An independent provider of cardiovascular health care

In association with Phoenix Hospital Group

Treatment

Coronary Stent

Coronary stenting is a treatment for coronary artery narrowings (stenosis)or blockages performed through a catheter, nearly always under local anaesthetic. The procedure is performed in the cardiac catheterisation laboratory (‘cath lab’ for short) where the patient lies on a procedure table and the X-ray equipment which generates the images is moved around the patient.

The catheter is passed through the artery in the groin (femoral artery) or the artery in the wrist (radial artery) to the heart. The narrowing is crossed with a thin ‘guidewire’ passed through the catheter and following this a coronary stent is placed. The stent itself is a thin metal ‘mesh’ tube of the same calibre as the artery designed to keep the artery open.

Many stents are coated in drugs (drug eluting sents, DES) designed to stop re-narrowing (in stent restenosis, ISR). An uncommon but serious complication of stenting is clot formation in the stent (stent thrombosis). It is very important that patients take blood thinning antiplatelet drugs according to the cardiologists instructions to reduce the risk of thrombosis as much as possible.

National Heart Lung and Blood Institute

As a general rule, if only a small number of coronary narrowings need to be treated stenting may be appropriate, whereas if there are many narrowings needing treatment, a bypass operation may be more appropriate.

Your cardiologist will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

Other Stent Procedures

Carotid stenting: For patients in whom a carotid artery narrowing needs to be treated, the traditional operation is carotid endarterectomy to clear away the narrowing and repair the artery. Carotid stenting however provides a less invasive approach which may be suitable for some patients.

Aortic stenting: Abnormalities of the aorta sometimes require an operation, however under certain circumstances for some patients with thoracic or abdomnal aortic anneurysm, a covered stent can be used as a less invasive alternative.

Renal artery stenting: Narrowing of the arteries supplying blood to the kidneys (renal arteries) sometimes needs treatment with a procedure. This is usually achieved with renal artery stenting.

National Heart Lung and Blood Institute

Iliac stenting: The areties in the pelvis conveying blood from the main blood vessel in the abdomen (aorta) to the legs can become narrowed or dilated due to atherosclerosis. If the iliac arteries require treatment stenting can sometimes be appropriate.

Lower limb stenting: If the arteries in the legs are narrowed from atherosclerosis and causing claudication or other problems with blood flow to the legs, the flow can sometimes be improved with a vascular operation (such as an arterial bypass) or angioplasty and stenting.

Your cardiologist and surgeon will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

Coronary Artery Bypass

Coronary Artery Bypass Surgery (‘bypass’, ‘CABG’) is an open heart surgery operation which may be performed with a machine taking on the work of the heart and lungs (cardiopulmonary bypass) or with the heart still beating (‘off pump’ or ‘beating heart’). The operation can be performed through the breastbone (midline sternotomy) or sometimes through a smaller incision in the left chest (minimal access, midcab). These various techniques all have attendant benefits and limitations thus the approach must be tailored to the individual patient.

The bypass is performed using grafts (arteries and veins) to bypass the blood around narrowings of the coronary arteries to supply blood to the arteries beyond the narrowings. The Internal Mammary Arteries (from inside the chest)-usually the left (LIMA) are the best grafts and they usually remain unblocked (patent) for many years. Radial artery grafts (from the forearm) can also be effective grafts. Sections of veins (from the legs) are also effective. Most bypass operations use both arterial and venous grafts.

National Heart Lung and Blood Institute

As a general rule, if only a small number of coronary narrowings need to be treated stenting may be appropriate, whereas if there are many narrowings needing treatment, a bypass operation may be more appropriate.

Your cardiologist and surgeon will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

Aortic Valve Replacement

Mechanical Aortic Valve Replacement

When the diseased valve is removed it can be replaced with a number of alternatives but the main groups are mechanical valves and biological valves. Mechanical valves are very durable and long lasting however they require long term blood thinning (anticoagulation). Biological valves don’t always last as long as mechanical valves, but have the advantage that anticoagulation is unnecessary.

Aortic valve replacement (AVR) is an open heart surgery operation performed whilst a machine takes on the work of the heart and lungs (cardiopulmonary bypass). The operation can be performed through the breastbone (midline sterrnotomy) or sometimes through a smaller incision in the right chest (minimal access, mini-thoracotomy AVR).

Your cardiologist and surgeon will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

Biological Aortic Valve Replacement

TAVI

Transcatheter Aortic Vave implantation (TAVI)

Balloon Expandable TAVI     Self Expanding TAVI

Transcatheter aortic valve implantation (TAVI) is an alternative to surgical aortic valve replacement (AVR). In TAVI the aortic valve is replaced through a catheter passed to the heart through the groin (femoral artery) just below the collar bone (subclavian artery) or sometimes through the breast bone or chest wall.

The technique is performed whilst the heart is beating and doesn’t require a machine to do the work of the heart and lungs (cadiopulmonary bypass).

When the procedure is performed through the femoral artery it can often be done with local anaesthetic and sedation. For the other approaches general anaesthetic is usually recommended.

In TAVI the native aortic valve is left in place and the new valve is expanded inside the old valve forming a seal between the two, with the new valve inside the TAVI device taking over the function of the old valve.

Your cardiologist and surgeon will discuss any proposed procedure with you including its attendant risks and benefits. In particular the risks and benefits associated with surgical aortic valve replacement and TAVI will be addressed. This will usually involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

TAVI valve in place within native aortic valve

Mitral Valve Repair/Replacement

Mechanical Mitral Valve Replacement

Mitral valve replacement (MVR) or repair is an open heart surgery operation performed whilst a machine takes on the work of the heart and lungs (cardiopulmonary bypass). The operation can be performed through the breastbone (midline sternotomy) or sometimes through an incision in the side of the chest (thoracotomy).

The best operation for a leaking valve (mitral regurgitation, MR) is, when possible to repair the valve. If the native valve is preserved then there is no need for a replacement valve, excellent valve function can often be achieved with good long term results and no need for blood thinning (anticoagulation).

If the diseased valve cannot be repaired and has to be removed it can be replaced with a number of alternatives but the main groups are mechanical valves and biological valves.

Biological Mitral Valve replacement

Mechanical valves are very durable and long lasting however they require long term blood thinning (anticoagulation). Biological valves don’t always last as long as mechanical valves, but have the advantage that anticoagulation is unnecessary.

Your cardiologist and surgeon will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

Ablation

Abnormal fast heart rates (tachyarrhythmias) are usually due to the electrical activity of the heart passing through an abnormal pathway, or the spontaneous generation of an abnormal extra impulse (ectopic beat). These problems may be amenable to conservative management of drug treatment however they can also sometimes be treated with ablation. This technique involves delivering energy through the tip of a cateheter passed to the heart, usually from the vein in the groin (femoral vein). The energy can be carefully directed to ablate some tissue to interrupt an abnormal pathway, or remove or isolate an abnormal ectopic focus. This technique can be useful in treating regular fast heart rhythms, as well as atrial fibrillation (AF)

Your cardiologist will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

Pacemaker

The principle function of basic cardiac pacemakers is to treat a slow heart rate, especially when it is causing symptoms or collapses (bradycardia pacing). In this procedure which is usually performed under local anaesthetic, one or two wires known as ‘leads’ are passed into the heart.

The leads are then connected to a pacemaker box or ‘generator’ which is placed in a ‘pocket’ under the skin at the front of the chest or sometimes beneath a muscle layer.

The generator monitors the heart rate continually and if it drops below a pre-set level generates electrical impulses to ‘pace’ the heart so that it beats at a normal rate. Single chamber pacemakers have a lead in the right ventricle only and dual chamber pacemakers also have a lead in the right atrium.

National Heart Lung and Blood Institute

Biventricular pacemakers (cardiac resynchronisation therapy, CRT) can deliver bradycardia pacing but their principle function is to resynchronise any desynchrony between different parts of the muscle of the heart. This can be useful for some patients with heart failure and can reduce breathlessness. CRT requires a further lead which paces the left ventricle of the heart.

Pacemakers require indefinite specialist follow up to monitor their function, the whether any ‘shock’ therapy has been needed and determine when the battery life is running out and replacement (‘box change’ ) is needed.

Your cardiologist will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

ICD

Implantable Cardiac Defibrillator (ICD)

Implantable cardiac defibrillators (ICD) also function as pacemakers or CRT devices but their principle function is to deliver a high energy electric shock to restore the normal heart rhythm if a patient goes into a dangerous abnormal rhythm (such as ventricular tachycardia-VT or ventricular fibrillation VT). Since ventricular fibrillation is often a fatal rhythm disturbance, ICDs can be life saving when implanted in the right patients.

ICDs are implanted in a similar way to a pacemaker with the wires (known as leads) being passed into the heart and connected to the pacemaker box ‘generator.’ The generator for an ICD is bigger than a simple pacemaker, but it is implanted similarly under the skin or beneath a layer of muscle at the front of the chest.

National Heart Lung and Blood Institute

Since it is a bigger device than a basic pacemaker and is often tested at the end of the implant, a general anaesthetic may be recommended.

Pacemakers and ICDs require indefinite specialist follow up to monitor their function, whether any ‘shock’ therapy has been needed and determine when the battery life is running out and replacement (‘box change’ ) is needed.

Your cardiologist will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

Renal Artery Ablation

The kidneys, their nerve supply and the hormones they and the adrenal glands secrete are central to many causes of hypertension (high blood pressure). Most cases of high blood pressure can be managed with lifestyle manoeuvres and when needed, drug therapy. Sometimes however in spite of these strategies the blood pressure can remain very high. In such cases a technique called renal artery ablation can sometimes be very effective. This technique is performed through a catheter and involves delivering energy to the inside of the arteries supplying blood to the kidneys to interrupt the nerve supply to and from the kidneys.

Your cardiologist will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

National Heart Lung and Blood Institute

Left Atrial Occlusion

Patients with atrial fibrillation are at increaed risk of stroke due to blood clot formation in the left atrium of the heart which doesn’t pump properly. The most important place for clot formation appears to be a small outpouching known as the left atrial appendage (LAA). The risk of stroke from blood clots in AF can be reduced by thinning the blood (anticoagulation) which is regarded as the first line approach and has much evidence to support it.

Some patients however are intolerant of anticoagulation, usually due to bleeding. An alternative to anticaogulation for stroke prevention in AF is to ‘plug’ the LAA with an occlusion device so that it is no longer a site for clot development. This approach is less well established than anticoagulation but can be useful for some patients.

Left Atrial Appendage closure device being deployed

To perform a LAA oclusion procedure a catheter is passed through the vein in the groin (femoral vein) into the right atrium. The atrial septum is then crossed using a fine needle and a catheter passed into the left atrium. The LAA occlusion device is then deployed into the LAA and the catheter removed.

Your cardiologist and surgeon will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

ASD and PFO Closure

National Heart Lung and Blood Institute

For patients with Atrial Septal Defects (ASD) and Patent Foeamen Ovale (PFO) closure is sometimes recommended.

To close some ASDs an open heart surgery operation may be required whilst a machine takes on the work of the heart and lungs (cardiopulmonary bypass). The operation can be performed through the breastbone (midline sterrnotomy) or through the side of the chest (thoracotomy). The hole is then closed with a patch.

Many ASDs and almost all PFOs however can be closed using a transcatheter technique and a small closure device to seal the hole. A catheter is passed through the femoral vein (in the groin) and passed up to the right atrium of the heart. A wire is then passed through the hole using X-ray and ultrasound guidance into the left atrium. The device is then deployed to close the hole.

Your cardiologist will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.

‘Umbrella’ type PFO/ASD Closure Device

Reveal Device

The heart rhythm can be monitored for short periods with a holter monitor or even a patient activated monitor. If however events are infrequent, but serious and potentially incapacitating it can sometimes be difficult to establish the heart rhythm during an event.

Under these circumstances it can sometimes be helpful to implant a small monitor into the body under the skin in the chest which can monitor the heart rhythm continually. Such devices are small, implanted under local anaesthetic through a small incision and can be left for long periods of time then be interrogated at a later date or after an event.

By defining the rhythm of the heart during an event it is often possible to identify whether or not the event was caused by an abnormal heart rhythm and to plan management accordingly.

Your cardiologist will discuss any proposed procedure with you including its attendant risks and benefits. When appropriate this will involve further discussion in a multidisciplinary meeting so that you may receive the best advice and reach a mutually agreeable management plan.