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is small enough to pass

    52 ACUTE CARE HANDBOOK FOR PHYSICAL THERAPISTS
    through the capillary beds. Commonly, PTCA is used as an adjunct
    to this procedure to increase final coronary diameter or ro allow
    for stent placemenr.
    4.
    Elldaillmillal stents are tiny spring-like tubes that can be
    placed permanently inro the coronary artery ro increase the intraluminal diameter. Stems are occasionally necessary when initial attempts at revascularization (e.g., angioplasty) have failed.12
    Clinical Tip
    Refer to the Diagnostic and Laboratory Section's discussion for precautions after a catheterization procedure.
    Transmyocardial Revascularization
    [n transmyocardial revascularizarion, a catheter with a laser tip creates
    transmural channels from patent coronary arteries into an area of the
    myocardium that is thought to be ischemic. It is intended for patients
    with chronic angina who, due to medical reasons, cannot have angioplasty or CABG. Theoretically, ischemia is reduced by increasing the amount of oxygenated blood in ischemic tissue. Angiogellesis (the
    growth of new blood vessels) has also been proposed as a mechanism
    of improvement after this procedure. Although therapists should expect
    improvements in functional capacity with decreased angina, the
    patient's risk status related to CAD or left ventricular dysfunction does
    not change.46 Postcatheterization procedure precautions, as previously
    described, will apply after this procedure.
    Coronary Artery Bypass Graft
    A CASG is performed when the coronary artery has become completely occluded or when it cannot be corrected by PTCA, coronary arrhrecromy, Or stenting. A vascular graft is used to revascularize the
    myocardium. The saphenolls vein and the left internal mammary
    artery are commonly used as vascular grafts. CABG can be performed either through a median sternotomy, which extends caudally from JUSt inferior to the suprasternal notch to below the xiphoid
    process and splits the sternum longitudinally, or through a variety of
    minimally i nvasive incisions.12
    A minimally invasive technique that is being used for CASG
    includes a CASG with a median sternoromy but without coronary

    CARDIAC SYSTEM
    53
    bypass (off-pump CASG). This procedure eliminates the need for
    cross clamping the aorta and is desirable in patients with left ventricular dysfunction or with severe atheroscierosis.12
    If a median sternotomy is performed instead of the minimally
    invasive incisions, then patients are placed on sternal precautions
    for at least 8 weeks. They should avoid lifting of moderate to heavy
    weights (e.g., greater than 1 0 Ib) with the upper extremities.
    Clinical Tip
    • To help patients understand this concept, inform them
    that a gallon of milk weighs approxminately 8.5 lb.
    •
    Because of the sternal incision, patients are at risk of developing pulmonary complications after a CABG. The physical
    therapist should be aware of postoperative complication risk
    facrors as well as postoperative indicators of poor pulmonary
    function. Refer to Chapter 2 and Appendix V for furrher
    description of postoperative pulmonary complications.
    Ablation Procedure
    Catheter ablation procedures are indicated for supraventricular tachycardia, AV nodal re-entrant pathways, atrial fibrillation, atrial flurrer, and some patients with cerrain types of ventricular tachycardia. 12 The procedure anempts to remove or isolate ectopic foci in an attempt to reduce the resultant rhythm disturbance. Radiofrequency ablation uses lowpower, high-frequency AC current to destroy cardiac tissue and is the most effective technique for ablation.12 After the ecropic foci are located
    under fluoroscopic guidance, the ablating catheter is positioned at the site
    to deliver a current for 10-60 seconds.
    Clinical Tip
    •
    Aftet an ablation procedure, the leg used for access
    (venous puncture site) must remain straight and immobile for
    3-4 hours. If an arrery was used, this time generally increases
    to 4-6 hours.