Revascularization of the Heart C H A P T E R 13 Revascularization of the Heart Patterson Chapter 13

Procedure Definitions Clinical procedures may be elected to restore myocardial blood flow with the specific intent of symptom relief and improved morbidity and mortality. Coronary artery bypass surgery Percutaneous transluminal coronary angioplasty Stent therapy

Coronary Artery Bypass Surgery Revascularization by use of a venous graft from an arm or leg or an arterial graft Role for CABS reserved for the following patients: Patients who are post-percutaneous transluminal coronary angioplasty (PTCA), stenting with restenosis, or both Patients who are no longer candidates for angioplasty but still have target vessels offering preservation of left ventricular systolic function Those with multivessel disease not amenable to angioplasty or stenting Those with technically difficult vessel lesions, for example, on the curve of a vessel or in a distal location not readily amenable to angioplasty or stenting

Percutaneous Transluminal Coronary Angioplasty The procedure may use one or more techniques alone or in combination to open the vessel: Balloon dilation is most commonly used in conjunction with stent placement. Rotational atherectomy may be applied to central bulky lesions. Directional atherectomy and laser may be used to debulk large lesions. Stent therapy reduces the risk of acute closure and restenosis of coronary arteries after PTCA.

Figure 13.1

Clinical Considerations Success rate of a revascularization procedure predicted by: Age Other existing comorbidities Severity and location of the lesion Coronary artery bypass surgery Percutaneous transluminal coronary angioplasty

Table 13.1

Exercise Prescription Cardiac rehabilitation begins as soon as possible. Shorter hospital stays have changed the inpatient program to basic range of motion exercises and ambulation. Educational focus is on medications, home activities, and follow-up appointments. (continued)

Exercise Prescription (continued) After hospital discharge, exercise should focus on: Improved cardiac performance at rest and during exercise Improved exercise capacity (aerobic and strength) Greater total work performed Improved angina-free exercise tolerance, much of which is attributable to peripheral muscular adaptations Improved neurohumoral tone (continued)

Exercise Prescription (continued) Special exercise considerations Coronary artery bypass surgery Primary concerns for the CABS patient when entering outpatient cardiac rehabilitation are the state of incisional healing and sternal stability, hypovolemia, and low hemoglobin concentrations. Percutaneous transluminal coronary angioplasty Primary concern for the PTCA or stent patient is restenosis. Patients must understand the signs or symptoms indicative of angina or their particular anginal equivalent. Patients with PTCAs and stents may begin the outpatient program as soon as they are discharged from the hospital or immediately following the procedure if it is performed on an outpatient basis. See table 13.3 for exercise prescription review.

Conclusion Advances in coronary revascularization procedures and an aging population have led to a greater number of patients presenting for rehabilitation following CABS, PTCA, and stenting. Appropriate exercise programming and risk factor modification are essential for prevention of recurrent events.