Coronary artery Bypass grafting
• It is a surgical revascularization procedure to restore the coronary blood flow through new grafts . It is a type of open heart surgery.
• Coronary artery bypass grafting is the surgical procedure performed to improve the circulation to the heart muscle in patient with severe coronary artery disease.
• In this procedure a healthy Artery or vein from another part of body is connected or graft to the blocked coronary artery.
• The grafted artery or vein bypass the blocked portion of the coronary artery carrying oxygenated blood to the heart muscle.
• One or more coronary Artery can be by passed during a single opertion.
• Mainly used grafts are internal thoracic artery or sephanous vein.
Aim of CABG
• Restore the blood flow to the heart.
• Releave chest pain and ischemia
• Lower the risk of heart attack
• Improve the life Quality of patient
• Ischemic heart disease (IHD)
• Stable angina pectoris with S -T segment displacement of more than 2 mm during stage I and stage II of treadmill stress test.
• Unstable angina with episodes at test
• Atherosclerosis of coronary arteries
• Coronary thrombosis or embolism
• Myocardial infarction
• Congestive cardiac failure
• The patient with stenosis of left coronary artery.
• Patient with failure of conservative or medical treatment.
• Median sternotomy or sternal splint.
Before the surgery
• IV line is started
• Oral or IV sedative are given
• General anesthesia
• Endotracheal tube is inserted.
• Urinary cather is placed
• An incision us made over the sternum and a chest is opened via median sternotomy.
• After reaching to the heart
• Heart lung machine is connected to the circulatory system throught the procedure.
• Heart lung machine temporarily perform the function of heart and lung during the surgery.
• It allow the heart to be stopped.
• For the sephanous vein graft.
• One end is connected to the aorta and other end to the narrowed coronary artery just beyond the blockage.
• For internal thoracic Artery graft
• One end -subclavian
• Other end -As for sephanous
• Once the graft is placed the surgeon will use on electrical signals to restore the heart beat.
• Once the heart start beating normally the heart lung machine will be disconnected.
• Chest tube are placed in the mediastinum to drain the blood around heart and lungs.
• The sternum is wired together & the incision is sutured.
Recently developed types of CABG surgery
-Off pump by pass surgery
-Minimally invasive by pass surgery off pump by pass surgery is also called as beating heart by pass grafting.
-Heart machine is not used.
• Patient is transferred into ICU
• Heart monitor
• Pacing wire to control heart rate temporarily
• Chest tube drainage will remain placed to drain the blood.
• Breathing tube will be removed once the patient can breath by its own.
Contra-indication for CABG
• Valvular disease
• Congenital disease
• Disease of blood
Vessel used for grafts
• Saphenous vein
• Radial artery
• Internal mammary artery
Post opertaive physiotherapy management
No physiotheraphy is given on the day of surgery.
1. Day I (Treatment In ICU) (1st session)
– Analgesic are given before physiotherapy management.
– Review of case sheet and vital signs drainage tubes.
– The patient should be medically stable
– Treatment session is for 20-30 min
– Comfortable positioning like half lying with small pad or pillow under the knee.
– In case of CABG the affected leg is supported on the pillows.
– Passive or active ankle/ toe movement, movement should not be vigorous
– Diaphragmatic breathing exercises.
i. Patient is not not ventilator
– Ask the patient to take slow deep inspiration through nose and expiration through mouth and do not use accessory muscles.
– Bilateral shoulder movements active or passively shoulder abduction upto 60-70
– Removal of lung secretions by manual percission or vibration maneuver to looser the secretions.
– Coughing or huffing technique with incisional support to remove airway secretions.
– If patient is on ventilator suctioning is done.
2. Day one (second session)
– Continue quadriturn position with pillows support.
– Keep knee in mild flexion to relieve strain from abdomen.
– Deep breathing exercise both unilaterally and Bilaterally are done with inspiration hold for a few seconds.
– Removal of secretion by percussion or vibration manual maneuvers.
– IPPB is given if necessary.
3. Day II.
– Analgesic are administered and check for vital signs auscultation of lungs.
– Continue with 1st day of treatment with gradual increase in shoulder movement.
– Teach the patient to get up and sit from half lying position using a rope ladder support.
– Ventilatory support and drainage tubes are removed.
– Changing of position from side lying, sitting
– Bed mobility exercises.
4. Day III
– If the patients is medically stable he js shifted from ICU to surgical unit.
– Continue with exercise program for 1st two days.
– Postural correction in sitting and standing using a mirror
– Deep breathing exercises.
– Incentive spirometry training to improve the inspiratory capacity.
– Shoulder girdle and bracing exercises.
– Gentle trunk mobility exercise like flexion, side flexion, rotation exercises.
– Shoulder drill exercise
– Walking can be gradually increased with arms swinging.
– Ask the patient to clasp the hand behind the back to prevent the shoulder protraction and maintain retraction of shoulder girdle.
– If venous graft is used from legs then apply crepe bandage with elastic stockings.
– Butterfly exercise can be done.
5 days IV
– Deep breathing exercises with breath control for few seconds.
– Pursed lip breathing
– Active cycle of breathing techniques (ACBT)
– Gradual increase in walking
6. Day V
– Most of the exercises are continued except for ankle toe movements.
– Staircase climbing corridor walking
– Advise the patient home exercise program before discharge.
– Continue with exercise and posture
– Gradual increase in walking upto 1-2 miles /day
– Avoid driving for at least 6 weeks
– Avoid sexual relation for 4 weeks.
– Avoid long distance travelling or lifting heavy weights.