Author(s): Maricarmen Cruz, MD, Isabel Borras, MD, Lorena Rivera, MD, Suzette Arias, MD
Originally published: September 20, 2013 Last updated: December 17, 2025
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Disease/Disorder

Definition

Heart transplantation (HT) is the procedure in which a failing heart is replaced by a healthy heart from a suitable donor to re-establish myocardial function and systemic blood flow when these patients are refractory to medical and device therapies.1

Etiology

Common causes leading to heart transplantation remain advanced cardiomyopathies (nonischemic cardiomyopathy 54%, ischemic cardiomyopathy 37%), severe valvular heart disease (3%), congenital heart disease (3%), and refractory ventricular arrhythmias or cardiogenic shock not manageable with medical/device strategies.2,3 Other causes leading to HT include hypertension (HTN), infections, alcohol/drug use, and other unknown causes.2 Evaluation and listing decisions balance individual benefit against organ allocation principles.3

Indications for evaluation and referral for heart transplant listing includes cardiogenic shock requiring intravenous inotropic support and/or mechanical support, refractory NYHA class III/IV heart failure, recurrent ventricular arrhythmias with hemodynamic compromise or refractoriness, and revascularization.4 Other indications may be related to the secondary impact of a failing heart to other organs (i.e. renal function) when managing medications, worsening right ventricular function, rising pulmonary artery pressure, and rising natriuretic peptide levels, among some.5

Epidemiology including risk factors and primary prevention

The worldwide number of adults with hypertension increased from 594 million people in 1975 to 1.13 billion people in 2015. In 2020, 47% of the United States population was reported to have hypertension, contributing to increased risk of stroke and heart disease. The World Health Organization reports that 42% of adults with hypertension are diagnosed and treated, but only 21% achieved control. Poorly managed hypertension may lead to heart failure; however advanced heart failure may be the result of congenital and acquired heart disease. In acquired etiologies, primary prevention is based on managing healthy lifestyles that may include nutritional, physical activity, tobacco avoidance, primary condition management, among some. 6

Heart transplantation is considered the treatment of choice for selected patients with advanced heart failure. Given the persistent imbalance between organ demand and availability, allocation requires weighing individual benefit against the needs of others on the waiting list, survival possibilities and quality of life outcomes.5

The median heart allograft donor age in 2010 was 31 years in the U.S. compared to 42 years in Europe, with 75% of transplant candidates being men. 7 Outcomes are influenced by age, comorbidities, prior history of transplant, and the need for mechanical support preoperatively.

Transplant volumes and recipient demographics have shifted modestly, with more older recipients and continued mismatch between demand and supply. Recent ISHLTT registry data show improved survival compared to earlier eras, yet emphasize ongoing complications from comorbidities (e.g., diabetes, renal dysfunction) and long-term immunosuppression, underscoring the need or lifelong follow up and rehabilitation strategies.3 Despite advances, limited organ availability remains a major barrier, even as improved pharmacologic and device therapies extend survival and increase the number of patients reaching end stage heart failure.8

Patho-anatomy/physiology

As the heart is failing and systemic perfusion is impaired, end organ function is affected creating a vicious cycle that compromises and affects the prognosis of the patient (renal and liver failure, intestinal ischemia and edema with disruption of the intestinal barrier and translocation of endotoxins as well as reduction in muscle mass). The musculoskeletal system is subject to deconditioning and muscle atrophy associated with decreased mitochondrial content, decreased oxidative enzymes, and a shift toward less fatigue-resistant type IIb fibers.9 In the lungs, there is ventilation/perfusion mismatch with a severity related to the same as heart failure (HF); after transplant, forced expiratory volume at1 second (FEV1), forced vital capacity, and total lung capacity normalize; however, decreased diffusing capacity may persist because of vascular and parenchymal abnormalities.10

Cardiac transplantation results in postganglionic denervation (e.g. loss of autonomic innervation), producing characteristic physiological changes: elevated resting heart rate (HR), lower maximal myocardial oxygen consumption, lower heart rate reserve, and decreased exercise duration.11,12 Physiologic changes in exercise response are primarily catecholamine dependent, leading to a blunted chronotropic response and delayed HR recovery. Over time, partial sympathetic reinnervation may occur, correlating with improved peak HR and exercise tolerance in some patients. Peripheral factors, including skeletal muscle deconditioning, mitochondrial and microvascular failure, and corticosteroid-related myopathy, also contribute significantly to reduce exercise capacity and are key targets for rehabilitation.13,14

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

HT candidates present with deteriorating cardiac function unresponsive to conventional medical therapy, typically fall into the New York Heart Association (NYHA) disease class III (moderate) or IV (severe).15

HT is indicated when end stage heart disease cannot be managed through conservative means. Since the first cardiac transplant procedure in 1967, survival has steadily improved the ISHLT registry data reports, 1- year survival is almost 90% with a conditional half-life of 13.2 years, but even with historic treatment advances, 5-year mortality rate is reported as high as 40%.16,17

Patients’ outcomes are influenced by pre-existing conditions, especially HTN, diabetes mellitus (DM) and obesity, and secondary complications.15 Long term patients face elevated risk of cardiac allograft vasculopathy, renal impairment, malignancy and metabolic complications from chronic immunosuppression, and these chronic complications which continue to drive late mortality and functional decline later in life.18,19

Specific secondary or associated conditions and complications

Expected conditions and complications include pulmonary HTN, DM, HTN, acute rejection, cardiac allograft vasculopathy, renal dysfunction/failure, opportunistic infection, wound dehiscence, peripheral neuropathy, myopathy, obesity, severe peripheral vascular, cerebrovascular disease, and malignancy.

The major cause of mortality in the first 30 days post-transplant is primary graft failure. In the early post-operative period, common complications include left ventricular failure, hyperacute rejection, tricuspid regurgitation, arrhythmias, coagulopathies, and cardiac tamponade, among some.20 In the first year after the transplant the most common complication includes graft failure, rejection and infection; after the first year, complications include cancer and cardiac allograft vasculopathy.21 From a functional and emotional point of view, the patient’s quality of life is significantly improved, and approximately 90% of patients report that they do not have any activity limitations within the first 5 years after a HT.7

Essentials of Assessment

History

After a heart transplantation, symptoms that are commonly encountered include

  • Chest pain
  • Shortness of breath
  • Persistent cough
  • Fatigue
  • Arrythmias
  • Limitations in physical activity, associated with angina or not
  • Anxiety
  • Depression
  • Sleeping problems
  • Nausea
  • Constipation
  • Edema

Early in the post-operatory period it is important to consider that some symptoms may be secondary to graft rejection or primary graft dysfunction. Thus, it is important to perform a comprehensive history to properly identify common post-transplant symptoms versus possible rejection.

History should also explore cardiac history including surgeries and associated complications, medications and compliance, diet, toxic habits, comorbidities and family history. Functional status includes prior functional level and interference of symptoms in ambulation and ADL, home and community environmental barriers, musculoskeletal complaints, symptoms consistent with neurologic and/or vascular diseases, a psychosocial assessment, use of assistive devices, and postsurgical complications.22

Physical examination

A thorough comprehensive physical examination is of outmost importance in this population. Signs observed during the examination reflect the physiological changes and consequences of deconditioning and of a denervated heart and should include monitoring of the following

  • General medical status including hypotension, fever, shortness of breath, edema, and fatigue (signs of acute rejection).9
  • Hemodynamic status including resting HTN, elevated resting HR, and decreased chronotropic response.
  • Cardiopulmonary status including jugular-venous distention, rales, displaced apical pulse, third and fourth heart sounds, hepatomegaly, edema, abdominal distension, and hyperventilation.
  • Musculoskeletal status including decreased muscle mass and strength, contractures, pain, proximal weakness (myopathy secondary to corticosteroid use), edema, pigmentation of skin, and diminished pulses (peripheral vascular resistance).
  • Neurologic status including decreased reflexes, impaired sensation, proximal muscles weakness, and impaired balance.

Functional assessment

Tools used for clinical functional assessments in HF patients mostly focus on measuring quality of life and symptom burden, such as the Minnesota Living with Heart Failure Questionnaire, the Sickness Impact Profile, and the Sense of Coherence Scale.23

Laboratory studies

Side effects related to chronic immunosuppression should be followed (leukopenia, thrombocytopenia, renal dysfunction, hyperglycemia, hyperlipidemia, opportunistic infection, and malignancies) using the following tests

  • Complete blood count
  • Comprehensive metabolic panel
  • Lipid profile
  • Trough levels of immunosuppressive medications (e.g., calcineurin inhibitors and mammalian target of rapamycin inhibitors (mTORs); maintenance doses are adjusted using the trough level).

Imaging

Essential imaging studies include electrocardiogram (previous myocardial infarct, conduction block), echocardiograms (cardiac structure and function), heart catheterizations (including right atrial and right/left ventricular assessment), metabolic stress tests (severity of cardiac functional impairment and risk stratification pretransplant), Holter monitoring (arrhythmias), endomyocardial biopsy, and coronary angiography (for cardiac allograft vasculopathy evaluation).24

Pre transplant echocardiography provides more specific information about biventricular function and valvular disease; echo can provide estimates too of the pulmonary artery systolic pressure. Right heart catheterization provides information on heart filling pressures. Right heart dysfunction is associated to a poorer prognosis.5 Awareness of these values should alert the physician when establishing precautions and goals of care in the rehabilitation plan.

Supplemental assessment tools

  • The six-minute walk test measures functional exercise capacity.
  • The Borg Rate of Perceived Exertion Scale determines the perceived exertion during various levels of exercise intensity.9
  • Patient reported outcome measures such as Kansas City Cardiomyopathy Questionnaire, Short form-36 and EuroQol 5-D which are validated tool in the heart transplant population25,26

Early predictions of outcomes

No single tool has enough predictive power to stratify patients in advanced HF, in part related to the variability in the clinical course prior to cardiac transplant. Poor prognostic factors include:

  • Peak oxygen consumption of less than 10 mL/kg/min, or less than 50% of predictive value for older age (>70 y)
  • Being a woman (worse prognosis)
  • Age (>70 y)
  • Etiology of heart disease (coronary artery disease, cardiomyopathy)
  • Longer duration of illness
  • Obesity (body mass index >30)
  • Active infections
  • Severe DM with end organ damage
  • Peripheral vascular or cerebrovascular diseases
  • Natriuretic peptide levels, creatinine greater than 2.5 mg/dL or creatinine clearance less than 25 mL/min
  • Bilirubin greater than 2.5 mg/dL
  • Serum transaminases greater than 3 times the reference ranges
  • International numeric ratio greater than 1.5 off warfarin
  • Severe pulmonary dysfunction with FEV1 less than 40% predicted
  • Recent pulmonary infarction within 6 to 8 weeks
  • Uncontrolled HTN
  • Neuromuscular disorders
  • Mental illness
  • Substance abuse
  • Female donor to male recipient mismatch.27
  • Reduced functional capacity whether estimated by NYHA class or exercise testing.28,29

The Seattle Heart Failure Model (SHFM) and the Heart Failure Survival Score (HFSS) are two instruments used in advanced heart failure that are associated to1-year survival prognostication.5

Other instruments include the MAGGIC score and the MECKI score. The MAGGIC score measures the risk of all-cause mortality in patients with HF, many of which are ultimately considered for heart transplant. On the other hand, the MECKI score has demonstrated superior discrimination for one year mortality as compared to the SHFM and the HFSS.30,31

In general, prognosticating tools are helpful in this population since they assist in risk assessment, clinical decision making and some are recommended in current evaluation guidelines. Which instrument you choose will depend on the outcome that you are looking to measure.

Social role and social support system

A holistic approach, including psychologic, social, and spiritual assessment is recommended. Depression, anxiety, sleeping difficulties, and adjustment disorders are commonly seen. Psychiatric history or history of substance abuse may contribute to functional limitations and affect compliance to treatment posttransplant.

It has been shown that interventions by medical providers even 1 day prior to surgery, which include discussing an individualized plan and providing emotional support, can have a significant impact. Social support in terms of whether the patient has family/friend they can depend on, especially during their recovery, is important as it can affect outcomes.32

Transportation barriers can interfere with continuity of care; family involvement is key home management support. Poor medical compliance after the postoperative recovery may account for significant morbidity and for up to 25% of deaths.32

Professional issues

There is a limited number of donors when compared to the demand. The number of heart transplants has increased through the years with 4,092 cases performed in 2023 in the USA. Most transplants receivers were adults between the age of 50 to 64, male>female.33

To ensure a fair system of distribution of donor hearts, the United Network for Organ Sharing (UNOS) created a system that uses wait time, severity of illness and geographic distance between the donor hospital and the transplant center.34

Rehabilitation Management and Treatments

Available or current treatment guidelines

Evidence on cardiac rehabilitation protocols recommends an early multidisciplinary approach in the treatment, management and rehabilitation of this population, following a supervised and structured tactic. Patients will benefit from both prehabilitation, e.g. rehabilitation interventions before the surgical event, and soon after the surgical event.35 The main goal is to optimize functional recovery, mitigate potential complications related to long prostration, and modify secondary risk factors.

Preoperative interventions, such as pre-rehabilitation, aim to improve patients’ physical, metabolic, and psychosocial capacities in preparation for surgery.36 The supervised approach is multimodal, and takes into consideration the promotion of physical activity, nutritional adjustments, and psychological support. A multimodal approach has demonstrated improved preoperative functional capacity, and reduced postsurgical complications, including mechanical ventilation time, faster standing and sitting times, earlier extubation, and decreased length of stay at the hospital.37,38

In the post-transplant stage, patients will be deconditioned, with impaired functional capacity, decreased cardiac output, and decreased maximal oxygen capacity. Some of the reasons for persistent abnormal exercise capacity may include.

  • Marked deconditioning before heart transplant
  • Surgical denervation
  • Skeletal muscle weakness
  • Corticosteroids use

Patients who undergo heart transplant are recommended to start a rehabilitation program as early as medically feasible, and this may occur 1-2 weeks after the surgery. Kothari et al reports that solid organ recipients who are discharged to inpatient rehabilitation programs have a lower 30-day readmission risk, and this includes heart transplant patients.40 Post transplant rehabilitation protocols will continue working essentially on the same elements that were started in the prehabilitation stage, although expanding attention to specific elements of the post-surgical recovery and its potential complications. Table 1.41

Table 1. Areas to observe in the post-operative care of a transplanted heart
Denervated heart
Primary graft dysfunction
Arrhythmias
Vasoplegia
Right heart failure
Neurologic deficits
Malignancy
Pulmonary
Swallowing complications
Acute kidney injury
Endocrine
Infectious disease

At different stages

  • Pretransplant stage23,38
    • Left ventricular assist devices (LVADs) can serve as a viable bridge before transplantation, allowing an opportunity to recondition through aerobic training that can include treadmill or free ambulation.
    • Functional scales can be used to establish baseline and track functional changes; some of these are the 6-Minute Walk test, and the Sit-to-Stand test.
    • Aerobic training 3 times per week can combine 1-3 minutes of continuous load with 1-3 minutes of rest. The Borg Scale can set up a training zone between 50-60% of the maximal capacity. Oxygen can be supplied if necessary.
    • Strengthening programs can be repeated 3 times per week combining upper and lower limb muscles, using 3 sets of 6-15 repetitions, and using the Borg Scale (between 3-5), observing the pulse (less than 120 BPM), and maintaining oxygenation over 90%.
    • Nutritional assessment should be closely followed on a weekly basis, particularly in underweight patients. Elements observed include the nutritional intake and the nitrogen balance.
    • Psychological intervention approach can occur in groups or individualized. This type of intervention must incorporate the family and/or caregivers.
  • Post-transplant stage, new onset/acute41,42
    • Physical conditioning should begin during the inpatient phase, once hemodynamic stabilization has been achieved.
    • Early mobilization is beneficial in the post-transplant care, and this can be done by a nurse, physical therapist or occupational therapist.
    • Exercise programs can include aerobic exercises in cycle-ergometer or walking with progressive increase in duration and intensity and articular mobility, flexibility, and resistance of large muscular groups. Monitoring should include HR and blood pressure; the Borg Scale can be used to track subjective fatigue.
    • Vitals must be monitored, looking out for hypotension, bradycardia or tachycardia since they may be related to medications used versus organ rejection.
    • On discharge, patients should be able to walk on leveled surfaces; the use of the upper limb to assist in a pull-to-stand and transfers should be limited to protect the sternum.
  • Post-transplant stage, sub-acute40,41,43
    • Programs can begin as early as 2 weeks post-surgery. Structured-supervised programs demonstrate superior outcomes over home-based programs in a physical work capacity and activities of daily living.
    • Considerations in denervated heart include longer warm-up and cool-down activities to allow heart rate (HR) adjustments, and the use of the Borg Scale to set up a training zone based on the exercise perceived exertion (between 11-14) versus targeting a HR.
    • Walking is recommended on alternate days; the exercise program should progress to include: closed-chain resistive activities (bridging, half squats, toe raises), abdominal exercises (curl ups and pelvic tilts), flexibility exercises (chest expansion and thoracic mobility, side stretch, trunk twist, scapular squeezes, shoulder rolls), and aerobic exercises (treadmill walking or pedaling on bicycle ergometer). The duration and intensity shall progressively increase to meet the patient’s tolerance with a goal of 30 minutes of continuous aerobic exercise at moderate intensity for each session.
    • Home based cardiac rehabilitation can become an alternative for patients who cannot participate from hospital-based rehabilitation programs, and in patients who are low to moderate risk.
  • Post-transplant stage, chronic/stable40,41
    • Cardiac transplant patients may survive for more than 25 years; exercise routines should be adopted daily as part of their lifestyle.
    • Chronic immunosuppression may lead to infections, malignancy, and renal deterioration.
    • Sarcoidosis in this population may be treated with low-dose corticosteroids as part of their maintenance pharmacology. Clinicians must observe sequelae of its long-term use.
  • Post-transplant stage, preterminal or end of life care42
    • An interdisciplinary approach is used to address patient and family needs.
    • Providers need to educate patient/family about disease progression, functional decline, advanced care planning, and end of life decisions.
    • Goals are targeted to maximize quality of life, focusing on symptoms management. These include pain relief, affirming life and regarding dying as a normal process, and offering a support system to help patients live as actively as possible.
  • Post-transplant stage, suspected organ rejection45
    • Rejection may occur at any time after the transplant and throughout the patient’s life (e.g. low stress tolerance, shortness of breath, edema, arrythmias, temperature changes).
    • It is advised to measure and record body temperature, blood pressure, fluid balance, and weight every day, at least for a few weeks to months, to detect these events early on.
    • The patient may continue with their current exercise program during a moderate severity graft rejection episode, but they should not progress until the graft rejection has been adequately treated.
    • Suspension of all physical activity, except for passive range of motion exercises, is recommended during severe acute graft rejection.

Coordination of care

Experiencing a chronic disease that leads to a heart transplant is a complex journey that is better navigated through care coordination in both ambulatory and hospitalized settings. Disease unpredictability challenges providers in forming enduring relationships with the patient and their family and which are necessary to establish difficult conversations like end-of-life decisions.45,46 Interdisciplinary coordination of care should begin pretransplant before end-stage heart disease occurs and led by a physician. The team should include specialists in HF, rehabilitation, palliative care, nutritionist, social work, and a spiritual and psychological counselor.32

Specialized case management has demonstrated to improve treatment compliance, enhance continuity of care through care coordination, and reduce hospital stay and mortality rates.47

Patient & family education

Empowerment of the patient and their family through education is core to the short- and long-term process. After the heart transplant, the patient must monitor signs of infection, weight changes, pulse, changes in blood pressure and sugar levels. Patients must adhere to nutritional recommendations, medications and exercise routine.

Secondary prevention education continues as an important element after a heart transplant, just as in any other cardiac disease. Lifestyle modifications should be adjusted in alignment with some of the realities of a denervated heart, including observing the heart rate and systolic blood pressure (SBP) at rest, which will be higher than expected when heart disease is related to a coronary artery disease and bypass. The American Heart Association revised guidelines (2025) on the management and prevention of high blood pressure promotes values of the SBP under 130/90 mmHg, and in coronary artery disease a pulse under 70 beats per minute.39 Patients and their caregivers must understand these goals and discuss with their primary provider what is aspirational when monitoring at home.

Adjustment to the post-transplant process can require psychosocial intervention. Adults are at risk of psychiatric comorbidities, including readjustment to their changing health, fear of death, concerns about their body image, financial concerns, anxiety and depression, and post-traumatic stress disorder.40

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

HT patients require an effective education program where they become aware of the course of their recovery, including understanding of the medication regimes need and potential side effects.

After a heart transplant, there is a spectrum of complications that clinicians must be aware and observant with the patient and their caregivers. Some of these complications include post-op delirium, stroke, neuropathies, seizures, central nervous system (CNS) infection, CNS lymphoma, thrombotic microangiopathies. This population can experience multiple comorbidities and consequently drug interactions may occur.40

Cutting Edge/Emerging and Unique Concepts and Practice

The future of cardiac transplant is optimistic. During the past years, there have been meaningful changes which have allowed for an expansion in the pool of heart donors for organ transplants.

These include ex vivo perfusion mechanisms such as hypothermic oxygenated perfusion (HOPE), which provides a controlled oxygen delivery to decrease the risk of ischemia-reperfusion injury.48 Another ex vivo perfusion method is the extended ultra oxygenated preservation (REUP), which is a practice for heart recovery and preservation for donation after circulatory death.49 Advances in medicine now allow for safe donation after circulatory death and from hepatitis C virus positive patients.50

After cardiac transplant, one of the most common limitations that patients encounter is the persistence of exercise associated intolerance. Most individuals only reach 50-70% of the age predicted peak oxygen uptake (VO2 peak), even in the context of an otherwise uncomplicated surgery. Reasons are multifactorial and include the effects of immunosuppression, skeletal muscle atrophy, and cardiac denervation.51 To minimize these effects the American Heart Association and American Association of Cardiovascular and Pulmonary Rehabilitation recommend early cardiac rehabilitation programs. Emerging evidence supports high intensity training (HIIT) as a safe modality for cardiac rehabilitation. It has also demonstrated to be superior to moderate intensity continuous training (MICT) when comparing peak VO2 improvements, muscle strength, and anaerobic threshold. HIIT as implemented during recent trials consists of 4×4 minute intervals of exercise at peak effort of 85-95%. It has been theorized that it augments central and peripheral adaptations which improve outcomes such as cardiac output, reinnervation, endothelial function and skeletal muscle oxidative capacity. Nonetheless, this type of program requires adequate supervision and patient selection which excludes recipients such as those with uncontrolled hypertension, cardiac arrythmia or unstable graft function.52,53

Regarding medical management, PCSK9 inhibitors such as alirocumab and evolocumab have shown a high safety profile and promising results. They act in lowering LDL cholesterol in cardiac transplant patients with treatment resistant hyperlipidemia or intolerance to statins.54,55

Stem cell and regenerative therapy continue as a promising field seeking therapeutics options for patients with cardiovascular disease and heart failure. Those theories contributing to the observed benefits have changed in the past decade, and these include the release of cardioprotective paracrine factors that lead to repair. Physicians must know that this is not yet ready for clinical application.55,56 Despite research, the translation of stem cells research to clinical therapeutic application is limited.

An important advancement in the last decade is cardiac allograft rejection monitoring; this emphasizes a non-invasive approach for monitoring allograft rejection. Currently the gold standard for monitoring rejection is endomyocardial tissue biopsy (EMB), however alternatives that are being evaluated include liquid biopsy and emerging biomarkers among others. Even though these techniques have shown promising results, further research is still needed. EMB remains the fold standard.56,57

Gaps in the Evidence-Based Knowledge

Although there has been much advancement in the field which includes novel methods for cardiac ex vivo perfusion, increase in donor pool, medication management and cardiac rehabilitation strategies; there continues to be significant gaps in knowledge in particularly regarding special populations. These groups include women and pediatric recipients, which have not been as represented in recent clinical trials as their counterparts. However, there are biologic differences that may affect how they respond to treatment options which have been found to be safe and effective in adult males.58,59

Despite improvements in the last decade, Black and Hispanic patients continue experiencing less organ transplant, when compared worse outcome than other racial groups.60 Even though the exact cause of this disparity is not clear, socioeconomic status, access to care, racial and ethnic differences, immunologic mechanisms and genetic mismatch are considered major contributors.61,62

Other areas that are in the works and require more robust scientific evidence before they can be widely implemented are xenotransplantation and tissue engineering.63 The long-term outcomes of novel immunosuppressive agents (such as mTOR inhibitors) and the effectiveness of telemedicine in cardiac rehabilitation programs are also some areas of ongoing investigation.64,65

Clinicians are still learning about the role of COVID-19 in heart disease. Patients with heart failure and those who have had heart transplants (HT) may have difficulties as a result of COVID-19, which can exacerbate presentation, care, and prognosis.65,66 In addition, myocarditis symptoms (high troponin levels, ECG changes, and new left ventricular dysfunction) can be misinterpreted as rejection of graft.66,67 Early detection and treatment can prevent further complication on regard to heart graft.

In moderate to severe COVID-19 presentations, the International Society for Heart and Lung Transplantation (ISHLT) guidelines recommend discontinuing immunosuppressive drugs such as mycophenolate, mofetil or azathioprine.67,68 However, there are no guideline on how to adjust exercise program in HT patient undergoing a COVID-19 infection.

The long-term outcome data on the benefits of exercise-based rehabilitation is still limited, therefore gaps still exist in benefits, health-related quality of life, and healthcare costs.50,51 This lack of evidence impacts the development of a consensus statement for the rehabilitation care after heart transplant.

References

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Original Version of the Topic

Maricarmen Cruz, MD, Isabel Borras-Fernandez, MD, Xavier Aviles-Guzman, MD, Cristina Isabel Sepulveda-Alamo, MD. Cardiac rehabilitation before and after cardiac transplantation. 9/20/2013.

Previous Revision(s) of the Topic

Maricarmen Cruz-Jimenez, MD, Francisco Merced-Ortiz, MD, Isabel Borras-Fernandez, MD. Cardiac rehabilitation before and after cardiac transplantation. 10/29/2019.

Maricarmen Cruz-Jimenez, MD, Isabel Borras-Fernandez, MD, Suzette Arias-Mejias, MD, MS, Lorena Rivera-Gonzalez, MD. Cardiac Rehabilitation Before and After Cardiac Transplantation. 1/4/2023

Author Disclosure

Maricarmen Cruz, MD
Nothing to Disclose

Isabel Borras, MD
Nothing to Disclose

Lorena Rivera, MD
Nothing to Disclose

Suzette Arias, MD, MS
Nothing to Disclose