Heart transplantation in adults: Exercise-based rehabilitation for transplant recipients

INTRODUCTION — While survival of cardiac transplant recipients has dramatically improved, studies have consistently shown abnormal levels of functional capacity. Exercise-based cardiac rehabilitation in cardiac transplant recipients improves exercise capacity.

This topic will review issues related to rehabilitation after cardiac transplantation. A more general discussion of cardiac rehabilitation and exercise capacity in patients with heart failure (HF) is presented separately. (See "Cardiac rehabilitation in patients with heart failure" and "Exercise capacity and VO2 in heart failure".)

RATIONALE

Pretransplantation — A rationale for instituting pretransplantation exercise is to familiarize the patient with exercise modes (including range of motion) so that the patient will be able to reinitiate these with minimal re-education shortly after transplantation and incorporate activity into their daily lives. Furthermore, if the patient is in a better conditioned state pretransplant, the few days of intubation and inactivity after transplant may have a lesser impact in reversing the level of conditioning.

Posttransplantation — After cardiac transplantation, most patients have a notable improvement in functional capacity compared with their preoperative condition, but exercise capacity usually remains below normal for the reasons described in this section. An exercise-based cardiac rehabilitation program provides a means of increasing the likelihood of restoring exercise capacity in the face of numerous factors that limit exercise capacity and may aid control of risk factors, such as hypertension and hyperlipidemia.

Factors limiting early exercise capacity — Although there is a rapid rise in exercise capacity that occurs at approximately two months posttransplant [1], and many patients return to their normal activities with improved quality of life, exercise function remains 30 to 40 percent below normal [2,3]. Factors that may limit exercise capacity early posttransplant include transplant-specific conditions (such as chronotropic incompetence due to denervation of the heart [4], and corticosteroid therapy-related myopathy (see "Glucocorticoid-induced myopathy")), as well as conditions related to pre- and posttransplant HF including deconditioning, cachexia, left and/or right ventricular systolic and/or diastolic dysfunction, peripheral vasoconstriction, and skeletal muscle derangements [5]. (See "Exercise capacity and VO2 in heart failure".)

Cardiac transplantation recipients are variably deconditioned due to HF. Some cardiac transplant recipients may have already participated in cardiac rehabilitation programs and thus will be more experienced and perhaps better conditioned. On the other hand, patients who have been very ill prior to transplantation, often with repeated hospitalizations and some receiving mechanical circulatory support [6], may be severely deconditioned, cachectic, and malnourished; these patients may not see an improvement in functional capacity early after transplantation. Patients receiving mechanical circulatory support are at risk for complications that may result in hospitalizations and more deconditioning. In addition, prolonged bedrest can also lead to decubiti ulcers and if infected can add to the complications of mechanical assistance. Therefore, mobility even at the lowest levels is recommended. After transplant, these patients are at risk for additional complications, which may lead to further deconditioning prior to initiation of rehabilitation. (See "Treatment of advanced heart failure with a durable mechanical circulatory support device" and "Management of long-term mechanical circulatory support devices".)

Factors limiting long-term exercise capacity — Cardiac transplantation recipients commonly have persistently low exercise capacity during the months and years after transplantation due to factors similar to those that limit exercise early after transplantation.

The limitation in long-term exercise capacity was illustrated by a study of 140 patients who underwent repeated treadmill exercise testing up to nine years after heart transplantation [1]. In the group as a whole, peak VO₂ increased from 14.2 mL/kg/min pretransplant to 21.4 mL/kg/min at 11 months after transplantation. When compared with the normal population, peak VO₂ was less than 50 percent predicted in 12 percent of patients, 50 to 70 percent predicted in 44 percent, 70 to 90 percent predicted in 31 percent, and greater than 90 percent in only 13 percent.

Exercise capacity may or may not improve after the first year posttransplantation. In the above report, the improved exercise capacity seen by six months did not change significantly over nine years of follow-up [1]. In contrast, a review of over 1800 patients found that VO₂ tends to increase after the first year post-cardiac transplantation [7]. Another study found that the peak VO₂ decreases with time in some patients at five years posttransplant [8]. However, if measured as an absolute value rather than normalized to body weight, VO₂ (mL/min) remains unchanged, suggesting that weight gain impacts negatively on exercise performance.

Factors that contribute to the persistently low exercise capacity in most heart transplant recipients are similar to those described above that limit early exercise capacity. Exercise response in transplant recipients may be limited by reduced preload and heart rate reserve [9]. Transplant recipients generate reduced peak cardiac index due to lower peak heart rate and lower peak end-diastolic volume index as compared with donor age-matched controls. During sustained exercise, end-diastolic volume index and cardiac index are lower in transplant recipients than in controls. The heart rate response to exercise remains subnormal up to five years after transplant, suggesting that there is no functionally significant cardiac reinnervation [10].

Neurohormonal abnormalities associated with HF do not normalize rapidly after transplantation and may contribute to persistent posttransplant peripheral vasoconstriction [11]. Further characterization of the neurohormonal profile posttransplant includes improvement in the natriuretic peptides, but levels of angiotensin II and endothelin remain elevated for up to 12 months [12]. The persistence of vasoconstrictor neurohormones may be responsible in part for the hypertension noted commonly posttransplant and provides a rationale for reconsidering the use of renin-angiotensin-aldosterone system inhibition early postoperatively.

Patients with chronic HF have skeletal muscle histologic abnormalities with an increase in type II (fast twitch) muscle fibers relative to type I (slower twitch) fibers. After transplant, the ratio of both fiber types remains unchanged, but a significant increase in fiber size occurs in association with an elevation in skeletal muscle oxidative capacity [13]. Thus, although some of the skeletal muscle abnormalities improve after transplantation, complete normalization does not occur.

Functional capacity can decrease naturally with age, and an age-dependent decline in peak VO₂ has been noted in normal subjects. This decline can be exacerbated in cardiac transplantation patients due to a number of factors including chronic immunosuppressive therapy, particularly corticosteroids, which impair proximal muscle strength and exercise capacity [5]. (See "Glucocorticoid-induced myopathy".)

PRETRANSPLANTATION REHABILITATION

Indication and exercise prescription — For cardiac transplant candidates who are able to participate in an exercise program, we suggest initiation of a formal exercise-based cardiac rehabilitation program as early as feasible after listing and prior to transplantation. Studies have found that exercise training in screened patients with compensated HF with reduced ejection fraction (HFrEF) is generally well tolerated with low risk of adverse events (see "Cardiac rehabilitation in patients with heart failure", section on 'Safety considerations'). A limited number of patients with New York Heart Association (NYHA) class IV HF (16 [14]) were included in HF-ACTION [15]. Determination of eligibility for enrollment was based on the referring physician's determination that the patient could exercise, and class IV patients were not specifically excluded. Severity of illness may be better defined by exercise duration during cardiopulmonary exercise testing rather than by NYHA class. An analysis of the modest improvements in HF-ACTION showed no difference in benefits of exercise training by either etiology or severity (by risk score or NYHA class, with NYHA III and IV combined). Thus, this study provides limited evidence that the decision to recommend exercise in patients with HFrEF may be made independent of severity or etiology [15]. Other studies have excluded patients that were determined to be decompensated [16].

The site and type of exercise program varies based upon the patient's condition and should generally include both aerobic and resistance training:

●For stable outpatients, we suggest exercise as an adjunct to pharmacologic therapy during the entire waiting period.

●For patients on home inotropic therapy, a monitored program in a cardiac rehabilitation center seems prudent, since inotropes can stimulate or worsen arrhythmias.

●For those patients who are hospitalized and who may be dependent upon inotropic support therapy, a cardiac rehabilitation program can be instituted in the hospital. A set routine consisting of bicycle, treadmill, upper body ergometry, and free weights can be carried out safely in the controlled intensive care setting. Walking can often dissipate boredom and may add to the patient's functional capacity. The exercise intensity may need to be determined by patient symptoms, rather than by heart rate or rate of perceived exertion.

●In addition, a sensitive frailty score will help to identify those patients that may need a more focused pretransplant exercise program [17].

●For patients on inotropic support who are being monitored hemodynamically (usually with pulmonary artery catheterization), activity will vary depending upon patient mobility. Certainly, range of motion and leg movement exercises can be performed at the bedside. The addition of incentive spirometry will assure that the ventilatory muscles remain active and trained.

Evidence on pretransplantation rehabilitation — The recommendation for exercise training for cardiac transplantation candidates is based in part on indirect evidence in patients with less advanced HF. As discussed separately, exercise training in screened patients with compensated HF confers clinical and physiologic benefits and is generally well tolerated with very low risk of adverse effects. Most of the evidence supporting exercise training for patients with HF is on aerobic training, with more limited available evidence on resistance training. (See "Cardiac rehabilitation in patients with heart failure".)

Although direct evidence in large trials has not been available on the efficacy and safety of exercise training in cardiac transplant candidates, several recent trials suggest the benefit of pretransplantation rehabilitation. In a small trial of hospitalized patients (n = 24) who were awaiting heart transplantation, patients were randomized into sessions of upper and lower limb active exercises plus breathing exercises (control) or stationary cycle ergometer upright exercises in intervals of three minutes of cycling and one minute of rest for a total of five periods (intervention) [18]. The cycling group improved the six-minute walking distance by 15.5 percent compared with the control group. The cycling group also had a greater improvement in inspiratory muscle strength by 15 percent compared with the control group. Importantly, the training was safe for both groups.

Since sarcopenia is commonly seen in advanced HF with loss of muscle mass and function, questions have arisen about the safety and benefits of high-intensity interval training (HIIT) designed to improve muscle conditioning. In 24 patients who were hospitalized for an acute HF exacerbation, and after medical therapy stabilization, aerobic training was initiated at low workloads or to a rate of perceived exertion of 13 for 15 minutes. If tolerated, patients were assigned to a program of one minute of HIIT with four minutes of recovery at a frequency of three to four sessions [19]. Knee extensor strength increased significantly after the HIIT portion of the training. There were no new arrhythmias or episodes of worsening HF symptoms.

A cardiac rehabilitation program (90 minutes, three times weekly for eight weeks) was undertaken by 46 patients with advanced HF (11 patients supported by a left ventricular assist device [LVAD], including 5 of 40 cardiac transplant recipients) [16]. Baseline peak VO₂ was lowest in the LVAD group. The two overlapping groups showed similar improvements in peak VO₂ and health status without any complications.  

Limited data suggest that exercise training may be beneficial in patients who receive an LVAD as a bridge to transplantation. A retrospective study of 41 patients receiving LVAD support found that exercise training was effective in increasing exercise capacity and safe with one training-related adverse event (non-sustained ventricular tachycardia) [20]. In patients receiving LVAD support, the left ventricle and LVAD work in parallel with the left ventricle actively contributing to the systemic circulation directly through ejection across the aortic valve and indirectly through LVAD filling. American Heart Association (AHA) statements on cardiac rehabilitation acknowledge that further work is needed since the effect of exercise training in patients receiving mechanical circulatory support is not clear [21,22]. With the growing role of ventricular assist devices, particularly those with continuous flow, the physiology and rehabilitation of those patients needs to be readdressed. In addition, as LVAD implantation is increasing as a bridge to a decision or as destination therapy, particularly in older patients [23], testing for frailty indices may be advisable and better inform a rehabilitation plan prior to transplantation or as a destination therapy. Both early and late mobilization may improve quality of life in this growing population of patients with limited functional capacity [24]. The American Academy of Physical Medicine and Rehabilitation has published a detailed guide for the rehabilitation physician that provides a narrative review of rehabilitation for patients with advanced HF who have received an LVAD [24]. (See "Treatment of advanced heart failure with a durable mechanical circulatory support device".)

POSTTRANSPLANTATION REHABILITATION

Indication and exercise prescription — For patients who have undergone cardiac transplantation, we suggest exercise-based cardiac rehabilitation. The transplant team determines the timing and prescription of rehabilitation based upon the patient's clinical status.

Rehabilitation posttransplantation includes sequential steps based upon patient condition to support transition from the immediate posttransplantation period to a posthospital exercise program.  

Immediate posttransplantation — A series of sequential steps should be initiated in the immediate posttransplant period:

●Prior to removal of the chest tubes and pacer wires, exercise consists mainly of passive and active range of motion accompanied by incentive spirometry to facilitate pulmonary toilet.

●Once out of bed in a chair, leg raising and hip girdle exercises become useful as a preparation to transfer weight from sitting to standing.

●Once the patient is able to stand, ambulation is initiated, initially in the patient room, progressing to the ward. It is assumed at this point that the patient is on telemetry monitoring. Intensity continues to be assessed by rate of perceived exertion (RPE), more commonly using the RPE (Borg) scale (table 1) [25].

●Prior to discharge, if no allograft rejection occurs, the patient may be able to exercise on a stationary bicycle ergometer and/or treadmill. It is our preference to perform a predischarge cardiopulmonary exercise test to better define an exercise prescription for an outpatient program. The rehabilitation team should not be surprised to find a peak VO₂ that is very similar to the value pretransplantation due to the deconditioned peripheral musculoskeletal system. (See "Cardiopulmonary exercise testing in cardiovascular disease".)

Posthospital — The exercise prescription posttransplantation includes all the essentials of intensity, duration, frequency, and progression. These issues will be reviewed briefly here and are described in detail elsewhere (see "Cardiac rehabilitation programs"). Patients receiving rehabilitation programs should also be given specific exercise modalities, such as resistance training after the first six weeks posttransplantation, the time required to permit healing of the sternal incision. Patients who have undergone cardiac transplantation pose a challenge to the cardiac rehabilitation team. Due to persistent sinus node denervation, the heart rate cannot be used as a measure of work intensity; as a result, the rehabilitation team must rely on clinical judgment and the RPE (Borg scale (table 1)) to guide exercise therapy. Alternatively, an empiric workload intensity level can be prescribed, as long as it is accompanied by a plan of progression to higher intensity levels over time.

●Intensity – The RPE at the anaerobic threshold is used to prescribe intensity since the heart rate will not be commensurate to the effort because of cardiac denervation. The anaerobic threshold or ventilatory threshold correlates with the lactate threshold in transplant recipients [26]. Alternatively, an empiric workload intensity level can be prescribed, as long as it is accompanied by a plan of progression to higher intensity levels over time. Reports of long-term effects of training suggest that intermittent periods of high intensity may be necessary to maintain function across the posttransplant years [27]. High intensity is defined as warm-up followed by one to four minutes of Borg scale 16 to 18, repeated at intervals of two to four. Each set is followed by an active break, which can consist of walking.

●Duration – Warm-up and cool-down is essential, with a minimum of 20 minutes at the prescribed intensity.

●Frequency – Exercise should be performed in a supervised setting three times per week for a minimum of six to eight weeks. Some programs are constructed for a 12-week period. A walking program is recommended for alternate days. An extension of this timetable is often necessary to take into account early episodes of rejection or infection, which may preclude exercise for several days at a time. There are no studies to indicate that electrocardiogram monitoring is required.

●Progression – It is important to outline a progressive increase in exercise activity to account for improvement in function, which may occur early in the program. An RPE of 11 to 13 often results in early deconditioning (table 1). Thus, every effort should be made to increase the intensity to at least RPE 13 to 15 to approach the ventilatory threshold, which may also improve with exercise. If an empiric workload level has been prescribed, a plan of progression to higher intensity levels over time should be incorporated.

●Resistance exercise – Although less well studied in transplant recipients, resistance exercise can be performed safely and will increase strength and flexibility for tasks of daily living. As noted above, a gradually incremental resistance program can improve fiber type in skeletal muscle, as well as increase oxidative capacity to enhance work. It is recommended, therefore, that a resistance program be added to the aerobic training regimen.

After the initial program of cardiac rehabilitation is completed, a repeat cardiopulmonary exercise test should be performed in order to update the exercise prescription. Patients should be encouraged to adopt exercise and activity as a way of life. Adherence to physical activity should be monitored in a similar fashion to adherence to the medical regimen.

Evidence for posttransplant rehabilitation — The available evidence indicates that aerobic exercise-based cardiac rehabilitation during the weeks and months posttransplantation improves exercise capacity. More limited data suggest that cardiac rehabilitation years posttransplant may also increase exercise capacity. (See 'Effect of early rehabilitation' below and 'Effect of later rehabilitation' below.)

As nearly all studies of cardiac rehabilitation posttransplant have involved aerobic exercise, there are only limited data on the effect of resistance training in cardiac transplant recipients. However, the potential efficacy of strength training is of particular interest in this population since proximal muscle weakness is common posttransplant for a number of reasons, including chronic corticosteroid use and the skeletal muscle changes associated with long-standing HF. The value of resistance training was suggested by a randomized controlled trial with eight patients in the training group and eight in the control group [28]. The program beginning two months after surgery included both upper and lower body exercises, using a set of variable resistance equipment twice weekly for six months. Among patients randomized to resistance training, skeletal muscle fibers shifted from the less oxidative type II to the more fatigue-resistant type I. In contrast, patients in the control group who participated in largely aerobic activity had a further loss of type I fibers and an increase in type II. In addition, resistance training produced greater increases in oxidative and glycolytic skeletal muscle enzymes than aerobic training alone. No complications were observed.

Unfortunately, participation in cardiac rehabilitation is low, as illustrated by an observational study of 595 posttransplant Medicare beneficiaries in which 55 percent of eligible patients initiated cardiac rehabilitation, and participation varied among geographic regions [29]. Two-thirds of patients were admitted within one year of transplantation. After multivariable adjustment, participation in cardiac rehabilitation was associated with a 29 percent lower one-year readmission risk (95% CI 13-42 percent).

Effect of early rehabilitation — The available evidence indicates that aerobic exercise-based cardiac rehabilitation early (during the first weeks to months) post-cardiac transplantation improves exercise capacity but does not impact short-term health-related quality of life (HRQoL) measures. A systematic review included 10 randomized controlled trials comparing exercise-based rehabilitation (early or late after cardiac transplantation) with no exercise (nine trials) or a different intensity of exercise training (one trial) with a total of 300 participants with median follow-up of 12 weeks [30]. Moderate-quality evidence from nine trials showed that exercise-based rehabilitation increased exercise capacity compared with no exercise control (mean difference in VO_2peak 2.49 mL/kg/min, 95% CI 1.63-3.36). One trial found that high-intensity interval exercise training was more effective than continuous moderate-intensity exercise in improving exercise capacity (mean difference 2.3 mL/kg/min, 95% CI 0.59-4.01). There were four studies of effect on HRQoL using differing outcomes and methods of reporting; there was no evidence of difference between exercise-based rehabilitation and no exercise in 18 of 21 HRQoL domains reported or between high- and moderate-intensity exercise in any of 10 HRQoL domains reported.

The efficacy of early cardiac rehabilitation was illustrated in a study that randomized 27 patients within two weeks of cardiac transplantation to a six-month structured rehabilitation program or unstructured therapy at home. Compared with the control group, the exercise group had a greater increase in peak oxygen consumption (49 versus 18 percent) and workload (59 versus 18 percent) and a greater reduction in the ventilatory equivalent for carbon dioxide (20 versus 11 percent) [31]. In experienced transplant centers, patients are enrolled in cardiac rehabilitation within two weeks of transplant, and improvements in peak VO₂ and six-minute walk distance are observed.

However, a relationship between early rehabilitation and long-term outcomes has not been firmly established. A retrospective single-center review of 201 patients who received a cardiac transplant found that among the factors predicting survival posttransplant were the number of cardiac rehabilitation sessions attended in the first 90 days after surgery, controlling for posttransplant six-minute walk and rejection episodes. Each rehabilitation session attended corresponded to a 10 percent decrease in risk of death [32].

There is limited evidence on optimal timing for rehabilitation; the available evidence supports early referral for outpatient cardiac rehabilitation following cardiac transplantation. A retrospective study found that earlier referral may lead to lower percent body fat, waist circumference, and body mass indices [33]. Obesity is linked to diabetes mellitus in all patient populations, and obesity and diabetes are associated with increased risk in patients receiving posttransplant medical therapy. In addition, patients with diabetes are less likely to remain adherent to cardiac rehabilitation. Thus, the timing of rehabilitation posttransplant should be decided by the medical team caring for the patient, with consideration of comorbidities that can ultimately impact patient well-being.

Effect of later rehabilitation — Studies suggest that cardiac rehabilitation can improve exercise capacity several years after transplantation; thus, physical conditioning should be encouraged late after transplantation. Long-term improvement in cardiac transplant patients is limited, which may be due to the effects of aging, cardiac denervation, transplant therapy, and prior HF.  

●The benefit of later rehabilitation was illustrated in a series of 21 patients who were five years posttransplant and not engaging in routine physical activity who were enrolled in a training program [34]. Endurance exercise capacity increased by 18 and 35 percent at three months and one year, respectively. The increases in exercise and peak VO₂ were related to improved aerobic metabolism, rather than improved cardiac performance. Maximum heart rate and stroke volume remained constant, as has been shown in other studies. Early in training, 50 percent of the improvement was due to better skeletal muscle conditioning and the remainder due to increased central responses.

●One study reported that with ≥23 sessions of cardiac rehabilitation posttransplant, major adverse events were decreased [35].

●Improvements in exercise capacity posttransplant do not seem to be related to ventricular function or to changes in endothelial function. In a trial performed a mean of five years posttransplantation, 43 patients were randomly assigned to a supervised strength and aerobic training program or no training [36]. Peak VO₂, total lean mass, and strength improved significantly more in the trained group, although submaximal exercise left ventricular systolic function and brachial artery endothelial-dependent or -independent vasodilation were not significantly improved.

The ultimate results of an exercise program depend in part upon the motivation of the individual. In one study, for example, patients underwent a 16-month program at the end of which there was a significant improvement in VO₂ in the more compliant patients (32.2 versus 21.3 mL/kg/min at baseline) but no significant change in the less compliant patients (24.5 versus 21.8 mL/kg/min at baseline) [37]. The overall exercise capacity of the combined group was 70 percent of normal. Nevertheless, the amount of work achieved in both groups increased, as did the peak double product achieved at similar effort levels, measured by the respiratory exchange ratio (RER = Vco₂/Vo₂) and Borg effort level (ie, the RPE) (table 1) [25]. As for many recommendations, behavior modification strategies may be key for enabling transplant patients to continue to adhere to increased activity in daily life. Transplant teams including clinicians should encourage and support exercise throughout the life of the patient. (See "Cardiac rehabilitation programs", section on 'Rating of perceived exertion (Borg scale)'.)

MAJOR SOCIETY GUIDELINES — The above recommendations for exercise-based cardiac rehabilitation prior to and following cardiac transplantation are in broad agreement with major society guidelines and policy statements. The 2007 and 2011 statements from the American Heart (AHA) on Cardiac Rehabilitation and the 2010 International Society of Heart and Lung Transplantation Guidelines recommend exercise training both prior to and after transplantation [21,22,38,39]. The 2010 American Association of Cardiovascular and Pulmonary Rehabilitation/American College of Cardiology/American Heart Association Performance Measures for Cardiac Rehabilitation include cardiac transplantation in its A1 inpatient measure for referral. The preferred timing of referral is during the hospital stay for the transplant event. The document also includes an A2 referral for rehabilitation in the outpatient setting for those not referred earlier [40]. The International Society of Heart Lung Transplant includes a strong recommendation for cardiac rehabilitation, including both aerobic and resistive training [38].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lifestyle management and cardiac rehabilitation".)

SUMMARY AND RECOMMENDATIONS

●After cardiac transplantation, most patients have a notable improvement in functional capacity compared with their preoperative condition, but exercise capacity usually remains below normal. An exercise-based cardiac rehabilitation program provides a means of increasing the likelihood of restoring exercise capacity in the face of numerous factors that limit exercise and may aid control of risk factors such as hypertension and hyperlipidemia. (See 'Rationale' above.)

●Factors that may limit early and long-term exercise capacity posttransplant include transplant-specific conditions (such as chronotropic incompetence due to denervation of the heart, and corticosteroid therapy-related myopathy), as well as conditions related to pre- and posttransplant heart failure (HF) including deconditioning, cachexia, left and/or right ventricular systolic and/or diastolic dysfunction, peripheral vasoconstriction, and skeletal muscle derangements. (See 'Factors limiting early exercise capacity' above.)

●For cardiac transplant candidates who are able to participate in an exercise program, we suggest initiation of an exercise-based cardiac rehabilitation program as early as feasible after listing and prior to transplantation (Grade 2C). The rationale for instituting pretransplantation exercise is to familiarize the patient with exercise modes (including range of motion) so that the patient will be able to reinitiate these with minimal re-education shortly after transplantation. (See 'Indication and exercise prescription' above.)

●For patients who have undergone cardiac transplantation, we suggest exercise-based cardiac rehabilitation, including both aerobic and resistive training for strength improvement. (Grade 2C). (See 'Indication and exercise prescription' above and 'Evidence for posttransplant rehabilitation' above.)

•Posttransplantation rehabilitation should begin in the immediate postoperative period if possible and should continue and progress as the patient's condition allows. The transplant team determines the timing and prescription of rehabilitation based upon the patient's clinical status. (See 'Immediate posttransplantation' above.)

•The posthospital exercise prescription includes targets for intensity, duration, frequency, and progression. (See 'Posthospital' above.)

●The available evidence indicates that aerobic exercise-based cardiac rehabilitation during the weeks and months posttransplantation improves exercise capacity. More limited data suggest that cardiac rehabilitation years posttransplant may also increase exercise capacity. Long-term improvement in exercise capacity in cardiac transplant patients is limited, which may be due to the effects of aging, cardiac denervation, transplant therapy, and prior HF. (See 'Evidence for posttransplant rehabilitation' above.)