Coronary Artery Bypass Grafting: Anatomy, Risks, Surgery and Physiotherapy

 Introduction of coronary arteries.
 Right coronary artery.
 Left coronary artery.
 Variations in coronary artery.
 Coronary blood flow.
 Coronary artery disease.
 Risk factors.
 Prevalence.
 Coronary artery bypass grafting.
 Post operative complications.
 Physiotherapy treatment.
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coronary artery bypass grafting

 What is coronary artery?
 What is Work of coronary arteries?
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 Heart muscle is supplied by two coronary
arteries, namely right and left coronary
arteries, which are the first braches of aorta.
 Arteries encircle the heart in the manner of a
crown, hence the name coronary arteries
(Latin word corona=crown).
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 Coronary arteries divide and subdivide into
smaller branches, which run all along the
surface of the heart.
 Smaller branches are called epicardiac
arteries and give rise to further smaller
branches known as finale arteries.
 Finale arteries run at right angles through the
heart muscle, near the inner aspect of wall of
the heart.
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 Right coronary artery is smaller than left
coronary artery.
 It arises from the anterior aortic sinus of
ascending aorta.
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It first passes forwards and to the right to
emerge on the surface of the heart between
the root of the pulmonary trunk and the right
auricle.
It then runs downwards in the right anterior
coronary sulcus to the junction of the right and
inferior border of the heart.
It winds around the inferior border and then it
runs backwards and to the left and reach the
posterior interventricular groove.
It terminates by anastomosing with the
circumflex branch of left coronary artery.
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 Large branches:-
1. Marginal.
2. Posterior interventricular.
 Small branches:-
1. Nodal in 60% cases.
2. Right atrial
3. Infundibular
4. Terminal
5. Right ventricular
6. conus
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 Right atrium.
 Greater part of the right ventricle.
 A small part of the left ventricle (posterior
portion).
 Posterior part of the interventricular septum.
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 Left coronary artery is larger than the right
coronary artery.
 It arises from the left posterior aortic sinus of
ascending aortic.
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First runs forwards and to the left and
emerges between the pulmonary trunk and
left auricle.
Here it gives the anterior interventricular
branch which runs downwards in the
interventricular groove.
Further continuation of the left coronary
artery is called the circumflex artery.
It winds around the left border of the heart
and continues in the left posterior coronary
sulcus.
Near the posterior interventricular groove it
terminates by anastomosing with the right
coronary artery.
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 Large branches:-
1. Anterior interventricular.
2. Diagonal branch.
 Small branches:-
1. Left atrial.
2. Pulmonary.
3. Terminal.
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 Left atrium
 Greater part of the left ventricle.
 A small part of the right ventricle.
 Anterior part of the interventricular septum.
 SA node is supplied by the left coronary
artery in about 40% of cases.
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 In 50% to 60% of human beings, the right
coronary artery is supplies more blood to
heart than left coronary artery (right
dominant).
 In 15% to 20% of human beings, the left
coronary artery is supplies more blood (left
dominant).
 In 20% to 30% of human beings, both
arteries supply almost equal amount of
blood.
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 Normal blood flow through coronary
circulation is about 200 mL/minute.
 It forms 4% of cardiac output.
 It is about 65 to 70 mL/minute/100 g of
cardiac muscle.
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 Coronary artery disease(CAD), also known as
atherosclerotic heart disease or coronary heart
disease(ASHD and CHD).
 Coronary occlusion:-
o Coronary occlusion is the partial or complete
obstruction of the coronary artery.
 Myocardial ischemia:-
o Myocardial ischemia is the reaction of a part of
myocardium in response to hypoxia.
o Hypoxia develops when blood flow to a part of
myocardium decreases severely due to occlusion of
a coronary artery.
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 Necrosis:-
o Ischemia leads to necrosis of myocardium if
a larger part of myocardium is involved or
the occlusion is sever involving large blood
vessels.
 Myocardial infarction-heart attack:-
o Myocardial infarction is the necrosis of
myocardium caused by insufficient blood
flow due to embolus, thrombus or vascular
spasm.
o It is also called heart attack.
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 Cardiac pain – angina pectoris:-
o Cardiac pain is the chest pain that is caused
by myocardial ischemia.
o It is common manifestation of coronary
artery disease.
o Pain starts beneath the sternum and radiates
to the surface of left arm and left shoulder.
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 Family history
 Cigarette smoking
 Hypertension
 Impaired fasting glucose or DM
 Obesity and overweight
 Sedentary lifestyle
 CV disease
 Other medical conditions
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 More than 10 million cases per year in India.
 0 – 18 year, very rare
 19 – 40 year, common
 41 + , very common
 Overall death rate 102.6 per 100000.
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 First performed in 1967, this has become a
common operation for a prevalent disease.
 The aim of the operation is to relieve the
symptoms of angina and in certain groups of
patients to prolong life.
 Patients with severe stenosis of coronary
arteries survive longer (over 5 years) with
surgery than with medical treatment.
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 The most important predictor of long-term
survival is the extent of damage of the left
ventricle.
 Once accepted for operation the patient is
admitted to hospital 48 hours in advance.
 Pre-operative medical treatment with beta-
blocker, calcium antagonists and nitrates is
designed to reduce cardiac work and reduce
the incidence of coronary spasm.
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 A careful anesthetic technique is used to
prevent hypoxia, tachycardia or hypertension
which may otherwise precipitate a
myocardial infraction.
 The operation is performed using
cardiopulmonary bypass.
 Reversed segments of the long saphenous
vein are used to form bypass grafts from the
ascending aorta to the coronary artery distal
to the stenosis.
 Up to five or six grafts may be required.
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 Post operative care occurs in an intensive
care ward for the first 24 hours.
 The majority of patients are fit to leave
hospital 1 week after operation.
 Operative mortality is now less than 2
percent and at 1 year after operation over 85
percent of patients are symptoms free.
 Re-operation can be carried out at a low risk
but the results are less satisfactory than the
initial procedure.
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 Because of the attrition rate of vein grafts,
surgeons are now using the internal
mammary artery on one or both sides.
 The patency of the internal mammary artery
(95 percent) is superior to that of saphenous
vein grafts (70 percent).
 Heart_Bypass_Surgery_(CABG)(240p).mp4
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 Early:-
1. Hemorrhage with or without cardiac
tamponade.
o tamponade describes the situation in which
blood accumulates within the pericardial
cavity and compresses all chambers of the
heart.
o It is recognized by a rise in right or left atrial
pressure.
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2. peri-operative myocardial infraction occurs
in approximately 5 percent of patients.
o This may or may not be clinically significant.
o Usually it is not associated with a fall in
cardiac output, but if extensive it will
obviously increase the risk of death.
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3. dysrhythmia: usually supraventricular tachy-
arrythmias, e.g. atrial fibrillation.
o This is common but easily treated and well
tolerated by the patient.
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4. cerebrovascular accident is now the most
serious complication after coronary artery
surgery particularly in the elderly.
o Two discrete neurological deficit associated
with emboli such as thrombus, atheromatous
plaque or surgically introduced air. But its now
rare.
o The second type of insult is a diffuse injury
usually associated with delayed return of
consciousness, impaired intellect and loss of
memory.
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5. acute renal failure is now a rare
complication.
o It is caused by low arterial pressure
producing renal hypoperfusion.
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 Late:-
o Recurrence of angina due to either occlusion
of vein grafts or progression of disease in
native coronary arteries.
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 Pre-operative treatment:-
 A patient for CABG is admitted at least 2
days prior to the operation.
 This enables him to meet all the staff, find
his way around the unit and to have tests.
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 During this time the aims of the
physiotherapist are as follows:
1. To gain the patient’s confidence.
2. To ensure that the lung fields are clear and
that all areas of the thorax are expanding.
3. To explain where the incision site will be
and how it will be supported during
coughing and moving.
4. To teach coughing or huffing.
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5. To teach the patient general leg and trunk
exercises.
6. To teach shoulder and shoulder girdle
exercise.
7. To train position sense.
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 Post-operative treatment:-
 For the first 48 hours after cardiac surgery,
the patient will be in an intensive care unit,
because he can be under continuous
supervision and skilled personnel are
immediately on hand to deal with any
emergency.
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 Aims of physiotherapy:-
1. To maintain a clear airway.
2. To prevent lung collapse and consolidation.
3. To help the patient to maintain good
posture.
4. To ensure that mobility of the shoulder,
neck trunk and legs is maintained.
5. To prevent deep vein thrombosis later-i.e.
after 48 hours up to 2 weeks.
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6. To restore the patient’s confidence.
7. To increase the patient’s exercise tolerance.
8. To teach the patient a home exercise plan.
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 Essentials of medical physiology, 6th edition,
K. Sembulingam and Prema Sembulingam.
 B D Chaurasia’s Human Anatomy, volume 1,
6th edition.
 Assessment, investigations, skills,
techniques and management, 3rd edition,
Jennifer Pryor.
 Cash’s textbook of chest, heart and vascular
disorders for physiotherapists,4th edition,
Patricia A. Downie.
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 Tidy’s physiotherapy, 12th edition.
 O’sullivan, 6th edition.
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Coronary Artery Bypass Grafting: Anatomy, Risks, Surgery and Physiotherapy

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