Coronary artery bypass grafting(stuti sah, bpt 4th yr)

corona artery bypass grafting

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

2. Definition- According to the American Heart Association, coronary artery bypass graft (CABG) surgeries are among the most commonly performed major operations. CABG is advised for selected groups of patients with significant narrowings and blockages of the heart arteries(coronary artery disease). CABG creates new routes around diseased, narrowed and blocked coronary arteries with healthy vessels taken from other places of body, permitting increased blood flow to deliver oxygen and nutrients to the heart muscle. 2

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4. Goals- Restore blood flow to the heart Relieve chest pain and ischemia Improves the patients quality of life Enable the patient to resume a normal life Lower the risk of a heart attack. Indications- Patients with blockages in coronary arteries. Patients with angina Patients who cannot tolerate PTCA and don’t respond well to drug therapy Immediately after Myocardial Infarction (to help perfusion of the viable myocardium) Life threatening arrhythmias caused by a previous myocardial infarction. Occlusion of grafts from previous CABG. 4

5. Contraindications- Aneurysms Valvular diseases Congenital diseases Diseases of blood, Haemorrhagic diseases Pregnancy Uncontrolled arrhythmias S evere hypertension Investigations- ECG Chest Radiography TMT Isotope scanning Coronary angiography Echocardiography MRI 5

6. Procedures of CABG- (Artery grafts- Mostly internal mammary artery is used. Vein graft- Saphenous vein is mostly used for grafting) 1. Traditional Coronary Artery Bypass Grafting or On pump surgery- It uses a heart-lung machine (cardiopulmonary bypass ). This machine temporarily takes over the heart’s job of pumping oxygen rich blood to the organs and tissues. This is traditional type of open heart surgery, chest bone is opened to access the heart. It allows surgeon to operate on a heart that is not beating and has no blood travelling through it. 2. Beating heart or Off-Pump Coronary Artery Bypass Grafting- It doesn’t use a heart-lung machine and surgeon operates on an actively beating heart. However, surgeon will slow heart rate with medication or a device. This type of surgery is limited to a few specific procedures. It is also known as “Beating Heart Surgery”. 6

7. Heart lung machine- A device used in open heart surgery to support the body during the surgical procedure while the heart is stopped. The heart-lung machine is often referred to as the “pump”’ and does the work of the heart and lungs during the operation. 7

8. 3. Minimaly Invasive Technique- In this type of surgery surgeon will make small incisions in the side of chest between the ribs. This cuts can be as small as 2-3 inches. The surgeon will insert surgical tools along with a small video camera to see inside the body. Some types of minimally invasive heart surgery use a heart-lung bypass machine and others don’t. 4. Robot- assited Technique- This type of procedure allows for even smaller, keyhole-sized incisions. A small video Camera is inserted in one incision to show the heart, while the surgeon uses remote-controlled surgical instruments to do the surgery. A heart-lung bypass machine sometimes is used during this procedure. This type of surgery is very precise. 8

9. Complications- Wound infection and bleeding at the incision site Reactions to anesthesia Pain Pneumonia Breathing problems Pancreatitis Kidney failure Abnormal heart rhythms Blood clots that can cause stroke, heart attack, lung problems or even death Fever associated with chest pain, irritability and decreased appetite Memory loss and other issues, such as problems concentrating or thinking clearly specially in older patients and ladies- improve in 6-12 months postop . 9

10. Post operation CABG- After surgery, patient will typically spend 1 or 2 days in an ICU. Health care team will check patient’s heart rate, blood pressure, and oxygen levels regularly during this time. An intravenous (IV) line will likely be inserted into a vein in arm. Through the IV line, patient may get medicines to control blood flow and blood pressure. Urinary catheter. Chest tube in chest to drain fluid. Oxygen therapy Temporary pacemaker to control abnormal rhythms. Compression stockings in leg. Moved to less intensive care area 3-5 days before discharge. 10

11. Cardiac Rehabilition - 11 Phases of cardiac rehabilitation Phase I or inpatient phase(few days) Discussion with primary provider. Early mobilization and mild activity. Phase II -early outpatient (2 to 12 weeks) Clinic or home based & late outpatient (min. of 6 months) Individualized treatment plan- Exercise prescription and Education classes. Psychological counselling . Risk modification- smoking, hypertension, diabetes, cholesterol, obesity, nutrition. Phase III or maintenance phase (indefinite) Community based Cardiac monitoring no longer needed. Independent continuation of risk-factor modification and exercise, with periodic physical evaluation

12. Phase I Cardiac Rehabilition - Involves Immediate inpatient exercise rehabilition that emphasises : Patient education Counselling Exercise therapy: Musculoskeletal ROM activities ADLs (sitting standing and walking) Purpose: Counter the deconditioning effect of prolonged bed rest Prepare patient for a return to normal daily activities 12

13. Exercise prescription for Phase I- 1 . ROM Exercises- Enhances blood flow to damaged areas, accelerate tissue repair, increasing muscular strength and flexibility. 2. Ambulation- Low in intensity (approx 1.5-3METS), initially include self care activities progressed to slow walking, ROM exercises and ADLs, later stair climbing and formalized physical activity program after gaining proper physical strength. 3. Discharge plan- Continuation of rehabilitation program after discharge. Pre discharge plan includes strategies for risk factor modification, dietary counselling , education on medications, exercise prescription for use at home. 4. HR, Haemodynamic and RPE to exercise- HR for ROM and ambulation should not exceed 5-10 beats/min above resting level during first few days of rehab; SBP should not rise more than 5 mmHg for ROM and !0-20mmHg during ambulation. 5. RPE for both activities should be between 10 -12 on RPE scale. 13

14. 6.Exercise Intensity- Should not exceed 2-3 METS, use of Borg Rating of Perceived Exertion Scale is encouraged after first few days in the hospital. FIIT principle for Phase I- Frequency- 2-3 times/day Intensity- RHR+20 Duration- 10-20 min Activity- ROM, walking, one flight of stairs Phase II Cardiac Rehabilitation- Once a patient is stable, outpatient cardiac rehabilitation may begin. Initially patients have an assessment with a focus on identifying limitations in physical function, restrictions of participation secondary to comorbidities and limitations to activities. A more rigorous patient therapy plan is designed . 14

15. Phase III- This phase involves more independence and self monitering - Phase III centers on increasing flexibility , strengthening and aerobic conditioning. Goal- Facilitate long term maintenance of life style changes and secondary prevention. Includes educational sessions, support groups, review in clinics Ongoing involvement of family . FIIT Principle Phase II Phase III Frequency 1-2 times/day 3-5times/week Intensity RHR+20, RPE 13 60-80% HR max Duration 20-60 min 30-60 min Activity ROM, treadmill(walking, jogging), bike, arm ergometer , calisthenics, weight training ROM, biking, jogging, swimming, calisthenics, weight training, endurance sports. 15

16. Patient shouldn’t exercise if they are generally unwell, symptomatic or clinically unstable- Fever/acute systemic illness Unresolved/unstable angina Resting BP systolic >200mmHg and diastolic >110mmHg Significant drop in BP Symptomatic hypotension Resting/uncontrolled tachycardia (>100bpm) Uncontrolled atrial or ventricular arrhythmias New/recurrent symptoms of breathlessness, lethargy, palpitations, dizziness Unstable heart failure Unstable or uncontrolled diabetes. 16

17. REFERENCES- medicinenet.com/ coronary_artery_bypass_graft /article.htm https://my.clevelandclinic.org/health/treatments/16897-coronary-artery-bypass-surgery https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/coronary-artery-bypass-graft-surgery https://www.physio-pedia.com/Cardiac_Rehabilitation 17