2. 2
CHAPTER – 1
INTRODUCTION
Coronary arteries are blood vessels that carry oxygen and nutrients to the heart. In people with
coronary artery disease a fatty substance builds up in the walls of the arteries, making the space
inside narrower. This makes it harder for the blood to pass. If the arteries become narrowed
then the amount of oxygen delivered to the heart muscle may be reduced. This can cause chest
pain, or other symptoms called angina, or lead to a heart attack.
Coronary artery bypass surgery is an operation that is carried out to improve the blood flow to
the heart muscle in people with coronary heart disease where the coronary arteries are severely
narrowed or blocked.
Coronary artery disease occurs when the arteries that supply blood to the heart muscle (the
coronary arteries) become blocked due to the buildup of a material called plaque (plak) on the
inside of the blood vessels. If the blockage is severe, chest pain (also called angina), shortness
of breath, and, in some cases, heart attack can occur.
CABG is one treatment for CAD. During CABG, a healthy artery or vein from another part of
the body is connected, or grafted, to the blocked coronary artery. The grafted artery or vein
bypasses (that is, it goes around) the blocked portion of the coronary artery. This new passage
routes oxygen-rich blood around the blockage to the heart muscle. If more than one artery is
blocked, patient may need more than one bypass. As many as four major blocked coronary
arteries can be bypassed during one surgery.
3. 3
CABG is the most common type of open-heart surgery in the United States, with more than
500,000 surgeries performed each year. Doctors called cardiothoracic surgeons perform this
surgery.
CABG isn’t used for everyone with CAD. Many people with CAD can be treated by other
means, such as lifestyle changes, medicines, and another revascularization procedure called
angioplasty.
CABG may be an option if you have severe blockages in the large coronary arteries that supply
a major part of the heart muscle with blood—especially if the heart’s pumping action has
already been weakened. CABG may also be an option if you have blockages in the heart that
can’t be treated with angioplasty. In these situations, CABG is considered more effective than
other types of treatment.
THE GOALS OF HAVING THE SURGERY ARE TO:
* Improve your quality of life and decrease angina and other symptoms of CAD
* Resume a more active lifestyle
* Improve the pumping action of the heart if it has been damaged by a heart attack
* Lower the chances of a heart attack (in some patients, such as those with diabetes)
* Improve your chance of survival
Repeat surgery may be needed if grafted arteries or veins become blocked, or if new blockages
develop in arteries that weren’t blocked before. Taking medicines as prescribed and making
lifestyle changes that your doctor recommends can lower the chance of a graft becoming
4. 4
blocked. In people who are candidates for the surgery, the results are usually excellent, with 85
percent of people having significantly reduced
symptoms, less risk for future heart attacks, and a decreased chance of dying within 10 years
following the surgery.
If coronary artery disease is suspected your doctor will perform other investigations such as an
exercise stress test, angiogram (threading a catheter through a vessel of your leg to the heart
and injecting a dye into your coronary arteries) or echocardiogram (ultrasound of the heart) to
determine the degree of obstruction.
If coronary heart disease (CHD) is identified a number of different treatment options are
available including medications, angioplasty (insertion of stents) or CABG surgery. These
treatments all improve the blood supply to the heart and will help prevent further symptoms or
heart attacks. Your doctor can discuss which of these treatments is best for you.
HISTORY:
The first coronary artery bypass surgery was performed on May 2, 1960 at the Albert Einstein
College of Medicine-Bronx Municipal Hospital Center by a team led by Dr. Robert Goetz and
the thoracic surgeon, Dr. Michael Rohman with the assistance of Dr. Jordan Haller and Dr.
Ronald Dee.[1][2] But in this technique the vessels are held together with circumferential
ligatures over an inserted metal ring. The internal mammary artery was used as the donor
vessel and was anastomosed to the right coronary artery. The actual anastomosis with the
Rosenbach ring took fifteen seconds and did not require Cardio-Pulmonary bypass. The
disadvantage of using the internal mammary artery was that, at autopsy nine months later, the
5. 5
anastomosis was open, but an atheromatous plaque had occluded the origin of the internal
mammary that was used for the bypass.
The Russian cardiac surgeon, Dr Vasilii Kolesov, performed arguably the first successful
coronary artery anastomosis in 1964
This technique was quickly superseded by Dr. René Favaloro who pioneered the bypass
grafting procedure in 1967 His new technique used a saphenous vein autograft to replace a
stenotic segment of the right coronary artery. He later began to use the saphenous vein as a
bypassing channel and become instantly successful. This is the typical bypass graft technique
we know today. Soon Dr Dudley Johnson extended the bypass to include left coronary arterial
systems. In 1968, Doctors Charles Bailey, Teruo Hirose and George Green used the internal
mammary artery instead of the saphenous vein for the grafting.
TERMINOLOGY:
There are many variations on terminology, in which one or more of 'artery', 'bypass' or 'graft' is
left out. The most frequently used acronym for this type of surgery is CABG, pluralized as
CABGs. More recently the term AORTOCORONARY BYPASS (ACB) has come into
popular use. CABs (Coronary Artery Graft Surgery, pronounced phonetically) should not be
confused with Coronary Angiography (CAG).
Arteriosclerosis is a common arterial disorder characterized by thickening, loss of elasticity,
and calcification of arterial walls, resulting in a decreased blood supply.
7. 7
CHAPTER – 2
ANATOMY AND PHYSIOLOGY OF HEART
ANATOMY AND PHYSIOLOGY OF HEART:
The cardiovascular system is made up of : heart; lungs; arteries and veins, and it is under the
control of the autonomic nervous system (sympathetic and parasympathetic). In a healthy
individual with a healthy heart, heart rate is dictated by the body's needs. If an individual is
8. 8
resting then organs, muscles and tissues require a reduced amount of blood and oxygen. The
result of this is a reduction in blood pressure and a slowing down of heart rate and respirations.
When the individual becomes active then the organs, muscles and tissues require an increasing
amount of blood and oxygen, resulting in raised blood pressure and an increase in heart rate
and respirations. These responses are all involuntary, under the direct control of the autonomic
nervous system. If the individual remains reasonably healthy with no cardiac complications
then the cardiovascular system will continue to work just like this for life.
THE HEART:
The heart is the hardest working muscle in the human body. Located almost in the center of the
chest, the adult human heart is about the size of two fists held side-by-side. At an average rate
of 80 times a minute, the heart beats about 115,000 times in one day or 42 million times in a
year. During an average lifetime, the human heart will beat more than 3 billion times -
pumping an amount of blood that equals about 1 million barrels. Even at rest, the heart
continuously works hard.
9. 9
Fig. 2.1Anatomy of heart
The heart itself is made up of:
Four chambers (two atria and two ventricles) that receive blood from the body and pump out
blood to it.
The atria receive blood coming back to the heart.
The ventricles pump the blood out of the heart.
Blood vessels, which compose a network of arteries and veins that carry blood throughout the
body.
Arteries transport blood from the heart to the body tissues.
Veins carry blood back to the heart.
Four valves to prevent backward flow of blood.
10. 10
Each valve has flaps, called leaflets, that allow the forward flow of blood and prevent the
backward flow.
An electrical system of the heart that controls how fast it beats.
Fig. 2.2 blood pathways
SUPERIOR VENA CAVA: receives blood from the head and upper body and drains it into the
right atrium.
INFERIOR VENA CAVA: receives blood from the legs and trunk and drains it into the right
atrium.
CORONARY VEINS: return deoxygenated blood from myocardium to coronary sinus.
11. 11
CORONARY SINUS: receives venous blood from the veins within myocardium and drains
into the right atrium.
All of the above bring blood to the heart and dump it into the Right Atrium
Fig.2.3 deoxygenated and oxygenated blood
Right Atrium: superior chamber of the heart that receives blood from the vena cavae and
coronary sinus.
Right Atrioventricular (tricuspid) Valve: located between the right atrium and right ventricle,
prevents back flow into the right atrium during ventricular contraction.
12. 12
Right Ventricle: right inferior portion of the heart, sends blood to the pulmonary trunk.
Pulmonary (semi-lunar) Valve: prevents back flow of blood from the pulmonary trunk to the
right ventricle during ventricular relaxation
Pulmonary Trunk: a large vessel on the anterior superior portion of the heart that receives
blood from right ventricle and directs to the lungs via the pulmonary arteries.
Pulmonary Arteries : paired branches of the pulmonary trunk that direct deoxygenated blood to
the lungs to be oxygenated. One of the few places that deoxygenated blood gets carried by
arteries.
Pulmonary Veins: two vessels from each lung that return oxygenated blood to the heart's left
atrium. One of the few places that oxygenated blood gets carried by veins.
Left Atrium: receives blood from the lungs via the pulmonary veins.
Left Atrioventricular (bicuspid or mitral) Valve: located between atrium and ventricle on the
left side, prevents back flow of blood into the left atrium during ventricular contraction.
Left Ventricle: Composed of an unusually thick myocardial wall for contraction against high
pressure
Aortic (semi-lunar) Valve: three half-moon shaped cusps that prevent back flow of blood from
the aorta to the relaxed left ventricle.
Ascending Aorta: receives blood immediately from the ascending aorta. supply blood to the
myocardium.
Aortic Arch: curved portion of the aorta that extends superiorly and posteriorly to the
pulmonary trunk.
13. 13
Descending Aorta: portion of the aorta that descends from the aortic arch and continues
inferiorly until it divides into the common iliac arteries.
Fig2.4 types of vavles
De-oxygenated blood returns to the right side of the heart via the venous circulation. It is
pumped into the right ventricle and then to the lungs where carbon dioxide is released and
oxygen is absorbed. The oxygenated blood then travels back to the left side of the heart into the
left atria, then into the left ventricle from where it is pumped into the aorta and arterial
circulation.
14. 14
Fig2.5 The passage of blood through the heart
The pressure created in the arteries by the contraction of the left ventricle is the systolic blood
pressure. Once the left ventricle has fully contracted it begins to relax and refill with blood
from the left atria. The pressure in the arteries falls whilst the ventricle refills. This is the
diastolic blood pressure.
The atrio-ventricular septum completely separates the 2 sides of the heart. Unless there is a
septal defect, the 2 sides of the heart never directly communicate. Blood travels from right side
to left side via the lungs only. However the chamber themselves work together . The 2 atria
contract simultaneously, and the 2 ventricles contract simultaneously.
15. 15
Fig.2.6 interior structures of heart
CORONARY ARTERIES:
The heart is composed primarily of cardiac muscle tissue that continuously contracts and
relaxes, it must have a constant supply of oxygen and nutrients. The coronary arteries are the
network of blood vessels that carry oxygen- and nutrient-rich blood to the cardiac muscle
tissue.
The blood leaving the left ventricle exits through the aorta, the body’s main artery. Two
coronary arteries, referred to as the "left" and "right" coronary arteries, emerge from the
beginning of the aorta, near the top of the heart.
The initial segment of the left coronary artery is called the left main coronary. This blood
vessel is approximately the width of a soda straw and is less than an inch long. It branches into
two slightly smaller arteries: the left anterior descending coronary artery and the left
circumflex coronary artery. The left anterior descending coronary artery is embedded in the
16. 16
surface of the front side of the heart. The left circumflex coronary artery circles around the left
side of the heart and is embedded in the surface of the back of the heart.
Fig.2.7 coronary artery
Just like branches on a tree, the coronary arteries branch into progressively smaller vessels.
The larger vessels travel along the surface of the heart; however, the smaller branches penetrate
the heart muscle. The smallest branches, called capillaries, are so narrow that the red blood
cells must travel in single file. In the capillaries, the red blood cells provide oxygen and
nutrients to the cardiac muscle tissue and bond with carbon dioxide and other metabolic waste
products, taking them away from the heart for disposal through the lungs, kidneys and liver.
When cholesterol plaque accumulates to the point of blocking the flow of blood through a
coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the
blockage is deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to
function properly. The condition when a coronary artery becomes blocked causing damage to
the cardiac muscle tissue it serves is called a myocardial infarction or heart attack.
17. 17
SUPERIOR VENA CAVA:
The superior vena cava is one of the two main veins bringing de-oxygenated blood from the
body to the heart. Veins from the head and upper body feed into the superior vena cava, which
empties into the right atrium of the heart.
INFERIOR VENA CAVA:
The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the
body to the heart. Veins from the legs and lower torso feed into the inferior vena cava, which
empties into the right atrium of the heart.
AORTA:
The aorta is the largest single blood vessel in the body. It is approximately the diameter of your
thumb. This vessel carries oxygen-rich blood from the left ventricle to the various parts of the
body.
PULMONARY ARTERY:
The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to
the lungs. A common misconception is that all arteries carry oxygen-rich blood. It is more
appropriate to classify arteries as vessels carrying blood away from the heart.
PULMONARY VEIN:
18. 18
The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left
atrium. A common misconception is that all veins carry de-oxygenated blood. It is more
appropriate to classify veins as vessels carrying blood to the heart.
RIGHT ATRIUM:
The right atrium receives de-oxygenated blood from the body through the superior vena cava
(head and upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends
an impulse that causes the cardiac muscle tissue of the atrium to contract in a coordinated,
wave-like manner. The tricuspid valve, which separates the right atrium from the right
ventricle, opens to allow the de-oxygenated blood collected in the right atrium to flow into the
right ventricle.
RIGHT VENTRICLE:
The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary
valve leading into the pulmonary artery is closed, allowing the ventricle to fill with blood.
Once the ventricles are full, they contract. As the right ventricle contracts, the tricuspid valve
closes and the pulmonary valve opens. The closure of the tricuspid valve prevents blood from
backing into the right atrium and the opening of the pulmonary valve allows the blood to flow
into the pulmonary artery toward the lungs.
LEFT ATRIUM:
19. 19
The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the
contraction triggered by the sinoatrial node progresses through the atria, the blood passes
through the mitral valve into the left ventricle.
LEFT VENTRICLE:
The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes
through the mitral valve into the left ventricle. The aortic valve leading into the aorta is closed,
allowing the ventricle to fill with blood. Once the ventricles are full, they contract. As the left
ventricle contracts, the mitral valve closes and the aortic valve opens. The closure of the mitral
valve prevents blood from backing into the left atrium and the opening of the aortic valve
allows the blood to flow into the aorta and flow throughout the body
PAPILLARY MUSCLES:
The papillary muscles attach to the lower portion of the interior wall of the ventricles. They
connect to the chordae tendineae, which attach to the tricuspid valve in the right ventricle and
the mitral valve in the left ventricle. The contraction of the papillary muscles opens these
valves. When the papillary muscles relax, the valves close.
CHORDAE TENDINEAE:
The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the
right ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and
relax, the chordae tendineae transmit the resulting increase and decrease in tension to the
20. 20
respective valves, causing them to open and close. The chordae tendineae are string-like in
appearance and are sometimes referred to as "heart strings."
TRICUPID VALVE:
The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-
oxygenated blood collected in the right atrium to flow into the right ventricle. It closes as the
right ventricle contracts, preventing blood from returning to the right atrium; thereby, forcing it
to exit through the pulmonary valve into the pulmonary artery.
MITRIAL VAVLE:
The mitral valve separates the left atrium from the left ventricle. It opens to allow the
oxygenated blood collected in the left atrium to flow into the left ventricle. It closes as the left
ventricle contracts, preventing blood from returning to the left atrium; thereby, forcing it to exit
through the aortic valve into the aorta.
PULMONARY VAVLE:
The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles
contract, it opens to allow the de-oxygenated blood collected in the right ventricle to flow to
the lungs. It closes as the ventricles relax, preventing blood from returning to the heart.
AORTIC VAVLE:
21. 21
The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens
to allow the oxygenated blood collected in the left ventricle to flow throughout the body. It
closes as the ventricles relax, preventing blood from returning to the heart
CARDIAC CONDUCTION SYSTEM:
The heart is able to create it's own electrical impulses and control the route the impulses take
via a specialised conduction pathway.
This pathway is made up of 5 elements:
1. The sino-atrial (SA) node
2. The atrio-ventricular (AV) node
3. The bundle of His
4. The left and right bundle branches
5. The Purkinje fibres
22. 22
Fig2.8: The cardiac conduction system
The SA node is the natural pacemaker of the heart. The SA node releases electrical stimuli at a
regular rate, the rate is dictated by the needs of the body. Each stimulus passes through the
myocardial cells of the atria creating a wave of contraction which spreads rapidly through both
atria.
The electrical stimulus from the SA node eventually reaches the AV node and is delayed
briefly so that the contracting atria have enough time to pump all the blood into the ventricles.
Once the atria are empty of blood the valves between the atria and ventricles close. At this
point the atria begin to refill and the electrical stimulus passes through the AV node and
Bundle of His into the Bundle branches and Purkinje fibres.
In the case of the heart, the SA node recharges whilst the atria are refilling, and the AV node
recharges when the ventricles are refilling. In this way there is no need for a pause in heart
function. Again, this process takes less than one third of a second.
The times given for the 3 different stages are based on a heart rate of 60 bpm , or 1 beat per
second.
The term used for the release (discharge) of an electrical stimulus is "depolarisation", and the
term for recharging is "repolarisation".
So, the 3 stages of a single heart beat are:
1. Atrial depolarisation
2. Ventricular depolarisation
23. 23
3. Atrial and ventricular repolarisation.
As the atria repolarise during ventricular contraction, there is no wave representing atrial
repolarisation as it is buried in the QRS.
24. 24
CHAPTER – 3
TYPES OF CABG
Traditional Coronary Artery Bypass Grafting:
This is the most common type of coronary artery bypass grafting (CABG). It's used when at
least one major artery needs to be bypassed. During the surgery, the chest bone is opened to
access the heart. Medicines are given to stop the heart, and a heart-lung machine is used to
keep blood and oxygen moving throughout the body during surgery. This allows the surgeon to
operate on a still heart. After surgery, the heart is restarted using mild electric shocks.
Off-Pump Coronary Artery Bypass Grafting:
This type of CABG is similar to traditional CABG in that the chest bone is opened to access
the heart. However, the heart isn't stopped, and a heart-lung machine isn't used. Off-pump
25. 25
CABG is sometimes called beating heart bypass grafting. This type of surgery may reduce
complications that can occur when a heart-lung machine is used, and it may speed up recovery
time after surgery.
Minimally Invasive Direct Coronary Artery Bypass Grafting:
This surgery is similar to off-pump, but instead of a large incision to open the chest bone,
several small incisions are made on the left side of the chest between the ribs. This type of
surgery is used mainly for bypassing the vessels in front of the heart. It's a fairly new
procedure, which is performed less often than the other types. This type of surgery is not for
everybody, especially if more than one or two coronary arteries need to be bypassed.
Traditional Coronary Artery Bypass Grafting:
This type of surgery usually lasts 3 to 5 hours, depending on the number of arteries being
bypassed. Numerous steps take place during traditional CABG.
Anesthesia is given to put you to sleep. During the surgery, the anesthesiologist monitors your
heartbeat, blood pressure, oxygen levels, and breathing. A breathing tube is placed in your
lungs through your throat, and connected to a ventilator (breathing machine).
An incision is made down the center of your chest. The chest bone is then cut and your ribcage
is opened so that the surgeon can get to your heart.
Medicines are used to stop your heart, which allows the surgeon to operate on it while it's not
beating. A heart-lung machine keeps oxygen-rich blood moving throughout your body. An
artery or vein is taken from a different part of your body, such as your chest or leg, and
prepared to be used as a graft for the bypass. In surgery with several bypasses, a combination
of both artery and vein grafts is commonly used.
26. 26
Artery grafts. These grafts are much less likely than vein grafts to become blocked over time.
The left internal mammary artery is most commonly used for an artery graft. It's located inside
the chest close to the heart. Arteries from the arm or other places in the body are sometimes
used as well.
Vein grafts. Although veins are commonly used as grafts, they're more likely than artery grafts
to develop plaque and become blocked over time. The saphenous vein-a long vein running
along the inner side of the leg-is typically used.
After the grafting is complete, your heart is restarted using mild electric shocks. You're
disconnected from the heart-lung machine. Tubes are inserted into your chest to drain fluid.
The surgeon uses wires that stay in your body permanently to close your chest bone and
stitches or staples to close the skin incision. The breathing tube is removed when you're able to
breathe without it.
Fig.3.1 bypass graft
27. 27
Nontraditional Coronary Artery Bypass Grafting:
Nontraditional CABG includes off-pump CABG and minimally invasive CABG.
Off-Pump Coronary Artery Bypass Grafting:
This type of surgery can be used to bypass any of the coronary arteries. Off-pump CABG also
is called beating heart bypass grafting because the heart isn't stopped and a heart-lung machine
isn't used. Instead, the part of the heart where grafting is being done is steadied with a
mechanical device.
Off-pump CABG may reduce complications that can occur when a heart-lung machine is used,
especially in people who have had a stroke or "mini-strokes" in the past, who are over age 70,
and who have diabetes, lung disease, or kidney disease.
Other advantages of this type of bypass surgery include:
Reduced bleeding during surgery and a lower chance of needing a blood transfusion
A lower chance of infection, stroke, and kidney complications
A lower chance of complications such as memory loss, difficulty concentrating, or difficulty
thinking clearly
Faster recovery from the surgery
Minimally Invasive Direct Coronary Artery Bypass Grafting:
There are several types of minimally invasive direct coronary artery bypass (MIDCAB)
grafting. These types of surgery differ from traditional bypass surgery because they only
require small incisions rather than opening the chest bone to get to the heart. These procedures
sometimes use a heart-lung machine.
MIDCAB procedure. This procedure is used when only one or two coronary arteries need to be
bypassed. A series of small incisions is made between your ribs on the left side of your chest,
28. 28
directly over the artery to be bypassed. The incisions are usually about 3 inches long. (The
incisions made in traditional CABG are at least 6 to 8 inches long.) The left internal mammary
artery is most often used for the graft. A heart-lung machine isn't used during this procedure.
Port-access coronary artery bypass procedure. This procedure is performed through small
incisions (ports) made in your chest. Artery or vein grafts are used. The heart-lung machine is
used during this procedure.
Robot-assisted 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 remotely controlled surgical instruments to perform the surgery. The heart-lung machine
is sometimes used during this procedure. Advantages of minimally invasive CABG include
smaller incisions, smaller scars, shorter recovery and hospital stay, less bleeding, less chance
for infection, and less pain.
Other Names for Coronary Artery Bypass Grafting:
Bypass surgery
Coronary artery bypass surgery
Heart bypass surgery
30. 30
Coronary artery bypass grafting (CABG) is only used to treat people who have severe coronary
artery disease (CAD) that could lead to a heart attack.
Your doctor may recommend CABG if other treatments, such as lifestyle changes or
medicines, haven't worked. He or she also may recommend CABG if you have severe
blockages in the large coronary arteries that supply a major part of the heart muscle with
blood-especially if your heart's pumping action has already been weakened.
CABG also may be a treatment option if you have blockages in the heart that can't be treated
with angioplasty.
Indications for Coronary Artery Bypass Grafting (CABG) depend on various factors, mainly
on the individual's symptoms and severity of disease. Some of these include -
1. Left main artery disease or equivalent
2. Triple vessel disease
3. Abnormal Left Ventricular function.
31. 31
4. Failed PTCA.
5. Immediately after Myocardial Infarction
(to help perfusion of the viable myocardium).
6. Life threatening arrhythmias caused by a previous myocardial infarction.
7. intractable angina not responding to medical therapy
8. Occlusion of grafts from previous CABGs. Coronary arteries less than 1mm in diameter by
angiogram measurement are not suitable for bypass grafting. Bypass grafting may be
contraindicated in patients, for e.g. absent viable myocardium or the artery that needs grafting
is too small.
The chief anatomical indications for CABG are the presence of triple-vessel disease, severe left
main stem artery stenosis, or left main equivalent disease (ie, 70 percent or greater stenosis of
left anterior descending and proximal left circumflex artery)—particularly if left ventricular
function is impaired. Overall, scientific studies have shown that CABG improves long-term
survival in these high-risk patients, while also relieving their symptoms of angina.
33. 33
CORONARY ARTERY DISEASE
Coronary artery disease (CAD), also called coronary heart disease, is a condition in which
plaque (plak) builds up inside the coronary arteries. These arteries supply your heart muscle
with oxygen-rich blood.
Plaque is made up of fat, cholesterol, calcium, and other substances found in the blood. When
plaque builds up in the arteries, the condition is called atherosclerosis.
34. 34
Figure5.1 A. shows a normal artery with normal blood flow.
B. shows an artery with plaque buildup.
Plaque narrows the arteries and reduces blood flow to your heart muscle. It also makes it more
likely that blood clots will form in your arteries. Blood clots can partially or completely block
blood flow.
When your coronary arteries are narrowed or blocked, oxygen-rich blood can't reach your heart
muscle. This can cause angina (an-JI-nuh or AN-juh-nuh) or a heart attack.
35. 35
Angina is chest pain or discomfort that occurs when not enough oxygen-rich blood is flowing
to an area of your heart muscle. Angina may feel like pressure or squeezing in your chest. The
pain also may occur in your shoulders, arms, neck, jaw, or back.
A heart attack occurs when blood flow to an area of your heart muscle is completely blocked.
This prevents oxygen-rich blood from reaching that area of heart muscle and causes it to die.
Without quick treatment, a heart attack can lead to serious problems and even death.
Over time, CAD can weaken the heart muscle and lead to heart failure and arrhythmias. Heart
failure is a condition in which your heart can't pump enough blood throughout your body.
Arrhythmias are problems with the speed or rhythm of your heartbeat.
36. 36
CHAPTER – 6
DEVELOPMENT OF CAD
DEVELOPMENT OF CAD
Coronary artery disease (CAD) occurs when atherosclerotic plaque (hardening of the arteries)
builds up in the wall of the arteries that supply the heart. This plaque is primarily made of
cholesterol. Plaque accumulation can be accelerated by smoking, high blood pressure, elevated
cholesterol, and diabetes. Patients are also at higher risk for plaque development if they are
older (greater than 45 years for men and 55 years for women), or if they have a positive family
history for early heart artery disease.
37. 37
The atherosclerotic process causes significant narrowing in one or more coronary arteries.
When coronary arteries narrow more than 50 to 70%, the blood supply beyond the plaque
becomes inadequate to meet the increased oxygen demand during exercise. The heart muscle in
the territory of these arteries becomes starved of oxygen (ischemic). Patients often experience
chest pain (angina) when the blood oxygen supply cannot keep up with demand. Up to 25% of
patients experience no chest pain at all despite documented lack of adequate blood and oxygen
supply. These patients have "silent" angina, and have the same risk of heart attack as those with
angina.
When a blood clot (thrombus) forms on top of this plaque, the artery becomes completely
blocked causing a heart attack.
38. 38
Fig.6.1 heart attack
When arteries are narrowed in excess of 90 to 99%, patients often have accelerated angina or
angina at rest (unstable angina). Unstable angina can also occur due to intermittent blockage of
an artery by a thrombus that eventually is dissolved by the body's own protective clot-
dissolving system.
40. 40
DIAGNOSIS
Physical Exam and Diagnostic Tests
The resting electrocardiogram (EKG) is a recording of the electrical activity of the heart, and
can demonstrate signs of oxygen starvation of the heart (ischemia) or heart attack. Often, the
resting EKG is normal in patients with coronary artery disease and angina. Exercise treadmill
tests are useful screening tests for patients with a moderate likelihood of significant coronary
artery disease (CAD) and a normal resting EKG. These stress tests are about 60 to 70%
accurate in diagnosing significant CAD.
If the stress tests do not reveal the diagnosis, greater accuracy can be achieved by adding a
nuclear agent (thallium or Cardiolite) intravenously during stress tests. Addition of thallium
allows nuclear imaging of the blood flow to different regions of the heart, using an external
camera. An area of the heart with reduced blood flow during exercise, but normal blood flow at
rest, signifies significant artery narrowing in that region.
Combining echocardiography (ultrasound imaging of the heart muscle) with exercise stress
testing (stress echocardiography) is also a very accurate technique to detect CAD. When a
significant blockage exists, the heart muscle supplied by this artery does not contract as well as
the rest of the heart muscle. Stress echocardiography and thallium stress tests are both at least
80% to 85% accurate in detecting significant coronary artery disease.
When a patient cannot undergo exercise stress test because of nervous system or joint
problems, medications can be injected intravenously to simulate the stress on the heart due to
exercise and imaging can be performed with a nuclear camera or ultrasound.
41. 41
Medical tests will be done to find out which arteries are clogged, how much they're clogged,
and whether there's any heart damage. Tests may include:
EKG (electrocardiogram). An EKG is a simple test that detects and records the electrical
activity of the heart. This test is used to help detect and locate the source of heart problems. An
EKG shows how fast the heart is beating, whether the heart's rhythm is steady or irregular,
where in the heart the electrical activity starts, and whether the electrical activity is traveling
through the heart in a normal way.
Stress test. Some heart problems are easier to diagnose when your heart is working harder and
beating faster than when it's at rest. During stress testing, you exercise (or are given medicine if
you're unable to exercise) to make your heart work harder and beat faster while heart tests are
performed.
During exercise stress testing, your blood pressure and EKG readings are monitored while you
walk or run on a treadmill or pedal a bicycle. Other heart tests, such as nuclear heart scanning
or echocardiography, also can be done at the same time. These would be ordered if your doctor
needs more detailed information on blood flow and the heart's pumping action than the
exercise stress test can provide.
If you are unable to exercise, a medicine can be injected through an intravenous line (IV) into
your bloodstream to make your heart work harder and beat faster, as if you are exercising on a
treadmill or bicycle. Nuclear heart scanning or echocardiography is then usually done.
During nuclear heart scanning, radioactive tracer is injected into your bloodstream, and a
special camera shows the flow of blood through your heart and arteries. Echocardiography uses
sound waves to show blood flow through the chambers and valves of your heart and to show
how well your heart pumps.
42. 42
Your doctor also may order two newer tests along with stress testing if more information is
needed about how well your heart works. These new tests are magnetic resonance imaging
(MRI) and positron emission tomography (PET) scanning of the heart. MRI shows detailed
images of the structures and beating of your heart, which may help your doctor better assess if
parts of your heart are weak or damaged. PET scanning shows the level of metabolic activity in
different areas of your heart. This can help your doctor determine if enough blood is flowing to
the areas of your heart. A PET scan can show decreased blood flow caused by disease or
damaged muscles that may not be detected by other scanning methods.
Echocardiogram. This test uses sound waves to create a moving picture of your heart.
Echocardiogram provides information about the size and shape of your heart and how well
your heart chambers and valves are functioning. The test also can identify areas of poor blood
flow to the heart, areas of heart muscle that are not contracting normally, and previous injury to
the heart muscle caused by poor blood flow.
There are several different types of echocardiograms, including a stress echocardiogram.
During this test, an echocardiogram is done both before and after your heart is stressed either
by having you exercise or by injecting a medicine into your bloodstream that makes your heart
beat faster and work harder. A stress echocardiogram is usually done to find out if you have
decreased pumping action of your heart (CAD).
Angiography. Angiography uses a special dye injected into the bloodstream to outline the
insides of arteries on x-ray pictures. An angiogram shows the location and severity of
blockages in blood vessels.
Cardiac catheterization with angiography (coronary arteriography) is the most accurate test to
detect coronary artery narrowing. Small hollow plastic tubes (catheters) are advanced under x-
43. 43
ray guidance to the openings of the two main heart arteries (left and right). Iodine contrast,
"dye," is then injected into the arteries while an x-ray video is recorded. Sometimes, an
exercise study is then done to determine whether a moderate narrowing (40 - 60%) is actually
causing ischemia and, therefore, requires treatment.
A newer modality, high speed CT scanning angiography has recently become available. This
procedure uses powerful x-ray methods to visualize the arteries to the heart. Its role in the
evaluation of CAD is currently being evaluated.
44. 44
CHAPTER- 8
TREATMENT
TREATMENT
Medicines used to treat angina reduce the heart muscle demand for oxygen in order to
compensate for the reduced blood supply. Three commonly used classes of drugs are the
nitrates, beta blockers and calcium blockers. Nitroglycerin (Nitro-Bid) is an example of a
nitrate. Examples of beta blockers include propranolol (Inderal) and atenolol (Tenormin).
Examples of calcium blockers include nicardipine (Cardene) and nifedipine (Procardia,
Adalat). Unstable angina is also treated with aspirin and the intravenous blood thinner heparin.
Aspirin prevents clumping of platelets, while heparin prevents blood clotting on the surface of
45. 45
plaques in a critically narrowed artery. When patients continue to have angina despite
maximum medications, or when significant ischemia still occurs with exercise testing,
coronary arteriography is usually indicated. Data collected during coronary arteriography help
doctors decide whether the patient should be considered for percutaneous coronary
intervention, or percutaneous transluminal angioplasty (PTCA), whereby a small balloon is
used to inflate the blockage. Angioplasty (PTCA) is usually followed by placement of a stent
or coronary artery bypass graft surgery (CABG) to increase coronary artery blood flow.
Angioplasty can produce excellent results in carefully selected patients. Under x-ray guidance,
a wire is advanced from the groin to the coronary artery. A small catheter with a balloon at the
end is threaded over the wire to reach the narrowed segment. The balloon is then inflated to
push the artery open, and a steel mesh stent is generally inserted.
CABG surgery is performed to relieve angina in patients who have failed medical therapy and
are not good candidates for angioplasty (PTCA). CABG surgery is ideal for patients with
multiple narrowings in multiple coronary artery branches, such as is often seen in patients with
diabetes. CABG surgery has been shown to improve long-term survival in patients with
significant narrowing of the left main coronary artery, and in patients with significant
narrowing of multiple arteries, especially in those with decreased heart muscle pump function.
47. 47
PRE-OPERATIVE PREPARATION
Prior to your operation your surgeon will explain the reasons for the operation, how it is
performed and the common and most serious risks associated with the operation (discussed
below). You will have to sign a written consent form that proves you agree to have the
operation and accept the risks explained to you. You will also have to say whether you consent
to a blood transfusion. As cardiac surgery is major surgery and can be associated with
bleeding, the doctors need your permission to administer blood products if you require them
during your operation. Many CABG operations are performed electively meaning that you will
be pre-booked for the operation and come into hospital the night before the surgery.
Prior to surgery you will have to have a number of investigations which may include:
Electrocardiogram (ECG)- An electrical tracing of the heart which can help diagnoses
ischaemic heart disease and helps to tell how fit your heart is for surgery.
48. 48
Echocardiogram- An ultrasound of the heart performed either through the chest or using a tube
down the oesophagus. This test shows how each chamber of the heart is working and can help
the surgeon to decide if any additional procedures need to be performed. If your heart is
pumping poorly you may need a 'balloon pump' inserted into the aorta (large artery descending
in the abdomen) via the femoral artery in the groin. This helps the heart fill so it can better
cope with surgery.
Occasionally your doctor may also decide that a valve within your heart also needs repair or
replacement at the time of surgery.
Carotid Doppler- This is an ultrasound examinations of the vessels in the neck. It determines
whether you have a blockage in the main artery in the neck which determines your risk of
stroke during cardiac surgery. If there is a significant blockage you may require a carotid
endarterectomy procedure (where the carotid artery is opened and atherosclerotic material
removed) prior to cardiac surgery.
Chest x-ray- Routine pre-operative investigation.
Blood tests- Including a full blood count, electrolytes, liver function tests (LFT) and
coagulation factors. These tell the doctor how well the systems in your body are working and
how fit you are for surgery. A sample of blood for cross-matching is also taken. This means the
laboratory tests your blood to identify antigens and determine which blood samples are
compatible in case blood is needed during your surgery.
Urine sample- To exclude infection.
49. 49
Nasal swab- To exclude Methicillin resistant Staphylococcus Aureus (MRSA) carriage. If this
is present a course of antibiotics may be needed prior to surgery to ensure other areas of the
body are not infected with this resistant bacteria.
Hepatitis C, hepatitis B and HIV serology- As there is a lot of blood involved in cardiac
surgery, there is a high risk of needlestick injury for cardiac surgeons. These tests are therefore
performed as a protective measure for theatre staff.
As forementioned, you will usually be admitted the night before your surgery. If you have
severe stenosis of your vessels you may need to take aspirin (a blood thinner) until a day before
the surgery. This reduces your risk of further ischaemia. However, in most other cases any
blood thinning medications will be ceased a week prior to surgery to reduce your risk of
bleeding. Your doctor will discuss with you how to manage your medications. Your doctor will
also prescribe a nasal smear called mupiricin to take 2 days prior and 3 days after your surgery.
This is an antibiotic drug which kills the bugs you carry in your nose. It is important to use this
drug twice daily to reduce your risk of wound infection from breathing on the wound. You will
also need to wash with a special chlorhexidine wash the night before and morning of your
surgery. In addition you will need to fast (usually from midnight) the night before your
surgery. This means no food or drink for several hours before your surgery to ensure your
stomach is empty and to minimise the risk of aspiration.
CABG surgery does not cure your disease. It is important that before and after your surgery
you take measures to reduce your cardiovascular risk. This involves:
Quitting smoking- This should be done pre-operatively to reduce the progression of disease.
Some surgeons may even refuse to operate on patients who continue to smoke. With
appropriate motivation it is possible for you to quit. Your doctor can refer you to several
50. 50
support groups to help you in this process and can even prescribe some medications (such as
Zyban) to reduce cravings. It is very important to quit smoking as smoking can damage all
vessels in the body as well as the lungs and heart.
Maintaining a healthy weight- You may need to cut down on fats, cholesterol and increase
your exercise.
Reducing excessive alcohol intake- Excess alcohol prior to surgery damages your liver and
inhibits the production of clotting factors. This may predispose to bleeding.
Reducing high blood pressure- This can be done by reducing salt in your diet and performing
regular exercise. You should have your blood pressure monitored regularly by your GP and
take any medications as prescribed.
52. 52
PROCEDURE
1. The patient is brought to the operating room and moved on to the operating table.
2. An anaesthetist places a variety of intravenous lines and injects an induction agent (usually
propofol) to render the patient unconscious.
3. An endotracheal tube is inserted and secured by the anaesthetist or assistant (e.g. respiratory
therapist or nurse anaesthetist) and mechanical ventilation is started.
4. The chest is opened via a median sternotomy and the heart is examined by the surgeon.
5. The bypass grafts are harvested - frequent conduits are the internal thoracic arteries, radial
arteries and saphenous veins. When harvesting is done, the patient is given heparin to prevent
the blood from clotting.
6. In the case of "off-pump" surgery, the surgeon places devices to stabilize the heart.
7. If the case is "on-pump", the surgeon sutures cannulae into the heart and instructs the
perfusionist to start cardiopulmonary bypass (CPB). Once CPB is established, the surgeon
places the aortic cross-clamp across the aorta and instructs the perfusionist to deliver
cardioplegia to stop the heart.
53. 53
8. One end of each graft is sewn on to the coronary arteries beyond the blockages and the other
end is attached to the aorta.
9. The heart is restarted; or in "off-pump" surgery, the stabilizing devices are removed. In some
cases, the Aorta is partially occluded by a C-shaped clamp, the heart is restarted and suturing
of the grafts to the aorta is done in this partially occluded section of the aorta while the heart is
beating.
10. Protamine is given to reverse the effects of heparin.
11. The sternum is wired together and the incisions are sutured closed.
54. 54
Fig10.1
12. The patient is moved to the intensive care unit (ICU) to recover. After awakening and
stabilizing in the ICU (approximately 1 day), the person is transferred to the cardiac surgery
ward until ready to go home (approximately 4 days).
55. 55
PROCEDURE DETAILS
The cardiac surgeon makes an incision down the middle of the chest and then saws through the
breastbone (sternum). This procedure is called a median (middle) sternotomy (cutting of the
sternum). The heart is cooled with iced salt water, while a preservative solution is injected into
the heart arteries. This process minimizes damage caused by reduced blood flow during
surgery and is referred to as "cardioplegia." Before bypass surgery can take place, a
cardiopulmonary bypass must be established. Plastic tubes are placed in the right atrium to
channel venous blood out of the body for passage through a plastic sheeting (membrane
oxygenator) in the heart lung machine. The oxygenated blood is then returned to the body. The
main aorta is clamped off (cross clamped) during CABG surgery to maintain a bloodless field
and to allow bypasses to be connected to the aorta.
fig10.2 CABG
56. 56
The most commonly used vessel for the bypass is the saphenous vein from the leg. Bypass
grafting involves sewing the graft vessels to the coronary arteries beyond the narrowing or
blockage. The other end of this vein is attached to the aorta. Chest wall arteries, particularly the
left internal mammary artery, have been increasingly used as bypass grafts. This artery is
separated from the chest wall and usually connected to the left anterior descending artery
and/or one of its major branches beyond the blockage. The major advantage of using internal
mammary arteries is that they tend to remain open longer than venous grafts. Ten years after
CABG surgery, only 66% of vein grafts are open compared to 90% of internal mammary
arteries. However, artery grafts are of limited length, and can only be used to bypass diseases
located near the beginning (proximal) of the coronary arteries. Using internal mammary
arteries may prolong CABG surgery because of the extra time needed to separate them from
the chest wall. Therefore, internal mammary arteries may not be used for emergency CABG
surgery when time is critical to restore coronary artery blood flow.
CABG surgery takes about four hours to complete. The aorta is clamped off for about 60
minutes and the body is supported by cardiopulmonary bypass for about 90 minutes. The use
of 3 (triple), 4 (quadruple), or 5 (quintuple) bypasses are now routine. At the end of surgery,
the sternum is wired together with stainless steel and the chest incision is sewn closed. Plastic
tubes (chest tubes) are left in place to allow drainage of any remaining blood from the space
around the heart (mediastinum). About 5% of patients require exploration within the first 24
hours because of continued bleeding after surgery. Chest tubes are usually removed the day
after surgery. The breathing tube is usually removed shortly after surgery. Patients usually get
out of bed and are transferred out of intensive care the day after surgery. Up to 25% of patients
develop heart rhythm disturbances within the first three or four days after CABG surgery.
57. 57
These rhythm disturbances are usually temporary atrial fibrillation, and are felt to be related to
surgical trauma to the heart. Most of these arrhythmias respond to standard medical therapy
that can be weaned one month after surgery. The average length of stay in the hospital for
CABG surgery has been reduced from as long as a week to only three to four days in most
patients. Many young patients can even be discharged home after two days.
A new advance for many patients is the ability to do CABG with out going on
cardiopulmonary bypass ("off pump"), with the heart still beating. This significantly minimizes
the occasional memory defects and other complications that may be seen after CABG, and is a
significant advance.
GRAFT PATENCY.
Grafts can become diseased and may occlude in the months to years after bypass surgery is
performed. Patency is a term used to describe the chance that a graft remain open. A graft is
considered patent if there is flow through the graft without any significant (>70% diameter)
stenosis in the graft.
Graft patency is dependent on a number of factors, including the type of graft used (internal
thoracic artery, radial artery, or great saphenous vein), the size or the coronary artery that the
graft is anastomosed with, and, of course, the skill of the surgeon(s) performing the procedure.
Arterial grafts (e.g. LITA, radial) are far more sensitive to rough handling than the saphenous
veins and may go into spasm if handled improperly.
Generally the best patency rates are achieved with the in-situ (the proximal end is left
connected to the subclavian artery) left internal thoracic artery with the distal end being
anastomosed with the coronary artery (typically the left anterior descending artery or a
58. 58
diagonal branch artery). Lesser patency rates can be expected with radial artery grafts and
"free" internal thoracic artery grafts (where the proximal end of the thoracic artery is excised
from its origin from the subclavian artery and re-anastomosed with the ascending aorta).
Saphenous vein grafts have worse patency rates, but are more available, as the patients can
have multiple segments of the saphenous vein used to bypass different arteries.
Veins that are used either have their valves removed or are turned around so that the valves in
them do not occlude blood flow in the graft. LITA grafts are longer-lasting than vein grafts,
both because the artery is more robust than a vein and because, being already connected to the
arterial tree, the LITA need only be grafted at one end. The LITA is usually grafted to the left
anterior descending coronary artery (LAD) because of its superior long-term patency when
compared to saphenous vein grafts[
Sternal Precautions
Patients undergoing coronary artery bypass surgery will have to avoid certain things for eight
to 12 weeks to reduce the risk of opening the incision. These are called sternal precautions.
First, patients need to avoid using their arms excessively, such as pushing themselves out of a
chair or reaching back before sitting down. To avoid this, patients are encouraged to build up
momentum by rocking several times in their chair before standing up. Second, patients should
avoid lifting anything in excess of 5-10 pounds. A gallon (U.S.) of milk weighs approximately
8.5 pounds, and is a good reference point for weight limitations. Finally, patients should avoid
overhead activities with their hands, such as reaching for sweaters from the top shelf of a closet
or reaching for plates or cups from the cupboard.
60. 60
POST-OPERATIVE MANAGEMENT:
Immediately after your surgery, you will be taken to the Surgical Intensive Care Unit (SICU).
It will take about 2 hours to get you settled in the SICU. During this time your family will be
asked to wait in the SICU waiting area. When your family comes to visit for the first time, they
will see equipment and people around your bed. There will be noise both from the equipment
and the activity. Some of the equipment will include:
Heart monitor: A machine that continuously shows the electrical activity in your heart.
Infusion pumps: A machine that controls the rate at which you will get various
medicines and fluids.
Arterial lines and monitors: A tube and machine that continuously measures your blood
pressure and allows blood to be drawn without a needle stick.
Swan-Ganz catheter: A long catheter that is put into a vein in your neck or upper shoulder. The
end of it is placed in your heart. It measures the pressure in your heart.
Endotracheal tube: A large tube that is put through your mouth or nose into
your lungs. It must be kept free of mucous to make it easy for you to
breathe. Since you cannot cough, the tube is kept clean through suctioning.
This procedure is slightly uncomfortable but lasts only a few seconds. While this tube is in
place, you will not be able to talk. You will be given paper and pencil to write.
Ventilator: This machine will help you breathe until the anesthesia wears off and you are
61. 61
able to breath on your own.
Fig:11.1 Showing I.C.U monitoring
Nasogastric tube: A tube that is put through your nose into the stomach. It removes stomach
contents to keep you from getting sick to your stomach.
Foley catheter: A tube that goes into your bladder and drains your urine.
Chest tube: Blood and fluid will collect in your chest during surgery. One or two of these tubes
will be put in during surgery, to drain this unwanted fluid.
Pacemaker: A pacemaker is put in during surgery. The pacemaker box is attached to wires and
is used temporarily until your heart rhythm returns to normal.
After your family's first visit, they will be allowed to return during posted visiting hours.
Visiting hours are limited so you can receive the care you need. Once you move out of the
62. 62
SICU, visiting hours will be increased. To keep your family informed of your progress, your
nurse will call one designated family member once a day at a previously agreed upon time.
There is a lot of activity in the SICU. There is little quiet time because activity continues 24
hours a day. This makes it difficult to get enough sleep. Lack of sleep may make you feel
confused. This confusion is temporary and will correc itself once you are transferred to the
step-down unit.
Pain:
Most patients feel some discomfort in their chest and shoulders after heart surgery. Let your
nurse know when you feel uncomfortable. While you are in the SICU, the pain medicine will
be given in your vein (IV). When you are able to eat, you will receive your pain medicine in
pill form.
# The Day After Your Surgery:
While each patient recovers at his / her own rate, the following changes usually take place on
the day after your surgery:
The ventilator is usually removed since you are now able to breathe on your own.
The endotracheal tube is removed and you are asked to cough and deep breathe to keep your
lungs clear.
The nasogastric tube is removed.
You will be given oxygen by either a mask on your face or nasal cannula that fits into your
nose.
The Swan-Ganz catheter and arterial lines are removed.
You will move out of the SICU to the nursing unit.
63. 63
Once you arrive on the nursing unit, you may be attached to a different type of heart monitor.
This monitor, called a telemetry unit, is a small battery powered unit that you carry with you
wherever you go. This telemetry unit sends a picture of the electrical activity in your heart to a
monitor at the nurses station.
# Over the next several days:
The chest tube is removed.
The foley catheter is removed from your bladder.
The pacemaker will be removed.
The intravenous line (IV) will be removed.
You will get clear liquids to drink. After your bowels move, you may start eating solid foods.
Your activity will increase as your heart gets stronger. By the time you are discharged from the
hospital, you should feel strong enough to do most of your daily activities, however you will
continue to need rest periods. Please follow your doctor's plan of care. If you have any
questions, feel free to talk with your doctor or nurse. You will be getting more education about
your heart and making plans for discharge while you are in the hospital.
64. 64
CHAPTER – 12
PHYSIOTHERAPY MANAGEMENT
PHYSIOTHERAPY MANAGEMENT
Physiotherapy plays an important role in the cardiac surgery patient before and after the
surgery. The physiotherapy cardiac rehabilition progranne is suggested according to the
65. 65
requirement of the individual specific needs. Few of the factors are considered before exercise
programme is prescribed like:
Age
Occupation
History of patient
Mental status of the patient
Severity of disease.
The physiotherapy rehabilitation programme is divided into two subdivision:
Preoperative physiotherapy
Postoperative physiotherapy.
PREOPERATIVE PHYSIOTHERAPY
The preoperative physiotherapy programme is started as soon as patient is admitted one week
prior to the surgery so that the patient can meet the medical team including physiotherapist, all
the tests are conducted thoroughly. During this period the role of physiotherapy is:
AIMS AND PLANS OF PREOPERATIVE PHYSIOTHERAPY ARE:
AIMS OF PHYSIOTHERAPY
To improve breathing efficiency
To ensure clear lung fields.
To teach effective coughing and huffing.
To teach correct technique of supporting the incision site.
To maintain the range of motion of upper limb.
To prevent deep vein thrombosis.
66. 66
To teach postural awareness.
To teach turning in bed, sitting, standing and walking.
PLANS OF CARE OF PHYSIOTHERAPY
Breathing exercises are taught.
Shaking, clapping, postural drainage and intermittent positive pressure breathing are taught.
Coughing and huffing techniques are taught.
Using bed sheet and pillow.
Shoulder girdle, shoulder elbow hand exercises are taught.
Ankle and toe movements are taught.
Position sense training by shoulders are at level, weight equally taken on both the buttocks.
Turning from supine lying to side-lying to sitting in bed and out of bed to standing and walking
are taught.
POSTOPERATIVE PHYSIOTHERAPY MANAGEMENT
The patient after under going cardiac surgery will be in intensive care unit for the first 48 hours
after the surgery under supervision to deal with the emergency situation. Physiotherapy is
started once the patient is stable.
AIMS AND PLANS OF POSTOPERATIVE PHYSIOTHERAPY
AIMS OF PHYSIOTHERAPY
67. 67
To prevent deep vein thrombosis for about 48 hours to two weeks
To maintain clear airway
To maintain good posture
To maintain mobility of shoulder, neck , trunk and legs
To restore the patient confidence
To increase the patient exercise tolerance
To teach patient the home exercise programme
PLANS OF CARE OF PHYSIOTHERAPY
Ankle and toe movements should be done.
Breathing exercises
Position sense training by shoulders are at level, weight equally taken on both the buttocks.
Shoulder and shoulder girdle exercises, neck exercises, trunk exercises and lower limb
exercises like hip, knee and foot exercises.
Psychological counseling.
Sets of exercises with frequent repetition and relaxation periods.
Complete rehabilitation programme include diet management, regular walking and exercises.
POSTOPERATIVE PHYSIOTHERAPY
The physiotherapy must start with the rehabilitation programme immediately after the surgery.
The programme is as follows:
DAY OF OPERATION
Regular monitoring of the temperature, blood pressure, ECG, pulse rate, respiratory rate and
administration of the drugs are done.
68. 68
The physiotherapist helps the patient to sit in the half lying position. The incision is supported
by the patient with a pillow and is encouraged to take deep breaths three times and
The patient is asked to try huffing at least at once or twice.
The patient head and trunk are fully supported with pillows.
POSTOPERATIVE DAY 1
Chest physiotherapy need to be done following gentle percussion and mild vibration in postural
drainage position
Breathing exercises
Coughing and huffing
Position sense training
Relaxation
Elevetion of arm on the operated side and if incision is medial sternotomy elevation of bilateral
arms till shoulder level
Ankle and toe movements
Hip and knee bending
Straight leg raising
Hip abduction and adduction
Griping
spirometer
TECHNIQUE USED:
POSTURAL DRAINAGE
69. 69
POSTURAL DRAINAGE is a means of mobilizing secretions in one or more lung
segments to the central airways by placing the patient in various positions so that
the gravity assists in the drainage process. Postural drainage therapy includes the
manual techniques such as percussion, vibration and voluntary coughing.
Manual techniques used during postural drainage therapy
Percussion
Percussion is performed with cupped hands over the lung segment being drained.
It is continued for several minutes or until the patient needs to alter position to
cough.
Vibration
Vibration is applied by placing both the hands directly on the skin and over the
chest wall and gently compressing and rapidly vibrating the chest wall as the
patient breathes out.
Shaking
Shaking is a more vigorous from of vibration applied during exhalation using a
intermittent bouncing maneuver coupled with the wide movement of therapist’s
hands.
RESPIRATORY EXERCISES
1.An Incentive Spirometer is a device that assists in lung expansion. (Expanded lungs are
healthier lungs.) You'll also find that taking slow, deep breaths and coughing periodically will
help keep your lungs clear.
70. 70
2.Use the Incentive Spirometer several times a day, preferably every hour while awake. If you
feel lightheaded or dizzy, you may be overdoing it. Stop and rest. Resume deep breathing when
you feel better.
3.Exhale completely, then close your lips tightly around the mouthpiece. Inhale slowly and
deeply, keeping the small, blue ball between the two arrows.
4.When you can't inhale anymore, hold your breath for six seconds. Then exhale slowly.
Repeat as often as prescribed by your physician.
Fig12.1 Intensive spirometer
Types of breathing
All the breathing patterns should be deep, voluntarily controlled and relaxed.
1. Diaphragmatic breathing:
Place the patient in a relaxed position such as reclined sitting. Place your hands
on the rectus abdomen just below the anterior costal margin. Ask the patient to
breathe in slowly and deeply through the nose. Then tell the patient to slowly let
the air out through the mouth. Practice this for 3 or 4 times. Then ask the patient
to keep his or her hand on the abdomen and practice.
71. 71
Fig12.2 diaphragmatic breathing
Incentive respiratory spirometry
It is form of low-level resistance training. The patient inhales through a spirometer
that provides visual or auditory feedback as the patient breathes in as
deeply as possible. Place the patient in a comfortable position. Have the
patient take 3 to 4 breaths and exhale with the fourth breath.Then have the
patient place the spirometer in the mouth and maximally inhale through the
spirometer and hold the inspiration for several seconds.
Coughing
An effective cough is necessary to eliminate respiration obstructions and keep
the lungs clear.
The cough mechanism
The following series of action occur when a person coughs.
1. Deep inspiration.
2. Glottis closes and vocal cords tighten.
72. 72
3. Abdominal muscles contract and the diaphragm elevates.
4. Glottis opens.
5. Explosive expiration of air occurs.
Controlled Cough Technique
Practice
1. Sit comfortably with your feet resting firmly on the floor, and lean forward slightly.
2. Take three to four deep diaphragmatic breaths before coughing.
3. Take a deep breath, hold your breath for three seconds, tighten your abdominal muscles and
cough twice. The first cough will loosen your sputum. The second cough will move the sputum
high in your throat.
4. Spit it into a piece of tissue and check the color. If it is a yellow, green or red in colour, talk
to your doctor. Throw the tissue away.
Take a break and repeat once or twice if you do not cough up any sputum.
Fig12.3 Stitch care during huffing, coughing,sneezing
73. 73
Additional means of facilitating a cough
Manual assisted cough
If a patient has abdominal weakness, manual pressure on the abdominal area
will assist in developing greater intra-abdominal pressure for a more forceful
cough.
Therapist assisted techniques
With the patient in a supine or semi-recycling position, the therapist places the
heel of one hand on the patient’s abdomen at the epigastric area just distal to the
xiphiod process. The other hand is kept on the first. After the patient inhales as
deeply as possible, the therapist manually assists the patient as he or she attempts
to cough.
3. Segmental breathing
a. Lateral costal expansion
The patient will be in a hook-lying position. Place your hands along the lateral
aspect of the lower ribs and ask the patient to breathe out, and feel the rib cage
move downward and inward.
b. posterior basal expansion
Have the patient sit and lean forward on a pillow. Place your hands over the
posterior aspect of the lower ribs. Follow the same procedure as above.
c. right middle-lobe or lingula expansion
74. 74
Patient is sitting. Place your hands at either the right or left side of the patient’s
chest just below the axilla. Follow the same procedure as above.
Fig12.4 Lateral costal breathing
d. apical expansion
Patient is sitting. Apply the pressure below the clavicle with the finger tips.
4. Glossopharyngeal breathing
The patient takes several gulps of air. Then the mouth is closed and the tongue
pushes the air back and traps it in the pharynx. The air is then forced into the
lungs and the glottis is opened. This increases the depth of the inspiration.
5. Pursed-lip breathing
75. 75
Have the patient assume a comfortable position. Explain to the patient that expiration
must be relaxed and contraction abdominals must be avoided. Instruct the
patient to breathe slowly and deeply then have the patient purse the lips and
exhale.
12.6a Inhale through the nose 12.6b Exhale through pursed lip
Fig.12.7 hip knee flextion
Hip and Knee Flexion
76. 76
Cradle the leg by placing one hand under the bent knee. With the other hand, grasp the heel for
stabilization. Lift the knee and bend it toward the chest, with the kneecap pointed toward the
ceiling. Do not allow the hip to twist during this movement. The foot should stay in a straight
line with the hip and not swing in or out.
Ankle Pumps
Slowly push your foot up and down. Do this exercise several times as often as every 5 or 10
minutes. This exercise can begin immediately after surgery and continue until you are fully
recovered.
Fig,12.8a ankle pumps
Ankle Rotations
Fig.12.8b ankle rotations
Move your ankle inward toward your other foot and then outward away from your other foot.
77. 77
Repeat 5 times in each direction 3 or 4 times a day.
Straight Leg Raises
Fig12.8c straight leg raises
Tighten your thigh muscle with your knee fully straightened on the bed. As your thigh muscle
tightens, lift your leg several inches off the bed. Hold for 5 to 10 seconds. Slowly lower.
Repeat until your thigh feels fatigued.
Abduction Exercise
Fig 12.8d abduction exercise
Slide your leg out to the side as far as you can and then back.
Elbow Flexion and Extension
78. 78
Fig12.8e elbow flexion and extetion
Hold the upper arm with one
hand and forearm with the other hand. Bend the arm at the elbow so that the hand touches the
shoulder. Then straighten the arm all the way out.
Fig 12.8f finger and wrist flextion extension
79. 79
Finger and Wrist
Flexion and Extension
Hold the forearm above the wrist with one hand and grasp the fingers with your other hand.
Holding the hand in this way, bend the wrist back, while straightening the fingers out. Then bend
the wrist the opposite direction, about 90 degrees, while curling the fingers into a fist.
POSTOPERATIVE DAY 2
Same as day 1 followed by:
A rope tied to the end of the bed and patient is trained to sit up himself
Practice elevation of arm on operated side and if the incision is medial sternotomy elevation of
bilateral shoulder movements till shoulder level are prescribed.
Fig12.8g shoulder flexion
Shoulder Flexion
Hold the wrist with one hand.
80. 80
With the other hand, grasp the elbow joint to stabilize it. Turn the palm inward, facing the
body, and keep the elbow relatively straight. Move the arm from the side of the body over the
head.
POSTOPERATIVE DAY 3
The patient is shifted to the cardio-thoracic unit
Breathing exercises
Huffing
Arm and trunk exercises
Short walk with in ward
Posture correction and arm swinging exercises during walking.
POSTOPERATIVE DAY 4
Patient goes to the toilet independently on his own
Chest expansion exercises are taught
Bed end exercises
Group therapy with other patients in the ward are taught arm, trunk, leg exercises.
Standing Knee Raises
81. 81
Fig12.9 standing knee raises
Lift your leg toward your chest. Do not lift your knee higher than your waist. Hold for 2 or 3
counts and put your leg down.
Repeat 10 times 3 or 4 times a day
Standing Hip Abduction
82. 82
Fig12.10 standing hip abduction
Be sure your hip, knee and foot are pointing straight forward. Keep your body straight. With
your knee straight, lift your leg out to the side. Slowly lower your leg so your foot is back on
the floor.
Repeat 10 times 3 or 4 times a day
Standing Hip Extensions
83. 83
Fig12.11 standing hip extention
Lift your operated leg backward slowly. Try to keep your back straight. Hold for 2 or 3 counts.
Return your foot to the floor.
Repeat 10 times 3 or 4 times a day
POSTOPERATIVE DAY 5 – 10
By 5 -7 days patient should ascend stairs of about 8 – 10
Exercise programme.
Before discharge: The patient should be confident of his ability to cope his situation at his own.
HOME PROGRAMME
Breathing exercises
Thoracic expansion exercises
Walking
84. 84
Activities of daily living
Return to work
Follow up.
Cardiac Rehab Home Exercises
Repeat each exercise 10 times. Do the exercises two times each day.
Stand for all the exercises. Be sure to breathe while you are exercising. Holding
your breath can raise your blood pressure and put more of a workload on your
heart.
On day 4 and 5, add ½ pound hand weights as you do your exercises. On day 6,
begin using one-pound hand weights. Small dumbbells or wrist weights are fine,
or you can use bags of dried beans for your weights
92. 92
Complications
People undergoing coronary artery bypass are at risk for the same complications as any
surgery, plus some risks more common with or unique to CABG.
CABG associated
Postperfusion syndrome (pumphead), a transient neurocognitive impairment associated with
cardiopulmonary bypass. Some research shows the incidence is initially decreased by off-pump
coronary artery bypass, but with no difference beyond three months after surgery. A
neurocognitive decline over time has been demonstrated in people with coronary artery disease
regardless of treatment (OPCAB, conventional CABG or medical management). However,
recent research suggests that the cognitive decline is not caused by CABG but is rather a
consequence of vascular disease.[17]
Nonunion of the sternum; internal thoracic artery harvesting devascularizes the sternum
increasing risk.
Myocardial infarction due to embolism, hypoperfusion, or graft failure.
Late graft stenosis, particularly of saphenous vein grafts due to atherosclerosis causing
recurrent angina or myocardial infarction.
Acute renal failure due to embolism or hypoperfusion.
Stroke, secondary to embolism or hypoperfusion.
General surgical
Infection at incision sites or sepsis.
Deep vein thrombosis (DVT)
Anesthetic complications such as malignant hyperthermia.
93. 93
Keloid scarring
Chronic pain at incision sites
Chronic stress related illnesses
Death
Risks
Although complications from coronary artery bypass grafting (CABG) are uncommon, the
risks include:
Wound infection and bleeding
Anesthesia reactions
Fever
Pain
Stroke, heart attack, or even death
Some patients can develop a fever associated with chest pain, irritability, and decreased
appetite. This is due to inflammation involving the lung and heart sac, and is sometimes seen 1
to 6 weeks after surgeries that involve cutting through the pericardium (the outer covering of
the heart). This reaction is usually a mild, self-limited illness, but some patients may develop
fluid buildup around the heart that requires treatment.
Use of the heart-lung machine also can cause complications. Memory loss and other changes,
such as difficulty concentrating or thinking clearly, may occur in some people. These changes
are more likely to occur in people who are older, who have high blood pressure or lung disease,
or who drink excessive amounts of alcohol. These side effects often improve several months
after surgery.
94. 94
The heart-lung machine also increases the risk of blood clots forming in your blood vessels.
Clots can travel to the brain or other parts of the body and block the flow of blood, which can
cause stroke or other problems. Recent technical improvements in heart-lung machines are
helping to reduce the risk of blood clots forming.
In general, the chances of developing complications are higher when CABG is done in an
emergency situation (for example, if performed during a heart attack), if you're over age 70, or
if you have a history of smoking. Your risks also are higher if you have other diseases or
conditions such as diabetes, kidney disease, lung disease, or peripheral vascular disease.
96. 96
After surgery, you will typically spend 1 or 2 days in an intensive care unit. Your heart rate and
blood pressure will be continuously monitored during this time. Intravenous medicines
(medicines injected through a vein) are often given to regulate blood circulation and blood
pressure. You will then be moved to a less intensive care area of the hospital for 3 to 5 days
before going home.
Recovery at Home
Your doctor will give you specific instructions for recovering at home, especially concerning:
How to care for your healing incisions
How to recognize signs of infection or other complications
When to call the doctor immediately
When to make followup appointments
You may also receive instructions on how to deal with common after-effects from surgery.
After-effects often go away within 4 to 6 weeks after surgery, but may include:
Discomfort or itching from healing incisions
Swelling of the area where an artery or vein was taken for grafting
Muscle pain or tightness in the shoulders and upper back
Fatigue (tiredness), mood swings, or depression
Difficulty sleeping or loss of appetite
Constipation
Chest pain around the site of the chest bone incision (more frequent with the traditional
surgery)
Full recovery from traditional CABG may take 6 to 12 weeks or more. Less recovery time is
needed for nontraditional CABG.
97. 97
Your doctor will provide instructions on resuming physical activity. This varies from person to
person, but there are some typical timeframes. Returning to work after 6 weeks is common
unless the job involves specific and demanding physical activity. Some people may need to
find less physically demanding types of work or work a reduced schedule at first.
Sutures are removed from the chest prior to discharge and from the leg (if the saphenous vein
is used) after 7 to 10 days. Even though smaller leg veins will take over the role of the
saphenous vein, a certain degree of swelling (edema) in the affected ankle is common. Patients
are advised to wear elastic support stockings during the day for the first four to six weeks after
surgery and to keep their leg elevated when sitting. This swelling usually resolves after about
six to eight weeks. Healing of the breastbone takes about six weeks and is the primary
limitation in recovering from CABG surgery. Patients are advised not to lift anything more
than 10 pounds or perform heavy exertion during this healing period. They are also advised not
to drive for the first four weeks to avoid any injury to the chest. Return to work usually occurs
after the six week recovery, but may be much sooner for non-strenuous employment.
Exercise stress testing is routinely done four to six weeks after CABG surgery and signals the
beginning of a cardiac rehabilitation program. Rehabilitation consists of a 12 week program of
gradually increasing monitored exercise lasting one hour three times a week. Patients are also
counseled about the importance of lifestyle changes to lower their chance of developing further
CAD. These include stopping smoking, reducing weight and dietary fat, controlling blood
pressure and diabetes, and lowering blood cholesterol levels.
Long-term results after CABG surgery
98. 98
A very small percentage of vein grafts may become blocked within the first two weeks after
CABG surgery due to blood clotting. Blood clots form in the grafts usually because of small
arteries beyond the insertion site of the graft causing sluggish blood run off. Another 10% of
vein grafts close off between two weeks and one year after CABG surgery. Use of aspirin to
thin the blood has been shown to reduce these later closings by 50%. Grafts become narrowed
after the first five years as cells stick to the inner lining and multiply, causing formation of scar
tissue (intimal fibrosis) and actual atherosclerosis. After 10 years, only 2/3 of vein grafts are
open and 1/2 of these have at least moderate narrowings. Internal mammary grafts have a much
higher (90%) 10 year rate of remaining open. This difference in longevity has caused a shift in
surgical practices toward greater use of internal mammary and other arteries as opposed to
veins for bypasses.
Recent data has shown that in CABG patients with elevated LDL cholesterol (bad cholesterol)
levels, use of cholesterol-lowering medications (particularly the statin family of drugs) to lower
LDL levels to below 80 will significantly improve long-term graft patency as well as improve
survival benefit and heart attack risk. Patients are also advised about the importance of lifestyle
changes to lower their chance of developing further atherosclerosis in their coronary arteries.
These include stopping smoking, exercise, reducing weight and dietary fat, as well as
controlling blood pressure and diabetes. Frequent monitoring of CABG patients with
physiologic testing can identify early problems in grafts. PTCA (angioplasty) with stenting, in
addition to aggressive risk factor modification, may significantly limit the need for repeat
CABG years later. Repeat CABG surgery is occasionally necessary, but may have a higher risk
of complication.
99. 99
Ongoing Care
Care after surgery may include periodic checkups with doctors. During these visits, tests may
be done to see how the heart is working. Tests may include EKG, stress testing, and
echocardiogram.
CABG is not a cure for coronary artery disease (CAD). You and your doctor may develop a
management plan that includes lifestyle changes to help you stay healthy and reduce the
chances of CAD getting worse. Lifestyle changes may include quitting smoking, making
changes in your diet, getting regular exercise, and lowering and managing stress.
In some cases, your doctor may refer you to a cardiac rehabilitation (rehab) program. These
programs can help you recover through supervised physical activity and education on how to
make choices that reduce your risk for future heart problems and help you get back to your
regular lifestyle after surgery.
Doctors supervise these programs, which include counseling about lifestyle changes as well as
exercise training to build strength and energy. Cardiac rehab programs may be offered in
hospitals and other community facilities. Ask your doctor whether you're a candidate for
cardiac rehab.
Taking medicines as prescribed also is an important part of care after surgery. Medicines may
be prescribed to manage pain during recovery; lower cholesterol, blood pressure, and the
chance of developing blood clots; manage diabetes; or treat depression.
101. 101
Self-care for recovery
several responsibilities while you are recovering from coronary artery bypass graft (CABG)
surgery, including:
Caring for your wounds.
Taking your medicines.
Monitoring your weight.
Improving your heart and lung health.
Attending cardiac rehabilitation.
Making changes in your lifestyle.
Caring for your wounds
102. 102
A major aspect of your recovery is caring for the incision (sternotomy) made to open your
chest during CABG surgery. Because it is so important that this incision heals properly. You
also need to take care of the skin around your arm or leg incisions. All of your incisions need
to be taken care of so that they can heal quickly and without infection. To do this, you need to:
Take a warm (not hot) shower every day.
Apply an antiseptic, such as povidone-iodine (Betadine, for example), to your incisions after
you shower.
Inspect your incisions every day.
Tell your doctor if you notice excessive pain, redness, or swelling or if you have a fever.
Donot:
Remove the tape from your incisions (it will come off by itself).
Take baths.
Scrub or rub your incisions.
Use lotion or powder on your incisions.
Overexpose your incisions to sunlight.
CHEST
Your surgeon may cut through your chest bone, or sternum, to perform your CABG surgery.
Unlike other bones in your body, your sternum cannot be placed in a cast while it heals.
Instead, your surgeon wraps heavy wire around it to hold the edges together. The sternum can
heal properly only if the ends are held together constantly for several weeks. Therefore, you
should not engage in strenuous activities that could shift the two edges apart during the first 4
to 6 weeks of your recovery.
103. 103
Two activities that can shift the edges of your sternum apart and therefore should be avoided
are:
Lifting objects heavier than 5 lb, including small children, trash baskets, and bikes.
Driving (even a minor car accident may cause your chest to hit the steering wheel).
ARM AND LEG
Your arm or leg incision may be swollen and painful. This results not only from the incision
that cut through your skin and muscle but also from losing a blood vessel in your arm or leg
that would normally circulate blood in the area of the incision. It will take a little time for your
arm or leg to adjust to the missing vessel and for your incision to heal.
To help your arm or leg recover faster and more comfortably, you can:
Keep your swollen arm or leg elevated.
Wear special supportive hose (available from your doctor).
Taking your medications:
You may need to take medicines after your CABG surgery. Your doctor or nurse will give you
written instructions for taking your medicines before you leave the hospital. These new
medicines may be in addition to or instead of the medicines you were taking before your
surgery.
You need to know:
The names and dosages of your medicines.
When to take each medicine.
What side effects to watch for with each medicine.
104. 104
What nonprescription medicines, vitamins, or herbal substances you cannot take because of a
possible bad interaction with your prescribed medicines.
You need to do the following:
Take each medicine regularly and on time.
Bring your medication sheet to every doctor's visit.
Report any side effects to your doctor.
Refill your medicines before they run out.
Bring enough medicine with you when you travel.
Keep your medicines away from children.
Do not increase, decrease, or stop a medicine without asking your doctor.
If you forget to take a medicine, do not double your dose. Call your doctor's office or
pharmacy for instructions.
Check with your doctor before taking any nonprescription medicines.
Blood thinners
One of the medicines you may be prescribed after CABG surgery is an anticoagulant, such as
warfarin (Coumadin, for example). This medicine helps prevent blood clots. You will likely
need regular blood tests to check how the blood thinner is working. If you are having home
health care, your home health nurse may take your blood test. If you do not have home health
care, you will go to your doctor's office, a lab, or the hospital for your blood test.
When taking anticoagulants:
Take the medicine at the same time each day.
105. 105
Know your dosage.
Keep track of blood test results.
Use a soft toothbrush to brush your teeth.
Use an electric razor to shave.
Check with your doctor before taking aspirin, other nonsteroidal anti-inflammatory drugs (such
as ibuprofen), and other nonprescription medicines.
Tell your doctor if you have bruising or bleeding.
Do not change your intake of vitamin K–rich foods, such as broccoli, brussels sprouts,
cabbage, asparagus, lettuce, spinach, and some vegetable juices. It is most important to
maintain a consistent level of vitamin K foods in your diet.
Do not drink alcohol excessively. If you drink, do so only in moderation. Alcohol decreases the
effect of warfarin.
Do not use tobacco of any kind.
Avoid playing contact sports or engaging in other activities where you could get bruised or
otherwise injured.
Monitoring your weight
It is important to watch your weight very closely after your surgery. A sudden increase in your
weight is often a sign of fluid retention. This fluid retention can indicate an underlying
problem, such as worsening heart function and kidney failure.
To monitor your weight, you should:
Weigh yourself at the same time every morning.
Keep a record of your weight.
106. 106
Bring your weight record with you when you visit your doctor.
Call your doctor if you gain 3 lb or more in 2 to 3 days.
Improving your heart and lung functions
While you are recovering from your CABG surgery, you will need to work on increasing your
physical activity, or exercising. You need to become more physically active because you need
to restore your full lung function. You also need to improve the blood circulation throughout
your body. This will help your body heal properly.
If you do not exercise, you risk developing blood clots within the blood vessels of your legs.
This is a painful condition that can cause several complications, including blockage of a blood
vessel.
Walking is an excellent exercise after CABG surgery. Walking is safe and someone else can
easily walk with you. Your leg will be sore if your surgeon removed blood vessels from your
leg to use during your surgery. Despite this pain, it is important to your recovery that you
continue to walk.
Attending cardiac rehabilitation
Based on your health and rate of recovery, your doctor will recommend that you enroll in a
cardiac rehabilitation program to help you recondition and strengthen your heart. Usually, the
program will start 4 to 6 weeks after your surgery. This type of cardiac rehabilitation program
is known as a phase II program. (A phase I program refers to any rehabilitation steps you begin
right after your CABG surgery).
107. 107
In the phase II program, a specially trained nurse will help you improve your heart's strength
and overall health in sessions of supervised exercise using a treadmill or a bike. In addition,
you will also receive education about healthy eating and lifestyle habits each week. For more
information, see the topic Cardiac Rehabilitation.
Some tips for exercising after CABG
Work with your doctor and rehabilitation specialist to develop a rehabilitation plan. The
following is a general guideline for increasing your exercise:
Take several walks each day. Spread the walks throughout your day.
Don't overdo it: Stop and rest if you get tired.
Gradually increase the distance and duration of your walks. Add one city block to your walk
each week.
Do not walk by yourself.
Take stairs at a slow pace.
Don't pull on the banisters with your arms to avoid straining the surgery site.
Don't do too much at once.
Although you may be weak, tired, or experiencing chest soreness as a result of your surgery,
many people with coronary artery disease (CAD) can work their way back up to normal
activity levels by participating in a structured cardiac rehabilitation program or by working
with their doctor to develop a home exercise program.
Making changes in your lifestyle
Your doctor probably told you that certain aspects of your lifestyle (such as smoking, an
unhealthy diet, or high stress) make your cardiac health worse. Now that you have had your
108. 108
diseased arteries repaired with open-heart surgery, you want to be sure that your CAD does not
get worse. In particular, it is important to keep your new bypass grafts healthy. Your doctors,
nurses, or rehabilitation team members can help you take steps to quit smoking, start eating a
heart-healthy diet, and reduce the stress in your life.
CHAPTER – 16
CONCLUSION
109. 109
CONCLUSION
While CABG surgery can be very hard on the body, you will be served far better by engaging
in regular physical activity during the recovery period. The immediate post-surgery phase is
the most difficult but after you break through the first two to three weeks, you'll be amazed at
how well you feel. The previously blocked arteries that were causing you shortness of breath
and chest pain are no longer limiting factors in your ability to carry out your daily tasks. Most
people who've had bypass surgery go on to live very fruitful and active lives, sometimes even
better than before! But be forewarned, surgery is not a cure for artery disease. If you previously
lived an unhealthy lifestyle and return to your old ways, there is a likelihood that your arteries
will block up again, leaving you in line for a follow up CABG procedure
Today, technology,doctors and other health care professionals are working together to give the
best care possible. Routine physical therapy allows the possibility of superior benefits
including faster recovery time and decreased complications
Early ambulation and mobility beginning the first day post CABG surgery will assist in the
patient’s physical and emotional recovery. HOME & cardiac rehabilitation based exercises
both are important.
111. 111
BIBLIOGRAPHY
1. Nirav J. Mehta, MD and Ijaz A. Khan, MD Houston Division of Cardiology, Creighton
University School of Medicine, Omaha, Nebraska 68131,"Cardiology's 10 Greatest
Discoveries of the 20th Century", FACC, 2002, Texas Heart Institute Journal, 29(3):164-171,
accessed online on 2 Jan 2009 at
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=124754
2. Nirav J. Mehta, MD and Ijaz A. Khan, MD Houston Division of Cardiology, Creighton
University School of Medicine, Omaha, Nebraska 68131,"Cardiology's 10 Greatest
Discoveries of the 20th Century", FACC, 2002, Texas Heart Institute Journal, 29(3):164-171,
accessed online on 2 Jan 2009 at
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=124754
3. American Heart Association. Heart Bypass Surgery. URL:
http://www.americanheart.org/presenter.jhtml?identifier=4484. Accessed on March 26, 2006.
4. Ohki S, Kaneko T, Satoh Y, et al. (2002). "[Coronary artery bypass grafting in octogenarian]"
(in Japanese). Kyobu geka. The Japanese journal of thoracic surgery 55 (10): 829–33;
discussion 833–6. PMID 12233100.
5. Rihal C, Raco D, Gersh B, Yusuf S (2003). "Indications for coronary artery bypass surgery and
percutaneous coronary intervention in chronic stable angina: review of the evidence and
112. 112
methodological considerations". Circulation 108 (20): 2439–45.
doi:10.1161/01.CIR.0000094405.21583.7C. PMID 14623791. Full Free Text.
6. SoS Investigators (2002). "Coronary artery bypass surgery versus percutaneous coronary
intervention with stent implantation in patients with multivessel coronary artery disease (the
Stent or Surgery trial): a randomised controlled trial". Lancet 360 (9338): 965–70.
doi:10.1016/S0140-6736(02)11078-6. PMID 12383664.
7. Serruys PW, Morice M-C, Kappetein AP, et al. (2009). "Percutaneous coronary intervention
versus coronary-artery bypass grafting for severe coronary artery disease". N Engl J Med.
doi:10.1056/NEJMoa0804626.
8. Desai ND (2008). "Pitfalls assessing the role of drug-eluting stents in multivessel coronary
disease". Ann. Thorac. Surg. 85 (1): 25–7. doi:10.1016/j.athoracsur.2007.08.063. PMID
18154771.
9. Hannan EL, Wu C, Walford G, et al. (2008). "Drug-eluting stents vs. coronary-artery bypass
grafting in multivessel coronary disease". N. Engl. J. Med. 358 (4): 331–41.
doi:10.1056/NEJMoa071804. PMID 18216353.
10. Eagle KA, Guyton RA, Davidoff R, et al. (2004). "ACC/AHA 2004 guideline update for
coronary artery bypass graft surgery: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to
Update the 1999 Guidelines for Coronary Artery Bypass Graft Surgery)". Circulation 110 (14):
e340–437. PMID 15466654.
11. Kitamura S, Kawachi K, Kawata T, Kobayashi S, Mizuguchi K, Kameda Y, Nishioka H,
Hamada Y, Yoshida Y. [Ten-year survival and cardiac event-free rates in Japanese patients
with the left anterior descending artery revascularized with internal thoracic artery or
113. 113
saphenous vein graft: a comparative study] Nippon Geka Gakkai Zasshi. 1996 Mar;97(3):202-
9. PMID 8649330.
12. Arima M, Kanoh T, Suzuki T, Kuremoto K, Tanimoto K, Oigawa T, Matsuda S. Serial
Angiographic Follow-up Beyond 10 Years After Coronary Artery Bypass Grafting. Circ J.
2005 Aug;69(8):896-902. PMID 16041156. Free Full Text.
13. http://www.scientificamerican.com/article.cfm?id=disease-may-cause-pumphead
14. Coronary angioplasty and coronary bypass surgery. British Heart Foundation, 2004 Heart
Information Series Number 10. www.bhf.org.uk
