CORONARY ARTERY BYPASS GRAFT 2° MYOCARDIAL INFARCTION (APK & MEDICAL BACKGROUND)
2024/2025
• Coronary Laser Angioplasty o Uses laser energy to create precise ablation of
paques without thermal injury to the vessel
o Use is limited because of the expense of the equipment and a high restenosis rate (>40%)
• Directional Coronary Atherectomy
o Can be perfomed by inserting a catheter with a cutter housed at the distal end on one side of the
catheter and a balloon on the other side. The balloon inflates and presses the cutter against the
atheroma (plaque). The cutter then can cut the atheroma and remove it from the arterial wall
Transmyocardial Revascularization
• A catheter with a laser tip creates transmural channels from patent coronary
arteries into an area of the myocardium thought to be ischemic.
• It is intended for patients with chronic angina who cannot have angioplasty or
CABG
Coronary Artery Bypass Graft
• Performed when the coronary artery has become completely occluded or
when it cannot be corrected by PTCA, coronary arthrectomy, or stenting
• Vascular graft is used to revascularize the myocardium
• Saphenous vein, radial artery, left internal mammary artery, or right internal
mammary artery
• Most commonly performed through a median sternotomy
Minimally Invasive Coronary Artery Bypass Graft
• Uses a small thoracotomy incision as an alternate to median sternotomy
Off-Pump Coronary Artery Bypass Graft Procedure
, • Uses a standard median sternotomy and grafting of the coronary arteries
under conditons of beating, normothermic heart
• Major advantage: reduce complications associated with artificial perfusion
induced by cardiopulmonary bypass pump.
Median Strenotomy and Sternal Precautions
• The primary premise for the use of sternal precautions is to reduce the
possibility of sternal dehiscence
Secondary Prevention After Revascularization
• Ensures continued success of the procedures via secondary prevention of
primary disease processes
Ablation Procedure
• Indicated for supraventricular tachycardia, AV nodal reentrant pathways,
atrial fibrillation, atrial flutter, and certain types of ventricular tachycardia
• Attempts to remove or isolate ectopic foci in an attempt to reduce the
resultant rhythm disturbance
Maze Procedure
• For surgical ablation of atrial fibrillation
• Aims to surgically create a “maze” along the atria to best direct the electrical
conduction appropriately to the AV node and the ventricles
• Performed in conjunction with CABG or valve replacement surgery
Standard nonpharmacological treatment of atrial fibrillation
Cardiac Pacemaker Implantation and Automatic Implantable Cardiac Defibrillator
• Placement of a unipolar or bipolar electrode on the myocardium
• Electrode is used as an action potential in the management of certain
arrhythmias
• Indications: Sinus node disorders, Atrioventricular disorders, Tachyarrhytmias,
improving atrioventricular and/or biventricular synchrony
, • Automatic implantable cardiac defibrillator is used to manage uncontrollable,
lifethreatening ventricular arrhythmias by sensing the heart rhythm and defibrillating
the myocardium
Life Vest
• An external device that continuously monitors the patient’s heart rhythm and
delivers a shock in the event of life-threatening arrhythmia
Valve Replacement
• Most common surgical treatment for valvular disease
• Primary candidates: patients with mitral and aortic stenosis, regurgitation, or
both
• Median sternotomy is the route of access to the heart
• Common valve replacements: Mitral valve replacement and aortic valve
replacements Percutaneous Aortic Valvotomy and Transcatheter Aortic Valve
Implantation
• For patients with aortic stenosis, the mainstay treatment involves an AVR
executed through a median sternotomy
• Percutaneous aortic balloon valvotomy is a procedure in which a balloon is
placed across the stenosed valve and inflated to relieve the stenosis
• Minimally invasive transcatheter aortic valve implantation involves a
replacement valve being fed through a small incision in the vascular system and
progressed into the heart or through direct aortic access either viia a mini-sternotomy
or right anterior thoracotomy
Cardiac Transplantation
• Acceptable intervention for the treatment of end-stage heart disease
Physical therapy is vital for the success of heart transplantation
REFERENCES:
Braddom, R. L., Chan, L., & Harrast, M. A. (2011). Physical medicine and rehabilitation. (4th ed.).
Philadelphia, PA: Saunders/Elsevier.
Frontera, W. R., & DeLisa, J. A. (2010). Physical medicine & rehabilitation: Principles and practice (5th
ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.
, Goodman, C. C., & Fuller, K. S. (2015). Pathology: Implications for the physical therapist. St. Louis, Mo:
Saunders/Elsevier.
Hillegass, E. A., & Sadowsky, H. S. (2016). Essentials of cardiopulmonary physical therapy (4th ed).
Philadelphia: Saunders.
O’Sullivan, S. B., Schmitz, T. J., & Fulk, G. D. (2014). Physical rehabilitation (6th ed). Philadelphia: F.A.
Davis Company.
Paz, J. C., & West, M. P. (2016). Acute care handbook for physical therapists (4th ed). Boston:
Butterworth-Heinemann.
ANATOMICAL, PHYSIOLOGICAL, AND KINESIOLOGICAL BACKGROUND
Anatomy of the Cardiac System
a. Structures Mediastinum
- Lies between the right and left pleura of the lungs and near the median sagittal plane of the chest.
From an anteroposterior perspective, it extends from the sternum in front to the vertebral column
behind and contains all the thoracic viscera except the lungs. It is surrounded by the chest wall
anteriorly, the lungs laterally, and the spine posteriorly. It is continuous with the loose connective tissue
of the neck and extends inferiorly onto the diaphragm. It is the central compartment of the thoracic
cavity and contains the heart, the great vessels of the heart, esophagus, trachea, phrenic nerve, cardiac
nerve, thoracic duct, thymus, and lymph nodes of the central chest. (Hillegass, 2016).
Heart
- Is the primary pump that circulates blood through the entire vascular system
that is somewhat pyramidal in shape. It is around 12 cm; 9 cm wide at its broadest part;
6 cm thick and weighs around 250 g for females and 300 g for males. (Tortora, 2014)
- Lies within the left thoracic cavity. The base of the heart is located superiorly,
approximately between the second and third rib; the apex if located inferiorly,
approximately at the end of the fifth rib. In this position, the heart is rotated in the
sagittal plane so that the right ventricle (RV) is positioned anterior to the left ventricle
(LV) and tipped anteriorly, bringing the apex closer to the chest wall. In the posterior-
anterior view of a chest x-ray, the RV occupies a significant portion of the frontal plane.
The right atrium (RA) is generally located in the area of the second intercostal spaces
and the angle of Louis. When one palpates the sternum, the angle of Louis is the “bump”
that demarcates the manubrium from the body of the sternum. The second intercostal
spaces are lateral and slightly below the angle of Louis. The second intercostal spaces
are an important auscultatory landmark; the right space is known as the aortic area; the
left as the pulmonic area. The apex of the normal heart is in the fifth intercostal space at
the midclavicular line. In a healthy heart, this area, known as the point of maximal
impulse (PMI), is where the contraction of the LV is most pronounced. (O’Sullivan, 2014)
2024/2025
• Coronary Laser Angioplasty o Uses laser energy to create precise ablation of
paques without thermal injury to the vessel
o Use is limited because of the expense of the equipment and a high restenosis rate (>40%)
• Directional Coronary Atherectomy
o Can be perfomed by inserting a catheter with a cutter housed at the distal end on one side of the
catheter and a balloon on the other side. The balloon inflates and presses the cutter against the
atheroma (plaque). The cutter then can cut the atheroma and remove it from the arterial wall
Transmyocardial Revascularization
• A catheter with a laser tip creates transmural channels from patent coronary
arteries into an area of the myocardium thought to be ischemic.
• It is intended for patients with chronic angina who cannot have angioplasty or
CABG
Coronary Artery Bypass Graft
• Performed when the coronary artery has become completely occluded or
when it cannot be corrected by PTCA, coronary arthrectomy, or stenting
• Vascular graft is used to revascularize the myocardium
• Saphenous vein, radial artery, left internal mammary artery, or right internal
mammary artery
• Most commonly performed through a median sternotomy
Minimally Invasive Coronary Artery Bypass Graft
• Uses a small thoracotomy incision as an alternate to median sternotomy
Off-Pump Coronary Artery Bypass Graft Procedure
, • Uses a standard median sternotomy and grafting of the coronary arteries
under conditons of beating, normothermic heart
• Major advantage: reduce complications associated with artificial perfusion
induced by cardiopulmonary bypass pump.
Median Strenotomy and Sternal Precautions
• The primary premise for the use of sternal precautions is to reduce the
possibility of sternal dehiscence
Secondary Prevention After Revascularization
• Ensures continued success of the procedures via secondary prevention of
primary disease processes
Ablation Procedure
• Indicated for supraventricular tachycardia, AV nodal reentrant pathways,
atrial fibrillation, atrial flutter, and certain types of ventricular tachycardia
• Attempts to remove or isolate ectopic foci in an attempt to reduce the
resultant rhythm disturbance
Maze Procedure
• For surgical ablation of atrial fibrillation
• Aims to surgically create a “maze” along the atria to best direct the electrical
conduction appropriately to the AV node and the ventricles
• Performed in conjunction with CABG or valve replacement surgery
Standard nonpharmacological treatment of atrial fibrillation
Cardiac Pacemaker Implantation and Automatic Implantable Cardiac Defibrillator
• Placement of a unipolar or bipolar electrode on the myocardium
• Electrode is used as an action potential in the management of certain
arrhythmias
• Indications: Sinus node disorders, Atrioventricular disorders, Tachyarrhytmias,
improving atrioventricular and/or biventricular synchrony
, • Automatic implantable cardiac defibrillator is used to manage uncontrollable,
lifethreatening ventricular arrhythmias by sensing the heart rhythm and defibrillating
the myocardium
Life Vest
• An external device that continuously monitors the patient’s heart rhythm and
delivers a shock in the event of life-threatening arrhythmia
Valve Replacement
• Most common surgical treatment for valvular disease
• Primary candidates: patients with mitral and aortic stenosis, regurgitation, or
both
• Median sternotomy is the route of access to the heart
• Common valve replacements: Mitral valve replacement and aortic valve
replacements Percutaneous Aortic Valvotomy and Transcatheter Aortic Valve
Implantation
• For patients with aortic stenosis, the mainstay treatment involves an AVR
executed through a median sternotomy
• Percutaneous aortic balloon valvotomy is a procedure in which a balloon is
placed across the stenosed valve and inflated to relieve the stenosis
• Minimally invasive transcatheter aortic valve implantation involves a
replacement valve being fed through a small incision in the vascular system and
progressed into the heart or through direct aortic access either viia a mini-sternotomy
or right anterior thoracotomy
Cardiac Transplantation
• Acceptable intervention for the treatment of end-stage heart disease
Physical therapy is vital for the success of heart transplantation
REFERENCES:
Braddom, R. L., Chan, L., & Harrast, M. A. (2011). Physical medicine and rehabilitation. (4th ed.).
Philadelphia, PA: Saunders/Elsevier.
Frontera, W. R., & DeLisa, J. A. (2010). Physical medicine & rehabilitation: Principles and practice (5th
ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health.
, Goodman, C. C., & Fuller, K. S. (2015). Pathology: Implications for the physical therapist. St. Louis, Mo:
Saunders/Elsevier.
Hillegass, E. A., & Sadowsky, H. S. (2016). Essentials of cardiopulmonary physical therapy (4th ed).
Philadelphia: Saunders.
O’Sullivan, S. B., Schmitz, T. J., & Fulk, G. D. (2014). Physical rehabilitation (6th ed). Philadelphia: F.A.
Davis Company.
Paz, J. C., & West, M. P. (2016). Acute care handbook for physical therapists (4th ed). Boston:
Butterworth-Heinemann.
ANATOMICAL, PHYSIOLOGICAL, AND KINESIOLOGICAL BACKGROUND
Anatomy of the Cardiac System
a. Structures Mediastinum
- Lies between the right and left pleura of the lungs and near the median sagittal plane of the chest.
From an anteroposterior perspective, it extends from the sternum in front to the vertebral column
behind and contains all the thoracic viscera except the lungs. It is surrounded by the chest wall
anteriorly, the lungs laterally, and the spine posteriorly. It is continuous with the loose connective tissue
of the neck and extends inferiorly onto the diaphragm. It is the central compartment of the thoracic
cavity and contains the heart, the great vessels of the heart, esophagus, trachea, phrenic nerve, cardiac
nerve, thoracic duct, thymus, and lymph nodes of the central chest. (Hillegass, 2016).
Heart
- Is the primary pump that circulates blood through the entire vascular system
that is somewhat pyramidal in shape. It is around 12 cm; 9 cm wide at its broadest part;
6 cm thick and weighs around 250 g for females and 300 g for males. (Tortora, 2014)
- Lies within the left thoracic cavity. The base of the heart is located superiorly,
approximately between the second and third rib; the apex if located inferiorly,
approximately at the end of the fifth rib. In this position, the heart is rotated in the
sagittal plane so that the right ventricle (RV) is positioned anterior to the left ventricle
(LV) and tipped anteriorly, bringing the apex closer to the chest wall. In the posterior-
anterior view of a chest x-ray, the RV occupies a significant portion of the frontal plane.
The right atrium (RA) is generally located in the area of the second intercostal spaces
and the angle of Louis. When one palpates the sternum, the angle of Louis is the “bump”
that demarcates the manubrium from the body of the sternum. The second intercostal
spaces are lateral and slightly below the angle of Louis. The second intercostal spaces
are an important auscultatory landmark; the right space is known as the aortic area; the
left as the pulmonic area. The apex of the normal heart is in the fifth intercostal space at
the midclavicular line. In a healthy heart, this area, known as the point of maximal
impulse (PMI), is where the contraction of the LV is most pronounced. (O’Sullivan, 2014)
