The textbook of exercise therapy is complete - rgufk. textbook physical rehabilitation

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

The problem of rehabilitation of patients with coronary heart disease after reconstructive operations on the vessels of the heart is relatively new in cardiology, many aspects of this complex process have not yet been sufficiently studied. Meanwhile, the previous experience of using 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 principles for the staged rehabilitation of patients after coronary artery bypass grafting and resection of a heart aneurysm and the use of physical factors for 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 a progressive improvement in the clinical condition and hemodynamics.

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

The third stage (polyclinic) is carried out in a polyclinic, and includes spa treatment.

Each of the stages of rehabilitation has its own tasks, due to 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 saving 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 (the first stage), the physical and mental rehabilitation of the patient is of the 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 to maximize the improvement of adaptive-compensatory processes, various forms of therapeutic physical culture, preformed and natural physical factors, which form the basis of rehabilitation treatment, are used more widely; mental rehabilitation and preparation of the patient for work continues.

In the studies 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 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 grafting and resection of left ventricular aneurysm, carried out at the All-Russian Scientific Center of Surgery of the USSR Academy of Medical Sciences, were determined. The second stage begins after discharge from the surgical hospital (3-4 weeks after the operation). The conducted clinical observations made it possible to establish that during this period, the operated patients had 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. Severe coronary heart disease before surgery, the operation itself cause a sharp restriction of the motor activity of patients, severe asthenia, a sharp change in emotional and vitality; patients quickly get tired, irritable, often fixed on the pain syndrome, anxious, sleep poorly, complain of dizziness, headaches. Almost all patients have changes in mental status, among them the leading place is occupied by asthenoneurotic and cardiophobic syndromes, there are severely impaired myocardial contractility (especially in patients who have had a myocardial infarction complicated by a heart aneurysm), hemodynamics.

Arterial hypotension, sinus tachycardia, extrasystole, 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). Most of the examined patients had disorders of the ventilation function of the lungs, a decrease in the reserve capacity of the respiratory system, due to both heart failure and postoperative complications from the lungs and pleura (pneumonia, pleurisy). The chest in operated patients is not very mobile, breathing is shallow, the strength of the respiratory muscles is reduced. This leads to disturbances in gas exchange and blood circulation in the lungs.

Due to the low fitness of adaptive-compensatory mechanisms, patients often have inadequate responses 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 the vein for the bypass, respiratory system disorders). It should be emphasized the importance of eliminating pain in the sternum. They often have to be differentiated from coronary pains, they are painfully tolerated by patients, support and aggravate astheno-neurotic and cardiophobic syndromes, prevent the expansion of motor activity, and adversely 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 act as an analgesic. These include therapeutic physical culture, balneotherapy, massage, electrotherapy.

When performing a physical rehabilitation program, various forms of physiotherapy exercises are used: dosed walking and a properly constructed motor regimen during the day (walks, movements in connection with self-service and treatment), therapeutic exercises. The motor mode should include the alternation of training loads with rest and relaxation. Such a rhythmic effect of training and rest improves the regulation of many body systems and adaptive-compensatory processes. In the second half of the day, training is carried out with a load of 50-75% of the loads carried out in the first half of the day. The increase in physical fitness is carried out by transferring the patient from one mode to another, more stressful.

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

The method of dosed walking was developed by L.P. Otto (1982) under the control of TEK. It is shown that to ensure the safety threshold, the training level of loads is 80% of the energy consumption for the maximum load, which corresponds to a certain calculated walking pace. For patients with a high level of functionality (grade I severity), the initial pace of walking was 100-90 steps/min, class II - 80-90 steps/min; for patients with limited functionality: class III - 60-70 steps / min, class IV - not 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. In the future, with adequate clinical and electrocardiographic reactions, the pace of walking increased every 4-7 days and amounted to 110-120 by the end of treatment for patients of severity class I 110-120, II - 100-110, III - 80-90 steps / min, and passed during the day the distance increased accordingly from 3 to 7-8 km, from 3 to 6 km and from 1.5 to 4.5 km.

The technique of carrying out the procedure of dosed walking is very important. Within 1-2 minutes, movements at a slow pace are recommended, then the patient switches to a training pace (3-5 minutes), after which, for 2-3 minutes, move again at a slow pace. After a short rest (50-100% of walking time), walking should be repeated. The number of repetitions is 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 severity class 1 and II, exercises with a dosed effort are connected, in patients of class III, such exercises are connected 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 the processes of inhibition in the receptors of the skin and in the higher parts of the nervous system, inhibition of the conduction of a nerve impulse, reduces pain, and has a sedative effect. In addition, massage increases blood circulation and blood flow in the 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 main mechanisms of action of massage determine its inclusion in the complex of rehabilitation treatment of patients after surgery on the coronary vessels. Massage is used to relieve pain in the chest, improve the tone of the muscles of the chest and reduce disturbances in the functions of external respiration, the disappearance of cardialgia.

Massage using classical techniques, with the exception of vibrations, is performed daily or every other day. The first 3 procedures massage only the collar zone, then massage the back, lateral and anterior surfaces 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, the course is 12-16 procedures. Contraindications to the use of massage: mediastinitis in the postoperative period, non-healed postoperative wound.

To relieve pain in the chest, we used novocaine electrophoresis according to 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, the 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" carbonic baths.

A comparative analysis of the results of treatment in groups of patients who received and did not receive four-chamber carbonic acid baths revealed a particularly positive effect on the cardiohemodynamics of the treatment complex, which included carbonic acid baths. This was manifested by a more pronounced decrease in heart rate, a decrease in the severity of the phase syndrome of hypodynamia, 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-value increased before treatment (according to the RVG of the lower extremities). The complex, which included carbonic 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 severity class III with clinical signs of circulatory failure, pathological clinical and hypodynamic reactions to a chamber carbonic bath were noted.

Thus, chamber carbonic 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 with I and II classes of severity and limited III (only with circulatory failure not higher than stage I). Sinus tachycardia, rare extrasystoles 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. An increase in the reserve capacity of the cardiovascular system was reflected 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. An increase in the threshold load power from 248.5+12.4 to 421.7+13.7 kgm/min or by 69.6% was also noted.

The use of physical methods of treatment made it possible to minimize or completely cancel drugs in all patients of II and some patients of III class of severity.

The positive role of physical methods of treatment was manifested in a comparative analysis of the results of treatment in the main and control groups. Patients in the control group were treated only with medications and expanded the mode of physical activity. 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 of 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 started their previous work, while in the control group - only 22.2% (P<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 Medicine and Pharmacy [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 of their implementation is the same as in patients with myocardial infarction in the early post-hospital period of the II stage of rehabilitation.

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

Great importance in the early post-hospital period is given to the mental aspect of rehabilitation. A powerful means of mental rehabilitation is the expansion of the motor regimen, the improvement of the somatic condition of patients. An integral component of rehabilitation measures is psychotherapy conducted by the attending physician on a daily basis in the form of explanatory conversations about the prospects of rehabilitation treatment, the positive results of special research methods. We observed a decrease in the clinical manifestations of astheno-peurotic 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 are used: electrosleep with a pulse frequency of 5-20 Hz, lasting 20-30 minutes, daily or every other day, for a course of 10-15 procedures; galvanic collars or drug electrophoresis according to the "collar" method (bromine, caffeine, beta-blockers, etc.). These types of electrotherapy are used for patients with I, II and III severity classes.

Just like in patients with myocardial infarction, the basic principle of rehabilitation is preserved - the complexity of restorative measures aimed at different parts of the pathological process.

Our observations have shown that it is most effective to apply a complex of therapeutic measures, consisting of physical methods of training action in combination with methods that have a positive effect on the neuropsychic status of the patient. An example of such a 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 regimen (according to the scheme according to the patient's severity class), therapeutic exercises, chest massage, novocaine electrophoresis and chamber carbonic baths. Treatment began with the expansion of the motor regimen, massage and novocaine electrophoresis to reduce pain. Balneotherapy was used after 5-7 days. This complex of rehabilitation treatment can be supplemented with other therapeutic factors, for example, electrosleep, drug electrophoresis. Treatment is carried out against the background of constant explanatory psychotherapy, some patients also need special psychotherapy.

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

Polyclinic (third) stage

In the late postoperative period, 60-70% of patients with coronary heart disease after reconstructive operations on the vessels of the heart have angina pectoris, usually milder than before surgery), often extrasystole and arterial hypertension, asthenoneurotic reactions, cardialgia. Violations of the contractile function of the myocardium and hemodynamics, less pronounced than in the early post-hospital stage, which, apparently, is due to the positive effect of myocardial revascularization and resection of the heart aneurysm. Remains reduced exercise tolerance (in our studies, from 500 to 250 kgm/min, an average of 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 do not fundamentally differ from those applied to patients with stable angina pectoris who have not undergone surgical treatment.

Among the patients examined by us, according to the severity of angina pectoris and exercise tolerance, 10% of patients could be assigned to FC I, 25% to FC II, and 65% to FC III.

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

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

The complex treatment used by us, including radon baths (40 nCi/l, 36°C, duration 12 min, for a course of 10-12 baths) 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, respectively, according to the types of baths used. There was a decrease and a decrease in the intensity of angina attacks in 52 and 50% of patients, respectively, in groups distinguished by types of baths, a decrease or cessation of extrasystole was observed only in the group of patients who received radon baths (in 50%), a decrease in high blood pressure in both groups (P<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 elevated before treatment (P<0,05).

In patients with tachycardia and extrasystole, the use of complex treatment, which included radon baths, led to a decrease in cardiac arrhythmias, while complex treatment, which included sulfide baths, did not significantly affect these manifestations of the disease.

We were convinced of the need for a differentiated approach to the appointment of baths by studies of hemodynamics and clinical reactions to individual baths. If in patients with II and III FC, when using radon baths, no pathological reactions were noted, then in the group of patients treated with sulfide baths, a more noticeable restructuring of central hemodynamics was observed. It consisted in reducing the 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 with the use of both types of baths reduced asthenoneurotic manifestations, while in patients with signs of hypersympathicotonia with a predominance of excitation processes, radon baths had the best effect.

Thus, differentiated approaches to the appointment of physical methods of treatment should be determined primarily by the degree of violation of the functional state of the cardiovascular system. In patients belonging to FC I, II and III, with extrasystole, severe asthenoneurotic syndrome, the treatment complex, including radon baths, electrosleep, 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 cardiac arrhythmias.

The system of rehabilitation applied by us with the use of physical methods of treatment of 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 on the basis of 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 blood volume 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 - due IOC; 2 - actual IOC: 3 - due UPS: 4 actual UPS.

The mental status of patients improved significantly, asthenonsvrotic complaints and cardialgia decreased, which played a role in improving the subjective state of patients, increasing their vitality, the appearance of a correct self-assessment of the state and a critical attitude towards cardialgia. This made it possible to perform greater physical activity than at an early stage of rehabilitation, despite the increase in angina attacks. This circumstance, in turn, led to positive medical and social results of rehabilitation. After 1 year, 56% of patients started work, while only 28% of patients who did not receive rehabilitation treatment; 8% of patients who received rehabilitation treatment started their professional activities already 3 months after the operation. The number of patients with complete disability decreased by 18%, the disability of group II was completely removed in 12%, 6% of patients were transferred from II to III group of disability. In patients of the control group, not a single case of complete recovery of working capacity was noted during the year. There was only a decrease in the degree of disability (from II to III group).

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 of 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 at climatic and balneological resorts.

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

In the conditions of a local sanatorium and a sanatorium of a climatic resort, complex treatment with the use of electrotherapy, therapeutic physical culture is necessarily supplemented by climatotherapy in the form of aerotherapy (dosed air baths, sleeping by the sea, walks), heliotherapy (partial and general sunbathing, in the cold season UFO), swimming in the sea and pool.

At balneological resorts in the complex spa treatment, the leading role 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 do not fundamentally differ from those used by patients with stable angina pectoris who have not undergone surgery. Expansion of the motor regimen, therapeutic physical culture are an obligatory background for all spa therapy.

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

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

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

With coronary heart disease, conservative treatment methods are not effective enough, therefore it is often necessary to resort to surgery. Surgical intervention is carried out according to certain indications. A suitable variant of surgical treatment is chosen individually, taking into account a number of criteria, the characteristics of the course of the disease and the state of the patient's body.

Indications for surgical treatment

Surgical intervention for coronary artery disease is carried out for the purpose of myocardial revascularization. This means that the operation restores the vascular blood supply to the heart muscle and blood flow through the arteries of the heart, including their branches, 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.

The operation is necessary in the presence of the following factors:

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 ischemic heart disease. Surgical intervention is necessary to improve the quality of life, reduce the risk 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 case of severe heart failure (stage III, stage II is considered individually).

All operations for IHD are divided into 2 large groups - direct and indirect.

Direct operations for coronary artery disease

The most common and effective methods of direct revascularization. Such an intervention requires long-term rehabilitation, subsequent drug therapy, but in most cases 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 along the shunt, that is, a new bypass is created.

How the operation goes, you can understand by watching this animated video:

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

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

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

With a successful operation, the prognosis is favorable. This approach has certain attractive advantages:

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

Coronary artery bypass grafting is attractive due to the possibility of using several arteries in stenosis at once, which most other methods do not allow. This technique is indicated for patients with a high risk group, that is, with heart failure, diabetes mellitus, over the age of 65 years.

Perhaps the use of coronary artery bypass grafting in a complicated form of coronary heart disease. It implies a reduced left ventricular ejection fraction, left ventricular aneurysm, mitral insufficiency, atrial fibrillation.

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

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

Coronary artery bypass grafting does not provide a permanent effect. Shunts typically last 5 years.

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

mammary artery resistance to atherosclerosis;
durability of the mammary artery as a bypass (versus a vein);
the absence of varicose veins and valves in the internal mammary artery;
reducing the risk of recurrence of angina pectoris, heart attack, heart failure, the need for reoperation;
improvement of the left ventricle;
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 possibility of revascularization of several arteries is limited, since there are only 2 internal mammary arteries.

Stenting of the coronary arteries

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

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 guide catheter. The balloon expands the stent, and the lumen of the artery is restored. A stent is placed opposite the atherosclerotic plaque.

How the stent is installed is clearly shown in this animated video:

Due to the use of a balloon during the operation, this technique is often called balloon angioplasty. The use of a balloon is optional. Some types of stents expand on their own.

The most modern option is scaffolds. Such walls have a biosoluble coating. The drug is released within a few months. It heals the inner shell of the vessel and prevents its pathological growth.

This technique is attractive with minimal trauma. Other benefits of stenting include:

the risk of re-stenosis is significantly reduced (especially with drug-eluting stents);
the body recovers much faster;
restoration of the normal diameter of the affected artery;
no general anesthesia required;
the number of possible complications is minimal.

There are some disadvantages of coronary stenting. They relate to the presence of contraindications to the operation 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 prophylactic agents.

The use of stenting is not justified in the stable course of coronary heart disease, but is indicated when it progresses or myocardial infarction is suspected.

Autoplasty of the coronary arteries

This technique is relatively young in medicine. It involves the use of the tissues of one's own body. Veins are the source.

This operation is also called autovenous shunting. A portion of the superficial vein is used as a shunt. The source can be a shin or a thigh. The saphenous vein of the leg is the most effective for coronary vessel replacement.

Carrying out such an operation implies the conditions of artificial circulation. After cardiac arrest, a revision of the coronary bed is carried out and a distal anastomosis is applied. Then, cardiac activity is restored and a proximal anastomosis of the shunt with the aorta is performed, while its lateral squeezing is performed.

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

The disadvantage of the method is that if it is necessary to replace a large portion of the vessel, the lumen of the ends of the insert differs in diameter. Features of the technique of the operation 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 the expansion of a narrowed artery with a special balloon. It is inserted into the desired area using a catheter. There, the balloon is inflated, eliminating the stenosis. This technique is usually used for lesions of 1-2 vessels. If there are more areas of stenosis, then coronary bypass surgery is more appropriate.

The whole procedure takes place under x-ray control. The bottle can be filled multiple times. For the degree of residual stenosis, angiographic control is performed. After the operation, anticoagulants and antiplatelet agents are prescribed without fail to avoid thrombosis in the dilated vessel.

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

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

Surgical intervention does not always allow you to get rid of the stenosis completely. If the vessel has a diameter of more than 3 mm, then in addition to balloon dilatation, coronary stenting can be performed.

Watch the animation of balloon angioplasty with stenting:

In 80% of cases, angina pectoris disappears completely or its attacks appear much less frequently. In almost all patients (more than 90%), exercise tolerance increases. Improves perfusion and contractility of the myocardium.

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, spasm of the coronary artery, ventricular fibrillation.

Anastomosis with gastroepiploic artery

This technique means the need to open the abdominal cavity. The gastroepiploic artery is isolated in 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 site.

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

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

At present, this technique is rarely used. The main indication for it is widespread atherosclerosis.

The operation can be performed by 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. The maximum incision is made and the atheromatous intima is removed. A defect is formed, which is closed with a patch from the autovein, and the internal thoracic artery is sewn into it (end to side).

The object 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. Then a shunt is 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 likely.

Indirect operations for coronary artery disease

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

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

Such an operation is performed to stop the transmission of a nerve impulse and relieve arterial spasm. To do this, clip or destroy the nerve fibers in the sympathetic trunk. 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 are in the effect obtained - the removal of vascular spasm, the subsidence of edema, the disappearance of pain.

Sympathectomy is inappropriate for severe heart failure. Among the contraindications are also 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 of 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 are closely fused, intracoronary anastomoses open and extracoronary anastomoses develop. This provides additional myocardial revascularization.

There is also omentocardiopexy. An additional source of blood supply in this case is created from a flap of the greater omentum.

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

Operation Weinberg

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

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

Today, such surgery is often carried out bilaterally. To do this, resort to transsternal access, that is, the mobilization of the internal thoracic artery throughout.

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

Operation Fieschi

This technique allows you to increase the collateral blood supply to the heart, which is necessary for chronic coronary insufficiency. The technique consists in bilateral ligation of the internal thoracic arteries.

Ligation is performed in the area below the pericardial diaphragmatic branch. This approach increases blood flow throughout the artery. This effect is provided by an increase in the discharge of blood 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. The patient is made an incision on the chest to bring a special conductor to the heart.

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

Thanks to the creation of temporary channels, the formation of a new network of vessels is stimulated. This allows compensating for myocardial perfusion and eliminating ischemia.

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

Laser technique can be used in combination with coronary artery bypass grafting.

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

Rehabilitation after surgical treatment of IHD

After any type of surgery, lifestyle changes are necessary. It is aimed at nutrition, physical activity, rest and work regime, getting rid of bad habits. Such measures are necessary to accelerate rehabilitation, reduce the risk of recurrence of the disease and the development of comorbidities.

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. Surgery does not mean the abolition of drug therapy - both methods are used in combination and complement each other.

Internal Medicine Oncology Geriatrics Treatment Diagnostics Ambulatory

Rehabilitation of patients with coronary heart disease

Ischemic 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 narrowing of their lumen. In medicine, two of its forms are distinguished: chronic (manifested as chronic heart failure, angina pectoris, etc.) and acute (unstable angina, myocardial infarction). Rehabilitation of patients with coronary heart disease can significantly improve their condition and supplement regular drug therapy.

Goals of rehabilitation of patients with coronary heart disease

In periods after exacerbations, the tasks of rehabilitation are:

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

Recovery in chronic and acute coronary heart disease includes:

improving the physical capabilities of the patient;
teaching the basics of a 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 comorbidities.

The health program is adjusted by the attending physician. Depending on the indications, it may include: physiotherapy, medication, moderate physical activity as part of exercise therapy. In addition, the patient, if necessary, is assisted in the rejection of bad habits and the fight against excess weight.

Doctors of the highest qualification create a rehabilitation plan that helps to reduce the manifestation of symptoms, 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 extracurricular 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 Wellbeing Center takes as its basis an interdisciplinary approach that combines the medical, social and psychological aspects of treatment. Patients receive consultations from various highly specialized specialists, including a psychotherapist and a psychiatrist, support in gaining a high quality of life.

Rehabilitation center "Prosperity" helps patients with any form of coronary disease. We accept residents of Moscow and the region, as well as other regions of Russia.

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We do not just rehabilitate, we return the quality of life to which you are accustomed. We will listen to you, support you and advise you on what to do in a difficult situation 12/7 by phone

Cardiorehabilitation - EURODOCTOR.ru - 2009

Rehabilitation for IHD aims to restore the state of the cardiovascular system, strengthen the general condition of the body and prepare the body for the previous physical activity.

The first period of rehabilitation for IHD is adaptation. The patient must get used to the new climatic conditions, even if the former were worse. Acclimatization of the patient to new climatic conditions can take about several days. During this period, an initial 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 amount of physical activity of the patient grows under the supervision of a doctor. This is manifested in self-service, visits to the dining room and walks around the territory of the sanatorium.

The next stage of rehabilitation is the main stage. It is milked for two to three weeks. During this period, physical activity increases, e duration, speed of therapeutic walking.

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

So, as you already understood, the main thing in cardiorehabilitation 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 loads during daily activity, work, etc.

In addition, it is now reliably proven that physical activity reduces the risk of developing cardiovascular diseases. Such therapeutic exercises can serve as a preventive measure 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 IBS. Terrenkur is metered by distance, time and angle of inclination on foot ascents. Simply put, health path is a method of treatment by dosed walking along specially organized routes. The terrenkur does not require special equipment or tools. It would be a good hill. In addition, climbing stairs is also a health path. Terrenkur is an effective tool for training the heart affected by coronary artery disease. In addition, with the health path it is impossible to overdo it, since the load has already been calculated and dosed in advance.

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

It is important to remember that the health path is a dosed load. And you should not try to be the first to climb a steep mountain or overcome the stairs faster than anyone else. Terrenkur is not a sport, but physical therapy!

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

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

In addition, the heart itself trains a little bit, and gets used to working with a slightly greater load, but at the same time, without reaching exhaustion. Thus, the heart "learns" to work under such a load, which will be 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 anxiety disappear. And with regular classes of therapeutic exercises, insomnia and irritability disappear. And as you know, the emotional component in IHD is an equally important factor. Indeed, according to experts, one of the causes of 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 the vessels becomes stronger, and its ability to adapt to pressure drops also 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 cycling, swimming, dancing, skating or skiing. But such types of loads as tennis, volleyball, basketball, training on simulators are not suitable for the treatment and prevention of cardiovascular diseases, on the contrary, they are contraindicated, since static long-term loads cause an increase in blood pressure and pain in the heart.

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

In addition, today, for the rehabilitation of patients after coronary artery disease, such an interesting method of treatment as aromatherapy. Aromatherapy is a method of prevention and treatment of diseases with the help of various aromas. Such a positive effect of smells on a person 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 therapeutic oils in medical practice was undeservedly forgotten. However, modern medicine is once again returning to the experience accumulated over thousands of years of using aromas in the treatment of diseases. To restore the normal functioning of the cardiovascular system, lemon oil, lemon balm, sage, lavender, and rosemary oils 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 experienced stress, then, undoubtedly, psychological rehabilitation is also important, along with physiotherapy exercises. Remember that stress can aggravate the course of the disease, lead to an exacerbation. This is why proper psychological rehabilitation is so important.

Diet is another important aspect of rehabilitation. Proper diet is important for the prevention of atherosclerosis - the main cause of coronary artery disease. A nutritionist will develop a diet specially for you, taking into account your taste preferences. Of course, certain foods will have to be abandoned. Eat less salt and fat, and more vegetables and fruits. This is important, since with the continued excess intake of cholesterol into the body, physiotherapy exercises will be ineffective.