Complete physical therapy textbook - rgufk. textbook physical rehabilitation

Currently, in our country and abroad, along with conservative treatment, surgical treatment of coronary heart disease is increasingly used, consisting of myocardial revascularization using a coronary artery bypass graft and resection of post-infarction cardiac aneurysm. The indication for surgery is severe angina pectoris of exertion and rest, refractory to drug treatment, which is more often observed in patients with low coronary reserve, coronary artery stenosis of 75% or more. In the presence of a post-infarction cardiac aneurysm, resection surgery is the only radical treatment method. Elimination of myocardial ischemia reduces angina pectoris and increases exercise tolerance, which indicates the effectiveness of surgical revascularization and makes postoperative rehabilitation treatment promising.

The problem of rehabilitation of patients with coronary heart disease after reconstructive operations on the heart vessels is relatively new in cardiology; many aspects of this complex process have not yet been sufficiently studied. Meanwhile, previous experience in the use of physical methods in the rehabilitation treatment of patients with myocardial infarction, as well as the known mechanisms of action of physical factors, made it possible to develop the principles of staged rehabilitation of patients after coronary artery bypass surgery and resection of a cardiac aneurysm and the use of physical factors in patients with coronary artery disease after surgery.

Rehabilitation treatment of patients with coronary heart disease after heart surgery includes several stages.

The first stage (surgical clinic) is a period of unstable clinical condition of the patient and hemodynamics, followed by progressive improvement of the clinical condition and hemodynamics.

The second stage (post-hospital) is a period of stabilization of the patient’s condition and hemodynamics. At this stage, the patient is transferred from the rehabilitation department (country hospital) or local cardiological sanatorium.

The third stage (outpatient) is carried out in a clinic and includes sanatorium-resort treatment.

Each stage of rehabilitation has its own tasks, determined by the clinical and functional state of patients.

Rehabilitation of patients with coronary heart disease in the postoperative period is a set of measures aimed at preserving the life of the patient, restoring his health and ability to work. It includes medical, physical, psychological and socio-economic aspects.

In the early postoperative period (first stage), the physical and mental rehabilitation of the patient becomes of greatest importance. Already from the first days of the postoperative period, the patient is actively managed - along with drug therapy, he is prescribed breathing exercises and massage.

Early post-hospital (second) stage

At the second stage, the task is set to maximize the improvement of adaptation-compensatory processes, various forms of therapeutic physical culture, preformed and natural physical factors that form the basis of rehabilitation treatment are more widely used; mental rehabilitation and preparation of the patient for work continues.

In the research of our clinic [Sorokina E.I. et al. 1977. 1980; Gusarova S.P., Otto L.P., 1981; Otto L.P., 1982; Sorokina E.I., Otto L.P., 1985] for the first time identified the main directions of the use of physical factors at the stages of post-hospital rehabilitation of patients with coronary heart disease after coronary artery bypass surgery and resection of the left ventricular aneurysm, carried out at the All-Russian Scientific Center for Surgery of the USSR Academy of Medical Sciences. The second stage begins after discharge from the surgical hospital (3-4 weeks after surgery). Clinical observations made it possible to establish that during this period, operated patients have various degrees of severe pain in the chest, among which typical angina pectoris (in our observations in 52% of patients) should be strictly differentiated from cardialgia and pain resulting from surgery. The severe course of coronary heart disease before surgery, and the operation itself, cause a sharp limitation of the patients’ motor activity, pronounced asthenia, and a sharp change in emotional and vital tone; patients quickly get tired, irritable, often fixated on pain, anxious, sleep poorly, and complain of dizziness and headaches. Almost all patients show changes in mental status, among them the leading place is occupied by asthenoneurotic and cardiophobic syndromes, there are severely expressed disturbances in myocardial contractility (especially in patients who have suffered a myocardial infarction complicated by a cardiac aneurysm) and hemodynamics.

Arterial hypotension, sinus tachycardia, extrasystole, and decreased exercise tolerance are often detected. According to our data, on average it was 248.5+12.4 kgm/min, however, the criteria for stopping the load were symptoms of physical inactivity (fatigue, shortness of breath). The majority of the examined patients had disturbances in the ventilation function of the lungs, a decrease in the reserve capacity of the respiratory system, caused by both heart failure and postoperative complications of the lungs and pleura (pneumonia, pleurisy). The chest in operated patients has little mobility, breathing is shallow, and the strength of the respiratory muscles is reduced. This leads to disturbances in gas exchange and blood circulation in the lungs.

Due to poor training of adaptation-compensatory mechanisms, patients often have inadequate reactions to physical activity.

During this period, the leading place is occupied by the physical and mental aspects of rehabilitation, along with measures to eliminate the consequences of the operation (pain in the chest and limbs at the site of taking a vein for a shunt, disorders of the respiratory system). The importance of eliminating pain in the sternum should be emphasized. They often have to be differentiated from coronary pain; they are painful for patients, support and aggravate astheno-neurotic and cardiophobic syndromes, prevent the expansion of motor activity, and negatively affect respiratory function.

To carry out the physical aspect of rehabilitation, which is closely related to the restoration of the functional state of the cardiorespiratory system, physical factors are used that have a training effect on the heart, mediated through peripheral circulation, improve the function of external respiration, normalize the course of nervous processes in the central nervous system and have an analgesic effect. These include therapeutic physical education, balneotherapy, massage, and electrotherapy.

When implementing a physical rehabilitation program, various forms of physical therapy are used: dosed walking and a properly structured motor regimen during the day (walking, movements in connection with self-care and treatment), therapeutic exercises. The motor mode should include alternating training loads with rest and relaxation. This rhythmic effect of training and rest helps improve the regulation of many body systems and adaptive-compensatory processes. In the second half of the day, training is carried out with a load that is 50-75% of the loads carried out in the first half of the day. Increasing physical fitness is carried out by transferring the patient from one mode to another, more stressful.

Restoration of physical activity and all types of treatment in the early post-hospital rehabilitation period are carried out differentially in accordance with the functional capabilities of the cardiovascular system. Taking into account the severity of clinical symptoms of the disease and the results of ergometric tests, four groups (severity classes) of patients can be distinguished: I - patients in whom normal physical activity (with the level of rehabilitation achieved by the end of the first stage) does not cause angina pectoris, shortness of breath, fatigue, with good tolerance motor mode, with tolerance to physical activity above 300 kgm/min; II - patients in whom moderate physical effort causes angina pectoris, shortness of breath, fatigue, with an exercise tolerance of 150-300 kgm/min and rare extrasystole; III-patients with angina pectoris, shortness of breath, fatigue with little physical effort and low tolerance to physical activity below 150 kgm/min; IV - patients with frequent attacks of angina pectoris on minor physical exertion and at rest, heart failure above stage IIA, often with severe heart rhythm disturbances.

The method of dosed walking was developed by L.P. Otto (1982) under the control of the ECP. It has been shown that to ensure a safety threshold, the training load level is 80% of the energy expenditure for the maximum load, which corresponds to a certain calculated walking pace. For patients with a high level of functionality (severity class I), the initial walking pace was 100-90 steps/min, class II - 80-90 steps/min; for patients with limited functionality: III class - 60-70 steps/min, IV class - no higher than 50 steps/min. The duration of dosed walking is 15-20 minutes at the beginning and 20-30 minutes at the end of treatment. Subsequently, with adequate clinical and electrocardiographic reactions, the walking pace increased every 4-7 days and by the end of treatment for patients of severity class I was 110-120, II - 100-110, III - 80-90 steps/min, and the distance walked during the day the distance increased respectively from 3 to 7-8 km, from 3 to 6 km and from 1.5 to 4.5 km.

The method of carrying out the dosed walking procedure is very important. Movements at a slow pace are recommended for 1-2 minutes, then the patient switches to a training pace (3-5 minutes), after which he again moves at a slow pace for 2-3 minutes. After a short rest (50-100% of the walking time), the walking should be repeated. Number of repetitions - 3-4.

The basis of the therapeutic gymnastics procedure at the beginning of the course of treatment is breathing exercises and relaxation exercises; starting from the middle of the course (10-12th day of treatment), in patients of class 1 and 2 severity, exercises with dosed effort are included; in patients of class 3, such exercises are used only after 18-20 days of treatment and with fewer repetitions. Therapeutic gymnastics procedures are carried out daily, lasting 15 minutes at the beginning of treatment with a gradual increase to 30 minutes, an hour after breakfast.

Massage is of great importance in the rehabilitation treatment of patients with coronary heart disease after surgery. Massage, causing an increase in inhibition processes in the skin receptors and in the higher parts of the nervous system, inhibition of the conduction of nerve impulses, reduces pain and has a sedative effect. In addition, massage increases blood circulation and blood flow in small vessels of the skin and muscles, improves their tone and contractility. Along with changes in the nervous system and peripheral microcirculation, massage has a regulating effect on the functions of internal organs, in particular, it increases lung volumes, improves bronchial patency, and somewhat slows down the rhythm of cardiac activity. These basic mechanisms of action of massage determine its inclusion in the complex of rehabilitation treatment for patients after surgery on the coronary vessels. Massage is used to relieve pain in the chest, improve the tone of the chest muscles and reduce disturbances in the functions of external respiration, and the disappearance of cardialgia.

Massage using classical techniques, with the exception of vibrations, is carried out daily or every other day. The first 3 procedures massage only the collar area, then massage the back, sides and front surface of the chest, bypassing the postoperative scar. Massage of the anterior surface of the chest mainly includes stroking and light rubbing techniques; back massage includes all the classic techniques. The duration of the massage is 12-15 minutes, for a course there are 12-16 procedures. Contraindications to the use of massage: mediastinitis in the postoperative period, unhealed postoperative wound.

To relieve pain in the chest, we used novocaine electrophoresis using the following method. An electrode with a pad moistened with a 10% solution of novocaine is applied to the area of pain and connected to the anode of the galvanization apparatus, a second indifferent electrode with a pad moistened with distilled water is placed on the left subscapular region or left shoulder. The current density is 0.3-0.8 mA, the duration of the procedure is 10-20 minutes, the procedures are carried out daily or every other day, 10-12 per course.

Balneotherapy in this period of rehabilitation is carried out with four-chamber baths or “dry” carbon dioxide baths.

A comparative analysis of treatment results in groups of patients who received and did not receive four-chamber carbon dioxide baths revealed a particularly positive effect on cardiohemodynamics of the treatment complex, which included carbon dioxide baths. This was manifested by a more pronounced decrease in heart rate, a decrease in the severity of the phase syndrome of physical inactivity, an improvement in peripheral hemodynamics in the form of a decrease in high total peripheral vascular resistance, an increase in the reduced rheographic index to normal and a decrease in the a-indicator that was elevated before treatment (according to RVG of the lower extremities). The complex, which included carbon dioxide chamber baths, led to a more pronounced decrease in DP when performing a standard load than in the control - by 17.5 and 8.5%, respectively, which indicates an increase in the adaptive capacity of the cardiovascular system with the inclusion of a metabolic component of compensation.

At the same time, in 17.1% of patients of class III severity with clinical signs of circulatory failure, pathological clinical and hypodynamic reactions to a chamber carbon dioxide bath were noted.

Thus, chamber carbon dioxide baths (hand and foot) with a carbon dioxide concentration of 1.2 g/l, temperature 35-36 ° C, duration 8-12 minutes are used from 21 to 25 days after surgery for patients of classes I and II of severity and limited III (only in case of circulatory failure not higher than stage I). Sinus tachycardia and rare extrasystole are not a contraindication for the use of chamber baths.

Complex treatment was effective in most patients. Clinical improvement was noted in 79% of patients. The increase in the reserve capacity of the cardiovascular system was expressed in an increase in the number of patients with higher functional reserves (15.7% of patients from class II moved to class I) and a decrease in the number of patients in class III by 11.4% due to the transition of patients to class II. There was also an increase in the threshold load power from 248.5+12.4 to 421.7+13.7 kgm/min or by 69.6%.

The use of physical methods of treatment made it possible to reduce to a minimum or completely eliminate medications in all patients of class II and some patients of class III.

The positive role of physical treatment methods was revealed in a comparative analysis of treatment results in the main and control groups. Patients in the control group were treated only with medications and expanded their physical activity regimen. Thus, exercise tolerance increased more in the main group (by 173 kgm/min) compared to the control group (by 132 kgm/min). Restoration of working capacity according to follow-up data was noted in 43.3% of patients in the main group, and in 25% of them 3-4 months after surgery; in the control group, these figures were lower - 36 and 16%, respectively. It should be noted that 61 .5% of patients in the main group resumed their previous work, while in the control group - only 22.2% (R<0,05).

The use of “dry” carbon dioxide baths, the effect of which on this group of patients was studied at the Central Research Institute of Physics and Physics [Knyazeva T. A. et al., 1984], is effective in restoring the impaired functional state of the cardiorespiratory system in most patients, including patients of severity class 111 , with circulatory failure stage IIA. The technique for conducting them is the same as for patients with myocardial infarction in the early post-hospital period of the second stage of rehabilitation.

In the early post-hospital period of rehabilitation of operated patients, we observed a beneficial effect from the use of fresh water foot baths at contrasting temperatures. The use of this type of hydrotherapy helped reduce signs of hypersympathicotonia (tachycardia, lability of heart rate, blood pressure, etc.), increased emotional lability, and reduce symptoms of asthenia. In addition, after individual baths and a course of treatment, a decrease in the phase syndrome of myocardial hypodynamia and arterial hypotension was observed, and exercise tolerance improved, as indicated by the results of the step test and the rapid expansion of the motor regime. The procedure consisted of alternating stays in a foot bath with a water temperature of 38°C (1-2 min) and in a bath with a temperature of 28-25°C (1 min). The duration of the procedure is 10-12 minutes. Baths were given every other day or daily, for a course of 8-10 baths.

The mental aspect of rehabilitation is of great importance in the early post-hospital period. A powerful means of mental rehabilitation is to expand the motor regime and improve the somatic condition of patients. An integral component of rehabilitation measures is psychotherapy, carried out by the attending physician daily in the form of explanatory conversations about the prospects of rehabilitation treatment and the positive results of special research methods. We observed a decrease in the clinical manifestations of asthenoneurotic syndrome in 93.7% of patients, along with an increase in mental performance according to a psychological test.

For sleep disorders, neurotic reactions in the form of increased emotional lability, as well as for sinus tachycardia, extrasystole, the following is used: electrosleep with a pulse frequency of 5-20 Hz, duration 20-30 minutes, daily or every other day, for a course of 10-15 procedures; galvanic collars or medicinal electrophoresis using the “collar” technique (bromine, caffeine, beta-blockers, etc.). These types of electrotherapy are used for patients of classes I, II and III.

Just as in patients with myocardial infarction, the basic principle of rehabilitation remains the same - the complexity of restorative measures aimed at different parts of the pathological process.

Our observations have shown that it is most effective to use a set of therapeutic measures consisting of physical training methods in combination with methods that have a positive effect on the patient’s neuropsychic status. An example of such complex restorative treatment is the one that we effectively (in 79% of patients) used in our observations. It included dosed walking and a gradual expansion of the motor regime (according to the scheme according to the patient’s severity class), therapeutic exercises, chest massage, novocaine electrophoresis and chamber carbon dioxide baths. Treatment began with expanding the motor regimen, massage and electrophoresis of novocaine to reduce pain. After 5-7 days, balneotherapy was used. This complex of rehabilitation treatment can be supplemented with other therapeutic factors, for example, electrosleep, medicinal electrophoresis. Treatment is carried out against the background of constant explanatory psychotherapy; some patients also require special psychotherapy.

The results presented above allow us to speak about the effectiveness of complex treatment using physical factors in the early period of the post-hospital stage of rehabilitation of patients with coronary heart disease who have undergone surgical treatment.

Polyclinic (third) stage

In the long-term postoperative period, 60-70% of patients with coronary heart disease after reconstructive operations on the heart vessels experience angina pectoris, usually milder than before the operation), often extrasystole and arterial hypertension, asthenoneurotic reactions, cardialgia. Disturbances in myocardial contractile function and hemodynamics are less pronounced than in the early post-hospital stage, which is apparently due to the positive effect of myocardial revascularization and resection of the cardiac aneurysm. Exercise tolerance remains reduced (in our studies from 500 to 250 kgm/min, on average 335.2±±10.3 kgm/min). In most patients, lipid metabolism disorders persist.

Observations have shown that approaches to determining the functional state of operated patients at this stage of rehabilitation are not fundamentally different from those applied to patients with stable angina who have not undergone surgical treatment.

Among the patients we examined, based on the severity of angina pectoris and exercise tolerance, 10% of patients could be classified as FC I, 25% as FC II, and 65% as FC III.

The detected disorders determine the tasks of the outpatient rehabilitation stage - the need to carry out measures aimed at compensating for coronary and heart failure, hemodynamic disorders, weakening neurotic disorders and risk factors for disease progression.

The tasks facing the outpatient stage determine approaches to the use of physical methods of treatment, taking into account their mechanism of action.

The complex treatment we used included radon baths (40 nCi/l, 36°C, duration 12 minutes, 10-12 baths per course) or sulfide baths (50 g/l), therapeutic exercises, massage of the heart area and electrosleep (pulse frequency current 5-10 Hz, procedure duration 30-40 minutes, 10-15 procedures per course), improved the condition in 87 and 72% of patients, according to the types of baths used. There was a decrease and decrease in the intensity of angina attacks in 52 and 50% of patients, respectively, in groups separated by type of bath; a decrease or cessation of extrasystole was observed only in the group of patients receiving radon baths (in 50%), a decrease in high blood pressure in both groups (R<0,05). Выявлена положительная динамика ЭКГ, свидетельствующая об улучшении метаболических процессов в миокарде (повышение сниженных зубцов T). Exercise tolerance increased from 335.1 + 10.3 to 376.0+ + 11.0 kgm/min (P<0,05) в группе больных, получавших радоновые ванны, и с 320,2+14,0 до 370,2+12,2 кгм/мин (Р<0,05) у больных, лечившихся с применением сульфидных ванн. ДП на стандартной нагрузке снизилось в обеих группах, что свидетельствовало об улучшении метаболического компонента адаптации к физическим нагрузкам.

After treatment, there was a decrease in the level of beta-lipoproteins that was elevated before treatment (P<0,05).

In patients with tachycardia and extrasystole, the use of complex treatment, including radon baths, led to a decrease in heart rhythm disturbances, while complex treatment, including sulfide baths, did not significantly affect these manifestations of the disease.

We were convinced of the need for a differentiated approach to prescribing baths from studies of hemodynamics and clinical reactions to individual baths. If in patients with FC II and III, no pathological reactions were noted when using radon baths, then in the group of patients treated with sulfide baths, a more noticeable restructuring of central hemodynamics was observed. It consisted of a decrease in specific peripheral resistance from 51.31 ± -±1.6 to 41.12-±1.18 arb. units (R<0,01) и повышении сердечного индекса с 1,8+0,03 до 2,0±0,04 (Р<0,05) за счет повышения как сниженного ударного объема, так и частота сердечных сокращений (с 78,2+3,2 до 80,44=2,8) в 1 мин (Р<0,05). Поэтому у больных III класса тяжести с частыми приступами стенокардии, с нарушениями сердечного ритма лечение сульфидными ваннами оказалось неадекватным резервным возможностям сердца. У них во время лечения учащались приступы стенокардии, наблюдалась тахикардия, экстрасистолия. Следовательно, сульфидные ванны, значительно снижая общее периферическое сопротивление сосудов, ведут к рефлекторному повышению симпатического тонуса вегетативной нервной системы и неадекватному в таких случаях увеличению сердечного выброса, что выявляет несостоятельность миокарда и коронарного кровоснабжения. Следовательно, у больных, оперированных на коронарных артериях, выявляется общая закономерность действия сульфидных ванн на гемодинамику и вегетативную регуляцию сердца. Поэтому больным с утяжеленным нарушением функционального состояния (III ФК) применять сульфидные ванны не следует.

Complex treatment using both types of baths reduced asthenoneurotic manifestations, while at the same time, in patients with signs of hypersympathicotonia with a predominance of excitation processes, radon baths had a better effect.

Thus, differentiated approaches to prescribing physical methods of treatment should be determined primarily by the degree of impairment of the functional state of the cardiovascular system. In patients belonging to FC I, II and III, with extrasystole, severe asthenoneurotic syndrome, a therapeutic complex including radon baths, electric sleep, therapeutic exercises and chest massage is more effective. Sulfide baths, which have a more pronounced effect on hemodynamics, are recommended only for patients with FC I and II without clinical signs of circulatory failure and heart rhythm disturbances.

The rehabilitation system we used using physical methods of treating patients with coronary heart disease after reconstructive operations on the coronary arteries during the first postoperative year is effective in most patients. This conclusion was made based on the results of clinical observations, the study of exercise tolerance in dynamics (Fig. 21), as the main indicator of effective treatment of patients with coronary heart disease, as well as important hemodynamic indicators of heart rate, minute volume of blood and total peripheral vascular resistance (Fig. 22). As can be seen in the presented figures, exercise tolerance increased at each stage of the study compared with the previous one, as well as with the control group of patients who did not receive staged rehabilitation treatment; The minute volume of blood also increased and the total peripheral vascular resistance decreased. At the same time, the minute volume of blood increased with a decrease in heart rate due to an increase in specific volume.

Rice. 21. Changes in exercise tolerance in patients with coronary heart disease at different times after surgery: 1, 2-4 months, 1 year. 1 - main group; 2 - control.

Rice. 22. Dynamics of minute volume of blood circulation (a) and specific peripheral resistance (b) in patients with coronary heart disease at different times after treatment.

1 - proper IOC; 2 - actual IOC: 3 - due UPS: 4 actual UPS.

The mental status of patients has significantly improved, asthenon-neurotic complaints and cardialgia have decreased, which played a certain role in improving the subjective state of patients, increasing their vitality, the emergence of a correct self-assessment of their condition and a critical attitude towards cardialgia. This made it possible to perform greater physical activity than at the early stage of rehabilitation, despite the increased frequency of angina attacks. This circumstance, in turn, led to positive medical and social results of rehabilitation. After 1 year, 56% of patients started working, while only 28% of patients who did not receive rehabilitation treatment; 8% of patients receiving rehabilitation treatment began their professional activities within 3 months after surgery. The number of patients with complete loss of ability to work decreased by 18%, disability group II was completely removed in 12%, 6% of patients were transferred from disability group II to III. During the year, not a single case of complete restoration of working capacity was observed in patients in the control group. There was only a decrease in the degree of disability (from group II to group III).

Sanatorium-resort treatment of coronary heart disease

Sanatorium-resort treatment at the outpatient stage of rehabilitation of patients with coronary heart disease after constructive operations on the coronary arteries is given great importance.

Sanatorium-resort treatment is prescribed in the final period of the post-hospital stage of rehabilitation - 3-4 months after surgery in a local cardiological sanatorium, and a year later in climatic and balneological resorts.

Patients with FC I and II are sent to climatic (without heart rhythm disturbances and circulatory failure above stage I) and balneological resorts, to local sanatoriums, patients with FC III - only to local cardiological sanatoriums.

In the conditions of a local sanatorium and sanatorium of a climatic resort, complex treatment using electrotherapy, therapeutic physical training is necessarily complemented by climatotherapy in the form of aerotherapy (dosed air baths, sleep by the sea, walks), heliotherapy (partial and total sunbathing, in the cold season, ultraviolet radiation), swimming in the sea and pool.

At balneological resorts, the leading role in complex spa treatment belongs to balneotherapy in the form of baths, and in case of lipid metabolism disorders, drinking treatment with mineral waters.

The methods of applying climatotherapeutic and balneological procedures are not fundamentally different from those used by patients with stable angina who have not undergone surgery. Expansion of the motor regime and therapeutic physical training are a mandatory background for all spa therapy.

Thus, rehabilitation treatment of patients with coronary heart disease after operations on the coronary arteries and resection of an aneurysm should be based on the general principles of rehabilitation of patients with coronary heart disease, i.e. it should be long-term, gradual, as early as possible and contain rehabilitation measures. preventive action.

Based on the example of the physical factors we studied, we can conclude that the targeted use of physical methods of treatment, taking into account the mechanisms of their action, increases the effectiveness of rehabilitation treatment at all stages of rehabilitation.

Based on the book: Sorokina E.I. Physical methods of treatment in cardiology. - Moscow: Medicine, 1989.

For coronary heart disease, conservative treatment methods are not effective enough, so surgery is often necessary. Surgery is performed according to certain indications. The appropriate surgical treatment option is chosen individually, taking into account a number of criteria, the particular course of the disease and the condition of the patient’s body.

Indications for surgical treatment

Surgery for ischemic heart disease is performed with the aim of myocardial revascularization. This means that through the operation, the vascular blood supply to the heart muscle and blood flow through the arteries of the heart, including their branches, are restored when the lumen of the vessels is narrowed by more than 50%.

The main goal of surgery is to eliminate atherosclerotic changes leading to coronary insufficiency. This pathology is a common cause of death (10% of the total population).

If surgical intervention is necessary, the degree of damage to the coronary arteries, the presence of concomitant diseases, and the technical capabilities of the medical institution are taken into account.

Surgery is necessary if the following factors are present:

pathology of the carotid artery;
reduced contractile function of the myocardium;
acute heart failure;
atherosclerosis of the coronary arteries;
multiple lesions of the coronary arteries.

All these pathologies can accompany coronary heart disease. Surgical intervention is necessary to improve the quality of life, reduce the risks of complications, get rid of some manifestations of the disease or reduce them.

Surgery is not performed in the early stages after myocardial infarction, as well as in cases of severe heart failure (stage III, stage II is considered individually).

All operations for coronary artery disease are divided into 2 large groups - direct and indirect.

Direct operations for ischemic heart disease

Direct revascularization methods are the most common and effective. Such an intervention requires long-term rehabilitation and subsequent drug therapy, but in most cases it restores blood flow and improves the condition of the heart muscle.

Coronary artery bypass grafting

The technique is microsurgical and involves the use of artificial vessels - shunts. They allow you to restore normal blood flow from the aorta to the coronary arteries. Instead of the affected area of the vessels, the blood will move through the shunt, that is, a new bypass path is created.

You can understand how the operation goes by watching this animation:

Coronary artery bypass grafting can be performed on a beating or non-beating heart. The first technique is more difficult to perform, but reduces the risk of complications and speeds up recovery. During surgery on a non-functioning heart, a heart-lung machine is used, which will temporarily perform the functions of the organ.

The operation can also be performed endoscopically. In this case, minimal incisions are made.

Coronary artery bypass grafting can be mammary-coronary, autoarterial or autovenous. This division is based on the type of shunts used.

If the operation is successful, the prognosis is favorable. This technique is attractive due to certain advantages:

restoration of blood flow;
the ability to replace several affected areas;
significant improvement in quality of life;
increasing life expectancy;
cessation of angina attacks;
reducing the risk of myocardial infarction.

Coronary artery bypass grafting is attractive because it can be used for stenosis of several arteries at once, which most other techniques do not allow. This technique is indicated for patients with a high risk group, that is, with heart failure, diabetes mellitus, and over 65 years of age.

It is possible to use coronary bypass surgery in complicated forms of coronary heart disease. This includes reduced left ventricular ejection fraction, left ventricular aneurysm, mitral regurgitation, and atrial fibrillation.

The disadvantages of coronary artery bypass surgery include possible complications. During or after surgery there is a risk:

bleeding;
heart attack;
thrombosis;
narrowing of the shunt;
wound infection;
mediastenitis.

Coronary artery bypass grafting does not provide a permanent effect. Typically, the service life of shunts is 5 years.

This technique is also called the Demikhov-Kolesov operation and is considered the gold standard for coronary bypass surgery. Its main difference is the use of the internal mammary artery, which serves as a natural bypass. In this case, a bypass path for blood flow is created from this artery to the coronary artery. The connection is made below the area of stenosis.

Access to the heart is provided by a median sternotomy; simultaneously with such manipulations, an autovenous graft is taken.

The main advantages of this operation are as follows:

resistance of the mammary artery to atherosclerosis;
durability of the mammary artery as a bypass (compared to a vein);
absence of varicose veins and valves in the internal mammary artery;
reducing the risk of relapse of angina pectoris, heart attack, heart failure, and the need for reoperation;
improvement of left ventricular function;
the ability of the mammary artery to increase in diameter.

The main disadvantage of mammary coronary bypass surgery is the complexity of the technique. Isolation of the internal mammary artery is difficult; in addition, it has a small diameter and a thin wall.

With mammary coronary artery bypass grafting, the ability to revascularize multiple arteries is limited because there are only 2 internal mammary arteries.

Stenting of coronary arteries

This technique is called intravascular prosthetics. For the purpose of the operation, a stent is used, which is a mesh frame made of metal.

The operation is performed through the femoral artery. A puncture is made in it and a special balloon with a stent is inserted through a guiding catheter. The balloon straightens the stent, and the lumen of the artery is restored. A stent is placed opposite the atherosclerotic plaque.

This animation video clearly shows how the stent is installed:

Because of the use of a balloon during surgery, this technique is often called balloon angioplasty. The use of a balloon is optional. Some types of stents deploy on their own.

The most modern option is scaffolds. Such walls have a biosoluble coating. The medicine is released over several months. It heals the inner lining of the vessel and prevents its pathological growth.

This technique is attractive due to its minimal trauma. The advantages of stenting also include the following factors:

the risk of re-stenosis is significantly reduced (especially when using drug-eluting stents);
the body recovers much faster;
restoration of the normal diameter of the affected artery;
general anesthesia is not required;
the number of possible complications is minimal.

There are also some disadvantages of coronary stenting. They relate to the presence of contraindications to surgery and the complexity of its implementation in the case of calcium deposits in the vessels. The risk of re-stenosis is not completely excluded, so the patient needs to take preventive medications.

The use of stenting is not justified in stable coronary heart disease, but is indicated in case of its progression or suspected myocardial infarction.

Autoplasty of coronary arteries

This technique is relatively new in medicine. It involves using tissue from your own body. The source is the veins.

This operation is also called autovenous shunting. A section of the superficial vein is used as a shunt. The source may be the lower leg or thigh. The saphenous vein of the leg is most effective for replacing a coronary vessel.

Carrying out such an operation requires artificial blood circulation. After cardiac arrest, the coronary bed is inspected and a distal anastomosis is performed. Then cardiac activity is restored and a proximal anastomosis of the shunt with the aorta is applied, while lateral compression is performed.

This technique is attractive due to its low morbidity relative to the stitched ends of the vessels. The wall of the vein used is gradually rebuilt, which ensures maximum similarity of the graft to the artery.

The disadvantage of the method is that if it is necessary to replace a large section of the vessel, the lumen of the ends of the insert differs in diameter. Features of the surgical technique in this case can lead to the occurrence of turbulent blood flows and vascular thrombosis.

Balloon dilatation of the coronary arteries

This method is based on expanding the narrowed artery using a special balloon. It is inserted into the desired area using a catheter. There the balloon inflates, eliminating the stenosis. This technique is usually used when 1-2 vessels are affected. If there are more areas of stenosis, then coronary bypass surgery is more appropriate.

The entire procedure is carried out under X-ray control. The can can be filled several times. Angiographic monitoring is performed to determine the degree of residual stenosis. After surgery, anticoagulants and antiplatelet agents must be prescribed to avoid thrombus formation in the dilated vessel.

First, coronary angiography is performed in a standard manner using an angiographic catheter. For subsequent manipulations, a guide catheter is used, which is necessary for inserting a dilatation catheter.

Balloon angioplasty is the main treatment for advanced coronary artery disease and is effective in 8 out of 10 cases. This operation is especially appropriate when stenosis is observed in small areas of the artery and calcium deposits are insignificant.

Surgery does not always eliminate stenosis completely. If the vessel has a diameter of more than 3 mm, then coronary stenting can be performed in addition to balloon dilatation.

Watch an animation of balloon angioplasty with stenting:

In 80% of cases, angina disappears completely or its attacks appear much less frequently. In almost all patients (more than 90%), tolerance to physical activity increases. Perfusion and contractility of the myocardium improves.

The main disadvantage of the technique is the risk of occlusion and perforation of the vessel. In this case, urgent coronary artery bypass grafting may be necessary. There is a risk of other complications - acute myocardial infarction, coronary artery spasm, ventricular fibrillation.

Anastomosis with the gastroepiploic artery

This technique means the need to open the abdominal cavity. The gastroepiploic artery is isolated in the adipose tissue and its lateral branches are clipped. The distal part of the artery is cut off and carried into the pericardial cavity to the desired area.

The advantage of this technique is the similar biological features of the gastroepiploic and internal mammary arteries.

Today, this technique is less in demand, as it carries a risk of complications associated with additional opening of the abdominal cavity.

Currently, this technique is used infrequently. The main indication for it is widespread atherosclerosis.

The operation can be performed using an open or closed method. In the first case, endarterectomy is performed from the anterior interventricular branch, which ensures the release of the lateral arteries. A maximum incision is made and the atheromatically altered intima is removed. A defect is formed, which is closed with a patch from an autovenous vein, and the internal mammary artery is sutured into it (end to side).

The target of the closed technique is usually the right coronary artery. An incision is made, the plaque is peeled off and removed from the lumen of the vessel. A shunt is then sewn into this area.

The success of the operation directly depends on the diameter of the coronary artery - the larger it is, the more favorable the prognosis.

The disadvantages of this technique include technical complexity and a high risk of coronary artery thrombosis. Re-occlusion of the vessel is also possible.

Indirect operations for ischemic heart disease

Indirect revascularization increases blood flow to the heart muscle. For this purpose, mechanical means and chemicals are used.

The main goal of surgery is to create an additional source of blood supply. Using indirect revascularization, blood circulation in small arteries is restored.

This operation is performed to stop the transmission of nerve impulses and relieve arterial spasm. To do this, nerve fibers in the sympathetic trunk are clipped or destroyed. With the clipping technique, it is possible to restore the patency of the nerve fiber.

A radical technique is the destruction of the nerve fiber by electrical action. In this case, the operation is highly effective, but its results are irreversible.

Modern sympathectomy is an endoscopic technique. It is performed under general anesthesia and is completely safe.

The advantages of such an intervention lie in the resulting effect - the relief of vascular spasm, the subsidence of edema, and the disappearance of pain.

Sympathectomy is inappropriate for severe heart failure. Contraindications also include a number of other diseases.

Cardiopexy

This technique is also called cardiopericardopexy. The pericardium is used as an additional source of blood supply.

During the operation, extrapleural access to the anterior surface of the pericardium is obtained. It is opened, the liquid is sucked out from the cavity and sterile talc is sprayed. This approach is called the Thompson method (modification).

The operation leads to the development of an aseptic inflammatory process on the surface of the heart. As a result, the pericardium and epicardium closely grow together, intracoronary anastomoses open and extracoronary anastomoses develop. This provides additional myocardial revascularization.

There is also omentocardiopexy. In this case, an additional source of blood supply is created from a flap of the greater omentum.

Other materials can also serve as a source of blood supply. With pneumocardiopexy it is the lung, with cardiomyopexy it is the pectoral muscle, with diaphragmocardiopexy it is the diaphragm.

Weinberg operation

This technique is intermediate between direct and indirect surgical interventions for coronary heart disease.

The blood supply to the myocardium is improved by implanting the internal mammary artery into it. The bleeding distal end of the vessel is used. It is implanted into the thickness of the myocardium. First, an intramyocardial hematoma is formed, and then anastomoses develop between the internal mammary artery and the branches of the coronary arteries.

Today, such surgical intervention is often performed bilaterally. To do this, they resort to transsternal access, that is, mobilization of the internal mammary artery along its entire length.

The main disadvantage of this technique is that it does not provide an immediate effect.

Operation Fieschi

This technique makes it possible to enhance the collateral blood supply to the heart, which is necessary for chronic coronary insufficiency. The technique consists of bilateral ligation of the internal mammary arteries.

The ligation is performed in the area below the pericardial diaphragmatic branch. This approach increases blood flow throughout the artery. This effect is ensured by an increase in blood discharge into the coronary arteries, which is explained by an increase in pressure in the pericardial-diaphragmatic branches.

Laser revascularization

This technique is considered experimental, but quite common. An incision is made in the patient's chest to insert a special guide to the heart.

The laser is used to make holes in the myocardium and create channels for blood flow. Within a few months these channels are closed, but the effect lasts for years.

By creating temporary channels, the formation of a new network of blood vessels is stimulated. This allows you to compensate for myocardial perfusion and eliminate ischemia.

Laser revascularization is attractive because it can be performed in patients who have contraindications to coronary artery bypass grafting. Typically, this approach is required for atherosclerotic lesions of small vessels.

Laser technology can be used in combination with coronary bypass surgery.

The advantage of laser revascularization is that it is carried out on a beating heart, that is, an artificial blood supply machine is not required. The laser technique is also attractive due to its minimal trauma, low risk of complications and short recovery period. Using this technique eliminates the pain impulse.

Rehabilitation after surgical treatment of coronary artery disease

After any type of surgery, lifestyle adjustments are necessary. It is aimed at nutrition, physical activity, rest and work schedule, and getting rid of bad habits. Such measures are necessary to speed up rehabilitation, reduce the risk of relapse of the disease and the development of concomitant pathologies.

Surgery for coronary heart disease is performed according to certain indications. There are several surgical techniques; when choosing the appropriate option, the clinical picture of the disease and the anatomy of the lesion are taken into account. Surgical intervention does not mean the abolition of drug therapy - both methods are used in combination and complement each other.

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Rehabilitation of patients with coronary heart disease

Coronary heart disease (CHD) is a pathology of the cardiovascular system that occurs as a result of insufficient blood supply to the coronary arteries of the heart due to a narrowing of their lumen. In medicine, two forms are distinguished: chronic (manifests in the form of chronic heart failure, angina, etc.) and acute (unstable angina, myocardial infarction). Rehabilitation of patients with coronary heart disease can significantly improve their condition and complement regular drug therapy.

Goals of rehabilitation of patients with coronary heart disease

In periods after exacerbations, the objectives of rehabilitation are:

reducing the risk of complications;
monitoring normal levels of laboratory blood parameters;
normalization of blood pressure;
reduction in symptoms.

Recovery for chronic and acute forms of coronary heart disease includes:

improving the patient's physical capabilities;
training in the basics of proper lifestyle for satisfactory well-being without constant medical care;
slowing down the development of pathology;
psychological assistance to adapt the patient to the presence of the disease;
therapy to eliminate concomitant pathologies.

The health program is adjusted by the attending physician. Depending on the indications, it may include: physiotherapeutic procedures, taking medications, moderate physical activity as part of exercise therapy. In addition, if necessary, the patient is given help in giving up bad habits and fighting excess weight.

Highly qualified doctors create a rehabilitation plan that helps reduce symptoms and improve the prognosis of recovery and physical capabilities. The program is developed taking into account the specific disease, its form, stage of development, existing signs, general condition and age of the patient, concomitant disorders, as well as other important parameters. Patients are provided with professional round-the-clock care, balanced meals 5 times a day and extra-therapeutic leisure.

Of particular importance for effective rehabilitation is a preliminary examination by a team of multidisciplinary specialists and constant monitoring of vital signs during the recovery process. The Well-being Center takes as its work an interdisciplinary approach that combines medical, social and psychological aspects of treatment. Patients receive consultations from various specialized specialists, including a psychotherapist and psychiatrist, and support in achieving a high quality of life.

The Blagopoluchie rehabilitation center helps patients with any form of coronary artery disease. We accept residents of Moscow and the region, as well as other regions of Russia.

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Cardiac rehabilitation - EURODOCTOR.ru - 2009

Rehabilitation for coronary artery disease is aimed at restoring the state of the cardiovascular system, strengthening the general condition of the body and preparing the body for previous physical activity.

The first period of rehabilitation for IHD is adaptation. The patient must get used to new climatic conditions, even if the previous ones were worse. Acclimatization of the patient to new climatic conditions may take about several days. During this period, a primary medical examination of the patient is carried out: doctors assess the patient’s health status, his readiness for physical activity (climbing stairs, gymnastics, therapeutic walking). Gradually, the patient's physical activity increases under the supervision of a physician. This is manifested in self-service, visits to the dining room and walks around the sanatorium.

The next stage of rehabilitation is the main stage. He milks for two to three weeks. During this period, physical activity, duration, and speed of therapeutic walking increase.

At the third and final stage of rehabilitation, a final examination of the patient is carried out. At this time, the tolerability of therapeutic exercises, dosed walking and climbing stairs is assessed.

So, as you already understand, the main thing in cardiac rehabilitation is dosed physical activity. This is due to the fact that it is physical activity that “trains” the heart muscle and prepares it for future stress during daily activity, work, etc.

In addition, it has now been reliably proven that physical activity reduces the risk of developing cardiovascular diseases. Such therapeutic exercises can serve as a prevention for both the development of heart attacks and strokes, as well as for rehabilitation treatment.

Terrenkur – another excellent means of rehabilitation for heart diseases, incl. and IHD. A path is a walking ascent measured in distance, time and angle of inclination. Simply put, health path is a method of treatment by dosed walking along specially organized routes. The path path does not require any special equipment or tools. It would be a good slide. In addition, climbing stairs is also a path. Health path is an effective means for training the heart affected by coronary artery disease. In addition, it is impossible to overdo it with a health path, since the load has already been calculated and dosed in advance.

However, modern simulators allow you to carry out a health path without slides and stairs. Instead of climbing a mountain, a special mechanical path with a changing angle of inclination can be used, and walking on stairs can be replaced by a step machine. Such simulators allow you to more accurately regulate the load, provide immediate control, feedback and, most importantly, do not depend on the vagaries of the weather.

It is important to remember that a health path is a dosed load. And you shouldn’t try to be the first to climb a steep mountain or climb the stairs the fastest. Health path is not a sport, but physical therapy!

Some may wonder how stress on the heart and coronary artery disease can be combined? After all, it would seem that you need to spare the heart muscle in every possible way. However, this is not the case, and it is difficult to overestimate the benefits of physical exercise during rehabilitation after coronary artery disease.

First, physical activity helps reduce body weight and increase muscle strength and tone. During physical activity, the blood supply to all organs and tissues in the body improves, and the delivery of oxygen to all cells of the body is normalized.

In addition, the heart itself trains a little bit and gets used to working under a slightly higher load, but without reaching the point of exhaustion. Thus, the heart “learns” to work under the same load as it would under normal conditions, at work, at home, etc.

It is also worth noting the fact that physical activity helps relieve emotional stress and fight depression and stress. After therapeutic exercises, as a rule, anxiety and restlessness disappear. And with regular exercises, insomnia and irritability disappear. And as you know, the emotional component in IHD is an equally important factor. After all, according to experts, one of the reasons for the development of diseases of the cardiovascular system is neuro-emotional overload. And therapeutic exercises will help to cope with them.

An important point in therapeutic exercises is that not only the heart muscle is trained, but also the blood vessels of the heart (coronary arteries). At the same time, the wall of blood vessels becomes stronger, and its ability to adapt to pressure changes improves.

Depending on the condition of the body, in addition to therapeutic exercises and walking, other types of physical activity can be used, for example, running, vigorous walking, cycling or exercise on an exercise bike, swimming, dancing, skating or skiing. But such types of exercise as tennis, volleyball, basketball, training on exercise machines are not suitable for the treatment and prevention of cardiovascular diseases; on the contrary, they are contraindicated, since long-term static loads cause increased blood pressure and heart pain.

In addition to therapeutic exercises, which is undoubtedly the leading method of rehabilitation for patients with coronary artery disease, herbal medicine and aromatherapy are also used to restore patients after this disease. Herbalists select medicinal herbal infusions for each patient. The following plants have a beneficial effect on the cardiovascular system: astragalus fluffy-flowered, Sarepta mustard, lily of the valley, carrots, peppermint, viburnum, cardamom.

In addition, today such an interesting treatment method as aromatherapy. Aromatherapy is a method of preventing and treating diseases using various aromas. This positive effect of smells on humans has been known since ancient times. It is known that not a single doctor of Ancient Rome, China, Egypt or Greece could do without medicinal aromatic oils. For some time, the use of medicinal oils in medical practice was undeservedly forgotten. However, modern medicine is once again returning to the experience accumulated over thousands of years in the use of aromas in the treatment of diseases. To restore normal functioning of the cardiovascular system, lemon oil, lemon balm oil, sage oil, lavender oil, and rosemary oil are used. The sanatorium has specially equipped rooms for aromatherapy.

Work with a psychologist is carried out if it is required. If you suffer from depression or have suffered stress, then psychological rehabilitation, along with physical therapy, is undoubtedly important. Remember that stress can aggravate the course of the disease and lead to exacerbation. This is why proper psychological rehabilitation is so important.

Diet– another important aspect of rehabilitation. A proper diet is important for the prevention of atherosclerosis, the main cause of coronary artery disease. A nutritionist will develop a diet especially for you, taking into account your taste preferences. Of course, you will have to give up certain foods. Eat less salt and fat, and more vegetables and fruits. This is important, since if excess cholesterol continues to enter the body, physical therapy will be ineffective.