Rehabilitation Perioperative Cardiac Surgery

Deddy Tedjasukmana

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo Hospital,

University of Indonesia, Jakarta, Indonesia

Keyword: Rehabilitation, Cardiac Rehabilitation, Perioperative, Cardiac Surgery

Abstract: Cardiac rehabilitation is a multidisciplinary program of exercise program, education, risk factor

modification, and psychosocial counseling resulted in reduces mortality and hospital stay, improves quality

of life in patients with heart disease. In Indonesia, 1.5% Indonesian suffer from coronary heart disease and

approximately one million of patients worldwide underwent revascularization program every year.

Perioperative cardiac rehabilitation helps patients to overcome the stress of surgery, prevention of

complication caused by prolonged bed rest. It also promotes physical and psychological readiness for

surgery, reduces length of stay, and improves the transition from the hospital to the community. In most

current guidelines of cardiovascular societies, cardiac rehabilitation is a class I recommendation.

1 INTRODUCTION

National Heart Lung and Blood Institute (NHBI)

defined coronary heart disease as a condition caused

by the buildup of plaque in the arteries that supply

oxygen-rich blood to the heart (National Heart Lung

dan Blood Institute, 2012). In Indonesia, 1.5%

Indonesian suffer from coronary heart disease.

According to Survey Sample Registration System in

2014, deaths due to coronary heart disease were

accounted for 12.9%. The highest prevalence of

heart disease in Indonesia is at the age of 75 years

old (Kementrian Kesehatan RI, 2018).

Approximately one million of patient worldwide

underwent revascularization program every year,

with the distribution between operation and

catheterization almost equal. Recent reports suggest

that more than half of cardiac surgeries are being

performed on older adults who are more likely to be

frail and have multiple comorbidities. Cardiac

surgery has been shown to improve the outcomes of

these patients (Kehler DS et al, 2017).

The recovery period for each individual was

affected by age, gender, premorbidity status and

operation technique. The recovery period varied

from a few days to weeks caused by clinical and

nonclinical effect from cardiac surgery. At the

beginning of postoperative period, depression is

more likely to develop, but as time goes, depression

rate will be lower due to the recovery process and

social support that was given. Initiation of cardiac

rehabilitation program for patients underwent

cardiac surgery should start as soon as possible after

patient condition was stabilized (Tedjasukmana and

Putra, 2016) .

2 DISCUSSION

Cardiac rehabilitation is a multidisciplinary program

of exercise program, education, risk factor

modification, and psychosocial counseling that

reduces mortality and hospital stay, improves quality

of life in patients with heart disease (Beatty et al,

2017). The first objective of cardiac rehabilitation is

to improve regular physical activities and control the

modifiable risk factors (smoking cessation, blood

pressure, diabetes, cholesterol). Another objective is

therapeutic education that emphasizes the

importance of the healthy lifestyle. Lastly, helping

manage psychosocial and professional problems of

the cardiac patients because depression is quite

frequent following after coronary events. Thus,

depression was associated with lower exercise

capacity, fatigue, reduced quality of life and sense of

wellbeing (Mampuya, 2012). Cardiac rehabilitation

are consist of breathing exercises, early

mobilization, and strength exercises. Research

conducted by Maines et al, showed that exercise

therapy improves exercise capacity by around 16%.

168

Tedjasukmana, D.

Rehabilitation Perioperative Cardiac Surgery.

DOI: 10.5220/0009087401680171

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 168-171

ISBN: 978-989-758-409-1

The improved exercise capacity will lower the

mortality by 12% for every one metabolic equivalent

improvement. In addition, regular exercise decreases

mortality by 28% which is associated with

improvements in quality of life (QoL) (Seo et al,

2017).

2.1 Cardiac Rehabilitation

Perioperative

Cardiac rehabilitation perioperative consist of

preoperative, intraoperative and postoperative.

Prehabilitation helps patients to overcome the stress

of surgery by improving functional capacity.

Preoperative exercise decreases sympathetic

overreactivity, improves insulin sensitivity, and

increases the ratio of lean body mass to body fat. It

also promotes physical and psychological readiness

for surgery, reduces postoperative complications and

length of stay, and improves the transition from the

hospital to the community. Patient who were given

education regarding postoperative mobilization

before surgery will respond more positively and

enthusiastically to the program (Kementrian

Kesehatan RI, 2018).

2.2 Cardiac Rehabilitation After

Surgery

After the surgery was perform, there is no place for

“bedrest” in the management of patient with

cardiovascular disease. Early mobilization of patient

after cardiac surgery shown to be beneficial for

patient’s recovery. Initiating physical activity in the

early period after cardiac surgery, especially walking

exercise is recommended since it can prevent

complications. Phase 1 begins after the patient has

been considered clinically compensated due to the

optimization of the clinical treatment and/or the use

of an interventional procedure. In this phase, a

combination of low-intensity physical exercise is

indicated as well as stress management techniques,

and education in relation to risk factors. The

duration of this phase has decreased in recent years,

due to shorter hospitalizations (Alexiey et al, 2017;

Priscila et al, 2017).

Cardiac rehabilitation contributes to the

prevention of lung complication and decondition

caused by prolonged bedrest after cardiac surgery.

Exercise-based cardiac rehabilitation decreases

hospital stay, speeds returns to work and reduces

costs in public health. Exercise training can partially

reverse activation of the neurohormonal system and

reduce levels of pro-inflammatory cytokines,

reduces skeletal muscle fatigability, improve skeletal

muscle metabolism, increase blood flow within the

active muscles, and reduce dependence on anaerobic

metabolism. Exercise also has some other benefits

such as lessen the intensity of breathing and muscle

discomfort, improve quality of life, attenuate or

reverse skeletal muscle atrophy and increase

endothelium activation. Therefore, it believes that

exercise training prolongs exercise duration, lowers

cardiovascular demand, lowers ventilator

requirement, allows higher exercise intensity, and

reduces symptoms of dyspnoea and leg discomfort.

This is in turns lead to increase independence and

improvement in general sense of

wellbeing(Mampuya, 2012; Priscila et al, 2017;

Price et al, 2016; Seo et al, 2017).

2.3 The Role Of Cardiac Rehabilitation

In most current guidelines of cardiovascular

societies worldwide, cardiac rehabilitation is a class

I recommendation. (Tedjasukmana and Putra, 2016).

Coronary artery bypass grafting (CABG) is a

procedure which artery or vein are use as graft to

revive the coronary artery (bypass) which is

occluded partially or totally caused by

atherosclerotic process. The procedure explain as

making a new route around the occluded coronary

arteries with the aim of expediting blood flow so the

intake of oxygen and nutrients to the myocardium is

maintained. CABG usually uses saphena veins or

internal mammary veins, in addition to the radial

arteries and gastroiliac arteries although its rarely

use (Tedjasukmana and Putra, 2016).

CABG usually needs an in-hospital stay for a

week and, after discharge, patients usually need a 2-

to 6-week recovery period, necessary to recover and

adapt to daily activities, including return to work. A

significant proportion of patients need to overcome

some problems, like heart failure, anemia, atrial

fibrillation, pulmonary abnormalities, and

thoracotomy- and saphenectomy-related pain.

Cardiac rehabilitation is important considering the

facts that patient’s need to achieve a full and prompt

physical recovery to allow a fast adaptation of daily

life activities (including return to work), the need of

healthy lifestyle and specific pharmacological

regime for a lifetime (Mendes, 2016; Tedjasukmana

and Putra, 2016; Priscila et al, 2017).

Rehabilitation Perioperative Cardiac Surgery

169

2.4 Cardiac Rehabilitation Program

There is no differences perioperative cardiac

rehabilitation program between patients underwent

coronary artery bypass graft and valve cardiac

surgery. Exercise training before preoperative are

(Tedjasukmana and Putra, 2016) :

• Breathing exercise, consist of deep breathing

and diaphragm breathing 10 times each

• Incentive spirometry exercise and effective

cough

• Mobilization of neck and shoulder along with

chest extension

• Streching exercise of extremity

• Shoulder muscle exercise for flexion and

extension

Postoperative patient can begin cardiac

rehabilitation sooner which resulted in faster

recovery. The exercise focus on flexibility

prioritizing the upper limb. During exercise,

symptom of stenosis or occlusion need to be

evaluated. The limitations during exercise are borg

scale and resting heart rate which increases more

than 30 times/minutes. Walking is the most

recommended exercise for postoperative program,

where the post CABG as well as post valve surgey

have several characteristic which need special

attentions to the range of motion (Tedjasukmana and

Putra, 2016).

After the operation, exercise recommendations

for patient are (Tedjasukmana and Putra, 2016):

• Breathing exercise and pulmonary expansion

• Cough exercises

• Range of motion exercise for upper and lower

extremity

• Spirometry

• Mobilization exercises as recommendation

shown in table 2.

According to Krusen’s Handbook of Physical

Medicine and Rehabilitation (1990), rehabilitation

for postoperative cardiac surgery shown in table 2.

Patients who have undergone cardiac surgery are

recommended to avoid strenuous upper extremity

exercise until the wound is stable (Seo et al, 2017).

Figure 1: Rehabilitation Postoperative Cardiac Surgery

STEP

POD

NURSING

ACTIVITY

OCCUPATIONAL

THERAPY ACTIVITIES

PHYSICAL

THERAPY

ACTIVITIES

EDUCATION

Up in chair

Introduce self and program

Introduce self and

program

Cardiac

Rehabilitation

Self-feeding

Bedside

commode

Walking short

distances

Lifestyle assessment

Work simplification

Energy conservation

Walking short

distances, active

assisted range of

motion, or 1-3 MET

calisthenics

Risk factor

III

Walk in hall 3x

Bathroom

privileges

Partial self-bath

in bed

Activity precautions

Pulse monitoring

Smoking cessation

Walk in hall x3

1-4 MET lv

calisthenics

METs level

Walk ad lib

Partial self-bath

Out of bed 3-4

hours

ADLs and METS

Smoking cessation

Walking ad lib

2-4 MET lv

calisthenics

Phase II

Walk ad lib

Increasing

distances

Relaxation training

Smoking cessation

Work equivalents as

appropriate

Walk ad lib

3-5 MET lv

calisthenics

Stair climbing

Discharge

planning

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

170

3 CONCLUSIONS

Cardiac rehabilitation is a multidisciplinary program

of exercise program, education, risk factor

modification, and psychosocial counselling that

reduces mortality and hospital stay, improves quality

of life in patients with heart disease. Cardiac

rehabilitation perioperative consist of preoperative,

intraoperative and postoperative phase. The

programs of cardiac rehabilitation are breathing

exercises, early mobilization, and strength exercises.

Prehabilitation helps patients to overcome the stress

of surgery and reduces postoperative complications.

Initiating physical activity in the early period after

cardiac surgery shown to be beneficial for patient’s

recovery. Phase 1 begins after the patient has been

considered clinically compensated due to the

optimization of the clinical treatment and/or the use

of an interventional procedure. Patients who have

undergone cardiac surgery are recommended to

avoid strenuous upper extremity exercise until the

wound is stable. In most current guidelines of

cardiovascular societies, cardiac rehabilitation is a

class I recommendation.

REFERENCES

Alexiev A, Terziev A, Gotcheva N. 2017. Effect of an

Early Cardiac Rehabilitation Following Heart Surgery

In Patients Over 70 Years. SM J Clin Med 3(1):1019

Beatty AL, Bradley SM, Maynar C., et al. 2017. Referral

to Cardiac Rehabilitation After Percutaneous Coronary

Intervention, Coronary Artery Bypass Surgery, and

Valve Surgery : Data from the Clinical Outcomes

Assesment Program. Circ Cardiovasc Qual Outcomes.

10, pp 1-8.

Kehler DS, Stammers AN, Tangri N., et al. 2017.

Systematic Review of Preoperative Physical Activity

and Its Impact on Postcardiac Surgical Outcomes.

BMJ Open. 7:e015712, pp 1-12.

Kementerian Kesehatan Badan Republik Indonesia. 2018.

Hasil Utama Riset kesehatan dasar

2018.http://www.depkes.go.id/resources/download/inf

o-terkini/hasil-riskesdas-2018.pdf?opwvc=1. Cited 30

September 2019 (13.25)

Mampuya WM. 2012. Cardiac Rehabilitation Past, Present

and Future: An Overview. Cardiovascular Diagnosis

and Therapy 2(1), pp 38-49.

Mendes M. 2016. Is There a Role for Cardiac

Rehabilitation After Coronary Artery Bypass Grafting.

AHA Journal; 133, pp 2538-44.

National Heart Lung and Blood Institute. 2012. Heart

Disease and Stroke Prevention Program 2012

Coronary Heart Disease Fact Sheet. Hawai State

Department of Health: Honolulu.

Tedjasukmana D, Putra HL. Indonesia. 2016. Rehabilitasi

Kardiovaskular. Perdosri: Jakarta.

Priscila A, Kondo NN, Guillermo M., et al. 2017. Physical

Training Programs After Coronary Artery Bypass

Grafting. Intech open science; pp 149-162.

Price KJ, Gordon BA, Bird SR., et al. 2016. A Review of

Guidelines for Cardiac Rehabilitation Exercise

Programs: Is There an International Consensus.

European Journal of Preventive Cardiology 23 (16),

pp 1715-33.

Seo GY, Jang MJ, Park WH., et al. 2017. Inpatient

Cardiac Rehabilitation Programs’ Exercise Therapy

for Patients Undergoing Cardiac Surgery: National

Korean Questionnare Survey. Journal of Exercise

Rehabilitation; 13(1), pp 76-83.

Rehabilitation Perioperative Cardiac Surgery

171