caused by partial reinnervation, as discussed previously (see page 162). The typical denervated heart increases rate slowly during submaximal exercise, and HR may drift gradually upward during steady-state exercise or may plateau after several minutes. RPE (Borg scale) of 12 to 14 (somewhat hard) may be used to prescribe exercise intensity. The exercise prescription includes standard warm-up and cool-down activities and a gradual increase in aerobic exercise duration to 30 to 60 min, with a frequency of 3 to 6 sessions/week. Modes of aerobic exercise commonly used during the early outpatient recovery period include walking outdoors or in shopping centers or schools, treadmill walking, cycle ergometry, and stair climbing.
The sternal incision necessitates a special emphasis on upper-extremity range-of-motion exercises. After 6 weeks from the surgery date, when sternal healing is nearly completed, rowing, arm cranking, combination arm-leg ergometry, outdoor cycling, hiking, jogging, and swimming are additional exercise options. The patient may engage in sports such as tennis and golf as early as 6 weeks after surgery if his or her fitness is adequate (directly measured VO2 peak of approximately 5 METs or greater) and sternal healing is nearly completed.
Skeletal muscle weakness in transplant patients is very common and relates to the following factors:
- Chronic heart failure may cause skeletal muscle atrophy.
- Before transplantation, patients may become very deconditioned.
- After surgery, patients take corticosteroids as part of the immunosuppressant drug program.
Muscle-strengthening exercises should be incorporated into the exercise rehabilitation program. For the first 6 weeks after surgery, bilateral arm lifting is restricted to less than 10 lb (4.5 kgs) to avoid sternal nonunion. After 6 weeks of satisfactory recovery from surgery, patients may be started on weight machines, emphasizing moderate resistance, 10 to 20 repetitions per set, one to three sets of exercises for the major muscle groups, on a two- to three-session-per-week basis.
This is an excerpt from Guidelines for Cardiac Rehabilitation and Secondary Prevention Programs, Fourth Edition.