Cardiothoracic transplant - a comprehensive rehab pathway
Cardiothoracic transplant - From pre-transplant frailty assessment, to early rehabilitation with patients on ECMO/VAD as a bridge to transplant. Reflections from a transplant physiotherapist - Laura McGarrigle
I’ve been a specialist in the field of cardiothoracic transplantation for 8 years. The constant developments in surgical techniques and medication available are only some of the ways that this dynamic speciality keeps physiotherapists on their toes.
One interesting area of change in this field is how we assess and prepare patients with chronic lung disease for transplantation. Internationally there are large, prospective investigations underway looking at the concept of frailty and its effect on outcomes after lung transplantation. Research has already shown an increased risk of death on the waiting list for frail individuals with chronic lung disease. Most studies have used a complex combination of outcome measures, imaging and blood tests in their evaluation of frailty. We wanted to find a simple single physical outcome measure could help us to better evaluate our patients at the assessment stage. We have used the Short Physical Performance Battery (SPPB) for 3 years and are finding it extremely useful. It is a simple and quick measure and requires little space or equipment – useful in a small 16 bedded ward! It allows us to identify the frailest candidates who require ongoing therapy closer to home or who sadly may not be robust enough to withstand the stress of surgery. We are very lucky in having so many fantastic pulmonary rehabilitation teams who support our waiting list patients for extended lengths of time while waiting for their donor lungs. The SPPB helps us ensure we are flagging up particularly frail patients for pulmonary rehabilitation as early as possible. We have found our first 3 years of SPPB data suggests what we anecdotally/instinctively suspected; the most frail patients at pre-transplant assessment have a longer ward length of stay after their transplant.
During the time I’ve worked in transplantation I’ve seen my typical patient caseload change significantly. Alongside an increase in the number of transplants we perform each year, the biggest change has been the increasing use of short term ventricular assist devices (VADs) as a bridge to heart transplantation. These individuals arrive in critical care in cardiogenic shock and once stabilised with a ST-VAD then enter a waiting period for a new heart. And wait they do. In some cases for over 120 days. The increasing body of literature surrounding ICU rehabilitation gives us a good rationale for getting these patients up and moving and we have proven we can do this safely and effectively despite the large, invasive pipes exiting the body connected to a cumbersome trolley with pumps and consoles. At any one time, we have between 2 and 5 patients with a short term VAD on our critical care and each rehab session will require on average 3 therapists (for 45 minutes) present to ensure safety (alongside bedside nurses, ECMO nurses and perfusionists in the vicinity). The staffing required appears excessive but is necessary for safety.
There have been many challenges in introducing this service but I’m proud of our team and how we’ve changed the culture of rehabilitation and care of these patients in our unit who would previously have remained on strict bed rest. I’m incredibly proud of the emerging positive outcomes; including an average 4-day shorter length of stay after heart transplantation (HT) for this VAD rehab group compared to those admitted for HT from home/other hospital wards. But I’m most proud when we see the benefits that the patients experience during their stay. We regularly see anger, frustration and non-compliance turn to motivation, humour and positivity. We see families in a period of uncertainty and see them experience achievement, hope and trust in our team and their own capabilities. The development of this service came through necessity; it was a hard slog to persuade and demonstrate to many staff the value and safety of this service but we are finding that the whole unit are now engaged in the benefits this rehabilitation can bring. This has led to patient trips outdoors, to the coffee shop and to private rooms outside of our main ICU where patients can spend time with their young children. Alongside the more obvious physical benefits we are seeing hugely positive psychological benefits which, during the wait for a donor heart, are incredibly valuable. As much as the geek in me loves data, numbers and statistics; sometimes the value of what we do as physiotherapists can’t be quantified. I know that my job satisfaction on a day to day basis can more accurately be measured in patient smiles, high fives and barely recognising patients who walk back into clinic after a few weeks at home.