Stroke rehabilitation in a patient with a history of heart transplantation

More than 4,000 human heart transplants have been performed worldwide since the inception of this procedure in 1967. More than half have occurred in the last two years, and current survival rates at one and five years are 81% and 78%, respectively. This increased incidence and survival has been attributed to the advent of cyclosporine as an immunosuppressive agent used to prevent graft rejection. As the obstacles to cardiac transplantation are overcome, more patients will require rehabilitation due to related neurologic sequelae. In the case reported, a 56-year-old man was admitted for rehabilitation of a right hemiparesis and nonfluent aphasia. His medical history was significant for coronary artery disease, multiple myocardial infarctions, and severe congestive heart failure, necessitating a recent orthotopic heart transplant. Although his recuperation from transplant surgery was uncomplicated, he required readmission for treatment of pneumonia and overwhelming infection. He developed hemiparesis and aphasia shortly before his anticipated discharge from this second hospitalization. In therapy, a mild resting tachycardia was noted, with a heart rate increase of 30 beats per minute on two occasions. No other significant change in heart rate or blood pressure occurred during rehabilitation. This altered cardiovascular response to training in self care and mobility skills is typical of the denervated heart's response to exercise. The neurologic complications of heart transplantation, the cardiovascular response of the denervated heart to exercise, and possible implications for physiatrists involved in the care of these patients are discussed.