Physical Activity After Heart Transplantation: Characteristics, Motifs, Barriers, and Influence of COVID-19 Pandemic

Purpose

After heart transplantation (HTX), regular physical activity (PA) is crucial to counteract transplant-related alterations and improve functional performance. Not much is known about the long-term implementation of PA and potential problems that may occur. The potential influence of COVID-19 pandemic is unknown.

Methods

Online questionnaire survey: 158 patients (53±14 yrs, 65% male, 8±7 yrs after HTX) were included. Recruitment was carried out via HTX outpatient departments, transplant sport associations, self-aid groups and social media. The questionnaire included 77 to 138 items divided into 6 categories and 3 time points (pre heart failure, after HTX before COVID-19, after HTX during COVID-19). The survey was approved by the local ethics committee.

Results

88% reported regular PA after HTX (before COVID-19) and 75% had taken up PA within the first year. Patients stated higher level of PA after HTX, compared to the pre heart failure period (p<0.05). Patients who completed cardiac rehabilitation (70%), started leisure-time PA significantly earlier (p<0.05) and with higher frequency (p<0.05). Figure 1 shows the most important motifs/barriers for regular PA and changes over the reported period. Satisfaction with sports facilities was moderate and 39% complained about the need for improvement (e.g. exercise education). 61% performed exercise training without a professional supervision. Exercise monitoring was mostly done using heart rate respond (52%), but frequently no monitoring was used (32%). During COVID-19, patients were more dissatisfied with their level of regular PA (p<0.01) or physical condition (p<0.05) and emphasized the beneficial effect of PA on their mental balance.

Conclusion

After HTX, most patients try to integrate regular PA in their leisure-time behavior, but complain about a lack of detailed exercise education and appropriate sports facilities. Participation in a cardiac rehabilitation after HTX may have positive long-term impact on PA levels.

Physiological and psychological effects of imagery techniques on health anxiety

Previous research has shown that intrusions are part of the psychopathology of mental disorders. Imagery techniques seem to be an effective treatment of negative intrusions. Since negative mental imagery is part of health anxiety, the present study investigated the impact of imagery techniques on health anxiety. A total of 159 students with elevated scores in a health anxiety questionnaire watched an aversive film concerning a cancer patient and were randomly allocated to one of three interventions (positive imagery, imagery reexperiencing, imagery rescripting) or the control group. The intervention lasted 9 min. Physiological data (heart rate and cortisol) as well as psychological measures, such as mood ratings, health anxiety scores, and intrusions, were assessed during the appointment, while psychological measures were assessed over a period of 1 week after the intervention. Cortisol levels changed over time depending on the intervention. Heart rate changed during the 9-min interventions as well, with the fastest decrease during imagery rescripting. Moreover, negative mood and distress decreased after the intervention, while intrusions were reduced 1 week after the intervention in all groups equally. The results suggest that imagery rescripting is a promising technique that seems to activate a process of deep elaboration. Therefore, it might be an adequate way to target health anxiety symptoms such as anxiety, intrusions, and avoidance or safety-seeking behavior. Further studies should focus on imagery rescripting in clinical samples with health anxiety and target individual intrusive images to increase effectiveness. Nevertheless, the development of a long-term explanatory model of rescripting is needed.

[Rehabilitation standards for follow-up treatment and rehabilitation of patients with ventricular assist device (VAD)]

The increasing use of ventricular assist devices (VADs) in terminal heart failure patients provides new challenges to cardiac rehabilitation physicians. Structured cardiac rehabilitation strategies are still poorly implemented for this special patient group. Clear guidance and more evidence for optimal modalities are needed. Thereby, attention has to be paid to specific aspects, such as psychological and social support and education (e.g., device management, INR self-management, drive-line care, and medication).In Germany, the post-implant treatment and rehabilitation of VAD Patients working group was founded in 2012. This working group has developed clear recommendations for the rehabilitation of VAD patients according to the available literature. All facets of VAD patients' rehabilitation are covered. The present paper is unique in Europe and represents a milestone to overcome the heterogeneity of VAD patient rehabilitation.

Implantation of Cardio West Total Artificial Heart for Irreversible Acute Myocardial Infarction Shock

Patients who develop cardiogenic shock after acute myocardial infarction have a very high mortality rate despite early reperfusion therapy. Hemodynamic stabilization can often only be achieved by implanting a mechanical circulatory support system. When, in cases representing expansive myocardial impairment without any chance of recovery, pharmacological therapy and the use of percutaneous assist devices have failed, the implantation of a total artificial heart is indicated. We report our first experiences with this extensive and innovative method of managing irreversible cardiogenic shock patients. The CardioWest total artificial heart was implanted in 5 patients (male; mean age, 50 years). All patients were in irreversible cardiogenic shock despite maximum dosages of catecholamines, an intra-aortic balloon pump and/or a femoro-femoral bypass. In all patients early reperfusion therapy was performed. After implantation of the Cardio West system, all dysfunctional organ systems rapidly recovered in all patients. Four of 5 patients underwent successful heart transplantation after a mean support time of 156 days. One patient died because of enterocolic necroses caused by an embolic event after termination of dicumarol therapy. In summary, our first experiences justify this extensive management in young patients who would otherwise have died within a few hours.

Initial experience with the medtronic ADVANTAGE valve prosthesis in the mitral position--clinical outcome and analysis of complications

OBJECTIVE

The Medtronic ADVANTAGE prosthetic heart valve is a bileaflet mechanical heart valve which has two main design modifications. The prosthesis has an enlarged central orifice to improve blood flow characteristics and an asymmetric butterfly pivot recess with expanded outflow component designed to enhance the blood flow washing through the pivot region. This report summarizes the initial experience with 55 patients who underwent isolated mitral valve replacement.

METHODS

We prospectively followed 55 patients undergoing mitral valve replacement with the Medtronic ADVANTAGE prosthesis in a single center study. All patients were operated on via a median sternotomy and a left atrial approach.

RESULTS

The age of the patients at implant ranged from 42 years to 77 years with a mean of 61.8 years. Forty-five percent of the patients were male. Seventy-five percent of the patients were in NYHA functional class III or IV prior to valve replacement. The diameters of the implanted prostheses were as follows: 25 mm in 2 patients, 27 mm in 12 patients, 29 mm in 20 patients, and 31 mm in 21 patients. Coronary artery bypass grafting was performed with valve replacement in 16.4 % of patients and additional tricuspid repair in 10.9 %. After one year, 97.6 % and after two years 100 % of the included patients were in NYHA functional class I or II. All patients had Coumadin (warfarin) therapy postoperatively with a target INR range of 2.5 to 3.5, or 3.0 to 4.0. There were 4 thromboembolic events (7.3 %) in the early period and 2 late events (2.6 %). Episodes of valve thrombosis were not seen during the follow-up, which consisted of 76.5 patient years. The hemodynamic performance was favorable and within clinically acceptable ranges. The incidence of valve-related mortality and morbidity in this preliminary study was extremely low, indicating good clinical results comparable to those reported for other bileaflet valves.

CONCLUSION

The ADVANTAGE valve is a safe and effective option for mitral valve replacement with a very low incidence of valve-related complications.

Results After Orthotopic Heart Transplantation Accepting Donor Hearts >50 Years: Experience at La Pitie Salpetriere, Paris

INTRODUCTION

We sought to examine the results of orthotopic heart transplantation accepting hearts from donors >50 years of age with special regard to the usefulness of peripheral extracorporeal membrane oxygenation for posttransplant graft dysfunction.

PATIENTS

Between January 2000 and December 2004, a total of 247 patients underwent orthotopic heart transplantation. In 143 patients (58%) the heart donor was <50 years (group I, mean age of donor hearts 36 +/- 11 years; range, 8-49 years). In 104 recipients (42%) the heart donor was >50 years (group II, mean age of donor hearts 56 +/- 15 years; range, 50-67 years). Pretransplant characteristics of the two groups showed no significant differences.

RESULTS

The in-hospital mortality was slightly increased in group II (24% vs 20% in group I, NS) and the 5-year survival rate significantly increased in group I (75% vs 63% in group II). Freedom from transplant vasculopathy after 3 years was similar in both groups (86% in group I vs 87% in group II). A total of 25 patients (17%) in group I and 27 patients (26%) in group II developed graft dysfunction. Eleven patients in group I and 10 patients in group II were treated using peripheral extracorporeal membrane oxygenation, whereas 3 of the 11 patients in group I and 5 of the 10 patients in group II were discharged following a complete recovery. Two patients in group I and 4 patients in group II were survivors beyond year.

CONCLUSION

In our experience it was possible to increase the cardiac donor pool by accepting allografts from donors >50 years of age in selected cases. The incidence of transplant vasculopathy was not increased, whereas in-hospital mortality was slightly higher. In our limited cohort, patients with older donor hearts was developed graft dysfunction profited from primary extracorporeal membrane oxygenation implantation, an indication that should be examined further without delay.

Mechanical Valve Replacement in Congenital Heart Defects in the Era of International Normalized Ratio Self-Management

As the number of patients with congenital heart defects requiring heart valve replacement increases, the need for durable valve substitutes with good hemodynamic performance and a low incidence of complications becomes more apparent. The use of porcine xenografts is burdened with early fibrocalcific degeneration, whereas the use of mechanical heart valves led to an increased number of thromboembolic events, especially when implanted in the right side of the heart. We report on our experiences implanting bileaflet heart valves in congenital heart defects since the introduction of international normalized ratio (INR) self-management. The data of 68 long-term survivors (33 males, 35 females) who underwent mechanical heart valve replacement in congenital heart defect were reviewed. Patient age at the time of valve replacement ranged from 5 months to 61 years (mean 21 years). Underlying diagnoses were tetralogy of Fallot (n=33), morbus Ebstein (n=4), atrioventricular canal (n=13), truncus arteriosus communis (n=5), transposition of the great arteries (n=10), and congenitally corrected transposition of the great arteries (n=3). In all patients, bileaflet valves were implanted (St. Jude Medical n=40, Carbomedics n=28). Anticoagulation was performed using dicumarol (Marcumar) and INR self-management in all cases. The mean follow-up was 72 months (range 6-132 months; 409 patient-years). Valve thrombosis developed in 3 of 68 patients (4.4%, all three had tetralogy of Fallot, mean age 9.8 years) after a mean follow-up of 3.5 years. In two of these three patients, re-pulmonary valve replacement was necessary, whereas the third patient was treated by thrombolysis. From our experience, we conclude that mechanical heart valve replacement is a good therapy option with a low complication rate for patients with congenital heart defects requiring valve replacement, especially when INR self-management is performed.

Einsatz des CardioWest-Kunstherzens beim irreversiblen kardiogenen Schock nach Myokardinfarkt

Patients in whom cardiogenic shock develops after acute myocardial infarction have a very high death rate despite early reperfusion therapy. Often hemodynamic stabilization can be achieved only by implantation of a mechanical circulatory support system. When pharmacological therapy and onset of percutaneous assist devices fails in cases representing expansive myocardial impairment without any chance of recovery, the indication for implanting a total artificial heart is given. We report on our first experiences with this extensive and innovative management of irreversible cardiogenic shock patients. In five patients (male, mean age 50 years) the CardioWest total artificial heart was implanted. All patients were in irreversible cardiogenic shock despite maximal dosages of catecholamines, intraaortic balloon pump and/or femorofemoral bypass. In all patients early reperfusion therapy was performed. After implantation of the CardioWest system, rapid recovery of all dysfunctional organ systems occurred in all patients. Four of five patients underwent successful heart transplantation after a mean support time of 156 days. One patient died because of enterocolic necroses caused by embolic event after termination of dicumarol therapy. In summary, first experiences justify this extensive management in these young patients who otherwise would have died within a few hours.

Biphasic modulation of protein kinase C and enhanced cell toxicity by amyloid beta peptide and anoxia in neuronal cultures

A major feature of Alzheimer's disease is the deposition of the amyloid beta peptide (Abeta) in the brain by mechanisms which remain unclear. One hypothesis suggests that oxidative stress and Abeta aggregation are interrelated processes. Protein kinase C, a major neuronal regulatory protein is activated after oxidative stress and is also altered in the Alzheimer's disease brain. Therefore, we examined the effects of Abeta(1-40) peptide on the protein kinase C cascade and cell death in primary neuronal cultures following anoxic conditions. Treatment with Abeta(1-40) for 48 h caused a significant increase in the content and activity of Ca2+ dependent and Ca2+ independent protein kinase C isoforms. By 72 h various protein kinase C isoforms were down-regulated. Following 90 min anoxia and 6 h normoxia, a decrease in protein kinase C isoforms was noticed, independent of Abeta(1-40) treatment. A combination of Abeta(1-40) and 30-min anoxia enhanced cytotoxicity as noticed by a marked loss in the mitochondrial ability to convert 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide and by enhanced 4',6-diamidino-2-phenylindole nuclear staining. Phosphorylation of two downstream protein kinase C substrates of apparent molecular mass 80 and 43 kDa, tentatively identified as the myristoyl alanine-rich C-kinase substrate (MARCKS), were gradually elevated up to 72 h upon incubation with Abeta(1-40). Anoxia followed by 30 min normoxia enhanced MARCKS phosphorylation in the membrane but not in the cytosolic fraction. In the presence of Abeta(1-40), phosphorylation of MARCKS was reduced. After 6 h normoxia, MARCKS phosphorylatability was diminished possibly because of protein kinase C down-regulation. The data suggest that a biphasic modulation of protein kinase C and MARCKS by Abeta(1-40) combined with anoxic stress may play a role in Alzheimer's disease pathology.

Implantation of the Biomedicus centrifugal pump in post-transplant right heart failure

BACKGROUND

Right heart failure after heart transplantation represents a life-threatening complication. When conventional therapy including NO-inhalation fails the only choice to reach sufficient haemodynamic conditions may be the implantation of a right ventricular support system.

METHODS

In all cases the Biomedicus centrifugal pump was implanted by cannulation of the right atrium and pulmonary artery.

RESULTS

Since March 1989 950 heart transplant procedures were performed at our center. In nine cases (7 male, 2 female, mean age 52 years) implantation of a right ventricular support system was necessary because of deterioration of right ventricular function. The implantation was carried out in 7 cases immediately after transplantation, in 2 cases after 2 days. The support time ranged from 4-348 hours. Six patients could be weaned, 2 patients underwent retransplantation and died and 1 patient died on the support system. Three of the six weaned patients died in the further course because of multiorgan failure.

CONCLUSIONS

Mechanical right ventricular support is often the only therapeutical tool to reach adequate haemodynamic conditions in post-transplant right heart failure. The Biomedicus centrifugal pump provides good conditions in these cases. Weaning is often possible after short-term support. The mortality rate is determined by multiorgan failure in immuno-suppressed patients. Retransplantation seems not to be successful despite maximal treatment.