Response of Cardiovascular Parameters to Physical Therapy Post Liver Transplantation
Condition: Liver Transplant; Complications
Study type: Interventional

Summary: 
      Liver transplantation (LT) is the only life-saving treatment option in patients with advanced
      liver disease. Deceased-donor LT is not frequent but is increasing in Asian countries.
      Because current liver allocation policies follow the severity principle wherein patients at
      highest risk for mortality receive top priority, anesthesiologists may face severely ill
      patients more frequently with deceased-donor LT than with living-donor LT. In this regard,
      with the outstanding surgical success of recent LT, cardiovascular complications have emerged
      as the leading cause of death after LT, particularly among those with advanced liver
      cirrhosis
    

Detailed description: 
      Cardiovascular complications have emerged as the leading cause of death after liver
      transplantation, particularly among those with advanced liver cirrhosis. Therefore, a
      thorough and accurate cardiovascular evaluation with clear comprehension of cirrhotic
      cardiomyopathy is recommended for optimal anesthetic management. However, cirrhotic patients
      manifest cardiac dysfunction concomitant with pronounced systemic hemodynamic changes,
      characterized by hyperdynamic circulation such as increased cardiac output, high heart rate,
      and decreased systemic vascular resistance. These unique features mask significant
      manifestations of cardiac dysfunction at rest, which makes it difficult to accurately
      evaluate cardiovascular status As cardiovascular complications are leading causes of nongraft
      related mortality after LT [2], the importance of identifying masked intrinsic cardiac
      dysfunction or decreased capacity of cardiac contractility due to external stress has been
      emphasized. However, detecting ventricular dysfunction in a resting state is difficult, as
      marked vasodilation and increased arterial compliance lead to latent or mild cardiac
      manifestations [4]. Different stress tests, using drugs or exercise, have been applied to
      unmask cardiac dysfunction; however, achieving a target HR and blood pressure is difficult
      given the poor functional conditions of patients with LC [5].

      Dobutamine stress echocardiography (DSE) is recommended to discriminate high-risk patients
      with ischemic heart disease; however, the accuracy of DSE varies widely among studies as a
      result of various selection criteria [3] and the inability to achieve the predicted target HR
      to provoke wall motion abnormalities. This inadequacy is based on the failure of beta
      receptors to respond to sympathetic stimulation in patients with LC or the use of beta
      blockers to prevent variceal bleeding. Therefore, the accuracy of DSE is questionable, and
      its sensitivity is reported as low as 13-14% [6-7]. Nicolau-Raducu et al. [8] demonstrated
      that DSE has 9% sensitivity, 33% positive predictive value, and 89% negative predictive value
      for predicting early cardiac events after LT.

      The autonomic nervous system is an important regulator of cardiovascular homeostasis, and an
      HR analysis is considered a surrogate of vagal and sympathetic disturbances. Therefore, HR
      measurements have been recognized as a prognostic factor in many clinical investigations
      [9-12]. Studies showing reduced HR variability, which correlates with disease severity,
      central hypovolemia, and the degree of portal hypertension have also been reported [13-14].
      Kim et al. [15] found that sympathetic withdrawal is associated with hypotension after graft
      reperfusion during LT.

      Patients with LC have an increased resting HR due to hyperdynamic circulation, increased
      circulating catecholamines, and cirrhotic cardiomyopathy [16-17]. Kwon et al. [18]
      demonstrated that resting HR is associated with all-cause mortality in LT recipients and
      showed that patients with HR >80 beats/min are significantly associated with a higher risk
      for all-cause mortality (hazard ratio 1.83) compared to patients with HR ≤65 beats/min.
    

Intervention name(s): 6 minute walk test , Blood pressure monitoring
Intervention type(s): Procedure
Intervention description(s): Heart rate monitors can assess a person's heart rate and reveal whether it is high or low. Heart rate Trusted Source is a "clinical indicator of overall cardiac health," and it can also help a person determine their performance during a workout.
Six minute walk test:
It will be carried out before and after interventions to determine the patients functional capacity (in the 7th.day &in the 21st.day.) It will be used as a training tool as well as an assessment tool. They will receive conventional physical therapy program which includes deep breathing exercise in form of (diaphragmatic, apical and costal breathing), Training about right way of cough and early ambulation from bed for 3 sessions / week, twice daily for 21 days.
Allocation: Non-Randomized
Intervention model: Single Group Assignment
Masking: Double (Care Provider, Outcomes Assessor)
Primary purpose: Supportive Care