CARDIAC CATHETERIZATION AND CORONARY ANGIOGRAPHY
A cardiac cath provides information on how well your heart works, identifies problems and allows for procedures to open blocked arteries. For example, during cardiac cath your doctor may:
- Take X-rays using contrast dye injected through the catheter to look for narrowed or blocked coronary arteries. This is called coronary angiography or coronary arteriography.
- Perform a percutaneous coronary intervention (PCI) such as coronary angioplasty with stenting to open up narrowed or blocked segments of a coronary artery.
- Check the pressure in the four chambers of your heart.
- Take samples of blood to measure the oxygen content in the four chambers of your heart.
- Evaluate the ability of the pumping chambers to contract.
- Look for defects in the valves or chambers of your heart.
PERCUTANEOUS CORONARY INTERVENTION (ANGIOPLASTY/STENTING)
Percutaneous coronary intervention (PCI) is a non-surgical procedure used to treat narrowing of the coronary arteries of the heart found in coronary artery disease. The process involves combining coronary angioplasty with stenting, which is the insertion of a permanent wire-meshed tube that is either drug eluting (DES) or composed of bare metal (BMS).
A peripheral angiogram is a test that uses X-rays and dye to help your doctor find narrowed or blocked areas in one or more of the arteries that supply blood to your legs. The test is also called a peripheral arteriogram.
Doctors use a peripheral angiogram if they think blood is not flowing well in the arteries leading to your legs or, in rare cases, to your arms. The angiogram helps you and your doctor decide if a surgical procedure is needed to open the blocked arteries. Peripheral angioplasty is one such procedure. It uses a balloon catheter to open the blocked artery from the inside. A stent, a small wire mesh tube, is generally placed in the artery after angioplasty to help keep it open. Bypass surgery is another procedure. It re-routes blood around the blocked arteries.
PERCUTANEOUS PERIPHERAL REVASCULARIZATION
We utilize a multitude of different devices to open up diseased peripheral arteries. Peripheral angioplasty is one such procedure. It uses a balloon catheter to open the blocked artery from the inside. A stent, a small wire mesh tube, is spmetimes placed in the artery after angioplasty to help keep it open. We also perform peripheral atherectomy’s utilizing Laser or Orbital atherectomy devices. We use peripheral intravascular ultrasound (IVUS) to determine morphology and size of the vessel.
VENOUS ANGIOGRAM AND STENTING
Why is an iliac venogram used?
A venogram is used to help diagnose abnormalities in your veins, such as deep vein thrombosis. Other uses for a venogram include:
- Determining the cause of swelling or pain in your legs
- Tracking down where a blood clot that has traveled to your lungs initially formed
If you have a narrowed iliac vein, also known as iliac stenosis, a stent procedure may be used to expand and support the vein.
Most people are familiar with coronary/peripheral stents placed in the arteries of the heart/legs to improve blood flow. Venous stents function in the same way.
Venous stents are metal mesh tubes that expand against blocked or narrowed vein walls. They act as a scaffold to keep veins open. In most cases, physician place venous stents in larger, central veins, such as those found in the leg and abdomen.
Venous stents can help people with chronic leg swelling, venous ulcers, chronic blood clots or other conditions that compress or narrow the veins, limiting blood flow.
Below are a few of the conditions that are treatable with venous stenting:
- Chronic deep vein thrombosis (DVT): DVT is a blood clot in one of the large, deep veins that returns blood from the leg — or less commonly, from the arm — to the heart and lungs.
- Post-thrombotic syndrome: DVT can damage veins, which can lead to symptoms such as chronic swelling and pain. People may not suffer from symptoms of post-thrombotic syndrome until years after DVT.
- May-Thurner syndrome: In this condition, the artery that runs from your abdomen to your right leg — called the right iliac artery — presses against the left iliac vein, causing it to narrow and scar, leading to chronic left leg swelling, pain, and sometimes fatigue.
Venogram with Intravascular Ultrasound (IVUS)
A venogram is an x-ray that allows your doctor to see the anatomy of your veins.
After inserting a catheter (thin, flexible tube) into a vein — most often in the leg — your doctor injects a contrast dye into the catheter, which allows your veins to be seen on the x-ray. We also perform an (IVUS) intravascular ultrasound which allows us to see the vein from the inside to evaluate for compression or thrombosis.
Your physician can use the venogram and IVUS to diagnose and treat your condition by performing venous angioplasty and stent placement at the same time if indicated.
What to Expect During Venous Stenting?
Your physician can place most venous stents on an outpatient basis, under moderate sedation.
During venous angioplasty, your physician will:
- Insert a needle into a vein in your groin or behind your knee, depending on which vein needs stenting.
- Insert a guide wire and pass a catheter sheath over it, followed by a guide catheter through the sheath.
- Use x-ray guidance (fluoroscopy) to steer the catheter to the site of the narrowing.
- Use (IVUS) Intravascular Ultrasound to assess the vessel and determine the % compression or thrombosis
- Advance a balloon-tipped catheter to the site of the narrowing.
- Inflate and deflate the balloon several times to widen the narrow vein.
To place a venous stent, your physician will:
- Remove the angioplasty balloon and insert a catheter with a closed stent on it.
- Place the stent in the vein. The stent pushes against the walls of the vein, serving as a support to keep it open.
- Remove the catheters and apply pressure to the insertion point to close the wound.
In most cases, people who undergo venous stenting go home the same day.
To prevent blood clots from developing, most people must take clopidogrel (Plavix) for a few months.
IMPLANTABLE LOOP RECORDER
A cardiac event recorder is a battery-powered portable device that you control to tape-record your heart’s electrical activity (ECG) when you have symptoms. There are two types of event recorders: a loop memory monitor and a symptom event monitor.
Cardiac event recorders and other devices that record your ECG as you go about your daily activities are also called ambulatory electrocardiographic monitors.
- A cardiac event recorder makes a record of your electrocardiogram (ECG or EKG) when you have fast or slow heartbeats, or feel dizzy or like you want to faint. It can also be used to see how you respond to medicines.
- Some cardiac event recorders store your ECG in memory in the monitor. Your ECG can be sent by telephone to a receiving center or to your doctor.
- There are no risks when using a cardiac event recorder.
TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE)
Transesophageal echocardiography (TEE) is a test that produces pictures of your heart. TEE uses high-frequency sound waves (ultrasound) to make detailed pictures of your heart and the arteries that lead to and from it. Unlike a standard echocardiogram, the echo transducer that produces the sound waves for TEE is attached to a thin tube that passes through your mouth, down your throat and into your esophagus. Because the esophagus is so close to the upper chambers of the heart, very clear images of those heart structures and valves can be obtained.
Cardioversion is a procedure that uses medicine or electric shocks to correct arrhythmias. An arrhythmia is a heartbeat that is too slow, too fast, or irregular. It may prevent your body from getting the blood and oxygen it needs. Your heart has 4 chambers, called the atria and ventricles. The atria are at the top of your heart, and the ventricles are at the bottom of your heart. Most arrhythmias that need cardioversion start in the atria.
TILT TABLE TESTING
If you often feel faint or lightheaded, your doctor may use a tilt-table test to find out why. During the test, you lie on a table that is slowly tilted upward. The test measures how your blood pressure and heart rate respond to the force of gravity. A nurse or technician keeps track of your blood pressure and your heart rate (pulse) to see how they change during the test.
- Doctors use tilt-table tests to find out why people feel faint or lightheaded or actually completely pass out.
- Tilt-table tests can be used to see if fainting is due to abnormal control of heart rate or blood pressure. A very slow heart rate (bradycardia) can cause fainting.
- During the test, you lie on a special table that can have your head raised so that it is elevated to 60 to 80 degrees above the rest of your body while a nurse or doctor monitors your blood pressure and heart rate. You may have an IV inserted to give medicine or draw blood.
Doctors use this test to trigger your symptoms while watching you. They measure your blood pressure and heart rate during the test to find out what’s causing your symptoms. The test is normal if your average blood pressure stays stable as the table tilts upward and your heart rate increases by a normal amount.
If your blood pressure drops and stays low during the test, you may faint or feel lightheaded. This can happen either with an abnormally slow heart rate or with a fast heart rate. That’s because your brain isn’t getting enough blood for the moment. (This is corrected as soon as you are tilted back to the flat position.) Your heart rate may not be adapting as the table tilts upward, or your blood vessels may not be squeezing hard enough to support your blood pressure.
Feeling lightheaded or fainting may be caused by taking certain medicines, severe dehydration, abnormal heart rhythms (arrhythmias), hypoglycemia (low blood sugar), prolonged bed rest and certain nervous system disorders that cause low blood pressure.
A valvuloplasty, also known as balloon valvuloplasty or balloon valvotomy, is a procedure to repair a heart valve that has a narrowed opening.
In a narrowed heart valve, the valve flaps (leaflets) may become thick or stiff and fuse together (stenosis). This reduces blood flow through the valve.
A valvuloplasty may improve blood flow through the heart valve and improve your symptoms.
Doctors will examine you and determine if valvuloplasty or another treatment is right for your valve condition.
Your doctor may recommend valvuloplasty if:
- You have severe valve narrowing and are having symptoms
- You have narrowing of the mitral valve (mitral valve stenosis), even if you don’t have symptoms
- You have a narrowed tricuspid or pulmonary valve
- You or your child has a narrowed aortic valve (aortic valve stenosis)
However, the aortic valve tends to narrow again in adults who’ve had a valvuloplasty, so the procedure is usually done if you are too sick for surgery or are waiting for a valve replacement.
In a valvuloplasty, a doctor inserts a long, thin tube (catheter) with a balloon on the tip into an artery in your arm or groin. X-rays are used to help guide the catheter to the narrowed valve in your heart. The doctor then inflates the balloon, which widens the opening of the valve and separates the valve flaps. The balloon is then deflated, and the catheter and balloon are removed.
You’ll be awake but sedated during the procedure. After the procedure, you’ll usually stay in the hospital overnight.
Valvuloplasty may improve blood flow through your heart and reduce your symptoms. However, the valve may narrow again. You may need to have another valvuloplasty or other heart procedure, such as valve repair or replacement, in the future.
TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR)
This minimally invasive surgical procedure repairs the valve without removing the old, damaged valve. Instead, it wedges a replacement valve into the aortic valve’s place. The surgery may be called a transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI).
Somewhat similar to a stent placed in an artery, the TAVR approach delivers a fully collapsible replacement valve to the valve site through a catheter.
Once the new valve is expanded, it pushes the old valve leaflets out of the way and the tissue in the replacement valve takes over the job of regulating blood flow.
This procedure is fairly new and is FDA approved for people with symptomatic aortic stenosis as an alternative to standard valve replacement surgery. The differences in the two procedures are significant.
Watch an animation of TAVR here.
Usually valve replacement requires an open-heart procedure with a “sternotomy.”, in which the chest is surgically separated (open) for the procedure. The TAVR or TAVI procedures can be done through very small openings that leave all the chest bones in place.
A TAVR procedure is not without risks, but it provides beneficial treatment options to people who may not have been candidates for them a few years ago while also providing the added bonus of a faster recovery in most cases. A patient’s experience with a TAVR procedure may be comparable to a balloon treatment or even an angiogram in terms of down time and recovery, and will likely require a shorter hospital stay (average 3-5 days).
The TAVR procedure is performed using one of two different approaches, allowing the cardiologist or surgeon to choose which one provides the best and safest way to access the valve:
- Entering through the femoral artery (large artery in the groin), called the transfemoral approach, which does not require a surgical incision in the chest, or
- Using a minimally invasive surgical approach with a small incision in the chest and entering through a large artery in the chest or through the tip of the left ventricle (the apex), which is known as the transapical approach.
ENDOVASCULAR ANEURYSM REPAIR (EVAR)
Abdominal aortic aneurysms can weaken the aorta, your body’s largest blood vessel. This can develop into a potentially serious health problem that can be fatal if the aneurysm bursts, causing massive internal bleeding.
Endovascular stent grafting, or endovascular aneurysm repair (EVAR), is a newer form of treatment for abdominal aortic aneurysm that is less invasive than open surgery. Endovascular stent grafting uses an endovascular stent graft to reinforce the wall of the aorta and to help keep the damaged area from rupturing.
The word endovascular refers to the area inside of a blood vessel such as the aorta. With endovascular stent graft therapy an endovascular stent graft is placed inside of your abdominal aorta to help protect the aneurysm from rupturing.
The stent graft is placed inside of the aortic aneurysm with the help of a long, very thin, soft, plastic tube called a delivery catheter. The delivery catheter contains the compressed stent graft.
Here is how the endovascular stent graft is placed in the aortic aneurysm:
- The catheter is inserted into an artery in the leg near the groin.
Delivery catheter is inserted through the vessel into the aneurysm to guide the stent into place.
- Using advanced imaging methods, the surgeon guides the delivery catheter carrying the stent graft to the area of the abdominal aortic aneurysm.
- Once the stent graft is in position, the surgeon fastens it into place and removes the delivery catheter.
- The endovascular stent graft is placed inside the abdominal aorta to help keep the aneurysm from bursting.
Endovascular stent grafting and open surgery grafting are both done to prevent an abdominal aortic aneurysm from rupturing. The difference is that the endovascular stent graft is put into place inside the aneurysm without removing any tissue from your aorta, and it does not require open-chest or open-abdominal surgery.
Because it is less invasive than open surgery, the recovery time for endovascular stent grafting may be faster. Usually, the patient can return home within a week and return to normal activities in 4 to 6 weeks.