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Heart Catheterization

Your cardiologist may recommend a heart catheterization to diagnose and treat heart disease which may be caused by blocked arteries. This is a common procedure and is performed in a cardiac catheterization laboratory, usually in a hospital. Many blockages can be fixed with angioplasty which typically involves placing a stent which is mounted on a balloon across the blockage. The stent is left behind and the balloon is removed after inflation.

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Heart Catheterization Procedure

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An angiogram produced of heart arteries during  a heart catheterization

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  Magnified view of a coronary stent

What Happens Before the Heart Catheterization?
  • You will need to arrive to the preparation and recovery area of the catheterization lab a few hours before the scheduled procedure.
  • Do not eat or drink anything after midnight the day before.
  • An IV will be started in your arm so that medications can be given by the nurses for the procedure as well as medicine to help you relax.
  • Labs will be checked to make sure the procedure will be safe for you.
  • The risks and benefits of the procedure will be explained to you, and you should make sure all of your questions are answered before the procedure starts.
Will I Be Asleep?
  • Typically the goal during a heart catheterization is to achieve “Moderate Sedation” where the patient is very relaxed and sometimes sleeps through the procedure though is not “all the way out”.
  • We are not stingy with medication and the goal is to keep you comfortable throughout the procedure so, if you are in any discomfort or anxious, please tell your nurse!
During the Procedure

Numbing medicine will be injected under the skin in the wrist or groin over the artery where a small tube will be inserted (like a large IV). After the initial “bee sting” of the numbing medicine, you should only feel pressure. The remainder of the procedure is generally not uncomfortable. Some things you may feel are:

  • Skipped beats
  • Pressure at the sheath site (wrist or groin)
  • Chest pressure or heaviness during stent placement

You will probably hear the doctors, nurses, and cath lab technicians talking to each other throughout the procedure. This is normal and you can always ask how things are going. You may be able to see some of the pictures of your heart during breaks in the procedure if circumstances allow.

How Are Pictures Taken of the Heart?
  • Pictures of the heart arteries are taken using an X-ray camera (fluoroscopy) while contrast dye is injected through a long plastic tube called a catheter directed into the heart arteries (coronary arteries).
  • Your cardiologist will look at the arteries at several different angles to assess for blockages.
  • The pressures inside the heart are often measured and often the pumping function is assessed if needed.
What if a Blockage is Found?
  • If a blockage in an artery is found your cardiologist will make a decision as to whether it should and can be fixed with a stent, which is a mesh wire cylinder. If so, a wire is placed across the blockage and a stent mounted on a small balloon is run across.
  • The balloon is inflated to expand the stent and this pushes the blockage material into the wall of the artery. The stent stays behind in the artery like scaffolding to keep the blockage recoiling.
  • Blood thinners are then necessary to prevent blood clots from forming on the stent and are an absolute necessity until your doctor says you can stop them.
  • Most patients stay at least one night in the hospital after a heart stent is placed but in some cases this may not be necessary.
What if I Need Bypass Surgery?
  • If blocked arteries are found which are too complex or too numerous for stenting to be a safe and durable procedure, bypass surgery may be recommended.
  • Depending on the situation you may be able to meet with the surgeon on another day after you recover from the catheterization. However, in some cases, it is best to stay in the hospital for surgery if necessary in the following days.
  • Typically 4-6 weeks of recovery can be expected.
How Long Will I Need for Recovery from a Heart Catheterization?
  • This varies but in general you can be back to normal activities within a week.
  • If your catheterization is done through the wrist artery it is best to treat the wrist as if it is broken for 3-5 days.
  • Likewise if it is done through the groin artery, we prefer you don’t do any squatting, bending at the waist or heavy exertion for 3-5 days so the artery can heal appropriately.
  • If you receive a stent, we generally advise taking it easy for a week but this can vary depending on your individual circumstances.

Cardiac Pacemakers

A pacemaker is a device which is designed to replace the function of the native electrical system of the heart. Sometimes damage from a heart attack can cause the “wires” in the heart one is born with to have problems. The heart beat may pause or stop altogether intermittently causing bothersome symptoms. In other patients, those wires simply wear out overtime and a pacemaker is needed to tell your heart muscle when to beat. There are typically two parts – a pulse generator which is the “brains” of the pacemaker, and leads or “wires”, which extend from the generator into the heart. The pacemaker generator sits in a small pocket under the skin created in a simple surgical procedure.

How is a Pacemaker Inserted into the Heart?
  • A pacemaker will be placed during a minor surgical procedure where a small incision about 2 inches wide is made in the upper chest under the collar bone.
  • A small “pocket” is made under the skin but on top of the chest muscle where the pacemaker pulse generator will be inserted.
  • One or two leads or “wires” will then be threaded through the vein under the collar bone which leads to the heart chambers where the wires will be attached. The wires are connected to the pulse generator under the skin and the pocket is sewn together.
  • An X-ray camera is used to show the cardiologist when the pacemaker wires are in the appropriate place in the heart and a computer which communicates with the pacemaker can verify the device is working well.
Will I be Asleep?

Much like a heart catheterization, the goal is to achieve “moderate sedation” where the patient is very relaxed but not “all the way out”. If you are uncomfortable during any portion of your procedure let the nurse know so that additional medicine to help you get comfortable can be given.

Can I Go Home the Same Day?
  • If this is the first time you are having a pacemaker inserted you will need to spend a night in the hospital and if all goes well you will be discharged the following day usually.
  • If you are having a battery changed out in a pacemaker that was placed some time ago, you can typically go home the same day after a few hours in recovery.

Echocardiography

Commonly known as “Echo”, “Sonogram”, or “Ultrasound” of the heart, this type of cardiac test uses non-invasive ultrasound waves (high speed sound signals) to obtain information about your heart. Many times this is a very helpful test and allows your cardiologist understand a great deal about the function of your heart, any signs of damage in the past, and will help guide your cardiovascular treatment

What to expect during an echocardiogram
  • During the exam an ultrasound probe, which is blunt with a rounded end, will be pressed on the chest over the region of the heart. Ultrasound jelly will be applied to the probe which is necessary for the images to be obtained.
  • An echocardiogram is performed in the office by a certified technician specifically in this field of ultrasonography (sonographer). There may be a few parts of the exam which can be less comfortable due to the probe being pressed on the chest to get detailed pictures, though it is very unusual that there is any pain. Do not hesitate to let the technician know if you are uncomfortable at any point!
  • In some instances a small IV may need to be placed int he arm so that the sonographer can watch saline mixed with a small amount of microscopic air bubbles flow through the pumping chambers of the heart while imaging your heart.
What information can my cardiologist gain from my echo?

Your doctor may order an echocardiogram for a variety of reasons. Many other things can be picked up on echocardiography which makes it such a great tool for helping your cardiologist understand your heart’s health!

Overall the structure and function of the heart is studied during the exam. Below is some of the information which may be obtained.

Squeezing or pumping function of the heart (systolic function)

  • If you have heard he term “E.F.”, this stands for Ejection Fraction, and is how the pumping efficiency of the heart is described.
  • Typically an Ejection Fraction greater than 55% is considered normal.
  • Congestive heart failure can result from lower than normal squeezing function or ejection fraction.

Relaxing or filling function of the heart (diastolic function)

  • The ability of the heart to relax and fill with blood can change over time as the heart “stiffens” with age.
  • This may cause symptoms in some patients, frequently shortness of breath. Other problems however, may lead to issues with the relaxation or “filling phase” of the heart including heart attacks among others.

Valve disease: Valve problems typically comes in two main varieties, which in turn can be due to several different problem:

  • Leaking of the Heart Valves (Regurgitation) This problem results in too much blood flowing backwards across a heart valve. This can lead to heart failure, enlargement of heart chambers as well as rhythm disorders, among other troublesome issues. A mild degree of leaking is typical for some heart valves so don’t worry if you see that in your report.
  • Tightening of the Heart Valves (Stenosis) This tends to occur when a heart valve becomes too thickened and/or hardened most commonly through deposits of calcium over time. This leads to trouble with the flow of blood forward from one chamber to another and pressure builds up behind the affected valve. Some people are born with stenotic valves which can cause problems early in life.
What happens after my echo?
  • Your cardiologist will review the images recorded by the sonographer and interpret the exam afterward. While you may be anxious to know the results, please understand the sonographer is not able to give preliminary results until a cardiologist has looked at the images.
  • Feel free to call the office for results but give at least 24 hours minimum to allow time for review of your study. We appreciate your patience!

Stress Tests

Your doctor may suggest a stress test as a way to determine if you are at risk for coronary artery disease (blocked heart arteries), a variety of heart rhythm disorders, or to determine your heart’s overall tolerance to exercise. These tests are non-invasive and are performed in several different ways. A doctor will be present to supervise the stress portion of the exam. While there are several different ways of performing stress tests, your doctor will choose which type is most appropriate for you.

How do you “stress” the heart?
  • Typically the preferred way to stress the heart is to use a treadmill which increases in height and speed every three minutes. If necessary your doctor can alter this to adjust to your individual needs.  The goal is to get the heart rate up to a “target heart rate” which varies with age.
  • Alternatively, if it is not possible for you to walk on a treadmill (for example, due to severe joint pain, etc.), or if you cannot get to your “target heart rate”, your doctor may choose to use a medicine to stress the heart. This is called a “pharmacologic stress”.
  • Medicines for pharmacologic stress tests include adenosine (Adenocard® and regadenosine (Lexiscan®), which open the arteries of the heart, while dobutamine (Dobutrex®) simply speeds up the heart rate. Your doctor will choose the most appropriate type depending on your individual circumstances which vary from patient to patient.
Types of Stress Tests:
  • Standard Treadmill Exercise Stress Test

During this type of stress your heart rhythm will be recorded by EKG throughout the test while you walk on a treadmill. The treadmill increases in height and speed every three minutes. Changes in the recorded EKG pattern can help your cardiologist determine if there are any problems that may be present with the heart arteries or its electrical system.

  • Nuclear Stress Test

Your doctor will choose the method by which the heart will be “stressed”, either using a treadmill or a medicine. This type of stress test then has two parts:

  1. An EKG tracing will be recorded throughout the stress portion of the exam just the same as during a standard exercise tolerance exam. This again gives information about the possibility of blockages being present.
  2. Second, a radiotracer material will be injected into a small IV which is taken up by the heart for a temporary period of time.  This is done twice (both at rest and during the stress portion of the exam), and pictures are taken of the heart during both portions with a special camera.

The pictures at rest and stress are compared to one another and this gives your cardiologist information about the possibility of heart blockages being present as well as insight as to how well the heart is pumping.

What to expect on the day of your stress test

We want you to be comfortable and well informed for your stress test so please do not hesitate to ask questions about your specific exam!

 

Standard Treadmill Exercise Stress Test:  

  • You should expect to spend about an hour at the office.
  • Several stickers will be attached to your chest so your heart rhythm can be monitored.
  • Wear comfortable walking shoes, preferably tennis shoes if you have any.

 

Nuclear Stress Test:

  • Remember not to eat anything after midnight and most importantly, do not drink any caffeine the morning of your nuclear stress test (it can interfere with the accuracy of the test).
  • You should expect to spend around 4 to 5 hours at the office since there are a few more steps to this exam. In addition the radiotracer material has to wear off in between the two phases of the exam to keep things accurate.
  • If you are having a nuclear stress where adenosine or regadenosine is being used to stress the heart, it is common for this medicine to cause temporary symptoms due to the way it works in the body. These may include; chest heaviness, shortness of breath and in some cases, a “queezy” feeling in the stomach

Don’t worry, it’s only temporary and most symptoms are gone within 2 to 4 minutes! We may offer you a caffeinated beverage which may help you feel better if symptoms last longer than usual.