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Heart surgery usually means either bypassing blocked coronary arteries, or repairing or replacing a heart valve. Most often the surgeon reaches the heart by dividing the breastbone, which then has to heal like any other bone. This page covers what happens afterwards, what is safe to do with the arms and chest, and why getting into a cardiac rehabilitation programme matters more than almost anything done in hospital.
The operations
Coronary artery bypass grafting
Blocked coronary arteries are bypassed with conduits — most commonly the left internal mammary artery to the left anterior descending, supplemented by radial artery or long saphenous vein grafts. The internal mammary graft is harvested from the inside of the chest wall, which is one reason chest wall pain after CABG is not solely sternal in origin. Vein harvest leaves a leg wound that is frequently more troublesome to the patient than the sternum.
Revascularisation may be surgical or percutaneous; contemporary guidance reserves surgery for multivessel and left main disease, particularly with diabetes or reduced ventricular function.1
Valve surgery
Valves are repaired where possible — particularly the mitral valve, where repair outperforms replacement — or replaced with a mechanical or bioprosthetic valve. The choice drives anticoagulation: mechanical valves require lifelong warfarin, bioprosthetic valves generally do not but have a finite lifespan.2,3 That distinction matters for exercise advice, fall risk and contact activity.
Transcatheter aortic valve implantation (TAVI) has displaced surgery for many older or higher-risk patients with aortic stenosis. TAVI patients are a different population with a different recovery — no sternotomy, much shorter stay, and often greater frailty. See Aortic Stenosis.
Access and bypass
Most cardiac surgery is performed through a median sternotomy on cardiopulmonary bypass. Off-pump grafting and minimally invasive approaches through a small thoracotomy are used selectively. Cardiopulmonary bypass itself contributes to the post-operative picture — a systemic inflammatory response, fluid shifts, and atelectasis that is near-universal on imaging.
Sternal precautions — what the evidence actually says
Restrictive sternal precautions expressed as a weight limit were never derived from evidence about sternal loading, and they are now understood to carry real costs — loss of independence, deconditioning, fear of movement and delayed return to normal activity.
The SMART trial randomised patients after median sternotomy to standard restrictive precautions or modified precautions and found similar outcomes, with no signal of harm from the less restrictive approach.4 The "Keep Your Move in the Tube" concept reframes the advice entirely: rather than a weight limit, patients are taught to keep the arms within an imaginary tube close to the body, allowing normal function — including pushing up from a chair — while avoiding the wide, loaded arm positions that distract the sternal edges.5
Practical guidance now favours progression by symptoms and sternal stability rather than by the calendar. Pain, a clicking or grinding sternum, or instability on palpation are the signals to modify. Full recovery of sternal bone strength takes around three months, but that is not a reason to immobilise for three months.
Screen for kinesiophobia. A patient who has been told not to lift a kettle will frequently not lift anything at all, and the resulting deconditioning outlasts the sternal healing. See Sternal Precautions for the full guide.
Early complications that change the session
| Complication | Notes for physiotherapy |
|---|---|
| Post-operative atrial fibrillation | Occurs in roughly a third of patients, typically days two to four.6 Heart rate becomes an invalid prescription variable — use perceived exertion and the talk test. Check anticoagulation before progressing mobility if fall risk is a concern. |
| Pleural effusion | Very common, more often left-sided after internal mammary harvest. Presents as persistent breathlessness with a dull base. No clearance technique will move it — it needs recognising and reporting, not treating. |
| Phrenic nerve injury | From cold cardioplegia or harvest. Produces diaphragm paresis, orthopnoea and a marked fall in vital capacity lying flat. Suspect it when a patient cannot lie down. Most recover over months. |
| Pericardial effusion / tamponade | Rising heart rate, falling blood pressure, breathlessness, distended neck veins. A medical emergency — stop and escalate. |
| Sternal wound infection | Higher risk with diabetes, obesity, bilateral mammary harvest and chronic obstructive pulmonary disease (COPD). New sternal pain, instability or discharge requires urgent surgical review. |
| Atelectasis and post-operative pulmonary complication (PPC) | Near-universal radiographically; clinically significant in a minority. Deep breathing exercises reduce atelectasis and improve early lung function after CABG.7 |
| Delirium and cognitive change | Common in older patients and a major barrier to mobilisation. Orientation, daylight, glasses and hearing aids are legitimate physiotherapy concerns. |
| Leg wound after vein harvest | Pain, oedema and cellulitis risk. Frequently the limiting factor in walking distance, and easily overlooked when attention is on the chest. |
Exercise after cardiac surgery
- Prescribe by perceived exertion. Beta blockade is near-universal and atrial fibrillation is common, so heart-rate-based prescription is unreliable in a large proportion of this population.
- Walking is the backbone of the first six weeks, progressed by duration before intensity.
- Upper limb work within the "tube" concept from the outset; loaded overhead and wide-arm work deferred until the sternum is comfortable and stable.
- Driving is usually restricted for around four weeks and is governed by licence class and jurisdiction — direct the patient to the surgical team and the licensing authority rather than guessing.
- Sternal clicking that is painful or progressive warrants review; a single painless click on a specific movement usually does not.
The referral that gets missed
Exercise-based cardiac rehabilitation reduces cardiovascular mortality and hospital admission after coronary heart disease, with improvements in quality of life, and it is recommended in every major guideline.8 Uptake nonetheless remains poor, particularly in rural and regional populations, among women, and in older patients — exactly the groups with most to gain.
The single highest-value action at discharge is a completed, followed-up referral into a structured programme, not a home exercise sheet. See Cardiorespiratory Rehabilitation.
Role of the physiotherapist
Before surgery, deliver the pre-operative education contact and set expectations for day-one mobilisation. On the ward, mobilise early, teach sternal management as function rather than prohibition, and recognise the complications above — particularly the ones that are not physiotherapy problems, such as effusion and tamponade. At discharge, make the cardiac rehabilitation referral and address kinesiophobia explicitly.
Evidence summary
Framing. Cardiac surgery is high-volume, protocolised, and the ward physiotherapy component is the part with the weakest evidence base while the post-discharge component has among the strongest in the whole of cardiorespiratory practice.8 Services that invest heavily in the inpatient episode and lightly in the referral pathway have the balance inverted.
Evidence — sternal precautionsThe SMART trial found no difference between standard restrictive and modified sternal precautions on function or sternal complications, supporting a less restrictive approach.4 "Keep Your Move in the Tube" provides a usable, function-preserving framing that has largely displaced weight-based instruction.5 The historical 5 kg limit has no identifiable biomechanical derivation, and the harms of over-restriction — deconditioning, dependence, kinesiophobia — are real and measurable.
Evidence — respiratory interventionDeep-breathing exercises reduce atelectasis and improve pulmonary function in the early days after CABG, though the effect on clinically defined PPC is less clear.7 As in abdominal surgery, mobilisation is likely to be the dominant active ingredient, and the strongest preventive evidence sits pre-operatively.
Physiotherapy implicationsAbandon heart-rate targets in this population by default. Treat new orthopnoea as possible phrenic injury rather than deconditioning. Treat a persistent unilateral dull base as effusion rather than a clearance problem. Address the leg wound as a mobility limiter in its own right. And treat the cardiac rehabilitation referral as a clinical intervention with an effect size, not an administrative task.
Evidence gapsThe optimal content and dose of inpatient physiotherapy after cardiac surgery is unresolved, and there is no contemporary trial of targeted versus universal provision within an enhanced-recovery cardiac pathway. Sternal precaution practice remains variable internationally despite SMART. Rehabilitation models for the TAVI population — older, frailer, no sternotomy — are underdeveloped and largely extrapolated from surgical cohorts.
References & evidence base
- Lawton JS, Tamis-Holland JE, Bangalore S, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization. Circulation 2022;145(3):e18–e114.
- Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease. Circulation 2021;143(5):e72–e227.
- Vahanian A, Beyersdorf F, Praz F, et al. 2021 ESC/EACTS guidelines for the management of valvular heart disease. Eur Heart J 2022;43(7):561–632.
- Katijjahbe MA, Granger CL, Denehy L, et al. Standard restrictive sternal precautions and modified sternal precautions had similar effects in people after cardiac surgery via median sternotomy ('SMART' trial): a randomised trial. J Physiother 2018;64(2):97–106.
- Adams J, Lotshaw A, Exum E, et al. An alternative approach to prescribing sternal precautions after median sternotomy, "Keep Your Move in the Tube". Proc (Bayl Univ Med Cent) 2016;29(1):97–100.
- Greenberg JW, Lancaster TS, Schuessler RB, Melby SJ. Postoperative atrial fibrillation following cardiac surgery: a persistent complication. Eur J Cardiothorac Surg 2017;52(4):665–672.
- Westerdahl E, Lindmark B, Eriksson T, Friberg Ö, Hedenstierna G, Tenling A. Deep-breathing exercises reduce atelectasis and improve pulmonary function after coronary artery bypass surgery. Chest 2005;128(5):3482–3488.
- Anderson L, Oldridge N, Thompson DR, et al. Exercise-based cardiac rehabilitation for coronary heart disease: Cochrane systematic review and meta-analysis. J Am Coll Cardiol 2016;67(1):1–12.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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