Interventional Cardiology (Cardiac Catheterization)
Interventional cardiology refers to non-surgical procedures used in the treatment of coronary artery and peripheral vascular disease and performed in the cardiac catheterization laboratory. A cardiac catheterization is a common, non-surgical procedure that allows physicians to determine if there is any narrowing in the arteries leading to the heart. It also shows physicians the outside heart size and pumping ability, the inside chamber size and how well the valves open and close.
Physicians perform catheterization procedures by inserting a small flexible tube (catheter) into a blood vessel and gently advancing it to the heart. Blood pressure measurements are taken and real-time digital imaging (angiograms) helps physicians visualize even the smallest vessels leading to the heart.
Sarasota Memorial has two cardiac catheterization labs – an advanced catheterization lab based in the main hospital and an outpatient cath lab in Sarasota Memorial’s Heart & Vascular outpatient center across the street from the main hospital. The hospital-based lab provides full-service diagnostic and interventional services, including coronary interventions, such as stents and angioplasty, and electrophysiology studies and treatment. Patients may use this lab as inpatients (if they need to stay overnight in the hospital) or as outpatients (if they are scheduled to go home the same day). We also partner with local physicians to provide an array of diagnostic and interventional services in our outpatient cath lab. It offers many, but not all of the services as the hospital-based lab. Please check with your physician to determine the best location to meet your needs.
Some of the more common procedures include:
Angioplasty back to top
Angioplasty is a procedure that uses a catheter and small balloon threaded through a blood vessel in the groin or arm and then guided into a heart (coronary) artery to open blocked or narrowed coronary arteries. It is minimally invasive and can often be an alternative to coronary artery bypass surgery. Angioplasty is used in patients with coronary artery disease to relieve chest pain caused by reduced blood flow to the heart and to minimize damage to the heart muscle during a heart attack (which occurs when blood flow is cut off to an area of the heart). Angioplasty performed at the time someone is suffering a serious heart attack (also called a myocardial infarction, or MI) can actually help prevent permanent damage to the heart muscle and greatly improve survival odds.
At Sarasota Memorial, we have one of the nation's most progressive programs for treating heart attack patients. Our DASH program (Direct Angioplasty Saves Hearts) ensures that those who need it receive life-saving Percutaneous Transluminal Coronary Angioplasty (PTCA) within 90 minutes of arriving at the hospital. Our team of emergency room physicians, cardiac physicians and nurses work together with paramedics and doctors at other emergency rooms to identify patients who need emergency angioplasty rather than thrombolytic therapy (“clot buster” drugs) used in some other hospitals.
Balloon Angioplasty With Stent Placement back to top
Balloon angioplasty with stent placement is now sometimes an option for alleviation of blockages in arteries and veins. A balloon catheter is directed to the area of obstruction and inflated to disrupt accumulated plaque and reestablish adequate blood flow. Placement of a stent, or wire-meshed tube, acts as a scaffold to prevent reoccurrence of the blockage at the angioplasty site. Because only a small incision is required to accomplish this technique, patients generally recover more quickly with decreased post procedural discomfort.
At the present time, carotid stenting has been approved for the treatment of patients with symptomatic carotid artery disease who are considered to be too high risk for carotid endarterectomy. Balloon angioplasty and stent placement for treatment of carotid artery disease remains in an investigational phase for asymptomatic patients. This technique may be used to disrupt plaque formation or atherosclerosis within the carotid arteries thus ensuring adequate blood flow to the brain. Studies of its effectiveness versus the open surgical approach of carotid endarterectomy are ongoing.
Atherectomy (Rotablator) back to top
Atherectomy involves techniques similar to those used for angioplasty. The difference is that atherectomy uses a cutting device (a blade, or a whirling blade called a rotablator) to remove the plaque buildup from the artery wall.
Brachytherapy back to top
This technique uses a special catheter or wire that is placed at the site of a previous artery blockage and controlled radiation is released in an attempt to prevent another restenosis or renarrowing from occurring once again. It has been found to be particularly effective in vein bypass grafts that have become narrowed by plaque development.
Coronary Artery Stenting back to top
Stent technology was developed to prevent the possibility of the tendency for plaque to redevelop at a previous angioplasty site and reblockage of the artery to occur. This created the need for multiple repeat angioplasties for some patients. A stent is usually a stainless steel mesh wire tube that is placed at the blockage site after angioplasty has been successfully accomplished. The wire mesh eventually becomes incorporated into the arterial walls as the natural cell regeneration process of healing occurs at the angioplasty site. Stents are available in various diameters and lengths. Multiple stents may be placed during one procedure if multiple blockages are present.
Drug-Eluting Stents back to top
Drug-eluting stents contain a drug delivery system incorporated into the wire mesh structure of the stent to help prevent cell regrowth from blocking the artery again at the angioplasty site. This will reduce the likelihood of requiring a repeat angioplasty at the very same site as a previous procedure. However, the decision to utilize a drug-eluting stent rather than the bare metal stent will be based on the location of the lesion within the coronary anatomy, the diameter of the vessel, and how aggressively the patient is developing heart disease. Each patient situation will be assessed on an individual basis.
Balloon Valvuloplasty back to top
Performed in the cardiac catheterization laboratory, balloon valvuloplasty is a procedure used to address valvular disease. As in coronary artery angioplasty, a balloon catheter is placed within the valve and inflated to widen the valvular area. The catheter is then removed, and the stenosis (narrowing) of the valve has been alleviated with improvement of blood flow across the valve. This technique is used most often for narrowing of the tricuspid, pulmonic, and mitral valves and rarely for aortic stenosis.
Catheter Ablation back to top
This procedure is helpful in the treatment of persistent cardiac arrhythmias and is performed by a specially trained cardiologist in the electrophysiology lab. When an abnormality of the heart’s electrical system occurs producing an abnormal heartbeat, the purpose of the ablation procedure is to disrupt the electrical conduction pathway creating the arrhythmia. This is accomplished by introducing electrode catheters via peripheral vessels and applying radiofrequency waves to the abnormal pathway. This stops the abnormal conduction in this particular region of the heart. To assess the procedure success, attempts will be made to reproduce the abnormal heartbeat under the controlled conditions of the electrophysiology lab. If the electrical challenge does not reproduce the arrhythmia, the radiofrequency waves have successfully eliminated this area of electrical conduction.
Developments in treatment options for vascular disease now include what is referred to as minimally invasive endovascular approaches. These procedures are accomplished through small peripheral incisions rather than the traditional open surgical approaches.
Pacemakers back to top
Placement of a pacemaker is indicated when there is a need to regulate the heartbeat. When the electrical conduction system of the heart is impaired, a pacemaker may be necessary. The procedure is considered minor surgery and is done utilizing sedation and a local anesthetic.
Pacemakers consist of a pulse generator and its leads or wires. Think of the pulse generator as providing electronic surveillance of the heart’s electrical activity. The battery unit is incorporated within the pulse generator and the leads are attached to one or more of the heart’s chambers. During the placement procedure, a small incision is made underneath the collarbone and leads are introduced by way of a vein in this region to the heart. A pocket underlying the chest wall will be created for the location of the pulse generator. The leads transmit the heart’s electrical impulses back to the pulse generator which is programmed to monitor this activity and provide additional electrical stimulation if the heart rate falls below a certain desirable rate. This is the most commonly implanted type of pacemaker and is known as a demand pacemaker.
A maintenance schedule for monitoring your pacemaker will be developed in order to interrogate the pacemaker. This is an evaluation of the pacemaker’s programmed messages according to your individual situation as well as an assessment of the pulse generator’s battery life. Batteries generally last from six to ten years and lose their energy at a slow rate allowing ample opportunity to identify a convenient time for replacement.
It is also possible to assess pacemaker function utilizing the telephone. The electronic impulses from the pulse generator can be transmitted over the telephone and a recording of this activity assessed.
Immediately after pacemaker placement, you may have some discomfort in the location of the incision that may require analgesics. You will be advised regarding appropriate care of the incision to prevent the possibility of infection.
Keep in mind that the following can adversely affect the safe programmed function of your pacemaker:
Patients are often concerned that cell phones may interfere with their pacemaker. Because the cell phones used in the USA generally produce less than 3 watts of energy, they usually do not affect pacer function, but the general rule is to keep your cell phone 6 inches away from your pacemaker and use it on the opposite side of the body from the pacer location.
Automatic Implantable Cardioverter Defibrillator (AICD or ICD) back to top
Commonly referred to as an ICD, automatic implantable cardioverter defibrillator devices can be permanently implanted in much the same fashion as a pacemaker. However, these devices address a different type of malfunction within the heart’s electrical system. They can be utilized to treat abnormally fast and irregular heart rhythms that have life-threatening potential.
The ICD monitors the heart’s electrical activity, and when it detects a dangerous heart rate or rhythm, the device is programmed to provide a sudden electrical shock to convert the heart rhythm back to a more normal state. This electrical shock is equivalent to that delivered via the external chest using pads and electrodes when patients experience life-threatening arrhythmias or sudden cardiac death.
Smaller than a cigarette pack, ICDs are implanted either in the upper chest or the abdominal region. The procedure is done under minor sedation and a local anesthetic. The ICD consists of a pulse generator and its wires or leads. A pocket will be created surgically for the pulse generator while a vein in the upper chest will be used to place the lead or leads in the chambers of the heart.
Sometimes, the ICD implanted will combine the capabilities of a pacemaker unit and can detect heart rates that are too slow and are programmed to respond accordingly. Patients who have had ICDs implanted report differing levels of awareness and sensation with the electrical shock provided by the ICD. Some note it as a minor fluttering sensation while others experience it as a major blow to the chest.
The usual function of an ICD may be compromised when exposed to major electrical or magnetic fields. Be sure to seek specific counsel as to what machines or devices to avoid. You will be given instructions about follow-up care and what to do when the device is activated by an arrhythmia. The battery life of the pulse generator will also be monitored and replacement planned when indicated.
Biventricular Pacemaker Placement (Cardiac Resynchronization Therapy) back to top
This pacemaker is a relatively new treatment option for moderate to severe congestive heart failure. For patients on maximum medical therapy who find their heart failure symptoms still remain self-limiting, biventricular pacemakers send impulses to both lower chambers of the heart (the ventricles) to provide synchronized pumping action. By increasing the efficiency and effectiveness of the heart as a pump, many patients receiving the biventricular pacer experience a lessening of symptoms with an increase in energy and decreased difficulties with shortness of breath. This device is technically challenging to place and not all patients show a benefit from its use. Usual pacemaker precautions and ongoing follow-up will be specified. Dietary measures and drug therapy for congestive heart failure will remain components of your treatment plan.
Non-surgical treatment for PFOs: Closing Holes In Hearts Without Surgery back to top
Small openings in the heart, known as the patent foramen ovale (PFO), is a normal part of fetal development. But in about one in four people, the hole does not close properly, increasing a person’s risk of dangerous blood clots and stroke when they are older. PFOs also have been linked to migraines. In the past, many people with holes in their hearts faced long-term drug therapy with blood thinners or open-heart surgery to close the holes. At Sarasota Memorial, people with holes in their hearts have another option – the CardioSEAL® – a minimally invasive cardiac catheterization procedure that allows doctors to seal the hole in less than an hour – without surgery or general anesthesia. The CardioSEAL® patch looks like two opened square umbrellas, which are folded into a special tube called a catheter. The catheter is inserted into a vein in the leg and advanced into the heart and through the hole. The device is slowly pushed out of the special catheter allowing each side of the device to open up and cover each side of the hole like a sandwich, closing the hole or defect. When the device is in proper position, it is released from the special catheter. Within a few days, the body’s own tissue will begin to grow over the device. By three to six months, the device is completely covered by heart tissue.