Jeevan Rekha Superspeciality Hospital

WHAT IS CORONARY ANGIOPLASTY ?

Coronary angioplasty or PTCA i.e. Percutaneous Transluminal Coronary Angioplasty is a therapeutic procedure used to treat the blockage in the coronaries. Through the same procedure as angiography, a long plastic tube known as guide catheter is taken to the coronaries. Through this a wire is taken down to the coronary artery with blockage and put across the blockage. Then a balloon is inflated across the blockage to make appropriate place for stent. Following this a stent is deployed across the blockage which scaffolds the artery and prevent further recurrence of blockage in future. Previously the angioplasties were performed without placement of a stent, but this was associated with high rates of reblockages. This procedure is now called as POBA i.e. Plain Old Balloon Angioplasty. With the advent of stent, this procedure has almost become obsolete now and most of the angioplasties now are being performed with stents and called PTCA +stent.

WHAT IS STENT ?

Stent is a metallic mesh tube which has enough strength to open up the coronary arteries. Most of the modern stents are made of alloys mostly cobalt chromium or platinum chromium and available in different diameters and lengths to suit the size of coronary in a given individual. Previously there were only non medicated stents available. Now for last 15 years we have medicated stents available. These medicated stents release some medicines locally into coronaries after deployment for a limited time period. These medicines do help to prevent reblockages into coronaries. With the advent of medicated stents, the reblockage rate in the stents have come down to around 4 percent from 20 percent in non medicated stents.

Coronary angiography underestimates or overestimates lesion severity, but still remains the cornerstone in the decision making for revascularization for an overwhelming majority of interventional cardiologists. Guidelines recommend and endorse non invasive functional evaluation ought to precede revascularization. In real world practice, this is adopted in less than 50% of patients who go on to have some form of revascularization. Fractional flow reserve (FFR) is the ratio of maximal blood flow in a stenotic coronary relative to maximal flow in the same vessel, were it normal. Being independent of changes in heart rate, BP or prior infarction; and take into account the contribution of collateral blood flow. It is a majorly specific index with a reasonably high sensitivity (88%), specificity (100%), positive predictive value (100%), and overall accuracy (93%). Whilst FFR provides objective determination of ischemia and helps select appropriate candidates for revascularization (for both CABG and PCI) in to cath lab itself before intervention, whereas intravascular ultrasound/optical coherence tomography guidance in PCI can secure the procedure by optimizing stent expansion. Functional angioplasty simply is incorporating both intravascular ultrasound and FFR into our daily Intervention practices.

Millions across the world have benefited by advancement in medicine and healthcare technology. Billions of dollars is spent on medical research and development to discover breakthrough technology that aims at improving the quality of people’s life.

What is Coronary Angiography?

Coronary angiography is an imaging technique which allows us to picture the coronary arteries supplying the heart and diagnose the extent of blockages in them. Angiography is used to determine which treatment option would be best for the patient.

Traditionally, coronary angiography is done by putting a plastic tube in the femoral artery i.e. The artery supplying the leg. Through this plastic tube called a sheath, small caliber plastic pipes are taken to the heart and dye injected into them to take pictures in cath lab.

Procedure Overview

Peripheral artery angioplasty is a procedure to treat peripheral arterial disease of the legs. The procedure widens narrowed arteries in the pelvis or legs. It can help blood flow better. This may decrease leg pain or help wounds heal better.

Your arteries can get narrowed by a substance called plaque. Plaque is a buildup of fats in your arteries.

You will be awake for the procedure. You will get medicine to prevent pain and help you relax. First, your doctor will do a test to find narrowed arteries. He or she will put a tiny tube into an artery in your groin or leg. This tube is called a catheter. The doctor moves the catheter through the artery and puts a dye into it. The dye makes your arteries show up on X-ray pictures. This lets the doctor see any narrowed parts of the arteries.

If your doctor finds a narrowed artery, he or she may do an angioplasty. To do this, the doctor uses a catheter with a balloon at the tip. It goes into the artery in your groin or leg. He or she moves the balloon to the narrowed area and inflates it. The balloon presses the plaque against the walls of the artery. This makes more room for blood to flow. The doctor may also put a stent in your artery. A stent is a small tube that helps keep the artery open. It can also keep small pieces of plaque from breaking off and causing problems.

You may need to spend the night in the hospital. For 1 or 2 days after the procedure, you will need to take it easy at home.

How It Is Done

Angioplasty is used to open narrowed arteries and increase oxygen-rich blood flow to muscle and tissue. These images show angioplasty for the iliac artery. Angioplasty can also be done for the femoral, popliteal, and tibial arteries.

CAS is a technically complex endovascular procedure that is associated with a distinct learning curve. The module provides tools and strategies for improving procedural outcomes. Staged training for a variety of anatomies and lesion positions include hostile necks, high lesions and cases of radiation induced stenoses. Simulator training allows the learner to gain a thorough hands-on understanding of this high-risk procedure, without any risk to the patient.

Interventions in structural heart disease cover a wide range of cardiac procedures for congenital and acquired diseases including valvular diseases, septal defects, arterial or venous obstructions, and fistulas, and a variety of techniques such as closure of the atrial appendage. The positive results obtained with transcatheter valve therapy have stimulated interest among cardiologists in this field. Taken together with the development and continuous improvement of the devices, this situation augurs a promising future for this subspecialty of cardiac intervention.

During this minimally invasive procedure a new valve is inserted without removing the old, damaged valve. The new valve is placed inside the diseased valve. The surgery may be called a transcatheter aortic valve replacement (TAVR) or transcatheter aortic valve implantation (TAVI).

What is involved in a TAVR procedure?

Usually valve replacement requires an open-heart procedure with a “sternotomy”, in which the chest is surgically separated (opened) for the procedure. The TAVR or TAVI procedures can be done through very small openings that leave all the chest bones in place.

While TAVR is not without risks, it provides beneficial treatment options to people who may not have been considered for valve replacement. A patient's experience with a TAVR procedure may be similar to a coronary angiogram in terms of recovery. You will likely spend less time in the hospital after TAVR compared to surgical valve replacement.

The TAVR procedure is performed using one of two 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.

EPS or electrophysiology study is a test procedure conducted to see how the electric impulses conducts through the pathways of your heart. In case the conduction pathway is normal it indicates your heart rates are normal. In case if abnormal signals are detected it indicates arrhythmia or irregular heart beats.

RFA or radiofrequency ablation is a type of invasive surgical procedure conducted to treat certain types of arrhythmias.

Both EPS and RF can be conducted at the same time. Normally a doctor assigns both the procedures together. EPS is conducted to diagnose presence of arrhythmia. Based on the nature and type of arrhythmia RFA is conducted as a treatment procedure.

The Normal, Healthy Heart Has Its Own Pacemaker That Regulates The Rate At Which The Heart Beats. However, Some Hearts Don't Beat Regularly. And A Pacemaker Device Can Correct The Problem. A Pacemaker Is A Small Device That Sends Electrical Impulses To The Heart Muscle To Maintain A Suitable Heart Rate And Rhythm. It Is Implanted Just Under The Skin Of The Chest During Minor Surgery.

The Pacemaker Has Two Parts: The Leads And A Pulse Generator. The Pulse Generator Houses The Battery And A Tiny Computer, And Resides Just Under The Skin Of The Chest. The Leads Are Wires That Are Threaded Through The Veins Into The Heart And Implanted Into The Heart Muscle. They Send Impulses From The Pulse Generator To The Heart Muscle, As Well As Sense The Heart's Electrical Activity. Each Impulse Causes The Heart To Contract. The Pacemaker May Have One To Three Leads, Depending On The Type Of Pacemaker Needed To Treat Your Heart Problem.

An implantable cardioverter defibrillator (ICD or AICD) is a permanent device in which a lead (wire) inserts into the right ventricle and monitors the heart rhythm. It is implanted similar to a single chamber pacemaker and the generator lays in the upper chest area and venous access is through the subclavian vein. Therapies are delivered in the form of anti-tachycardia pacing (ATP) or shocks to convert to sinus rhythm from sustained ventricular tachycardia or ventricular fibrillation, both of which are life-threatening rhythms.

What is cardiac resynchronization therapy?

Cardiac resynchronization therapy (CRT) is treatment to help your heart beat with the right rhythm. It uses a pacemaker to restore the normal timing pattern of the heartbeat.

The CRT pacemaker coordinates how timing of the upper heart chambers (atria) and the lower heart chambers (ventricles). It also works on the timing between the left and right sides of the heart.

When your heart doesn’t pump strongly enough, fluid can build up in your lungs and your legs. This is called heart failure. This condition can happen when the two bottom chambers (ventricles) of your heart don’t beat at the same time.

Your doctor may find out that you also need an implantable cardioverter defibrillator (ICD). This device helps fix serious heart rhythm problems. If you need this device, it may be combined with the CRT.

CRT therapy means you will need to have the pacemaker placed under your skin by minor surgery. Wires from the device are connected to the ventricles on both sides of your heart. The CRT device sends electrical signals to the ventricles to make them pump together the way they should. This type of electrical stimulation is called biventricular pacing.

CRT therapy works in about 7 out of 10 cases of heart failure. Not everyone with heart failure can be helped by CRT. For instance, if you have advanced heart failure, you are not as likely to respond to CRT. Overall, CRT may improve your survival, heart function, and quality of life if you have mild to moderate heart failure. It also improves your ability to exercise.

During a coronary artery bypass surgery, the diseased sections of your coronary arteries are bypassed with healthy artery or vein grafts to increase blood flow to the heart muscle tissue. This procedure is also called coronary artery bypass grafting (CABG). Bypass typically requires open-chest surgery.  

There are several newer, less invasive techniques for bypass surgery that can be used instead of open-chest surgery in some cases. In some procedures, the heart is slowed with medicine but is still beating during the procedure. For these types of surgery, a heart-lung bypass machine is not needed. (For open-chest surgery, a heart-lung machine is needed to circulate the blood and to add oxygen to it.) Other techniques use keyhole procedures or minimally invasive procedures instead of open-chest surgery. Keyhole procedures use several smaller openings in the chest and may or may not require a heart-lung machine.

Open-chest surgery

You'll receive anesthesia before the surgery that will make you sleep. In most cases, bypass surgery is open-chest surgery slideshow.gif. During the surgery, your chest will be open and your heart exposed. The surgeon makes a large cut, or incision, in the middle or side of your chest. He or she may cut through your breastbone and spread apart your rib cage. The surgeon removes a healthy blood vessel-often from the leg-and attaches (grafts) it to the narrowed or blocked artery. The new blood vessel bypasses the diseased artery to increase blood flow to the heart. You may need just one bypass graft, or you may need more. Some people have as many as two, three, or even four (double, triple, or quadruple bypass surgery). How many grafts you need depends on how many arteries are narrowed or blocked and where.

When the surgery is complete, the doctor may use wire to put your rib cage back together and stitches to close the incision. The surgery can take 3 to 6 hours. You will stay in the hospital at least 3 to 8 days after the surgery. It can take 4 to 6 weeks to recover at home. Most people are able to return to work within 1 to 2 months after surgery.