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Angioplasty / Stenting

Angioplasty is a surgical procedure to correct a narrowed blood vessel of the heart. This procedure is carried out in a cardiac catheterization laboratory, simply known as cathlab. Patient is generally awake during the procedure. They are relaxed by providing pain relief medications before as well as after the surgery.

In this procedure, a sheath is inserted into the blood vessels. Usually, vessels of the upper leg, arm or groin are preferred. A hollow tube, catheter, is carried down the sheath to access the vessels. This catheter has a small balloon on the tip which is deployed into the coronary arteries.

When the balloon has reached the blockage site in the artery, it is inflated to widen or compress the pathway. Depending on the nature of the blockage, the inflation can last anywhere from 30 seconds to several minutes. There can be side effects in the form of chest pain which is very similar to angina. As the balloon temporarily blocks the flow of blood and oxygen that is transported to the heart, there is chest pain. Doctor should be immediately communicated if this happens.
In recent times, there is a process known as stent placing which is used in this method. It is a small mesh like device which is made of metal. It is also placed on the balloon and used when it reaches the site of obstruction. The primary function of this stent is to act as a support and keep the vessel open. This will not only improves the blood flow but will also reduce the pain of angina. After the blockage has been cleared, the balloon will be deflated and removed along with the catheter. The stent, however, will be left behind to hold the artery open.

FAQ

1. What are the benefits of stent placing?

Stent placing significantly improves the flow of blood and prevent damage to the heart muscle. It also reduces the occurrence of blockage after balloon angioplasty.

2. When can I get back to normal routine?

After the procedure, you will be kept in an observatory room for 2-3 days. After you are discharged, you can resume daily activities within a couple of days. Lifestyle changes are a must. You should follow a particular diet along with the medications that are suggested.

Balloon Valvotomy

Balloon valvotomy is the most preferred procedure for treating narrowed mitral valve. In most of the cases, it is used to treat mitral valve stenosis. This procedure can be performed on other valves too.

It is a non surgical and minimally invasive procedure in which long and slender tubes known as catheters are inserted through the artery of either groin or the arm. It is them threaded into the heart. A tiny hole is created in the wall between the upper two chambers of the heart to access the left atrium. This catheter has a balloon on the tip which is positioned directly inside the narrowed valve. The balloon is then inflated and deflated regularly to widen the opening. Once the valve is widened to its normal size, the balloon is first deflated and then removed.

Why is it performed?

The most common reason to perform this procedure is to get rid of the symptoms of mitral valve stenosis. Balloon valvotomy is recommended if you are showing moderate to severe symptoms of stenosis.

In case of no detected symptoms, there is need of this procedure if you have high blood pressure in the lungs. It is also recommended to old people who won’t be able to sustain a surgery.

What are the success rates?

The success rates of balloon valvotomy are very high. 80-95 percent of individuals who have undergone the procedure have successful outcomes and are relieved of symptoms. The results can be seen immediately.

One thing to remember about balloon valvotomy is that it does not cure the condition or make the valve normal. It just allows the valve to function normally which means that normal flow of blood is achieved. Improvement in blood flow will directly impact the symptoms. Lung congestion symptoms will be relieved as the blood pressure inside the left atrium decreases.

What are the risks involved?

When compared with an open heart surgery like commissurotomy and valve replacement, this procedure has lower risk of complications and fatality. After 5 years, around 35-50 percent of people will need another surgery.

EPS (heart electrophysiology studies)

What are electrophysiology studies?

Electrophysiology studies (EPS) are a type of medical tests which controls the rate and timing of the heart contractions. It studies the electrical activity of the heart to locate the irregular heartbeat. It is seen from where this heartbeat arises.

The results of EPS will act a diagnostic test. This will help the doctor get better understanding of the treatment method which an individual require. The options include medicine, pacemaker, Implantable Cardioverter Defibrillator (ICD), cardiac ablation or surgery. EPS do not take place in any ordinary room. They are carried out in a specially made room such as electrophysiology lab or cath lab. In both of the labs, you are given mild sedation.

Why are these tests needed?

  • These tests are done to locate the exact source of cardiac arrhythmias and other defects which might be present in the heart’s electrical system.
  • These tests are also done to see effectiveness of different drugs or therapies that are used in monitoring arrhythmia.
  • Symptoms such as dizziness, fainting, weakness and palpitation are assessed when other treatments are not working.

What are the risks involved?

  • Arrhythmia is the most common risk involved in this test. There are abnormal heart rhythms which make you dizzy. Electrical shock is given to bring back a regular heartbeat.
  • Clotting of blood can be seen at the tip of the catheter. They break off and cause blood vessel blockage.
  • Other risks are infection, bruising and bleeding at the exact site where the catheter is inserted.

Complex Arrhythmia Ablation by 3D Mapping

What is Arrhythmia?

Arrhythmia is a group of conditions which results in irregular beating of the heart. The heartbeat can either be too slow or fast. It is caused when there is any interruption to the electrical impulses. Factors that cause this condition are alcohol abuse, diabetes, drug abuse, heart failure etc. It is identified by breathlessness, dizziness, angina, palpitations etc.

What is 3D mapping?

3D mapping of the heart is a procedure that is used in diagnosing the location of arrhythmia. They can arise from different parts of the heart such as ventricles and atria. This procedure uses a thin tube called as catheter which is inserted into a small incision made in the arm or the thigh. Another smaller electrically sensitive catheter is inserted inside the sheath and senses the electrical activity and maps it on a 3D model of the heart chambers. It is most commonly used in ablation process.

What are the risks involved?

When compared with other invasive methods, there are fewer chance of complications and risks. The only risk that can occur in this procedure is from the use of catheters. They are long and thin tubes which are inserted into the arteries and veins. It can occasionally cause damage to the blood vessels. There can also be bleeding or infection.

What happens during the ablation process?

In this procedure, local anesthesia is given to numb the legs where needles will be inserted. They are inserted into the veins of the right and left legs. A series of small tubes are inserted into the veins. Wires are passed through the tubes and guided using fluoroscopy to the heart. This induces arrhythmia which analyzes using different modalities of 3D electroanatomic mapping system. When the area that is causing arrhythmia is found, heat or cryotherapy is applied to get rid of it.

CABG (heart bypass surgery)

What is Coronary Artery Bypass Surgery?

Coronary Artery Bypass Surgery (CABG) is surgical process performed on the heart to improve the blood flow to the heart. This procedure diverts the blood flow around the section of the artery that is blocked. It bypasses the blocked artery and creates a new pathway to the heart. Healthy blood vessel can be taken from your leg, arm or chest. In some individuals, this surgery can be done to improve the function of heart and remove the possibility of fatality.

Why is CABG carried out?

This procedure is an option for the following scenarios –

  • In case of artery blockage which cannot be solved with angioplasty. It is also used if you have had unsuccessful angioplasty before.
  • Narrowing of arteries that supply blood to the heart muscle causing chest pain.
  • If you have one or more diseased coronary artery. It can either be narrowed or blocked.

What happens during the procedure?

In this procedure, you are administered general anesthesia. They may be multiple bypasses required and it depends on the severity and location of the blockages. During this procedure, the blood flow is diverted through a heart lung machine. A long incision is made in the blood to open the rib cage. This exposes the heart. During this time, a heart-lung machine takes over to circulate the blood as heart is temporarily stopped. A section of the healthy blood vessel is taken and attached above and below the blocked artery so that the blood flow is bypassed around the narrowed portion of the diseased artery.

What happens after the surgery?

You will be shifted to ICU for one or two days. Your vital signs such as heart, blood pressure etc. are monitored. You will be discharged if no complications arise. Complete recovery takes about six to twelve weeks. You will remain free of the symptoms for as long as 10-15 years.

What are the risks involved?

It is an open heart surgery and therefore a complex one. Bleeding is the most common risk. There may be infection of the chest wound. Additional risk includes memory loss, kidney problems, stroke and heart attack.

Valve Repair & Replacement (TAVI/TAVR)

Transcatheter Aortic Valve Replacement (TAVR) is a minimally invasive surgical procedure which repairs the valve without removing the old and damaged valve. Instead, a replacement valve is wedged into the aortic valve’s place. This type of a surgery is different from the standard valve replacement procedure and it is approved for people with symptomatic aortic stenosis but won’t be able to sustain an open heart surgery.

Our heart team comprises of Cardiac Surgeons, Cardiologists, Intensivists, Physicians, Cardiac Anesthesiologists and Intensive Care Experts working in synergy providing the best possible outcomes of TAVR and making sure that the patient is benefitted from this surgery.

Who needs TAVR?

TAVR is mostly needed in case of two major conditions

Aortic valve regurgitation
It is a condition in which the heart’s aortic valve does not close tightly. The body does not get enough blood as some of the blood that was pumped out of the heart’s main pumping chamber is leaked back. As a result you may feel fatigued and short of breath along with swollen ankles and feet. This condition may be congenital or aorta may be enlarged due to hardening of the arteries.

Aortic valve stenosis
It is a condition which narrows down our heart’s aortic valve. It prevents the valve from opening properly. This in turn blocks blood flow from the heart into the main artery and onward to the rest of the body and as a result less blood will flow. The signs develop when the symptoms are severe. This condition is caused due to calcium buildup on the valve. It is found in the blood and deposits of calcium can be there as blood repeatedly flows over the aortic valve.

How is TAVR performed?

In this procedure, you will be administered general anesthesia. You will be asleep during the procedure and will not feel any pain. To prevent blood clots, medications will be given through an intravenous line. The heart may be accessed through a blood vessel in the leg or it can be accessed by making tiny incisions in the chest and access the heart through a large artery. A hollow tube is then inserted through the access point which is known as catheter. Advanced imaging techniques are used to guide the catheter through the blood vessels to your heart and into the aortic valve. Once the position is precise, a balloon is expanded to press the replacement valve into place in the native aortic valve. As the valve is securely in place, the catheter is withdrawn from its place.

Procedure

You may spend the night in the intensive care unit for monitoring after the procedure. In most cases, you will spend two to five days recovering in the hospital. Blood thinning medications are prescribed to you to prevent blood clots.

Pacemaker Implantation

A pacemaker is a small battery operated medical device which is implanted in the chest or abdomen to treat abnormal heart rhythms. These are known as arrhythmias and it causes heart to either beat to fast or too slowly. Pacemaker is used to treat two forms of arrhythmia –

  • Tachycardia – In this condition, heartbeats are too fast.
  • Bradycardia – In this condition, heartbeats are too slow.

Why is it needed?

Pacemaker is needed when your heart is not able to receive enough blood. It can happen in case heart is pumping quickly or slowly. This can cause different abnormalities in the body such as fatigue, fainting, shortness of breath, damage to vital organs. If it is not diagnosed in early stages, then it can result in death.

What are the components?

It has two components –

  • Pulse generator – It comprises of a sealed lithium battery and an electronic circuitry package. It is used in producing the electrical signals that make the heart beat.
  • Leads – they are insulated flexible wires that conduct electrical signals to the heart from the pulse generator.

How is the surgery performed?

Anesthesia is administered to the site where the surgery is to be performed. A small incision is made near the shoulder. A small wire is guided through the incision into a major vein near the collarbone. An x ray machine is used in guiding this wire through to the heart. With the help of this wire, an electrode will be attached to the heart’s right ventricle. The other end will be attached to a pulse generator which contains battery and electrical circuits. It will be implanted under the skin near the collarbone. After the procedure, the incision will be closed with stitches.

Angiography

Coronary angiography is an imaging technique or a radiological test that helps visualize the insides of the coronary arteries. It shows the exact location and severity of any plaque formation and consequent narrowing of the coronary arteries. This helps the doctor to decide on what treatment is needed.

The test is commonly carried out within the Cath lab in a hospital set up. The procedure normally takes around 15 to 20 minutes.

The site of the procedure or insertion of the catheter at the upper part of the thigh near the groin or an artery in the arm. is anesthetized using a local anaesthetic injection. This will numb the site of the test.

A thin, plastic tube called a sheath is inserted into an artery. Catheters are passed through this sheath to the coronary arteries of the heart

Via this catheter, under X ray guidance contrast medium or dye is injected through the catheter into the coronary arteries.
As the blood along with the dye flows through the arteries and the chambers of the heart, X rays show the path of the blood and outline the branches of the arteries. A series of x-ray pictures from different angles to check for blockages is recorded

FAQs

What are the preparations for Coronary angiography?

Patients who are prescribed this test need to be admitted to the hospital on the day of the test. Sometimes admission on the previous evening and a stay overnight may also be advised. A few hours of fasting with nothing taken via mouth (including water) is recommended.

What are the implications of an angiography results?

Normal result of coronary angiography means that there is adequate blood supply to the heart. Abnormal result on the other hand means that one or more coronary arteries may be blocked or narrowed in one or more places. The degree or percentage of each block is also reported. If the narrowing of the arteries is mild, it can be treated with medicines alone. If the arteries and their branches are more severely occluded and narrowed, coronary artery bypass graft or coronary angioplasty may be required

Heart Failure Mgmt

Eternal Hospital runs a Heart Failure Clinic dedicated to patients with heart failure. Patients are educated about the cause and treatment of heart failure and proper counselling is done to stabilise their symptoms. Our focus is to avoid unnecessary hospitalisations and improve quality of life of heart failure patients. The Centre offers a patient and family-centered approach to care.

Heart Transplantation is an operation to replace a diseased heart with a healthy donor heart. Heart Transplantation is a treatment used for severe heart failure, when medication or surgery is ineffective. Heart Transplant can dramatically improve the survival and quality of life of patients with severe heart failure. However, transplant candidates often have to wait for a long time before a suitable donor heart is available.

Left Ventricular Assist Device (LVAD)

Q. What is a left ventricular assist device (LVAD)?

The left ventricle is the large, muscular chamber of the heart that pumps blood out to the body. A left ventricular assist device (LVAD) is a battery-operated, mechanical pump-type device that's surgically implanted. It helps maintain the pumping ability of a heart that can't effectively work on its own.

Q. When is an LVAD used?

This device is sometimes called a "bridge to transplant," but is now used in longer-term therapy. People awaiting a heart transplant often must wait a long time before a suitable heart becomes available. During this wait, the patient's already-weakened heart may deteriorate and become unable to pump enough blood to sustain life. An LVAD can help a weak heart and "buy time" for the patient or eliminate the need for a heart transplant. Most recently, LVADs are being used longer-term as ‘destination therapy’ in end-stage heart failure patients when heart transplantation is not an option.

Q. How does an LVAD work?

A common type of LVAD has a tube that pulls blood from the left ventricle into a pump. The pump then sends blood into the aorta (the large blood vessel leaving the left ventricle). This effectively helps the weakened ventricle. The pump is placed in the upper part of the abdomen. Another tube attached to the pump is brought out of the abdominal wall to the outside of the body and attached to the pump's battery and control system. LVADs are now portable and are often used for weeks to months. Patients with LVADs can be discharged from the hospital and have an acceptable quality of life while waiting for a donor heart to become available.

Extracorporeal Membrane Oxygenation (ECMO):

A therapy that is used in acute decompensated heart failure resulting in a cardiac arrest. This form of resuscitation is known as E-CPR and is known to salvage these patients much better. It is an invasive form of therapy and involves placing cannulas or tubes in the femoral vessels to help gain access to the circulation and then connecting the patient on to a ECMO machine which is very similar to a heart lung machine. This helps rest the heart and protects all other organ systems. The ECMO is generally used as a last resort when all medical therapies have been exhausted and the patient is heading towards getting an either a artificial heart or a heart transplant. The ECMO works best for a period of 2-3 weeks post which in our experience we see a lot of destruction cells leading to bleeding complications and end organ damage. There two forms of ECMO:

  • Veno- Arterial ECMO: this form is used to resuscitate cardiac arrest patients and has improved our salvage rates in this subset of patients. It can be used temporarily to tide over the acute phase or as a bridge to definitive therapy like LVAD or heart transplant.
  • Veno-Venous ECMO: This form of ecmo is used mainly in patients who have severe lung related pathology such as H1N1 infection, viral pneumonias and ARDS. It is excellent form of therapy with good salvage rates. It is best used early in the disease when the lungs are soft and compliant for maximum benefit. It is greatly under utilized in India due to lack of knowledge and cost factors.

Minimally Access Surgery

It is a well-known fact that Cardiac Surgery has excellent long-term benefits. However, with Midline Sternotomy and Cardiopulmonary Bypass, there’s high morbidity during the postoperative period. Opening the chest by Sternotomy is not only very traumatic, but also the most invasive part of Cardiac Surgery. With advancements in the field of Minimally Access Surgery, it is now possible to use this technique in most Cardiac Operations. Cardiac Surgeries can be performed through small thoracotomy incisions either on the right or left chest. This avoids both Midline Sternotomy and the morbidity associated with it.

At Eternal, we perform almost all types of adult Cardiac Operations using Minimally Invasive Cardiac Surgery (MICS). In fact, the Minimally Invasive approach is not only restricted to adults but has also been used in pediatric cases as well.

The advantages of MICS include:

  • Small thoracotomy incision
  • Less pain
  • Less risk of infection
  • Reduced ICE and shorter hospital stay
  • Improved postoperative pulmonary function
  • Early recovery
  • Improved cosmetic results
  • Improved quality of life

Aortic Aneurysm

Aortic Aneurysm Surgery: An aortic aneurysm is a bulge in a section of the aorta, the body’s main artery. The aorta carries oxygen-rich blood from the heart to the rest of the body. An aneurysm occurs when the pressure of blood passing through part of a weakened artery forces the vessel to bulge outward, forming what you might think of as a blister. Because the section with the aneurysm is overstretched and weak, it can burst. If the aorta bursts, it can cause serious bleeding that can quickly lead to death. An aneurysm that bleeds into the brain can lead to stroke or death

Where do aneurysms occur in the body?

In the tiny arteries that supply blood to the brain (the cerebral arteries).

In parts of the large vessel that carries blood from the heart to other parts of the body (the aorta). Aortic aneurysms can occur in the area below the stomach (abdominal aneurysms) or in the chest (thoracic aneurysms). An abdominal aortic aneurysm (AAA) is usually located below the kidneys.

In the heart's main pumping chamber (the left ventricle).

Why do I need surgery?

Different operations treat the different kinds of aneurysms. Surgery to treat aortic aneurysms, those that occur in the body's main artery, depends on the size and location of the aneurysm and your overall health. Aortic aneurysms in the upper chest (the ascending aorta) are usually operated on right away. Aneurysms in the lower chest and the area below your stomach (the descending thoracic and abdominal parts of the aorta) may not be as life threatening. Aneurysms in these locations are watched for varying periods, depending on their size. If they become about 5 centimeters (almost 2 inches) in diameter, continue to grow, or begin to cause symptoms, you may need surgery to repair the artery before the aneurysm bursts.

What does the surgery involve?

Surgery involves replacing the weakened section of the vessel with an artificial tube, called a graft. This means that surgeons will have to open either the stomach area (for abdominal aneurysms) or the chest (for thoracic aneurysms).

The cardiovascular surgeon leads the surgical team, which includes other assisting surgeons, an anesthesiologist, and surgical nurses. When the operation begins, the surgeon will make a cut (called an incision) either in the abdomen or the chest. The incision depends on where the aneurysm is located.

The bulging section of the aorta is cut out (excised). The surgeon will then replace the missing piece with a fabric tube called a graft. The clamps are then removed slowly to allow blood to flow through the vessel again.

Sometimes surgeons do not cut out the bulging section of the aorta. In these cases, the operation is the same except that surgeons place the fabric graft inside the vessel, like a lining, to decrease the pressure on the wall of the artery. This procedure is called endoaneurysmorrhaphy.

If the aneurysm is located in the ascending aorta just above the heart, the heart-lung machine will be used. The surgery takes about 2 to 4 hours.

Recovery Time

You can expect to stay in the hospital for 5 to 7 days, including at least 1 to 2 days in the Intensive Care Unit (ICU).

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Eternal Hospital (A unit of Eternal Heart Care Centre and Research Institute) is a state-of-the-art tertiary care hospital in Jaipur city. This landmark Healthcare Institute is the result of the vision of Dr. Samin K. Sharma, world renowned Interventional Cardiologist based at Mount Sinai Hospital, New York, USA. Founded in 2013, today it is one of the most preferred hospital not only in Jaipur but also nationally and internationally owing to the exclusive services and excellent medical outcomes delivered. Eternal Hospital brings the best in multispecialty treatment to the state of Rajasthan. Hospital with capacity of 250 bedded hospital has state-of-the-art technology focusing on the specialities like Cardiology, Cardiac Surgery, Neurology, Neuro Surgery, Orthopaedic & Joint Replacement, Spine Surgery, Nephrology, Paediatrics, Gynaecology, Critical Care, Urology, Pulmonology, Gastroenterology, Diabetes and Endocrinology and many more.

Eternal Hospital has a knowledge sharing arrangement with Mount Sinai Hospital New York USA, which has been internationally recognized for its top-performing physicians and revolutionary research centres.

ETERNAL HOSPTIAL has emerged as a destination of choice for many national & international patients owing to the exclusive services and excellent medical outcomes delivered at ETERNAL HOSPTIAL.

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