Integrated cardiorespiratory and neurorehabilitation following off-pump coronary artery bypass grafting complicated by acute ischemic stroke

Balasubramanian*

Physiotherapist, Kauvery Hospital, Salem, Tamil Nadu

*Correspondence

Abstract

Background: Concomitant acute myocardial infarction and ischemic stroke represent a complex clinical challenge, particularly in patients with severe ventricular dysfunction requiring surgical revascularization. Early multidisciplinary physiotherapy can significantly affect functional recovery, deconditioning, and quality of life.

Case Presentation: A 52-year-old male with newly diagnosed diabetes and longstanding hypertension presented with acute anterior wall myocardial infarction, acute pulmonary edema, and sudden right lower limb weakness. Imaging confirmed triple vessel disease, severe left ventricular (LV) dysfunction (ejection fraction 28%), and an acute ischemic infarct in the left high frontoparietal region. He underwent successful Off-Pump Coronary Artery Bypass Grafting (CABG) x 4. Following surgery, an integrated rehabilitation program was initiated.

Results: Standardized measures showed substantial improvements, with the patient progressing from complete right lower limb paralysis (Manual Muscle Test 0/5) at discharge to near-functional independence over two months.

Conclusion: An early, comprehensive, and integrated physiotherapy program addressing both cardiopulmonary and neurological impairments is safe, feasible, and highly effective for maximizing recovery.

Key words: Acute myocardial infarction; Acute pulmonary edema; Manual Muscle Test 0/5

Patient Information & Admission Details

  • Patient Name: Mr. Y
  • Age & Gender: 52 years / Male
  • Admission Date: 03.11.2024 | Date of Surgery: 04.11.2024 | Discharge Date: 09.11.2024
  • Past Medical History: Newly diagnosed Diabetes mellitus, and Hypertension for 15 years (not on regular treatment).
  • Personal history: Normal sleep pattern; prescribed low fat/low cholesterol diabetic diet (1800kcal), fluid restriction (1.5 Lit/Day) upon discharge.
  • Presenting Complaint: The patient developed sudden chest pain & right lower limb weakness at 3:00 PM on 01.11.24. He was admitted to the CCU and managed initially with non-invasive ventilation (NIV) support and diuretics for acute pulmonary congestion.

Diagnostic Investigations

Radiological (Brain & Neck)

  • Initial MRI Brain & MR Angiogram (01.11.2024): Revealed patchy areas of diffusion restriction in the left high fronto parietal region. Noted an aplastic A1 segment of the right anterior cerebral artery; no occlusion of major carotid/cerebral arteries.
  • Carotid & Vertebral Artery Doppler (03.11.2024): Normal parameters in bilateral carotid and vertebral arteries, with no hemodynamically significant plaque.
  • Repeat MRI Brain (06.11.2024 – Post-operative): Showed a subacute infarct with hemorrhagic transformation measuring 34 x 23 x 33mm in the left high fronto parietal lobe, causing effacement of adjacent sulcal spaces.

Cardiopulmonary & Abdominal:

  • Echocardiography (01.11.2024): Confirmed severe LV systolic dysfunction (LVEF 28%), RWMA with a hypokinetic LAD territory, mild concentric LVH, moderate pulmonary artery hypertension, and mild tricuspid regurgitation.
  • USG Abdomen (04.11.2024): Grade 1 fatty liver and bilateral mild pleural effusion.

Final Diagnosis

  • Coronary artery disease – Triple vessel disease.
  • Recent anterior wall myocardial infarction & Old inferior wall myocardial infarction.
  • Severe left ventricular dysfunction (LVEF-28%) & Acute pulmonary edema.
  • Acute cerebrovascular accident (Left high frontoparietal infarct).

Surgical Course & Hospital Stay

The patient underwent Off Pump CABG X 4 (SVG -> PDA, SVG -> OM, LIMA -> LAD, LIMA -> SVG -> D1) on 04.11.2024. Following surgery, he was transferred to the CTICU, shifted to the general ward on the 2nd post-operative day, and discharged hemodynamically stable on 09.11.2024 with a healthy operated site wound.

Drug History (On Discharge)

Cap. Clopilet-A (75mg), Tab. Rosuvas (40mg), Tab. Betaloc (25mg), Tab. Ivabrad (5mg), Tab. Dytor (5mg), Tab. Aldactone (25mg), Inj. Mixtard 30/70 (18U, 15U), Cap. Becosules, Tab. Xykaa BD (1gm), Tab. Rantac (150mg), Tab. Strocit Plus, Tab. Anxit (0.5mg), Syp. Cremaffin Plus, Syp. Reswas.

Comprehensive physiotherapy assessment

On observation

  • Patient is conscious, oriented, and alert. Moderately built, no jaundice or cyanosis.
  • Attitude of limb: Complete loss of active movement in the right lower limb; upper limbs and left lower limb normal.

On palpation & pain Assessment

  • Tenderness: Present over the mid-sternal region (post-operative CABG incision site).
  • Oedema: Absent.
  • Type of pain: Aching pain over the mid-sternal site, aggravated by deep breathing, coughing, and trunk movement. Relieved by sternal splinting (using a pillow) and rest.
  • VAS Pain scale:
    • On assessment (09/11/2024): 6/10
    • 4th week Follow up (09/12/2024): 3/10
    • 8th week Follow up (09/01/2025): 1/10

Initial functional assessment (Baseline – 09/11/2024)

  • Vital signs: Resting HR: 98 bpm, BP: 110/70 mmHg, RR: 20/min, SpO2: 97% (room air).
  • Exercise capacity: 6-Minute Walk Test (6MWT): 0 meters (Non-ambulatory due to right leg paralysis).
  • Psychological status: Mild anxiety related to sudden functional loss.
  • Sensory & reflexes: Sensation intact. Deep tendon reflexes demonstrated hyperreflexia (Grade 3+) in the right leg.

Range of Motion (ROM)

  • Baseline (09/11/2024): Right lower limb showed reduced active hip and knee ROM due to neuro-deficit (hemiparesis). Left lower limb and bilateral upper limbs were normal.
  • Last session (09/01/2025): Bilateral Upper and Lower Limbs Normal.

Manual muscle testing (MMT)

Baseline Assessment (09/11/2024)RightLeft
Upper limb5/55/5
Lower limb0/55/5
Last Session (09/01/2025)RIGHTLEFT
Upper limb5/55/5
Lower limb4+/55/5

Physiotherapy Goals

Short term goals (Weeks 1-4)

  • To maintain airway clearance, improve lung volumes, and manage sternal pain.
  • To prevent bed complications (DVT, contractures, pressure sores) in the affected right lower limb.
  • To facilitate muscle firing and improve MMT of the right lower limb from Grade 0 to Grade 2.
  • To achieve independent unsupported sitting balance and safe transfer techniques (bed to chair).

Long term goals (Weeks 5-12)

  • To make the patient independent in out-of-bed activities and ADLs.
  • To safely improve cardiovascular endurance considering the severe LV dysfunction (EF-28%).
  • To restore optimal walking pattern and independent ambulation.
  • To reintegrate the patient into the community with appropriate sternal and cardiac precautions.

Physiotherapy Rehabilitation Protocol

Phase I: Acute inpatient & early discharge care (Weeks 1-3)

  • Respiratory care: NIV support management initially. Progressed to incentive spirometry, chest physiotherapy, diaphragmatic breathing exercises (10 reps * 2 sets), and supported coughing/huffing with sternal splinting.
  • Bed mobility & positioning: Passive ROM for the right lower limb to prevent contractures. Active ROM for upper limbs (within sternal precautions) and left lower limb.
  • Neuro-facilitation: Tapping and sensory stimulation for the right lower limb; Initiation of Proprioceptive Neuromuscular Facilitation (PNF) for the right lower limb.
  • Functional mobility: Assisted sitting edge of bed, progressing to heavily assisted sit-to-stand tolerance.

Phase II: Subacute phase (Weeks 4-6)

  • Lower limb strengthening: Active-assisted progressing to active exercises for the right lower limb (seated knee extension, hip flexion).
  • Balance & trunk Control: Static and dynamic standing balance exercises in parallel bars; trunk rotation in sitting.
  • Gait training: Initiated slow walking with walker support, closely monitoring HR/BP. Hemodynamic monitoring during all activities was strictly maintained due to severe LV systolic dysfunction and moderate PAH.

Phase III: Advanced Phase (Weeks 7-9)

  • Progressive resistance: Light resistance band exercises for the right lower limb (10 reps * 3 sets), leveraging intact sensation to improve proprioceptive feedback.
  • Gait & mobility: Stair climbing (step-to pattern), Static cycling, weaning off the walker to independent ambulation.
  • Cardiovascular endurance: Unsupervised, graded walking program based on pacing limits given the underlying triple vessel disease history.

Outcome measures & results

Outcome MeasureBaseline (Hospital Discharge)1 Month Outpatient2 Months Outpatient
Manual Muscle Test (Rt LL)0/52+/54+/5
Functional Ambulation (FAC)0 (Non-ambulatory)2 (Max Assist)4 (Independent)
6MWT Distance0 meters85 meters210 meters
Barthel Index20 / 10055 / 10090 / 100
Berg Balance Scale3 / 5625 / 5648 / 56
VAS Pain Scale (Sternal)6 / 103 / 101 / 10

Discussion & conclusion

The patient presented with a highly complex clinical picture: critical triple vessel CAD necessitating an Off-Pump CABG x 4, complicated simultaneously by an acute left frontoparietal infarct causing right lower limb monoplegia. Operating on a patient with an LVEF of 28% and an acute neurological deficit requires precise surgical and medical management.

Remarkably, despite the repeat MRI showing a 34 x 23 x 33mm subacute infarct with hemorrhagic transformation, the targeted integration of prescribed therapies—specifically chest physiotherapy to support the cardiovascular system and early gait training with targeted MMT improvements for the neuro-deficit—allowed the patient to transition safely from absolute paralysis (MMT 0/5) to independent ambulation within two months. This case underscores that aggressive, tailored, and strictly monitored dual-rehabilitation is both safe and vital for maximizing functional recovery in multimorbid patients.

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