corona artery bypass grafting

1. Centre of Physiotherapy and Rehabilitation Sciences
Jamia Millia Islamia, New Delhi
Submitted to:- Dr. Jamal Ali Moiz
Submitted by :- Stuti Sah (BPT IV YEAR)
Subject:- 402 Physiotherapy in cardiopulmonary conditions

2. Definition-
 According to the American Heart Association, coronary artery bypass
graft (CABG) surgeries are among the most commonly performed
major operations.
 CABG is advised for selected groups of patients with significant
narrowings and blockages of the heart arteries(coronary artery
disease).
 CABG creates new routes around diseased, narrowed and blocked
coronary arteries with healthy vessels taken from other places of body,
permitting increased blood flow to deliver oxygen and nutrients to the
heart muscle.
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4. Goals-
 Restore blood flow to the heart
 Relieve chest pain and ischemia
 Improves the patients quality of life
 Enable the patient to resume a normal life
 Lower the risk of a heart attack.
Indications-
 Patients with blockages in coronary arteries.
 Patients with angina
 Patients who cannot tolerate PTCA and don’t respond well to drug therapy
 Immediately after Myocardial Infarction (to help perfusion of the viable
myocardium)
 Life threatening arrhythmias caused by a previous myocardial infarction.
 Occlusion of grafts from previous CABG.
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5. Contraindications-
 Aneurysms
 Valvular diseases
 Congenital diseases
 Diseases of blood, Haemorrhagic diseases
 Pregnancy
 Uncontrolled arrhythmias
 Severe hypertension
Investigations-
 ECG
 Chest Radiography
 TMT
 Isotope scanning
 Coronary angiography
 Echocardiography
 MRI
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6. Procedures of CABG-
(Artery grafts- Mostly internal mammary artery is used.
Vein graft- Saphenous vein is mostly used for grafting)
1. Traditional Coronary Artery Bypass Grafting or On pump
surgery- It uses a heart-lung machine (cardiopulmonary bypass ).
This machine temporarily takes over the heart’s job of pumping
oxygen rich blood to the organs and tissues. This is traditional type
of open heart surgery, chest bone is opened to access the heart. It
allows surgeon to operate on a heart that is not beating and has no
blood travelling through it.
2. Beating heart or Off-Pump Coronary Artery Bypass Grafting-
It doesn’t use a heart-lung machine and surgeon operates on an
actively beating heart. However, surgeon will slow heart rate with
medication or a device. This type of surgery is limited to a few
specific procedures. It is also known as “Beating Heart Surgery”.
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7. Heart lung machine-
• A device used in open heart surgery to support the body during the
surgical procedure while the heart is stopped.
• The heart-lung machine is often referred to as the “pump”’ and does the
work of the heart and lungs during the operation.
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8. 3. Minimaly Invasive Technique-
In this type of surgery surgeon will make small incisions in the side
of chest between the ribs. This cuts can be as small as 2-3 inches.
The surgeon will insert surgical tools along with a small video
camera to see inside the body.
Some types of minimally invasive heart surgery use a heart-lung
bypass machine and others don’t.
4. Robot- assited Technique-
This type of procedure allows for even smaller, keyhole-sized
incisions.
A small video Camera is inserted in one incision to show the heart,
while the surgeon uses remote-controlled surgical instruments to do
the surgery.
A heart-lung bypass machine sometimes is used during this
procedure.
This type of surgery is very precise.
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9. Complications-
 Wound infection and bleeding at the incision site
 Reactions to anesthesia
 Pain
 Pneumonia
 Breathing problems
 Pancreatitis
 Kidney failure
 Abnormal heart rhythms
 Blood clots that can cause stroke, heart attack, lung problems or even
death
 Fever associated with chest pain, irritability and decreased appetite
 Memory loss and other issues, such as problems concentrating or
thinking clearly specially in older patients and ladies- improve in 6-12
months postop.
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10. Post operation CABG-
 After surgery, patient will typically spend 1 or 2 days in an ICU.
Health care team will check patient’s heart rate, blood pressure,
and oxygen levels regularly during this time.
 An intravenous (IV) line will likely be inserted into a vein in arm.
Through the IV line, patient may get medicines to control blood
flow and blood pressure.
 Urinary catheter.
 Chest tube in chest to drain fluid.
 Oxygen therapy
 Temporary pacemaker to control abnormal rhythms.
 Compression stockings in leg.
 Moved to less intensive care area 3-5 days before discharge.
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Phases of cardiac rehabilitation
Phase I or inpatient phase(few days) Discussion with primary provider.
Early mobilization and mild activity.
Phase II -early outpatient (2 to 12
weeks) Clinic or home based & late
outpatient (min. of 6 months)
Individualized treatment plan-
Exercise prescription and Education
classes.
Psychological counselling.
Risk modification- smoking,
hypertension, diabetes, cholesterol,
obesity, nutrition.
Phase III or maintenance phase
(indefinite)
Community based
Cardiac monitoring no longer needed.
Independent continuation of risk-
factor modification and exercise, with
periodic physical evaluation

12. Phase I Cardiac Rehabilition-
Involves Immediate inpatient exercise rehabilition that emphasises:
• Patient education
• Counselling
Exercise therapy:
• Musculoskeletal ROM activities
• ADLs (sitting standing and walking)
Purpose:
• Counter the deconditioning effect of prolonged bed rest
• Prepare patient for a return to normal daily activities
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13. Exercise prescription for Phase I-
1. ROM Exercises- Enhances blood flow to damaged areas,
accelerate tissue repair, increasing muscular strength and flexibility.
2. Ambulation- Low in intensity (approx 1.5-3METS), initially include
self care activities progressed to slow walking, ROM exercises and
ADLs, later stair climbing and formalized physical activity program
after gaining proper physical strength.
3. Discharge plan- Continuation of rehabilitation program after
discharge. Pre discharge plan includes strategies for risk factor
modification, dietary counselling, education on medications, exercise
prescription for use at home.
4. HR, Haemodynamic and RPE to exercise- HR for ROM and
ambulation should not exceed 5-10 beats/min above resting level
during first few days of rehab; SBP should not rise more than 5 mmHg
for ROM and !0-20mmHg during ambulation.
5. RPE for both activities should be between 10 -12 on RPE scale.
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14. 6.Exercise Intensity- Should not exceed 2-3 METS, use of Borg Rating of
Perceived Exertion Scale is encouraged after first few days in the hospital.
FIIT principle for Phase I-
Frequency- 2-3 times/day
Intensity-RHR+20
Duration-10-20 min
Activity-ROM, walking, one flight of stairs
Phase II Cardiac Rehabilitation-
• Once a patient is stable, outpatient cardiac rehabilitation may begin.
• Initially patients have an assessment with a focus on identifying limitations in
physical function, restrictions of participation secondary to comorbidities and
limitations to activities.
• A more rigorous patient therapy plan is designed .
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15. Phase III-
• This phase involves more independence and self monitering- Phase III centers
on increasing flexibility , strengthening and aerobic conditioning.
• Goal- Facilitate long term maintenance of life style changes and secondary
prevention.
• Includes educational sessions, support groups, review in clinics
• Ongoing involvement of family .
FIIT Principle Phase II Phase III
Frequency 1-2 times/day 3-5times/week
Intensity RHR+20, RPE 13 60-80% HR max
Duration 20-60 min 30-60 min
Activity ROM,
treadmill(walking
, jogging), bike,
arm ergometer,
calisthenics,
weight training
ROM, biking,
jogging,
swimming,
calisthenics,
weight training,
endurance sports.
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16. Patient shouldn’t exercise if they are
generally unwell, symptomatic or clinically
unstable-
 Fever/acute systemic illness
 Unresolved/unstable angina
 Resting BP systolic >200mmHg and diastolic >110mmHg
 Significant drop in BP
 Symptomatic hypotension
 Resting/uncontrolled tachycardia (>100bpm)
 Uncontrolled atrial or ventricular arrhythmias
 New/recurrent symptoms of breathlessness, lethargy, palpitations,
dizziness
 Unstable heart failure
 Unstable or uncontrolled diabetes.
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17. • medicinenet.com/coronary_artery_bypass_graft/article.htm
• https://my.clevelandclinic.org/health/treatments/16897-coronary-
artery-bypass-surgery
• https://www.hopkinsmedicine.org/health/treatment-tests-and-
therapies/coronary-artery-bypass-graft-surgery
• https://www.physio-pedia.com/Cardiac_Rehabilitation
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