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Rehabilitation after cardiac transplantation

Ileana L Piña, MD, MPH
Section Editor
Sharon A Hunt, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


In spite of dramatic advances in the survival of cardiac transplant recipients, published reports have consistently shown abnormal levels of functional capacity. Although there is a rapid rise in exercise capacity that occurs at approximately two months post-transplant [1], and many patients return to their normal activities with improved quality of life, exercise function remains 30 to 40 percent below normal [2,3]. Unfortunately in the United States, participation in cardiac rehabilitation is low and varies by region and yet could reduce readmissions. This observation in 2531 post-transplant patients associating participation in cardiac rehabilitation with a lower one-year readmission for Medicare beneficiaries adds a significant layer of benefit [4].

Prior studies describing persistently abnormal exercise capacity in the early post-transplant period suggested several possible explanations, including [5]:

Marked deconditioning prior to transplant due to heart failure (HF) or due to extended mechanical assistance with a left ventricular assist device. (See "Skeletal muscle dysfunction and exercise intolerance in heart failure" and "Intermediate- and long-term mechanical circulatory support" and "Practical management of long-term mechanical circulatory support devices".)

Surgical denervation of the heart [6]

Corticosteroid therapy-related myopathy (see "Glucocorticoid-induced myopathy")

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Literature review current through: Oct 2017. | This topic last updated: Jul 17, 2017.
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  1. Osada N, Chaitman BR, Donohue TJ, et al. Long-term cardiopulmonary exercise performance after heart transplantation. Am J Cardiol 1997; 79:451.
  2. Degre SG, Niset GL, De Smet JM, et al. Cardiorespiratory response to early exercise testing after orthotopic cardiac transplantation. Am J Cardiol 1987; 60:926.
  3. Daida H, Squires RW, Allison TG, et al. Sequential assessment of exercise tolerance in heart transplantation compared with coronary artery bypass surgery after phase II cardiac rehabilitation. Am J Cardiol 1996; 77:696.
  4. Bachmann JM, Shah AS, Duncan MS, et al. Cardiac rehabilitation and readmissions after heart transplantation. J Heart Lung Transplant 2017.
  5. Renlund DG, Taylor DO, Ensley RD, et al. Exercise capacity after heart transplantation: influence of donor and recipient characteristics. J Heart Lung Transplant 1996; 15:16.
  6. Lord SW, Brady S, Holt ND, et al. Exercise response after cardiac transplantation: correlation with sympathetic reinnervation. Heart 1996; 75:40.
  7. Anderson L, Nguyen TT, Dall CH, et al. Exercise-based cardiac rehabilitation in heart transplant recipients. Cochrane Database Syst Rev 2017; 4:CD012264.
  8. Kirklin JK, Naftel DC, Pagani FD, et al. Sixth INTERMACS annual report: a 10,000-patient database. J Heart Lung Transplant 2014; 33:555.
  9. Kobashigawa JA, Leaf DA, Lee N, et al. A controlled trial of exercise rehabilitation after heart transplantation. N Engl J Med 1999; 340:272.
  10. Rosenbaum AN, Kremers WK, Schirger JA, et al. Association Between Early Cardiac Rehabilitation and Long-term Survival in Cardiac Transplant Recipients. Mayo Clin Proc 2016; 91:149.
  11. Marconi C, Marzorati M. Exercise after heart transplantation. Eur J Appl Physiol 2003; 90:250.
  12. Givertz MM, Hartley LH, Colucci WS. Long-term sequential changes in exercise capacity and chronotropic responsiveness after cardiac transplantation. Circulation 1997; 96:232.
  13. Braith RW, Welsch MA, Feigenbaum MS, et al. Neuroendocrine activation in heart failure is modified by endurance exercise training. J Am Coll Cardiol 1999; 34:1170.
  14. Baroud I, Niset G, Vachiery JL, et al. Long-term follow-up of heart transplant patients. Acta Cardiol 1996; 51:315.
  15. Scott JM, Esch BT, Haykowsky MJ, et al. Cardiovascular responses to incremental and sustained submaximal exercise in heart transplant recipients. Am J Physiol Heart Circ Physiol 2009; 296:H350.
  16. Tegtbur U, Busse MW, Jung K, et al. Time course of physical reconditioning during exercise rehabilitation late after heart transplantation. J Heart Lung Transplant 2005; 24:270.
  17. Haykowsky M, Taylor D, Kim D, Tymchak W. Exercise training improves aerobic capacity and skeletal muscle function in heart transplant recipients. Am J Transplant 2009; 9:734.
  18. Kavanagh T, Yacoub MH, Mertens DJ, et al. Cardiorespiratory responses to exercise training after orthotopic cardiac transplantation. Circulation 1988; 77:162.
  19. Borg G. Perceived exertion as an indicator of somatic stress. Scand J Rehabil Med 1970; 2:92.
  20. Marzolini S, Grace SL, Brooks D, et al. Time-to-referral, use, and efficacy of cardiac rehabilitation after heart transplantation. Transplantation 2015; 99:594.
  21. Giannuzzi P, Temporelli PL, Tavazzi L, et al. EAMI--exercise training in anterior myocardial infarction: an ongoing multicenter randomized study. Preliminary results on left ventricular function and remodeling. The EAMI Study Group. Chest 1992; 101:315S.
  22. Giannuzzi P, Tavazzi L, Temporelli PL, et al. Long-term physical training and left ventricular remodeling after anterior myocardial infarction: results of the Exercise in Anterior Myocardial Infarction (EAMI) trial. EAMI Study Group. J Am Coll Cardiol 1993; 22:1821.
  23. Piña IL, Apstein CS, Balady GJ, et al. Exercise and heart failure: A statement from the American Heart Association Committee on exercise, rehabilitation, and prevention. Circulation 2003; 107:1210.
  24. O'Connor CM, Whellan DJ, Lee KL, et al. Efficacy and safety of exercise training in patients with chronic heart failure: HF-ACTION randomized controlled trial. JAMA 2009; 301:1439.
  25. Wenger, NK, Froelicher, ES, Smith, LK, et al. Cardiac Rehabilitation, Clinical Practice Guideline, No. 17, US Department of Health and Human Services, Rockville, MD, Public Health Service, Agency for Health Care Policy and Research, National Heart, Lung, and Blood Institute, AHCPR Publication No. 96-0672, 1995.
  26. Whellan DJ, O'Connor CM, Pina I. Training trials in heart failure: time to exercise restraint? Am Heart J 2004; 147:190.
  27. Balady GJ, Ades PA, Bittner VA, et al. Referral, enrollment, and delivery of cardiac rehabilitation/secondary prevention programs at clinical centers and beyond: a presidential advisory from the American Heart Association. Circulation 2011; 124:2951.
  28. Balady GJ, Williams MA, Ades PA, et al. Core components of cardiac rehabilitation/secondary prevention programs: 2007 update: a scientific statement from the American Heart Association Exercise, Cardiac Rehabilitation, and Prevention Committee, the Council on Clinical Cardiology; the Councils on Cardiovascular Nursing, Epidemiology and Prevention, and Nutrition, Physical Activity, and Metabolism; and the American Association of Cardiovascular and Pulmonary Rehabilitation. Circulation 2007; 115:2675.
  29. American Association of Cardiovascular and Pulmonary Rehabilitation, American College of Cardiology Foundation, American Heart Association Task Force on Performance Measures (Writing Committee to Develop Clinical Performance Measures for Cardiac Rehabilitation), et al. AACVPR/ACCF/AHA 2010 Update: Performance Measures on Cardiac Rehabilitation for Referral to Cardiac Rehabilitation/Secondary Prevention Services Endorsed by the American College of Chest Physicians, the American College of Sports Medicine, the American Physical Therapy Association, the Canadian Association of Cardiac Rehabilitation, the Clinical Exercise Physiology Association, the European Association for Cardiovascular Prevention and Rehabilitation, the Inter-American Heart Foundation, the National Association of Clinical Nurse Specialists, the Preventive Cardiovascular Nurses Association, and the Society of Thoracic Surgeons. J Am Coll Cardiol 2010; 56:1159.
  30. Marko C, Danzinger G, Käferbäck M, et al. Safety and efficacy of cardiac rehabilitation for patients with continuous flow left ventricular assist devices. Eur J Prev Cardiol 2015; 22:1378.
  31. Weiss ES, Nwakanma LU, Patel ND, Yuh DD. Outcomes in patients older than 60 years of age undergoing orthotopic heart transplantation: an analysis of the UNOS database. J Heart Lung Transplant 2008; 27:184.
  32. Corrà U, Pistono M, Mezzani A, et al. Cardiovascular prevention and rehabilitation for patients with ventricular assist device from exercise therapy to long-term therapy. Part I: Exercise therapy. Monaldi Arch Chest Dis 2011; 76:27.
  33. Ben Gal T, Piepoli MF, Corrà U, et al. Exercise programs for LVAD supported patients: A snapshot from the ESC affiliated countries. Int J Cardiol 2015; 201:215.
  34. Braith RW, Magyari PM, Pierce GL, et al. Effect of resistance exercise on skeletal muscle myopathy in heart transplant recipients. Am J Cardiol 2005; 95:1192.
  35. Brubaker PH, Berry MJ, Brozena SC, et al. Relationship of lactate and ventilatory thresholds in cardiac transplant patients. Med Sci Sports Exerc 1993; 25:191.
  36. Yardley M, Gullestad L, Bendz B, et al. Long-term effects of high-intensity interval training in heart transplant recipients: A 5-year follow-up study of a randomized controlled trial. Clin Transplant 2017; 31.