Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Coronary Bypass


Related Terms

  • Bypass Surgery
  • CABG-Coronary Artery Bypass Grafting
  • CPB-Cardiopulmonary Bypass
  • Open Heart Surgery

Specialists

  • Cardiovascular Surgeon
  • Thoracic Surgeon

Comorbid Conditions

Factors Influencing Duration

Length of disability may depend on severity of pre-existing CAD, type of surgical treatment used (open vs. minimally invasive), individual response to surgical treatment, underlying medical conditions (e.g., diabetes), development of complications, and specific job requirements including activity level.

Medical Codes

ICD-9-CM:
36.10 - Aortocoronary Bypass for Heart Revascularization NOS, Direct Revascularization: Cardiac with Catheter Stent, Prothesis, or Vein Graft, Coronary with Catheter Stent, Prothesis, or Vein Graft, Heart Muscle with Catheter Stent, Prothesis, or Vein Graft, Myocardial with Catheter Stent, Prothesis, or Vein Graft, Heart Revascularization NOS
36.11 - Aortocoronary Bypass of One Coronary Artery
36.12 - Aortocoronary Bypass of Two Coronary Arteries
36.13 - Aortocoronary Bypass of Three Coronary Arteries
36.14 - Aortocoronary Bypass of Four or More Coronary Arteries
36.15 - Single Internal Mammary-coronary Artery Bypass; Anastomosis (Single): Mammary Artery to Coronary Artery, Thoracic Artery to Coronary Artery
36.16 - Double Internal Mammary-coronary Artery Bypass; Anastomosis, Double: Mammary Artery to Coronary Artery, Thoracic Artery to Coronary Artery
36.17 - Abdominal-coronary Artery Bypass; Anastomosis: Gastroepiploic-coronary Artery
36.19 - Bypass Anastomosis for Heart Revascularization, Other

Overview

© Reed Group
Coronary bypass surgery refers to several procedures that graft new channels (bypass conduits) into the heart to reroute blood flow (revascularize) around a section of coronary artery blocked by hardened, fatty deposits (plaque). Coronary artery bypass grafting (CABG) is one of the most frequently performed surgeries in the US, and is most often performed as an open surgical procedure with the patient on cardiopulmonary bypass. This major surgery involves arresting (paralyzing with "cardioplegia") the heart muscle and grafting a new bypass conduit in place while maintaining circulation and lung function via a heart-lung machine or "pump." However, the trend is toward less invasive techniques with smaller incisions instead of the traditional open procedure, including port access CABG, total endoscopic robotically-assisted CABG (TECAB), "off-pump" CABG (OPCAB) and a minimally invasive direct coronary artery bypass (MIDCAB), which is used primarily when a single artery is obstructed. In all of these procedures, grafts for the bypass conduit use veins taken from the legs (greater and lesser saphenous veins), or an artery taken from the inside of the chest wall (internal mammary artery or IMA), or radial arteries.

The advantages of minimally invasive coronary bypass procedures include less post-operative discomfort, reduced risk of wound infection, and a shorter recovery period. Avoiding the need to perform cardiopulmonary bypass with the heart-lung machine reduces risk of bleeding and clot formation (embolism), reduces postoperative inflammatory response, and was thought to reduce the possibility of postoperative conditions such as kidney failure, stroke, or nervous system deficit, especially in elderly patients or individuals severely compromised by coronary artery disease (CAD). However, the 2012 meta-analysis of 86 randomized controlled trials of "off-pump" versus "on-pump" coronary artery bypass showed no significant short term difference in the rates of myocardial infarction, repeat coronary revascularization surgery, stroke, or kidney failure, but a slightly higher (and statistically significant) rate of long term mortality (Moller).

Coronary bypass surgery generally is the treatment of choice for severe coronary artery disease (CAD) that affects more than 3 vessels in the heart or the left main artery. Less severe disease, affecting one vessel, is usually treated either by percutaneous coronary intervention (PCI) with the placement of cardiac stents or by less invasive percutaneous coronary transluminal angioplasty (PCTA), which breaks up the atherosclerotic plaque in the artery.

Source: Medical Disability Advisor



Reason for Procedure

Coronary bypass surgery is performed to revascularize the heart in individuals with coronary artery disease (CAD), also called coronary atherosclerosis, whose coronary arteries are narrowed by the formation of plaque. Coronary bypass surgery relieves chest discomfort (angina pectoris) that occurs with activity (effort angina) in individuals with CAD and prolongs life when CAD is pervasive and irreversible.

Plaque (atheroma) is an accumulation of white blood cells, cell debris, fatty substances (cholesterol and fatty acids), calcium, and fibrous tissue that forms on artery walls. Formation of plaque narrows the arteries and limits the flow of blood, oxygen, and nutrients needed for proper functioning of the heart muscle (myocardium). Without a constant supply of blood, nutrients, and oxygen (ischemia), cells in the heart tissue begin to die and heart attack (myocardial infarction) can result. Angina pectoris occurs when oxygen demand by the heart muscle (myocardial oxygen demand) is greater than is supplied by blood flow. CABG surgery restores blood flow and the critical delivery of oxygen.

Source: Medical Disability Advisor



How Procedure is Performed

The traditional open heart (“on-pump”) procedure is major surgery that requires opening the chest with a long vertical incision in the chest wall, followed by sawing the sternum in half vertically (median sternotomy). Because heart activity must be arrested to allow the surgeon to work on the heart, the patient's blood is routed through a heart-lung machine that performs the normal work of the heart during the surgery (cardiopulmonary bypass or CPB). The individual's blood is supplemented by the blood of multiple compatible donors and/or blood expanders to ensure that an adequate volume of oxygen-carrying red blood cells continues to circulate within the body. The heart-lung machine oxygenates the blood and continuously pumps it back into the individual's body while the heart is not beating. The motionless state of the heart allows this sometimes lengthy surgery (3 to 7 hours) to be done under conditions conducive to the best technical result. During the surgery, the surgeon will attach the grafts (saphenous vein, mammary artery or synthetic conduit) to the aorta (the main artery coming from the heart) and attach the other end to the coronary artery on the far side of the blockage or blockages. After these bypasses are performed, the heart is restarted and the individual is weaned from the heart-lung machine. Sometimes a device known as an intra-aortic balloon pump is used to help with weaning. The balloon pump is then gradually discontinued over one to several days.

The less invasive surgical methods use smaller incisions and do not always require CPB with the heart-lung machine. Port access CABG requires only limited incisions and uses chemical substrates and/or hypothermia to arrest heart activity (cardioplegic arrest). It is noted for less postoperative discomfort and faster recovery than the open procedure. Total endoscopic robotically assisted CABG is performed similarly with cardioplegic arrest of heart activity and small incisions; the surgeon views the heart and controls robotic placement of bypass conduits through a flexible, lighted fiber-optic instrument (endoscope). Off-pump CABG (OPCAB) requires opening the chest with sternotomy or several smaller incisions and is performed on the beating heart with mechanical suction stabilization without using the heart-lung machine. An incision in the left chest (left anterior thoracotomy) allows minimally invasive direct coronary artery bypass (MIDCAB) to be performed, also without use of the heart-lung machine. The details of which surgery is selected for which patient are too complex to list here.

If venous grafts are being used, a saphenous vein (usually the greater saphenous vein but sometimes the lesser saphenous vein is used as well) is removed from one or both legs and used to bypass narrowed areas of the coronary arteries identified preoperatively by a coronary angiogram. Usually at least one, and sometimes both, internal mammary arteries (which have a larger diameter than veins) is used in addition to the saphenous veins. Use of both internal mammary arteries is reserved for younger patients or those whose saphenous veins are unsuitable for the procedure. Venous grafts are not always favored because of a high rate of failure shown in long-term experience. The selection and type of preparation of bypass conduits varies depending on surgeon preference.

Source: Medical Disability Advisor



Prognosis

Relief of angina pectoris and increased life expectancy is achieved in most individuals undergoing CABG surgery. However, recurrence of coronary artery blockage and angina is common in individuals with pervasive CAD due to partial narrowing or complete occlusion of the vein bypass. About half of individuals undergoing this surgery eventually die of late atherosclerosis and occlusion at the grafting site (Eagle). Vein bypass occlusion occurs more often in older individuals, diabetics, overweight or obese individuals, and those who continue to smoke and/or who continue to consume a high-fat, high-glycemic diet. Results of bypass surgery using bilateral internal thoracic artery grafts are promising and are being shown to increase survival rates (Kelly). Surgeons report that newer, less invasive surgical techniques and use of arterial grafts rather than venous grafts will eventually result in fewer people needing repeat surgeries.

Source: Medical Disability Advisor



Rehabilitation

Please refer to the frequency of visits below.

FREQUENCY OF REHABILITATION VISITS
Surgical
SpecialistCoronary Bypass
Cardiac RehabilitationUp to 3 times/week for 12 weeks, or 36 total visits
Coronary Artery Bypass Graft Surgery

Source: Medical Disability Advisor



Complications

Major complications of coronary bypass surgery include stroke (which carries a 10% to 21% chance of death) and chest infection (1% to 4%) (Eagle). Other possible complications include bleeding, kidney failure (depending on preoperative kidney function), and heart attack during or after surgery. Infection of the sternum (osteomyelitis) or non-union of the sternum are uncommon, complications that limit upper limb function. Risk for complications is a case-by-case consideration depending on age, general health, smoking history, underlying chronic disease, and pre- and postoperative heart function.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

After the recovery period many individuals can return to the job they performed before surgery. Although energy levels generally increase after recovery, physical activity may be limited for a period or indefinitely in individuals with pervasive CAD whose symptoms recur.

Risk: Some occupations have been identified as posing a priori risk for coronary disease and thus may be of concern if underlying risk factors are not addressed. These can include workers in metal processing, paper, chemicals, plastics, air traffic control, bus operation, assembly, firefighters, nursing, and waiting tables. For more information, refer to "Work Ability,” page 264.

Capacity: A graded physical therapy program of cardiac rehabilitation will help ensure higher levels of capacity are achieved after surgery, and will reassure patients that this level of achieved exercise is safe. If there has been no myocardial infarction, and pumping ability (ejection fraction) is normal, then capacity is generally not reduced by having had uncomplicated bypass surgery, and return to pre-surgery levels of work activity is typically recommended.

Tolerance: Limits of patients returning to work with angina usually result from social factors of low education, concerns over job performance, depression, shift work, lower socioeconomic status. For more information, refer to “Work Ability,” page 266.

Accommodations: Temporary modified duty while the patient recovers endurance and use of the upper limbs is usually all that is required.

Source: Medical Disability Advisor



Maximum Medical Improvement

MMI is usually reached within 6 months of coronary artery bypass surgery.

Source: Medical Disability Advisor



References

Cited

Eagle, Kim, et al. "ACC/AHA 2004 Guideline Update for Coronary Artery Bypass Graft Surgery ." Circulation 110 (2004): e340-e437.

Kelly, R. , KJ Buth, and JF Légaré. "Bilateral internal thoracic artery grafting is superior to other forms of multiple arterial grafting in providing survival benefit after coronary bypass surgery." Journal of Thoracic and Cardiovascular Surgery 144 (6) (2012): 1408-1415.

Moller, C. H. , et al. "Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease." Cochrane Database of Systematic Reviews 3 (2012): CD007224.

Source: Medical Disability Advisor






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