Interventional: Patient Care

Coronary Artery Disease (CAD)

Coronary Artery Disease (CAD) is a disease affecting the arteries surrounding the heart and supplying the heart muscle. When the arteries are narrowed from the gradual buildup of plaque, the blood supply to the heart muscle is reduced. The blood supply (and therefore the oxygen supply) to the heart muscle may be adequate when a person is at rest; however, during exertion, the heart muscle will get significantly less oxygen than it needs (ischemia).

Symptoms

When the imbalance of the oxygen that the muscle needs is significantly less than what it gets, a person may develop chest pain, chest pressure, arm or shoulder ache or pain, shortness of breath with exertion, dizziness, palpitations, indigestion, and/or diaphoresis (sweating).

Diagnosis

Non-invasive tests are available to evaluate for CAD, including tests such as EKG, stress test, or cardiac CT angiogram. If your physician is concerned about CAD based on your symptoms or the non-invasive tests, you might then be referred for a cardiac catheterization to evaluate the presence of narrowing in the heart arteries.

Left heart catheterization is a procedure in which the catheter is placed through an artery in your arm or leg, and threaded to the left side of the heart. This is performed to evaluate the pressures inside of your heart chamber and to perform a coronary angiogram. A coronary angiogram is a part of the left heart catheterization in which contrast or dye is placed in the coronary arteries to visualize whether there are any blockages in the arteries.

Treatment

Based on the findings of the coronary angiography, your physicians will then decide on the best course of therapy. These include:

  • Medical therapy only
  • Medical therapy in addition to performing a coronary angioplasty/stenting procedure; or
  • Medical therapy in addition to performing a coronary artery bypass grafting (CABG)

Coronary angioplasty is a procedure performed to widen significantly narrowed coronary arteries. A tiny balloon built on the tip of a catheter is advanced to the narrowed area and inflated for about 20 seconds, pressing the plaque against the wall of the artery.

A stent procedure is usually performed after a coronary angioplasty to prevent the plaque from recoiling back and resulting in restenosis (causing the vessel to become narrow again). The stent is placed by a catheter in the same location that the angioplasty was performed.

Coronary artery bypass graft (CABG) surgery is an open-heart surgical procedure that reroutes new vessels to the heart muscle, “bypassing” the blockage in the coronary artery.

Right heart catheterization is a procedure in which a catheter is placed through a vein in the neck, arm or leg, enabling the measurement of the cardiac filling pressures in the heart and lung. Pressures obtained by the catheter give valuable information for the diagnosis and treatment of patients with pulmonary hypertension, valvular diseases or other medical conditions that might be causing symptoms of shortness of breath.

Cardiac biopsy is a procedure that is used to obtain a small amount of heart tissue for microscopic evaluation to diagnose and treat certain cardiac conditions. This procedure is frequently performed in patients with a heart transplant to assess for possible cardiac rejection after a transplant. At times, this procedure is recommended for patients who have not had a cardiac transplant to assess whether there are certain other conditions which might be affecting the cardiac muscle. The procedure can be performed during right heart catheterization through a vein in the neck or leg with the use of a special biopsy bioptome (a tiny catheter-based implement with a grasping device on the end).

PFO (Patent Foramen Ovale)

A foramen ovale is a normal opening in the atrial septum of a fetus that allows blood to flow between the atrial chambers of the heart. Typically, the foramen ovale closes shortly after birth. In some people, the foramen ovale does not close completely, and a patent foramen ovale (PFO) remains. A PFO may not cause any symptoms or difficulty. However, in a few people, the PFO may cause concerning symptoms. In these cases, the PFO can be closed.

Symptoms

Many people do not have any symptoms with a PFO and do not require any treatment. There are a few individuals who develop signs of clots passing across the hole. This can be manifested through transient ischemic attacks or strokes. When this occurs, it is important to be evaluated for the need to close the PFO.

Diagnosis

A PFO is usually diagnosed using echocardiography (ultrasound of the heart). During the echocardiogram, echogenic contrast is used to detect abnormal blood flow across the atrial septum.

Treatment

Percutaneous PFO closure - A PFO closure device can be placed across the PFO to seal the hole between the atria. This is performed in the catheterization lab through an intravenous tube (IV) in the vein. Once the device is placed across the atrial septum, the catheters are removed, the IV site is sealed and a bandage is applied to the IV site.

ASD (Atrial Septal Defect)

An atrial septal defect (ASD) is a congenital abnormality caused by the incomplete growth of the atrial septum during fetal development. The ASD can be very small or large, and there are multiple types of ASDs.

Symptoms

Small defects may not cause symptoms and may go undetected until later in life. If symptoms are present, they might include shortness of breath and/or palpitations.

Diagnosis

An ASD is diagnosed using echocardiography (ultrasound of the heart). During the echocardiogram, echogenic contrast is used to detect abnormal blood flow across the atrial septum. Some types of ASDs can be associated with abnormal EKG (electrocardiogram) or chest X-ray findings.

Treatment

Treatment of the ASD depends on the type, size and location of the ASD, and the presence or absence of associated symptoms. An ASD can be closed using either percutaneous (catheter-based) technique, or through surgery.

Percutaneous ASD closure – An ASD (Atrial Septal Defect) closure device is placed across the ASD to seal the hole between the atria. This can be achieved in the catheterization lab through an intravenous tube in the vein in the leg.

Surgical ASD closure is required for ASDs that are too large, or if the location of the ASD is not favorable for the use of the percutaneous device. Surgical closure involves open-heart surgical procedure in which the surgeon puts a patch over the hole to seal the ASD.

Hypertrophic Cardiomyopathy

Hypertrophic cardiomyopathy (HCM) is a condition in which the heart muscle is abnormally thickened. The thick muscle is not as flexible as a normal heart, and is unable to relax.

In some cases of HCM, because of the thickening of the heart muscle in the ventricular septum, an obstruction to blood flowing out of the left heart chamber occurs. This condition is called hypertrophic obstructive cardiomyopathy (HOCM).

Symptoms

Some patients do not have signs and symptoms related to HCM. Others might have dizziness, lightheadedness, palpitations, high blood pressure and heart failure.

Symptoms of HOCM include dizziness, chest pain, and a specific type of murmur.

Diagnosis

HCM is usually diagnosed by EKG (electrocardiogram) and echocardiography (ultrasound of the heart). Patients with a family history of HCM are screened.

Treatment

For patients with significant obstruction in the left ventricular outflow tract, your physician may make a decision to perform a procedure to alleviate this obstruction. There are two approaches that may be recommended: 1) percutaneous ethanol ablation, and 2) surgical resection.

Ethanol ablation is a procedure in which ethanol is placed through a catheter in a specific area of the heart to cause abnormally thick muscle of the heart to shrink back to a more normal size.

Surgical resection is an open-heart surgery where a surgeon can remove the thickened portion of the ventricular septum to alleviate the left ventricular outflow tract obstruction.

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Valvular Disease

Patients with valvular heart disease are sometimes referred to the cardiac catheterization laboratory for evaluation of the severity of the valvular condition and for treatment of the valvular condition. There are different types of valvular heart conditions that patients might develop. These include either leakage or stenosis (narrowing) of the involved heart valve.

Symptoms

Symptoms can vary, depending on which heart valve is involved. Often, patients develop shortness of breath, fatigue, lightheadedness, fluid build-up in the lungs, or swelling in the feet.

Diagnosis

The diagnosis is made by careful physical examination, EKG (electrocardiogram), chest X-ray, and echocardiography (ultrasound of the heart).

Treatment

The treatment strategy of valvular lesions (e.g., catheter-based or percutaneous interventions vs. surgery) depends on the type of valvular heart condition. For pulmonary valve stenosis/regurgitation, mitral valve stenosis/regurgitation or aortic valve stenosis, there are possible percutaneous treatment options.

A percutaneous mitral/pulmonary/aortic valvuloplasty is a procedure in which a balloon-tipped catheter is placed through an intravenous tube in the vein and across the stenotic valve. The balloon is inflated to open the valve, thereby allowing the valve to move more effectively. Novel technologies allow the placement of a new valve mounted on a stent in the pulmonic or aortic valve position to treat leaky pulmonic valves and stenotic aortic valves. Special percutaneous techniques are also being developed for the treatment of leaky mitral valves.

Peripheral Arterial Disease (PAD)

PAD is a disease affecting the arteries located in different regions of the body (including, but not limited to, arteries in the neck, abdomen, arm, kidney and legs). When the arteries are narrowed from the gradual buildup of plaque, the blood supply to the involved organs is reduced.

Symptoms

When the blockages are severe, the patients might present with symptoms, which vary depending on the location of the arterial blockages and the organs involved. For example, carotid artery occlusions (blockages in blood vessels in the neck) can lead to stroke or transient ischemic attacks and neurologic symptoms. Blockages in the leg arteries might cause pain in the calf or leg when walking, which improves with rest.

Diagnosis

In addition to a complete physical examination, non-invasive tests are available to evaluate for PAD. These include tests such as ankle-brachial index testing or computed tomography or magnetic resonance (CT/MR) angiography. If your physician is concerned about PAD based on your symptoms or the non-invasive tests, you might then be referred for an invasive angiogram to evaluate the presence of narrowing in the peripheral arteries.

Treatment

The treatment of PAD depends on the location and severity of the angiographic findings. In addition to aggressive medical therapy that your doctor will recommend for PAD management, percutaneous and surgical treatment options are also available. This may involve percutaneous (catheter-based) balloon angioplasty or stenting, or open surgical treatments.

Balloon angioplasty is a procedure performed to widen significantly narrowed arteries. A tiny balloon built on the tip of a catheter is advanced to the narrowed area and inflated for about 20 seconds, pressing the plaque against the wall of the artery.

A stent procedure is usually performed after angioplasty to prevent the plaque from recoiling back and resulting in restenosis (causing the vessel to become narrow again). The stent is placed by a catheter in the same location that the angioplasty was performed.