Diagnosis

Cardiac Catheterization

What is it ?

Cardiac catheterization is a general term, which means placement of a catheter in the heart. The catheter in the heart can be used to measure chamber pressures, inject dyes and other medications, passage of wires, balloons, or other devices, measuring oxygen saturations or mapping the electrical conduction.

Foetal Echo Cardiography

What is it ?

It is an ultrasound examination of the baby's heart in the mother's womb.

Treatment – Non Surgical

ASD Device Closure

What is it ?

It is a hole, or abnormal communication between two upper chambers of the heart called atria.

Valvotomies

What is it ?

Valvotomy is a procedure in which a doctor stretches a heart valve or breaks the obstructions in a valve that don't allow normal flow. Heart valves need to function properly. They direct the flow of blood through the chambers of the heart and to the rest of the body.

When is it used ?

The doctor may perform this procedure if you have a scarred valve that blocks the flow of blood to the lungs, to other chambers of the heart, or to the body. This procedure is not the answer for all people with blocked valves. The procedure can be done for aortic, mitral and pulmonary valves.
Examples of alternatives to this procedure are:

• replacing the valve
• repairing the valve with open-chest surgery
• choosing not to have above treatment but continue with drugs while recognizing the risks of this approach.

Coarctation of Aorta

What is it ?

A defect that develops in the fetus in which there is a narrowing of the aortic arch, the main blood artery that delivers blood from the left ventricle of the heart to the rest of the body.

Coarctation of the aorta is diagnosed in both newborns and adults. Approximately 10% of newborns with congenital heart disease have coarctation of the aorta. Blood leaves the heart by way of the left ventricle and is distributed to the body by arteries. The aortic arch is the first artery to carry blood as it leaves the heart.

Other arteries to the head and arms branch off the aortic arch. A narrowing of the aorta at any spot produces resistance to the flow of blood. This causes high blood pressure before the narrowing and low pressure below the narrowing (downstream). Parts of the body supplied by arteries that branch off the aortic arch before the narrowing have high blood pressure, while most of the lower body doesn't receive enough blood supply. To compensate for this, the heart works harder, and the blood pressure rises. Approximately half of all infants with coarctation of the aorta are diagnosed within the first two months of life.

Frequently, there are other congenital cardiac complications present. Infants with Turner syndrome have a 45% rate of also having coarctation. There is evidence that some cases of coarctation may be inherited. In newborns with congenital heart disease, coarctation of the aorta develops while the baby is in the womb. Among the consequences of coarctation of the aorta is ventricular hypertrophy, an enlarging of the left ventricle in response to the increased back pressure of the blood and the demand for more blood by the body.

Symptoms in infants include shortness of breath, difficulty in feeding, and poor weight gain. Older children usually don't have symptoms, but may display fatigue, shortness of breath, or a feeling of lameness in their legs. Infants usually have an abnormal "gallop" heart rhythm and may also have heart murmurs. Sometimes excessive arterial pulses can be seen in the carotid and suprasternal notch arteries, indicating increased pressure in these arteries, while the femoral pulse is weak or can't be detected. The systolic pressure is higher in the arms than in the legs.

Enlargement of the heart can be seen in x rays. Similar symptoms are seen in older children and adults. A 10 mm Hg (mercury) pressure difference between the upper and lower extremities is diagnostic for coarctation of the aorta. For some patients, the systolic pressure difference is observed only during exercise.

Infants frequently have an abnormal electrocardiogram (ECG) that indicates that the right or both ventricles are enlarged, while in older children the ECG may be normal or show that the left ventricle is enlarged. The coarctation may be detected in echocardiographic examination.

Coil Occlusion of Aortopulmonary Collaterals

What is it ?

They are abnormal communicating vessels found in babies born with cyanotic defects in the heart. The vessels run from aorta, the main artery arising out of the heart and reach to the lungs, and are essentially nature’s way of compensating for the defect.

Surgical

Repair of Congenital Heart Disease

What is it ?

Birth defects of the heart in children, many amongst them may present for the first time later in life, are divided into three categories:

• Obstructive heart defects which includes congenital aortic stenosis, coarctation of aorta
• Simple holes (abnormal communication) in the heart like ASD, VSD, PDA
• Blue babies (TOF, TAPVC, TGA, pulmonary atresia & tricuspid atresia)

What is angioplasty or PTCA ?

Percutaneous transluminal coronary angioplasty (PTCA), usually simply called angioplasty, involved opening the blocked artery. A typical angioplasty procedure involves the following steps: (also see animation)

• The cardiologist threads a narrow catheter (a tube) containing a fiber optic camera directly to the blocked vessel.
• The physician opens the blocked vessel using balloon angioplasty , in which the cardiologist passes a tiny deflated balloon through the catheter to the vessel.
• The balloon is inflated to compress the plaque against the walls of the artery, flattening it out so that blood can once again flow through the blood vessel freely.
• In order to keep the artery open afterwards, cardiologists now commonly employ a device called a coronary stent , which is an expandable metal mesh or scaffolding tube that is implanted during angioplasty at the site of the blockage.
• Once in place, the stent pushes against the wall of the artery to keep it open. (A number of studies are reporting fewer future heart attacks and restenosis in patients who receive stents compared with those who had angioplasty alone.)

Stenting is now used in about 60%, at BHIRC the figure is touching 90%, of angioplasty procedures. Studies report high survival rates with the use of stents, including their use with multiple blood vessels and as the initial device after a heart attack instead of balloon angioplasty. Some experts now recommend they be used only to prevent restenosis in patients with large blood vessels (greater than 3 mm).

Recuperation : Angioplasty is less invasive than bypass surgery, requiring only one night in the hospital. Recuperation takes about a week. It should be pointed out the chest pain after the procedure is very common and usually due to problems other than ischemia. Chest pain is even more common when a stent is used, possibly because the artery is stretched.

Short-Term Complications : Reclosure During or Shortly after Angioplasty. Reclosure of the artery during or shortly after angioplasty is often but not always due to blood clots. Aspirin, heparin, coumarin, or combinations of anti-clotting drugs are generally used during and after the operation. Aspirin is more effective than heparin. New anti-clotting agents (tirofiban, abciximab, argatroban, clopidogrel, or bivalirudin) may be more effective for preventing reclosure, often when administered in combination with heparin or aspirin. Anti-clotting drugs are not wholly protective, in any case, because reclosure in some cases is due to other, unknown causes.

Long-Term Complications : Reclosure (Restenosis) Within a Year of Angioplasty. Narrowing or reclosing of the artery (restenosis) occurs within a year of angioplasty in nearly half of angioplasty patients, often requiring a repeat operation. Reclosure, in this case is not due to blood clots and so anti-clotting agents are not useful. Theories for the cause of restenosis include the following:

A number of approaches, including coronary stents, have been developed to prevent restenosis.

The result of this procedure is that the blood vessel is dilated, and blood can flow more easily through the (formerly narrowed) part of the coronary artery. It is used mostly to relieve angina, but is sometimes used as an emergency procedure to improve blood flow during a heart attack, (Primary angioplasty).

Sometimes the plaque is also removed through atherectomy in which a catheter with a coarse burr (rotablator) at the tip is used to grind the plaque into small bits. These bits float away in the blood stream.
After Angioplasty or atherectomy, a stent may be placed in the artery to improve upon the result (nowadays about 90% of patients receive stents). Stent becomes a part of body in about four weeks.

How will my doctor know if I need PTCA ?

You may have already undergone coronary angiography - a dye test showing the details of the narrowed coronary arteries. Your coronary anatomy and symptomatic status will guide your doctor to decide whether you need PTCA or a bypass surgery or simply medication to manage your condition.

How is PTCA different from bypass surgery ?

In bypass surgery, blood vessel(s) from the chest or leg is / are grafted to the coronary artery beyond its most diseased segment. This lets the blood detour past the narrowing to reach the heart. In PTCA, however, the obstructed part of the coronary artery is widened rather than bypassed. Both operations achieve the same result.

Can everyone who has chest pain have PTCA ?

No. Whether you are a candidate for this procedure depends on a number of variables. The number of arteries showing blockages, number of segments blocked, type of blockage (focal or diffuse), diameter of vessels and functioning of your heart muscle etc. Only a doctor who's familiar with your case can determine the best form of treatment for you out of medication, PTCA or bypass.

Will I ever need to have another PTCA ?

It's possible especially for those who do not take care in diet, exercise regimen, lifestyle, etc. The dilated part of the coronary artery may re-narrow in 15 to 20 percent of the people who've had PTCA. If this happens to you, your doctor will advise you if the procedure should be repeated. However, if there is no re-narrowing within six months, it is unlikely to occur thereafter.

How long does it last ?

It usually takes about 45 min. to one hour, under a local anesthetic, and involves a short hospital stay of two to three days.

What are the risks involved ?

Angioplasty has many of the same risks as coronary angiography. An additional risk is that in less than 1 percent of case, the artery being treated may close off suddenly in the initial few days after angioplasty. Very rarely you may need an urgent bypass surgery. Therefore, it should only be performed in a setting where an emergency heart surgery team is on standby.

Is it painful ?

Not,really. About an hour before the procedure you will be given a sedative to help you relax. You may feel some chest heaviness when the balloon is inflated because blood flow in the artery is temporarily blocked. After the procedure, the place where catheter was inserted may be a little sore.

Preparation for PTCA at BHIRC

You will come to the hospital one or two days before the procedure for some tests. These may include an electrocardiogram (ECG), blood and urine tests and a chest x-ray. You will probably fast for about six hours before the procedure. Depending upon the schedule of cases in the Cath Lab, your doctor will advise whether you need to fast overnight, or may have light refreshment during the day of the procedure. Routine preparation includes being shaved in the area where the catheter will be inserted, and sometimes from chest to ankles and showering with an antiseptic solution to prevent infection.

What to expect after the procedure is over ?

When the doctor is satisfied after the procedure, the catheters are removed but the plastic sheath is left in the groin for about 4 hours and then removed. A nurse will check your blood pressure. She will also check the insertion site for bleeding.
You will then return to an intensive care area for a few hours (usually till the sheath is removed) for monitoring and then into the ward. While you are in the CCU you will remain attached to the heart monitor. An IV line may also continue to give fluids and medications for a few hours. After the sheath removal, you will have to keep the leg straight for another about 6 hrs. You can start moving after that.
You may tell the nurse if:

What care do I have to take once back home?
You will be discharged after one or two days if you are feeling well and have no angina. Your doctor or his / her team doctor will talk to you about:

You may have a lump, the size of an olive under your skin at the insertion site. There may also be a bruise. These are common and should go away on their own after a few weeks. You can go back to your normal activities a day or two after getting home. You will most likely be able to return to work within 2 weeks. Try not to overdo it at first. Get an OK from your doctor before you start exercising or doing heavy work.

See your doctor regularly for checkups first within six months and then once every year. These visits help monitor your medication. Your doctor may subject you to exercise tests and see your progress.

Do I have to change my lifestyle?
Your doctor may refer you to a cardiac rehabilitation / lifestyle management program. This program can provide guidance, classes, and support groups to help you:

ECG/EKG

What is it ?

An electrocardiogram (ECG or EKG) is a recording of the electrical activity of the heart. Each heartbeat is caused by an electrical impulse that causes the heart to squeeze. The ECG records the electrical pattern of the heartbeat. Many different diseases and conditions affect the ECG pattern. Small, sticky electrode patches are placed on chest, wrists, and ankles. These patches are connected to a machine that records the electrical activity of heart. The recording is printed on paper for doctor to interpret.

TMT

What is it ?

Treadmill Test (TMT) or Stress test or Exercise testing is done to see how your heart functions while exercising on a treadmill or exercise bike. During the test, the patient's heart rate, breathing, blood pressure, electrocardiogram (ECG), and how you feel are monitored.

On many occasions, an ECG taken while resting when oxygen and hence blood requirement of heart is minimal, it may not reveal any abnormality even if there are blockages. During exercise, the heart has to pump more blood. This increase in stress on the heart may reveal heart problems that go unnoticed when the body is resting. The exercise stress test is not the absolute in diagnostics; it is a superior initial and noninvasive coronary test.

The exercise stress test shows the doctors how well your heart handles the increased stress brought on by exercise. It confirms a diagnosis of coronary heart disease or angina, detects low levels of blood supply to the heart, predict risk of future heart problems, and decide what treatments are needed.

Blood tests in the diagnosis of acute myocardial infarction

What is it ?

When a heart attack is suspected, apart from clinician's bedside review of patient's symptoms, history and mandatory ECG, certain blood tests may also help in clinching the diagnosis. As a result of injury to the heart tissue, certain proteins are released, which can be detected in blood by doing tests. However, one must remember that these proteins are indicators of injury to heart tissue in general, rather than heart attack per say.
These tests are:

EHAS

What is it ?

When a patient has a heart problem, the first test that a doctor usually orders is an ECG. However on many occasions, an ECG trace taken after the problem has settled, may not reveal much. Ideally, if an ECG trace can be taken during the problem, it may help a doctor clinch the diagnosis. EHAS makes that dream come true. It not only helps record an ECG trace during the problem, but it also transmits the trace, using a small device and ordinary telephone line, to a specialist at Escorts Heart Institute.

The specialist reviews the ECG, may talk to the patient or his relative if required, and advise the immediate management, thus on many occasions picking up life threatening diagnoses and saving lives. EHAS is first of it kind in India, and opens a new dimension in providing remote yet instant cardiac attention. It's a development in cardiac telemedicine that has already been proven across Europe & USA where it has FDA approval. The service is available 24 hrs a day, 365 days a year. EHAS is backed by a newly commissioned Heart Command Centre (HCC) and a fleet of mobile cardiac care ambulances. EHAS thus provides the highest possible level of domiciliary life saving service hitherto unknown in our country.

STRESS ECHO

What is it ?

In a TMT, the heart is challenged by increasing the heart rate achieved by making the patient walk on treadmill. In certain situations when a patient can't be made to walk, or situations where doing a ECHO may be more useful than seeing the ECG at the target rate, the heart rate is increased by infusion of a drug called Dobutamine.

Dobutamine stress echocardiography is a test in which the reaction of the heart is measured under chemically induced stress, in order to assess the wall motion of the heart muscle. Dobutamine is one of several medications that cause the heart to react as if the person is exercising, though the patient is actually at rest.

THALLIUM STUDY

What is it ?

Thallium study' is a general term used for 'Stress myocardial perfusion scintigraphic study', a test which is aimed at viewing the distribution of blood to the heart muscle. The distribution varies between a patient with previous heart attack, a patient of angina and a normal individual. Thallium 201 (Tl201) and Technicium 99m (Tc99m)- radiopharmaceuticals are used for this study. These radiopharmaceuticals map the distribution of blood supply to the heart muscle when imaging is done using a Gamma Camera/SPECT.This is performed on exercise and at rest.

Before starting to exercise, the patient receives an injection of thallium 201, a radioactive chemical, which is taken up by normal heart muscle cells :

Damage due to a prior heart attack will persist when the heart scan is repeated. Injury caused by angina, however, will have resolved by that time.

Cardiac Imaging

Cardiac Imaging

What is it ?

X-rays are a form of radiant energy, which penetrate various tissues of the body differentially, in the process capturing shadows and reflections on the photographic plate. The radiologist can view these on photographic film, on a TV or computer monitor. The films created by X rays show different features of the body in various shades of gray.

Some X-ray exams improve visibility by using contrast, a range of substances, which are opaque to X-rays. The contrast may be introduced by injection, patient swallowing the dye himself or enema. In fluoroscopy, X-rays are used to capture a moving image of an organ on the screen while it's functioning.

ECHOCARDIOGRAPHY DOPPLER

What is it ?

Echocardiography is a specialized ultrasound imaging of the heart. It is done with help of a blunt flexible probe which is rotated over chest to send ultrasound waves to heart and receive the reflected waves to construct the image of heart and its functioning in real time. It is called an non-invasive procedure since it does not involve any injections. Patient will lie down on an examining table.

A technician places some lubricant and a transducer on the chest. The transducer beams high frequency sound waves at heart. This information is returned, or echoed, to the transducer and converted into a picture, which is recorded on videotape. Then the technician moves the transducer to several locations on chest until the picture is complete.

Cardiac MRI

What is it ?

MRI is a method of producing extremely detailed pictures of body tissues & organs without the need for x-rays. MRI uses radiowaves & a strong magnetic field. In a strong magnetic field the radiowaves are directed at protons, the nuclei of hydrogen atoms. The protons are first "excited" & then "relaxed" emitting radio signals, which can be computer processed to form an image.

MRI requires specialized equipment & expertise & allows evaluation of some body structures that may not be as visible with other imaging methods.

CT SCAN

What is it ?

CT (Computed Tomography) is a diagnostic test that combines the use of x-rays with computer technology .A series of x-rays beams from different angles around the body are used to show cross sectional images of the patient's body. The images so obtained are assembled in a computer into a three- dimensional picture that can display organs, bones & tissues in great detail.

In spiral CT the examination table advances at a constant rate through the scanner gantry. While the x-ray tube rotates continuously around the patient, tracing a spiral path through the patient. This spiral path gathers continous data with no gaps between images.

CT Angiography (CTA) is an examination that is used to visualize blood vessels in many areas of the body including the brain, kidneys, pelvis and the arteries serving the lungs. Compared to catheter angiography, which involves injecting contrast medium into an artery CTA is much less invasive & a more patient friendly procedure; contrast medium is injected into a vein rather than an artery.

MUGA

What is it ?

MUGA is an acronym (short form) for Multi-Gated Acquisition. MUGA was first introduced in the early 1970s and quickly became accepted as the preferred technique for measurement of LVEF with a high degree of accuracy. Several early studies demonstrated an excellent correlation of MUGA-derived LVEF with values obtained by cardiac catheterization contrast ventriculography.

Multi-Gated Acquisition is a form of Ventriculography, which is performed by using radioisotope i.e. Technetium 99m (Tc99m). The RVG is performed by labeling the patient's red blood pool with a radioactive tracer and measuring radioactivity over the anterior chest, with a suitably positioned gamma camera, as the radioactive (labeled) blood flows through the large vessels and heart.

THALLIUM STUDY

 What is it ?

'Thallium study' is a general term used for 'Stress myocardial perfusion scintigraphic study', a test which is aimed at viewing the distribution of blood to the heart muscle. The distribution varies between a patient with previous heart attack, a patient of angina and a normal individual. Thallium 201 (Tl201) and Technicium 99m (Tc99m)- radiopharmaceuticals are used for this study. These radiopharmaceuticals map the distribution of blood supply to the heart muscle when imaging is done using a Gamma Camera/SPECT.This is performed on exercise and at rest.

Before starting to exercise, the patient receives an injection of thallium 201, a radioactive chemical, which is taken up by normal heart muscle cells:

Heart Rhythm Disorder

ECG

What is it ?

An electrocardiogram (ECG or EKG) is a recording of the electrical activity of the heart. Each heartbeat is caused by an electrical impulse that causes the heart to squeeze. The ECG records the electrical pattern of the heartbeat. Many different diseases and conditions affect the ECG pattern. Small, sticky electrode patches are placed on chest, wrists, and ankles. These patches are connected to a machine that records the electrical activity of heart. The recording is printed on paper for doctor to interpret.

HOLTER MONITORING

What is it ?

This is a small monitoring device, which continuously records the ECG for 24 hours while patient continues his daily routine activities without remaining confined to bed.

Electrophysiology Study

What is it ?

An electrophysiology (EP) study finds the source of abnormal heart rhythms. Cardiac catheters and computers generate electrical impulses, and the speed at which the impulses travel within the heart is measured. These measurements help to locate impulses that are in the wrong place, as well as identify abnormal rhythms. The test takes about an hour and is not painful.
It is a diagnostic procedure to identify the cause for irregularity in the rhythm of the beating heart.

Ablation

It is a curative procedure that corrects the arrhythmia identified. It involves delivering current at a particular radio frequency to break the abnormal circuit in the heart, returning it to its regular rhythm. BHIRC is one of the few hospitals in India to offers this therapy.

Cardiac Pacemaker

It is also a curative procedure performed on patients with abnormally slow heartbeat. It involves inserting wires into the heat chambers and regulating the heartbeat by delivering current from an external pacemaker placed under the skin.

Automatic Implantable Cardio-verter Defibrillator (AICD)

What is it ?

It involves implanting the AICD beneath the skin to monitor the rhythm of the heart and to deliver a carefully timed electric shock automatically, for life threatening rhythm disturbances.

TILT-TEST

What is it ?

One of the most common causes of fainting is called neuro-cardiogenic syncope also called vasovagal syncope. This condition is not really a disease but an abnormal reaction that results in a fall in blood pressure. The blood pressure may become so low that a person may experience light-headedness or fainting. The abnormal reaction that causes neurocardiogenic syncope may be brought on by pain, or anxiety, although frequently, this may occur without a trigger. Because there are other causes for syncope, your doctor may advise you to undergo head-up tilt testing to confirm the diagnosis. Because an episode of syncope may lead to serious injury, this test is important to diagnose the condition and, if necessary, treat it with medications and other regular daily practices, such as tilt training that will reduce your symptoms.

Head -up tilt testing is a way to safely diagnose neuro-cardiogenic syncope by deliberately creating the symptoms of neuro-cardiogenic syncope in a special room called an electrophysiology (EP) lab.

Lung Function Test

PULMONARY FUNCTION TEST

What is it ?

PFT are a group of tests that are performed to assess the functions of the lungs. Measuring the volumes during different phases of breathing, adequacy of airflow in and out of lungs and expanding capabilities or elasticity of lungs can assess the lung functions. Tests can be performed not only to assess the breathing volumes and flows, but also the adequacy of oxygenation of blood that lungs are supposed to carry out. The major types of pulmonary function tests include spirometry, measurement of lung volumes, and quantitation of diffusing capacity usinf small quantity of carbon monoxide. Measurements of maximal respiratory pressures and forced inspiratory flow rates are also useful in specific clinical circumstances Evaluation of lung functions is important in many clinical situations, both when the patient has a history or symptoms suggestive of lung disease, and when risk factors for lung disease are present, such as cigarette smokingparallel in our country before.

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