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Cardiology - Cardiac Catheterization Procedure

What Is Cardiac Catherterization?

Cardiac Catheterization is a diagnostic test, not an operation. During the procedure a catheter (small, thin hollow tube) is inserted into an artery or vein and passed into the heart. This technique will give the doctor information on how well your heart is pumping and what the coronary arteries look like. In some cases, this technique is used to treat Coronary Artery Disease (CAD). Coronary angiography is a test in which radiographic contrast material, or dye, is injected into the coronary arteries through the catheter. When injected, the contrast material mixes with the blood in the coronary arteries allowing the doctor to visualize the blood flow through the arteries. The dye causes no discomfort but some individuals may experience sensation of flushing, hotness, shivering or a slightly metallic taste in the mouth. None of these symptoms are serious but do tell us if you experience them. The contrast material is iodine-based; some people have a known allergy to iodine, shellfish, or x-ray dye. If you are one of them, let your doctor know before the test. Medication can be given to prevent an allergic reaction.

The doctor will also inject contrast into the left ventricle, which is the main pumping chamber of the heart. This will allow him to see how well the heart muscle squeezes and if there has been any damage to the muscle.

These injections are recorded on 35mm film, similar to movie film, or onto a compact disc. This is kept as part of a permanent record of the procedure. Although cardiac catheterization is a highly specialized diagnostic technique performed only in a specially equipped laboratory by carefully trained staff, it is a common procedure. In fact, more than one million people undergo cardiac catheterization every year in this country. More than 3,000 diagnostic catheterization procedures are performed annually at Genesis alone.

Why Should You Have A Cardiac Catheterization?

You may have had a heart attack or have been experiencing symptoms indicative of heart disease, such as shortness of breath, chest or jaw pain, and fatigue. It is also possible that you have not experienced symptoms, but are at risk for CAD due to family history or an abnormal EKG. You may have had an exercise/resting stress test during which changes were found on your EKG, and your doctor therefore advised further study. Whatever the case, you probably have been through a series of tests, personal history, electrocardiogram (EKG), X -rays, treadmill stress tests, blood tests and nuclear medicine tests, these indicate a cardiac catheterization is the next and most decisive test for evaluating your symptoms.

How Does Your Heart Work?

Your heart is a muscular organ approximately the size of your fist. It functions as a constant pump, contracting rhythmically to send blood throughout your body. The heart is stimulated to contract by electrical impulses located within the heart. It is composed of four chambers - the upper two chambers being the left and right atria, and the lower two portions being the left and right ventricles. The right side (your system of veins) receives un-oxygenated blood from the body and sends it to the lungs for oxygenation.

The oxygenated blood from the lungs is then carried to the left side of the heart to be pumped throughout the body. Between each chamber in the heart are valves that open and close with each heartbeat, preventing blood from flowing backwards. When the doctor listens to your chest with a stethoscope he is listening to your heart sounds. If these valves become diseased, damaged, or hardened, they will open and close with a snap, which can be heard with a stethoscope. Echocardiography will also demonstrate valve disease, but catheterization is needed to measure pressures between chambers to determine the degree of valve dysfunction.

The heart, like the rest of your body, needs a supply of oxygenated blood to function. As blood leaves the left ventricle, it is forced into the body's main artery, the aorta. At the very beginning of the aorta, near the top of the heart, emerge the two coronary arteries. They are referred to as the "left " and "right" coronary arteries.

The first segment of the left coronary artery is called the left main artery. It is about as wide as a drinking straw and less than an inch in length. The left main then branches into two slightly narrower arteries: The left anterior descending which travels down the front side of the heart: and the left circumflex which circles around the left side and then the back of the heart. The right coronary artery comes from the aorta, circles around the right side and then to the back of the heart.

The coronary arteries travel on the surface of the heart and divide into smaller branches. These are the three main arteries that nourish the heart muscle (myocardium). If these arteries become narrowed or completely blocked, the blood flow to the muscle is decreased, causing you to experience symptoms of coronary artery disease. Coronary artery disease is caused by atherosclerosis (hardening of the arteries) which occurs when a fatty substance called plaque forms in the wall of an artery. When the plaque in the artery becomes severe, your heart cannot get enough oxygen-rich blood when it needs it most, such as during exercise. This can lead to chest pain or discomfort which is called angina. Angina usually lasts for only a few minutes and is relieved by resting. This is different than a heart attack where the supply of oxygen rich blood to the heart muscle is cut off and can lead to permanent damage to a portion of the heart muscle. The pain of a heart attack usually lasts for a longer period of time and does not go away with rest.

Preparation

You will be admitted to the hospital the evening prior to, or the morning of, your study to have tests done if they have not been done previously.

Day Of The Procedure

After your arrival to the hospital a nurse will check your vital signs (blood pressure, pulse and temperature) and obtain a current height and weight. An EKG may be done, and you will be asked to put on a patient gown. You may not be allowed to eat or drink after midnight, or you may have a light breakfast depending on the time of the day your procedure will be done. The time of your procedure depends on many factors, including doctor availability and other patients needing emergency treatment. Pagers are available for family members/significant others, enabling them to have a flexible routine prior to the start of your procedure. (To request pagers, please ask your room nurse.) Medication will be administered before the procedure to help you feel relaxed, but you will remain awake. You may wear your glasses, dentures and wedding ring.

The Cath Lab

Two members from the Cath Lab staff will bring a large, hammock-style cart to your room and introduce themselves when it is time for your procedure. You will be asked to lie on a black transport sheet, which attaches to the frame of the cart. Your family is encouraged to accompany you to the 2nd floor where they will be directed to waiting rooms and be regularly updated by the cardiologist and/or the staff; the procedure will take 1 to 3 hours. The Cath Lab is kept cool because the large x-ray equipment and computers require cool air. You will be given warm blankets upon arriving to the lab, and more blankets are available anytime during the procedure should you become cold.

The table in the procedure room moves under you, then the cart frame is removed. It takes about 20 minutes to prepare for the procedure before the doctor arrives. During this time, EKG patches are applied, an IV is started, and your groin will be slightly uncovered while it is shaved. For your privacy, your genitalia will remain covered. After your groin is shaved, the area will be washed with a sterile solution, and it is important to keep your hands at your sides. The procedure is done under sterile technique to prevent any possibility of infection. Therefore, you will notice the staff wearing hats, masks and shoe covers. The doctor and the person assisting him will be wearing sterile gowns, gloves and protective goggles.

The Procedure

After the site is numbed with local anesthetic, the doctor will make a small puncture with a needle into the artery. You may feel some pressure with the insertion of the sheath (small tube) into your groin, but it should not be painful. As the catheter is passed up to your heart and pictures are taken; you should not feel any discomfort other than some pressure at the groin site. If you should feel pain tell the nurse or doctor in the room.

The doctor may ask you to take a deep breath. This is to lower your diaphragm and give him/her a better view of the heart. To take a deep breath, don't bear down; simply take a full breath in gradually until the doctor tells you to breathe normally, then exhale. You will be asked to hold your breath for only 5-10 second intervals.

The left ventricle of your heart is studied by the rapid injection of dye. This will cause you to feel extremely warm, for about 15- 20 seconds. The contrast material (dye) is filtered out by the body and eliminated through the kidneys. Your heart beat and blood pressure will be closely monitored during catheterization.

The coronary arteries are studied by moving the x-ray camera to various angles around your chest and head. When the camera is at the angle the doctor wants, he/she may ask you to take a deep breath (as described earlier). You will hear the camera run as the artery is being injected with contrast material. When the camera stops you can breathe normally. This will last 5-8 seconds. Approximately 10 - 12 pictures will be taken. You can watch the screen during the study if you desire.

Percutaneous Transluminal Coronary Angioplasty (PTCA Or Balloon Angioplasty) Your doctor may recommend a PTCA to follow your cardiac catheterization. A PTCA procedure improves blood flow to you heart. Special supplies are used for this procedure, including a larger groin catheter, a small wire to cross the area of disease, and a balloon-tipped catheter to inflate within the area of disease. The wire and balloon catheters are positioned across the area of blockage and the balloon is inflated, compressing the plaque against the artery wall. It may be inflated several times, sometimes causing chest discomfort; although this is normal, please let your nurse know if you experience any pain or discomfort. A coronary stent may be placed. With the plaque pushed aside blood flow to the heart muscle is improved. The PTCA is a success when the narrowed artery has been opened wide enough to allow adequate blood flow.

Coronary Stents

A stent is a small metal coil, slotted or mesh tube that is placed in a coronary artery to help keep it open. Although angioplasty is successful in most cases, the blockage may reoccur. Your doctor may choose to place a stent in the artery to help keep it open. The stent is mounted on a balloon catheter and advanced to the site of blockage. When the balloon is inflated, the stent is expanded, this also helps to further compress the plaque. When the balloon is deflated and removed, the stent remains, supporting the wall of the artery. The stent is permanent in the artery. The stent helps hold the artery open, improves the blood flow and relieves symptoms of coronary heart disease. Within several weeks, the lining of the artery will grow over the stent and completely cover it.

Your doctor may prescribe an antiplatelet medication for you to take for 2 to 4 weeks after the stent is in place. This medication helps prevent blood clots from forming on the stent. It is very important that you continue taking your medication. Consult with your physician before stopping any of your medication.

Atherectomy

Atherectomy may be done to improve blood flow to your heart. With this procedure, a catheter with a cutting device is used. This device cuts away the plaque in the blocked artery. The atherectomy catheter has a cutter and a collection chamber. The doctor uses the cutter to remove the plaque from the artery. After the atherectomy, the doctor may do a PTCA procedure (refer to PTCA) and/or a stent may be placed.

Rotablator

Rotablator can also be done to improve blood flow to your heart. During this procedure, a catheter with a special grinding device is used to clear away the plaque in your blocked artery. The rotablator catheter has a coarse burr near its tip to grind the plaque into small bites. These bits float away in the bloodstream. After the rotablator, the doctor may do a PTCA that compresses any remaining plaque against the artery wall. A stent may also be placed.

Whichever procedure your doctor chooses, he/she is taking into consideration the type of plaque at the blockage, location of the blockage and the best device to use in your individual situation.

* PTCA Angioplasty, Coronary Stents, Artherectomy, and Rotablator Procedures are performed at Genesis Medical Center in the event emergency open heart surgery is needed.

After The Procedure

When the procedure is complete, the groin catheter (sheath) may be removed and pressure applied to the puncture site for 20 to 30 minutes to stop the bleeding or one of several closure devices may be used to seal the artery. If the physician decides to leave the sheath in place it will be removed in a couple of hours in your room. When you return to your room, your nurse will check your blood pressure and the puncture site frequently to be sure there is no bleeding. You will have an IV infusing, oxygen and an EKG monitor on, and you may eat and drink as your physician orders.

The physician requires you to remain flat in bed for a specified time. Your nurse will turn you and/or raise the head of your bed as the doctor orders. Your leg is to remain straight, and if you need to cough, laugh or sneeze, hold pressure over the Band-Aid applied to your groin. If you have some discomfort inform your nurse, pain medication has been prescribed and can be given. A bruise or small lump under the skin at the point of catheter insertion is common and will disappear in about a week. It is possible that your groin site may bleed after returning to your room. Signs to watch for are painfulness or a warm, wet feeling near the groin site. If you feel this, hold pressure on the site and call your nurse immediately. Your nurse may need to hold additional pressure to your groin or apply a pressure device.

If your arm was used for the catheterization, you may move it, but do not bend or lie on it, and report to your nurse any numbness or tingling in your hand or fingers.

You will be encouraged to drink plenty of liquids to flush the contrast material through the kidneys and out of your body. The contrast material may cause you to pass more urine than usual. Your nurse will bring you a bedpan or urinal when needed. It is important that you DO NOT get out of bed to use the bathroom.

After the procedure, the cardiologist will provide a progress report to your family. Later your doctor will talk with you and your family about the results when you are back in your room, usually that same day.

When You Get Home

  • Avoid heavy lifting (over 20 pounds) or strenuous exercise for three days.
  • No driving for 2 days
  • You may shower but do not take a tub bath or swim for one week.
  • Watch for signs of infection including fever, increased swelling, drainage, or tenderness at the puncture site.
  • Do not have a MRI scan within 8 weeks of stent implantation without first discussing it with your cardiologist.
  • Call your doctor if you notice increasing chest pain or discomfort, marked shortness of breath or excessive fatigue with exertion, all of which may signal restenosis.
  • Call an ambulance and come to Genesis Medical Center East Campus, Illini Hospital or your local emergency department if:
    • The puncture site begins to bleed, in a steady stream or soak your clothing (lie flat and apply firm downward pressure slightly above the puncture site)
    • The bruising or swelling suddenly increases at the leg (or arm) in which the catheters were inserted.
    • Your affected leg/foot or arm/hand becomes numb, pale or cold to touch.
    • Do not delay treatment awaiting a phone call from your physician.

Follow Up Visit

You will need to call immediately upon discharge for a follow up appointment with your cardiologist. This visit will help monitor your healing process. In some cases, the treated artery may close again. If this occurs, it is most likely to happen in the first 6 months after your procedure. Tests may be done during this time also.

Cardiac Rehabilitation

Your doctor may refer you to a cardiac rehabilitation (cardiac rehab) program. This program will teach you ways to make lifestyle changes that can improve your heart health. These changes may also reduce your risk for future heart problems.

  • If you smoke-quit
  • Enjoy a diet low in fat and cholesterol
  • Exercise regularly (consult physician before you start)
  • Maintain proper weight
  • Lower blood pressure
  • Control diabetes
  • Reduce stress

In Summary

It is important for you to realize that the benefits derived from cardiac catheterization far outweigh the risks. The more your doctor knows about the condition of your heart, the better the chance that treatment will be successful.

The knowledge gained from cardiac catheterization enables your doctor to make a much more informed decision about the kind of treatment you may need. It is possible that:

  • You may be able to stop taking medications because your symptoms are not caused by your heart disease
  • Your medication or dosage may be changed or a new medication prescribed. However, medication does not remove existing coronary blockage
  • You may be advised to have surgery, possibly coronary bypass surgery or a repair to the heart's wall or it's valves.

Glossary

Angina (Angina Pectoris): An intense, steady pain or pressure felt in the mid chest, shoulder or jaw caused by decreased blood flow to the heart muscle.

Catheter: A long, thin tube through which contrast is injected.

EKG (Electrocardiogram): Electrical impulses of your heartbeat recorded on graph paper

Lesion: An area of disease or narrowing in an artery

Myocardial Infarction (MI) (or Heart Attack): An event which occurs when the heart muscle is damaged due to decreased blood flow or total blockage of a coronary artery

Sheath: A short, thin tube inserted in an artery or vein, which allows the catheter to be introduced.

Stent: A small, metal, stainless-steel coil mounted on a balloon catheter used to better hold an artery open after angioplasty.

Stenosis: A narrowing in a blood vessel, or the hardening of a valve causing diminished blood flow and CAD symptoms.

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