Case Study 17: Patient Status Post-Orthotopic Heart Transplant Followed Through the Continuum of Care

EXAMINATION

History

• Demographic Information:

  Patient is a 66-year-old right-handed male status post-orthotopic heart transplant.

• History of Present Illness:

  Patient suffered from cardiovascular disease requiring a robotic assisted mitral valve repair and pericardial patch of the atrioventricular (AV) groove. Three weeks postop, the patient returned to the hospital with worsening shortness of breath and difficulty lying flat because of light-headedness and weakness. Evaluation revealed that the patient was found to have chronic systolic and diastolic heart failure with ejection fraction of 20%, severe mitral regurgitation with bileaflet mitral valve prolapse, acute kidney injury, and transaminitis. Because of a large clot burden in the left atrium and nonfunctional mitral bioprosthesis, he was not a candidate for a left ventricular assist device. After 2 weeks of hospital care, follow-up evaluation revealed ventricular failure, tricuspid regurgitation, pulmonary valve regurgitation leading to atrial flutter, and thrombus in the mitral valve. Patient received thrombolysis with tissue plasminogen activator (tPA).

  Despite medical management the patient continued to decline and was scheduled for heart transplant evaluation 2 months after his mitral valve repair. An intra-aortic balloon pump (IABP) was placed to help support the patient’s heart during the wait for a potential heart transplant. The patient was examined by multiple providers and was presented before the heart transplant committee board. He was subsequently listed and received a donor heart in 2 weeks. During the wait for the transplant, the patient was confined to bed and participated in a tilt table protocol 5 days per week for 1 hour to help maintain upright tolerance while maintaining IABP precautions.

  Once the transplant was available, he underwent an orthotopic heart transplant procedure. After the heart transplant, he began acute care physical therapy. His postoperative course was complicated by an ileus, which is now resolving. He additionally experienced increasing tremors affecting ambulation and activities of daily living (ADLs). He has been tolerating bedside rehabilitation in acute care and is making functional gains.

• Past Medical History:

  Recent acute kidney injury, hyperbilirubinemia, hypertension (HTN), mitral valve prolapse, shortness of breath (SOB), transaminitis, valvular heart disease

• Past Surgical History:

  Mitral valve repair 5 months ago, colonoscopy, hernia repair, left inguinal hernia repair tonsillectomy

• Current Medications:

  Acute Care: See Table CS17.1 for full list of medications, dosage, drug class, and indications during acute care.

  Inpatient Rehab: See Table CS17.2 for full list of medications, dosages, drug class, and indications during inpatient rehab.

• Social History:

  Patient is married and lives with his supportive spouse who is in good health herself. She works from home and will be able to physically assist patient upon discharge. Patient is currently employed as a security guard in a museum.

• Living Environment:

  Patient lives in an apartment with no steps to enter; however, they have recently found that their apartment has mold. Patient and his wife have been actively looking for a new place to live while trying to get the apartment renovated. Pending date of discharge, the ...