Coronary Artery Bypass Graft Surgery PPT

1. CABG AND ITS
MANAGEMENT
By Dr. Ajay Kumar Banjara (PT)

2. ANATOMY OF HEART
The heart contains 4 chambers: the right atrium, left
atrium, right ventricle, and left ventricle. the heart.
Heart is covered by three muscular layers
Epicardium
Myocardium
Endocardium

4. CABG – Coronary Artery Bypass Graft
DEFINITION-
A form of bypass surgery that can create new routes
around narrowed and blocked coronary arteries,
permitting increased blood flow to deliver oxygen and
nutrients to the heart muscle. CABG surgery is one of the
most commonly performed major operations.

5. TYPE OF CABG
There are two basic ways of performing CABG: On pump
CABG and Off pump CABG.
They both begin with the surgeon harvesting blood vessels
from the leg saphenous vein, chest internal mammary artery,
internal thoracic artery or the arm radial artery, and
occasionally ulnar artey.
The surgeon gains access to the heart using
8-10cm midline sternotomy incision.

6. Currently, the internal thoracic artery is the standard choice
for bypass surgery because of the morphological
characteristics of the wall that makes less prone to
developing atherosclerosis and hyperplasia .
Cardioplegia A cold (4 C), high potassium content solution
administered at the time of CABG bypass surgery to arrest
the heart in diastole. Diastolic cardiac arrest signifi-cantly
reduces leads to significant reduction in myocardial cellular
metabolism and thereby reducing myocardial ischemia dur-
ing the operation.

7. ON PUMP CABG
In on-pump CABG the heart is stopped with the body’s
blood supply being maintained by the cardiopulmonary
bypass (CPB) machine. While the heart is stopped the
surgeon performs the graft procedure by sewing one end
of a section of a blood vessel over a tiny opening made in
the aorta and the other end over a tiny opening made in
the blocked coronary vessel, distal to its blockage. With
the grafting complete, the body is removed from the
cardiopulmonary bypass machine and the heart is
restarted.

8. OFF PUMP CABG
In off-pump CABG, the area around the blocked coronary
artery is stabilized while the surgeon grafts the blood
vessel on the pumping heart.
Off pump CABG is relatively a newer procedure to On-
pump CABG and doesn’t require the use of the
cardiopulmonary bypass machine.
Polypropylene suture is commonly used in vascular and
cardiac surgeries for anastomosis due to its long-term
tensile strength and minimal tissue trauma.

11. PURPOSE-
 Restore blood flow to the heart.
 Relieve chest pain & ischemia.
 Improves the patient’s quality of life.
 Enables the patient to resume a normal life cycle.
 Lower the risk of a heart attack.

12. INDICATION-
 Left main artery disease or equivalent
 Triple vessel disease
 Abnormal Left Ventricular function.
 Failed PTCA.
 Immediately after Myocardial Infarction.
 Life threatening arrhythmias caused by a
previous myocardial infarction.
 Occlusion of grafts from previous CABG.

13. MANAGEMENT
PHARMACOLOGICAL
PHYSIOTHERAPY

14. PHARMACOLOGICAL
 ACE inhibitors like ramipril.
 Angiotensin-II antagonists like losartan.
 Anti-arrhythmic medicines like amiodarone.
 Anticoagulant medicines like warfarin.
 Anti-platelet medicines like aspirin.
 Beta-blockers like bisoprolol.
 Calcium-channel blockers like amlodipine

15. PHYSIOTHERAPY ASSESSMENT
 SUBJECTIVE :-
DEMOGRAPHIC DETAILS
1. NAME
2. AGE
3. GENDER
4. OCCUPATION
5. ADDRESS
6. CHIEF COMPLAINT
7. HISTORY

16.  OBSERVATION
OBJECTIVE FINDINGS
1. CTVS ICU POD 1-2 MEDIASTINAL CHEST DRAIN PRESENT
2. VITALS- HR, BP,RR, SPO2
3. IV LINE PRESENT / CENTRAL LINE PRESENT
4. FOLLEYS PRESENT
 EXAMINATION.
ROM
MMT

17. PAIN VAS SCALE
1 2 3 4 5 6 7 8 9 10
 AUSCULTATION
Auscultation is an evaluation technique used to
listen and interpret the sounds produced by the
body organ with the help of stethoscope.

18. HEART AND LUNGS

20.  PHYSIOTHERAPY CARDIAC REHABILITATION
Cardiac rehabilitation programs aim to limit the
psychological and physiological stresses of CVD,
and improve cardiovascular function to help
patients achieve their highest quality of life
possible.

21. Goals:
Short-term goals:-
• Physical reconditioning sufficient for resumption of activities.
• Inform the patient and family about the disease process psychological
support throughout the early stages of recovery
Long-term goals:-
• Identify and treating risk factors that influence the progression of disease
(diet, alcohol intake, tobacco chewing)
• Teaching and reinforcing prognosis-improving health behaviours
• Improving physical conditioning and making it easier to return to work and
other activities.

22. PHASES OF CARDIAC REHAB

23.  PHASE 1 :- In patient
This phase begins in the inpatient setting soon after a cardiovascular event.
Therapists start by guiding patients through non-strenuous exercises in the bed or at
the bedside, focusing on a ROM and limiting hospital deconditioning ,team may also
focus on activities of daily living (ADLs) and educate the patient on avoiding excessive
stress.
Chest Physio
Nebulizer
Vibration
Percussion
ACBT
Coughing/Huffing
Breathing exercises
Incentive Spirometry
Limb Physio – Rom for UL /LL
Mobilization

25.  PHASE 2 :- Out Patient
Once a patient is stable and cleared by cardiology, outpatient cardiac
rehabilitation may begin.
Phase II typically lasts 3 to 6 weeks though some may last up to up to 12
weeks.
A more rigorous patient-centered therapy plan is designed, comprising
three modalities: information/advice, tailored training program, and a
relaxation program.
Format :-
Check in (vitals assessed)
Warm Up (15 mins)
Main class (30 mins)
Cool down (10 mins)
Monitoring and reassessment of vitals and check out

26. EXERCISES
 GENTLE STRETCHING
 BREATHING EXS
 STRENGTHENING EXS FOR UL/LL
 RESISTANCE BAND EXS FOR UL/LL
 AEROBIC AND ENDURANCE EXS
Walk/Jogging
Static cycling
Treadmill
6 Min walk test to assess endurance

27.  PHASE 3:- Home program
This phase involves more independence and self-
monitoring. Phase III centers on increasing
flexibility, strengthening, and aerobic conditioning.
Same as phase 2 Exs
Stretching
Resistance Exs
Aerobic Exs
Relaxation Exs

28.  PHASE 4:- Maintenance
If you have completed the previous three stages of
cardiac rehabilitation, you should have a clear grasp of
your heart condition and how best to manage it.
Phase 4 essentially continues for the rest of your life.
Continue to follow the guidance on exercise, nutrition,
and lifestyle, as set out by your rehab team.
Keep up with your exercise regime, continue to avoid
tobacco, eat well, and manage your stress.

29. Program should include:-
• Warm up phase- only bed mobilization initially; as fitness improves patient can sit
stand by the bed trunk movements can be given and stretching can be given.
• Aerobic phase- walking
• Cool down phase- ROM exercises, stretching
• Monitoring for exercise response:-giddiness, chest pain, palpitations
 FITT criteria
 Frequency 2-3times/day
 Intensity RHR+30bpm
 Timing 5-20 mins intermittent bouts of activity <5mins interspersed with rest periods
 Type- sitting/standing functional activities, ROM exercises, progressive walking,
climbing stairs, self care, ADLs.

30. To improve chest compliance:-
• Maintenance of lung hygiene by giving relaxed deep breathing
exercises and breathing control
• Incentive spirometry
• Splinted huffing/coughing
To prevent DVT:-
• Ankle toe movements
• AROM exercises of lower limbs
Mobilization:-
• Dynamic exercises of quadriceps, hamstrings

31. Complications:-
 Low cardiac output
 MediaStinal bleeding
 Cardiac tamponade
 Deep sternal wound infection
 Arrhythmias
 Stroke
 Pleural effusion

32. THANK YOU