greffe capillaire

Heart Transplant patient
and Sports
JC Verdier
Institut Cœur Effort Santé
Paris
Reconditioning : When ?
The best : initialised before Transplantation….. ( heart failure )
• Phase I :
– With respect to recovery ( Anémia; complications…)
Personnalisation +++
• Phase II:
– As soon as possible !....
Rejections ?
1 month post Graft ( 1 )
– Always :
5 years post Graft ; fonctionel improvment : 35% ( 2 )
A reduced training response contributes to a poorer prognosis. (4)
• Phase III :
– Effectivness and security ( 3)
– Same physiological involution than non H.Tx. ( 12 years )… ( 4)
Physical activity patterns
and
Exercise Performance in
H.Tx.
«H.Tx. Recipients still achieve only 50% to 70% of normal values for
exercise capacity. »
« Among the factors suggested to explain the reduced exercise
tolerance in CTx recipients is deconditioning. »
Myers J.
J Cardiopulm Rehabil. 2003 Mar-Apr;23(2):100-6
What for limitations ?...
•
•
•
•
•
•
•
•
•
cardiac denervation,
Systolic / diastolic dysfunction,
Pulmonary diffusing capacity impairment
endothelial dysfunction
Peripheral chemoreceptor sensitivity
peripheral limitations
abnormal muscle structure and function
pharmacological side effects
physical deconditioning...
Capacités Fonctionnelles: Quelles limites ?
• Vasodilatation périphérique limitée ?
Endothèline : x 5
(1)
Capacités de dilatation
(2)
• Capacités d’extraction périphérique d’ O2 limitée ?
• Myopathie ?
(3)
Post I.C. + Immunothérapie ?
Densité capillaire
Fibres type I
Enzymes mitochondriales..... mais la restauration de corrige pas tout
(4)
(5)
• Fonction ventriculaire gauche ?
Fraction de raccourcissement
Relaxation
(6)
• Fonction ventriculaire droite ?
(7)
Régénération myocardique: une chimère ? (8)
Ne pas oublier les effets ostéoarticulaires et musculo tendineux des corticoïdes…
H.Tx. : Myocardial Reinnervation ?
• No parasympathetic reinnervation
• Possible sympathetic reinnervation (anteroseptal wall);
Correlation with:
Time after transplantation ; nonrejecting patients
Recipient Age at the time of H.Tx;
Donor Age
• Higher H.R. max. during Exercise ( p < 0.01 )
• Improvment of contractile Fonction of L.V.( p < 0.01 )
Bengel F. M. 2001
« The evidence for sympathetic reinnervation is reviewed, with the conclusion that
while it may occur over time, it is inconsistent, and partial in nature. »
Kavanagh T. 2005
• Influence of the beta1-Adrenoreceptor polymorphism
on cardiac reserve in transplanted hearts.
Scharin Täng M. 2007
Témoin
H.T.
E.E H.T. et Témoins : % de variation F.C; Index cardiaque; V.T.D.; V.T.S.
H.Tx :
Heart Rate is not a limitation
14 H.Tx. Runners
• VO2 Peak ( Bicycle )
• VO2 Peak ( Treadmill )
32.5+/-7.8 ml/kg/min.
39.8+/-6.9 ml/kg/min
• H.R. max. Bicycle
• H.R. max. Treadmill
• F.C. max. Running
159+/-16
169+/-14
p < 0.01 ( T / B )
179+/-14
p < 0.01 ( R / T )
(101+/-10% F.M.T.)
p < 0.001 (T / B)
RICHARD R ; VERDIER JC. JACC 1999; 33:192-7.
VO2 max.
HTR (Cœur) / KTR (Rein)
Peak VO2 (ml.kg-1.min-1)
*
70
*
60
50
40
30
20
10
0
HTR
KTR
CS
Maximal treadmill speed (km.h-1)
HTR
KTR
CS
*
*
18
*
16
Richard R,
14
12
Verdier JC
10
8
Doutreleau S
6
Piquard F
4
Geny B
2
Rieu M.
0
HTR
VO2 ( % théorique )
101 12 *
KTR
122 19
CS
123  22
J Heart Lung Transplant.
2005 Nov;24(11)
H.T. greffe Cœur
K.T. greffe Rein
H.T.
K.T.
Controls.
« La F.C. n’est pas une limite chez le greffé cardiaque »
R. RICHARD; J.C. VERDIER and all. J.A.C.C 1999
Physical Activities Post Rehabilitation
• Leisure - time physical Activities :
– Endurance Training ( intensity < 85 % VO2 max. )
– Gymnastic
– Strenght training ( < 50 % M.V.C. )
• Competitive Sports :
– After Cardiac screening
– Importance of performing regular physical exercise
to maintain the highest level of aerobic fitness
World Transplant Games Federation
« Programs for recipients through involvement of the W.T.G. »
Games Objectives:
•
•
•
•
•
To encourage rehabilitation through sport
To demonstrate quality of life after organ transplantation
To promote organ donor awareness
To recognise doners and donor families
To celebtrate life
www.wtgf.org
Sports after TRANSPLANTATION
• Europeen Transplant Games
• World Transplant Games
… since 25 Years !
• 2005 :
Cardiac screening introduced for > 40 years
… No adverse events
...
But orthopedic injuries
World Transplant Games…
ETE
athlétisme, aviron,
badminton, beach volley,
bowling, course à pied,
cyclisme, golf, natation,
squash, tennis, tennis de
table, volley Ball,
tir à l’arc, tir au pistolet,
pétanque et volley Ball.
All Sports !...
HIVER
slalom, slalom géant,
super géant, slalom parallèle,
snowboard, snowboard parallèle,
ski de fond 5km, ski de fond 1h,
Biathlon,
Raquette Course d’orientation,
Ski de fond 3x3km (en équipe),
Slalom team event,
Team Managers fun event
World Transplant Games :
Conclusion *
• W.T. Games activities are safe
• Sporting activities for recipeients of all ages presents
benefits which far exceed the risks
• Safe W.T. Games require a fierce commitment to
protocols of risk management
• On demonstrating the safety of the W.T. Games (500
events), it is now possible to reassure recipients and
their medical teams and carers.
* XXIII International Congress of the Transplantation Society, Vancouver, Canada 2010
« Extremes Cases » …
• COMPETITION ?
– Tennis : Competition in …..Australia Rajendran AJ. 2006 (1)
– Athlétisme : 11 s au 100 m
Carl Whittaker
22 s au 200 m
• Saut à l’élastique ( Normandie Française ! )
• MONT BLANC, France
– 5 H.Tx. ; 2003 ; Transforme.
• 6.000 m Bolivie !
Bedard S. 2006 (2)
Training…
• Ironman … Brune S 2006 (3)
Eligibility Recommendations for
Competitive Athletes With H.T. ?
• Recognizing that there may be exceptional circumstances where an
athlete will require an otherwise prohibited substance for medical
purposes,
• Formal therapeutic exemption mechanisms are available with prior
consideration and approval A.U.T.
• www.afld.fr
Secrétariat général 229, boulevard Saint-Germain 75007 Paris
Tél. : +33(0)1 40 62 76 76 Fax : +33(0)1 40 62 77 39
[email protected]
Conclusions
« Regular physical exercise has a major potential to improve Tx. outcomes
and should therefore be incorporated in routine standard Tx. Management »
Patients limits:
78 % are sedentary;
Most frequently identified barriers in newly transplanted recipients:
« Too sick » : 40%
Lack of motivation : 40 %
Bad weather : 32 %
Medical Care limits:
15 % did not discuss exercise;
39 % did not prescribe a specific amount
S. DE GEEST University of Basel, Switzerland 2010
Heart Transplant patient
and Sports
JC Verdier
Institut Cœur Effort Santé
Paris
www.trans-forme.org
www.lacourseducoeur.com
www.wtgf.org
World Anti-Doping Agency.
www.wada-ama.org.
STRESS TEST : P.A. + versus P.A.
–
( P.A. = Physical Activities )
P.A.
Age ( ans )
Peak W ( w )
VO2 Pic
H.R.. max
H.R. Reserve *
H.R. . Inertia * *
S.B.P. max.
D.B.P. max
+
44 +/- 14
122 (+/- 22)
24 (+/- 6)
140 (+/- 17)
41 (+/- 6)
56 (+/- 54)
185 (+/- 23)
94 (+/- 28)
P.A.
-
p
48 +/- 8
0.1
110 (+/- 17)
22 (+/- 4)
141 (+/-17.1)
34 (+/- 14)
80 (+/- 58)
182 (+/- 43)
84 (+/- 43)
0.009
0.02
0.8
0.05
0.03
0.6
0.16
( * H.R. max – Resting H.R.;
** H.R. max – H.R. at Peak W ; in sec.)
J.C. Verdier ( 100 H.Tx ; 50 P.A. + / 50 P.A. -)
Controls.
K.T.
H.T.
O2 pulse = VO2 / F.C. = V.E.S. x C(a-v)O2
R. RICHARD; J.C. VERDIER and all. J.A.C.C 1999