Cardiologists see this happen all too often: A patient is waiting in the hospital for a heart transplant, only to be disqualified because their fitness has fallen with each day in bed.
Dismayed by such cases, Radha Gopalan, a heart transplant cardiologist at Banner–University Medical Center Phoenix, decided to try a twist on other rehabilitation programs.
There’s cardiac rehabilitation, a set of programs designed to return people to healthy activity after a heart attack, surgery, or other serious cardiovascular event.
There’s cardiac prehab, an outpatient effort to prepare patients before they undergo the rigors of cardiac surgery and recovery, including heart transplantation.
Now there’s in-patient cardiac prehab for people waiting to receive a heart transplant. Patients on the transplant waitlist who are admitted to the hospital for worsening heart failure, abnormal heart rhythms, or coronary artery disease — the most common conditions leading up to transplant — can now take part in a novel program that keeps them from failing further and losing their hope.
Gopalan and his team began testing this approach in 2023 after seeing patients become weaker the longer they stayed in the hospital, jeopardizing their chances for a lifesaving transplant. Over two years, 56% of pretransplant patients in the first year and 62% in the second year met transplant listing criteria after improvement, with no reported adverse events. (“All patients that went through the program started off as ‘not qualified’ from a frailty perspective for immediate transplant. Therefore, the stated percentages reflect how many qualified and the rest did not qualify,” Gopalan said.) The team reported their results in April at the International Society of Heart and Lung Transplantation meeting in Toronto.
“The idea started as post-hospitalization or intra-hospitalization rehab, and then we also realized there are patients who never went home before their transplant, but we didn’t have the ability to improve their frailty before they go for surgery,” Gopalan said. “The scientific literature says, the stronger you go for surgery, the better your outcome. Based on that was born the idea of prehab.”
Gopalan recently spoke with STAT about his inspiration and the results so far for 45 patients. This conversation has been edited for length and clarity.
Where did you see a gap in health care services?
If you have a hospitalized Medicare patient, every day they are in bed their muscles lose power. In studies in athletes, for one day of bed rest it takes three days to get back the muscle strength that was lost. So if you have a patient who stayed in the hospital for 10 days and was bedbound, that will take 30 days to get to where they were before they were hospitalized.
Some of the patients didn’t even get to transplant. They developed other complications and they never qualified.
How did you hope to bridge that gap?
This was an opportunity to get people who would otherwise not have a door open, to try to improve their frailty so that they can get their transplant faster. We came up with this idea: How about we reduce their loss of function in the hospital?
How did patients respond when you brought this up?
Some of them were skeptical. They didn’t know if they could do it, so they needed reassurance from our team. But the most motivated patients actually asked to go for it. They would do anything to get out of the hospital.
What does prehab involve?
In our gym we have a recumbent bicycle to exercise the legs as well as the arms at the same time, a sit-down bicycle, and an arm bicycle, where arms only can be exercised. We intentionally did not put a treadmill in there because we didn’t want to put patients at risk of falling down.
By increasing their heart rate and increasing their lung function, they improved their cardiopulmonary status as well as the skeletal muscles that give rise to frailty.
How well did patients do?
Most of our patients started with an average frailty score of 2.5 out of 5 and then they improved to 1.5 in these sessions with our exercise physiologist.
What does that mean?
We get excited in transplant selection if someone has a score of 2 or lower. If they get 3 or 5, we have to rehabilitate them, one way or another because they are at high risk for postoperative complications. So 3 is our cutoff.
Who pays for this?
We sought out and secured philanthropic funding through our foundation. I proposed to the hospital, if I came with the funding, would you provide the space on one of our telemetry floors? And they agreed.
To apply for NIH funding, you need to collect a little bit more data.
What lessons have you learned so far?
One, it is safe. When you do something new, you have to make sure you are not putting patients at risk. We had no deaths and no complications. No falls.
Two, it was effective. It improved the frailty score.
Three, it improved the METS [metabolic equivalent tasks score].
Those are three important things.
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