Cardiology

Introduction

Introduction

The Cardiology Department of the Medistate Kavacık Hospital offers healthcare services based on infrastructure including modern equipment and the professional physicians as well as 3 coronary intensive care units.

In the Cardiology Department, diagnosis and treatment of following conditions are performed; heart attack, heart failure, coronary failue, heart and rhythm disorders, cardiac valve diseases, peripheral heart diseases, aortic diseases, hypertension, hypercholesterolemia and congenital heart diseases.

Cardiology outpatient clinic offers daily examination and control services after an appointment is scheduled, while Biochemistry Laboratory of the hospital runs necessary cardiologic tests and examinations in detail. Cardiac Rehabilitation and Coronary Intensive Care Units offer healthcare service to patients requiring emergent treatment and follow-up.

In the Echocardiogram Laboratory of the Medistate Kavacık Hospital, ECHO, ECG and Effort Tests and examinations are performed, but the laboratory also emerges based on invasive cardiology and electrophysiological studies.

Services offered in the Echocardiogram Laboratory are as follows:

  • Trans-thoracic (superficial) echocardiographic examination,
  • Trans-esophageal echocardiography,
  • Stress echocardiography,
  • Contrast echocardiography,
  • Effort test conducted on treadmill (exercise electrocardiography),
  • Rhythm Holter Test,
  • Blood Pressure Holter Test.


Invasive Cardiology Services:

  • Coronary angiography,
  • Hemodynamic studies,
  • Right-left cardiac catheterization,
  • Balloon coronary angioplasty (PTCA),
  • Intra-coronary stent placement,
  • Mitral and pulmonary balloon valvuloplasty,
  • Percutaneous atrial septal defect repair,
  • Alcohol septal ablation.


Services Provided with Electrophysiological Study:

  • Placement of permanent pacemaker,
  • ICD ( implantable cardioverter defibrillator),
  • RF ablation.

Electrocardiogram (ECG)

Electrocardiogram (ECG)

Electrical stimuli are periodically sent out from a stimuli-generating center, also referred as sinus node, which is located at superior aspect of the right atrium of the heart. Those stimuli are collected at the beginning of the ventricle via atriums and they are spread to both ventricles from this point. Following this electrical distribution, heart contracts first at atrial level and later ventricular level. Electrocardiogram (ECG) is the graph where such electric currents are plotted on a paper. For this purpose, electrodes are placed on arm, legs and anterior chest wall of the patients and the electrocardiographic traces are obtained.

ECG is a simple diagnostic tools which does not only indicate structural changes in the heart, but also rhythm and conduction disorders and if it reveals a finding, the information obtained is very important.

  • Structural changes include atrial dilatations, ventricular dilatations or increase in wall thickness, previous non-small myocardial infarctions (heart attack) originating from coronary heart diseases or heart spasm during chest pain or new episode of heart attack and developmental stages of the heart attack in daily follow-up.
  • Findings about rhythm and conduction demonstrate number of heart beats per minute, the status of rhythm, extra-cystoles and origin point, if available, palpitation episodes, rhythm disorder and imbalanced, irregular or independent contraction of atriums and ventricles if there is damage in stimuli-generating center of the heart (heart blocks) and whether cardiac pacemaker is necessary or not.

ECG findings are interpreted by physician. It is an inevitable tools in the diagnosis, follow-up and treatment of heart diseases.

Exercise ECG (Effort Test, Stress Electrocardiogram)

Exercise ECG (Effort Test, Stress Electrocardiogram)

ECG recorded in resting will be insufficient in the diagnosis of particularly coronary heart diseases, excluding the ones recorded during chest pain (angina pectoris). In conditions where ECG reveals no finding despite complaint of the patient, the patient is instructed to walk on a treadmill within scope of particular program protocol (the inclination and walking pace of the treadmill are increased in every 3 minutes) until the patient gets tired or experiences chest pain or ECG findings indicating coronary disease are observed.  Blood pressure of the patients is measured and ECG trace is recorded once in every 3 minutes.  At the end of the test, ECG and blood pressure readings are obtained for additional 3 or 5 minutes and the procedure is ended.

Purpose of the test is to increase heart beat of the patient in accordance with the age and to increase cardiac output and cardiac oxygen consumption. Moreover, if coronary arteries are normal when the heart beats at high rates during the test, the patient will well tolerate the test and the test will be ended when the patient gets tired. But, in patients with stenosis and obstruction in coronary arteries, patient starts to experience chest pain and/or ECG changes start to occur since oxygenation of cardiac muscle will not be sufficient and the test is ended when such indications appear. Patient is allowed to seat and the complaint of the patient recovers. This test is always performed under supervision of the physician and necessary safety measures are taken by making any and all types of first aid materials available.


The effort test is performed for assessing and following up the treatment of coronary heart diseases. In addition, it may also be performed in order to determine operation timing of cardiac valve disease or in some special conditions of stimuli-generating center of the heart.  This test should be necessarily performed in subjects who starts playing sports over a particular age. In some countries, the test is conducted using a bicycle loaded the test program.

The Stress ECG can be performed in patients with advanced stage arthrosis or walking disability by administering drugs such as Dobutamine under a particular protocol.

Blood Pressure Holter (Blood Pressure Monitoring)

Blood Pressure Holter (Blood Pressure Monitoring) Arterial blood pressure varies throughout the day. In general, it is at lowest level during sleep. The basal value is the blood pressure values obtained in the morning when you wake up. It has diurnal fluctuations. It elevates with excitement, stress and activity, and it decreases when you rest. Those fluctuations will be within a particular physiological range in healthy subjects.

Using a mobile blood pressure meter, which is referred as Blood Pressure Holter, attached to the patient, blood pressure is measured in pre-planned intervals and the values are saved to the memory of the device. The patient is instructed to continue normal daily activities and routine lifestyle after the device is attached.  Moreover, if the patient experiences specific complaints, it is also instructed to write the time of the complaint to the log also given to the patient. Later, patient’s blood pressure measurements in the device are transferred to a computer and thus, blood pressure and daily variations are determined.

The purpose of this test is to determine findings of subjects with high blood pressure and to reveal out whether the treatment is adequate and the test is useful in indicating the time to administer the medication.

Rhythm Holter Examination (ECG Monitoring)

Rhythm Holter Examination (ECG Monitoring) When the complaints of rhythm disorders (tachycardia, bradycardia, frequent extra-cystoles), which are defined as palpitation by patients, and of conduction defects (blocks) cannot be revealed out with ECG during non-complaint periods, a small-pack sized device, referred as Rhythm Holter, is attached to patients and 24-hour rhythm of the patient is recorded. Later, recording device is detached at the hospital and rhythm recordings are examined.

This examination is of importance in order to determine type of rhythm disorder or whether syncope originates from rhythm disorder in patients with complaints such as palpitation and fainting. It might be necessary to repeat the test several times, but there are also types where the device is attached to the body for 3 days.

Color Doppler Echocardiography (ECHO)

  • Superficial Echocardiography (Color current, Doppler and B-mode examinations)


The method is based on sending ultrasound waves from anterior chest wall to the heart using a device referred as transducer and the reflected waves are converted into image in the device. Using this examination, it is possible to

  • Measure heart chambers, determine whether a clot, referred as thrombus, or a tumor is present inside the chamber, the degree of dilatation in chamber, if available, and the underlying reason, fluid collection in heart membrane,
  • TDetermine thickness of ventricular wall, regional contractility due to previous heart attack, degree of contractile functions, presence/absence of relaxation,
  • Determine closing function of heart valves, presence of regurgitation, the degree of regurgitation, if present, or stenosis in valves, presence of inflammation in valves, pressure difference between two neighboring chambers, follow-up of prosthetic valves,
  • Detect congenital heart diseases (a hole between two atriums or between two ventricles), positions of vessels and abnormalities.


Advantage of this method is that it can be performed at any time in any center, it is a cheap and non-invasive (no blood) method.

  • Transesophageal echocardiography


The distal 30-40 cm portion of a probe, which is approximately 90-100 cm long, is similar to the gastroscopy probe, is mobile and can be manipulated, is advanced through esophagus after the throat is sedated and intravenous tranquilizer is administered. Images obtained from the prove are very clear in comparison with that of external chest imaging, since there is no muscular or bony structure lowering the quality of the image and the imaging is performed in close proximity with the heart. The finest details are examined with Color currents, Doppler.

This method is not available for all patients. It is mostly performed in conditions where there is possibility of thrombus in the atrium and ventricle and in patients with previous mitral and aortic valve operation in order to assess structure and functions of valves, examine infrastructures of mitral valve, determine aortic perforation, valve inflammation and to make final diagnosis of inter-atrial holes and defects.

  • Intra-operative transesophageal echocardiography

 

This method is performed via esophagus (trans-esophageal) in repairs of inter-atrial or inter-ventricular defects particularly in open heart operations and to control whether regurgitation is present after a valve is implanted

Balloon Angioplasty

Coronary Artery Disease (CAD) occurs due to partial or complete cessation of blood flow arising from stenosis and obstruction of arteries referred as coronary arteries, which supplies blood to the cardiac muscle tissue. The best diagnostic tool to image coronary arteries is the angiography. Following coronary angiography, a decision can be made to treat patient with medications or operate the patient without further intervention. Balloon angioplasty and/or stent (steel mesh) can be used in order to open suitable stenosis and obstructions.

Coronary Balloon Angioplasty is a treatment approach used for patients decided to undergo restoration of blood flow based on the result of coronary angiography and the procedure can be applied to restore blood flow in obstructed or narrow vessel at same or subsequent session. The balloon dilatation procedure can be performed during the angiography procedure in the catheter laboratory or it may be scheduled to another session. It is immediately performed in patients with current heart attack.
For this purpose, a 2-3 mm thick plastic tube, also referred as catheter, is placed to the inlet of coronary artery and a very fine wire passed through the catheter is advanced along the stenotic region. The deflated balloon with previously defined diameter and length is advanced over the wire to the stenotic region on the coronary artery.

Cardiac Catheterization and Angiography

Cardiac catheterization and angiography is a diagnostic method, but not a treatment option. The procedure is based on the principle that cardiac chambers and coronary arteries are imaged by administering a contrast agent (a type of medical dye) and a motion videois obtained using "X" rays. The data obtained are very valuable in term of directing the treatment and the data is the principal determinant of the treatment strategy in most patients. Success rate of procedures is over 99 percent.

Patients should fast for 4-12 hours before the procedure. (drugs can be received with water). Before the patient is referred to the catheterization laboratory, inguinal region should have been shaved for ensuring better sterilization. If required, a sedative drug can be administered. Anesthesia is applied to the inguinal or antecubital (arm) region where procedure will performed and a cannula is inserted to the artery located in relevant region. (an entry site is opened). Cardiac chambers are reached using a thin tube (catheter) made from plastic-like material and the pressure of relevant chamber is recorded; coronary artery is imagedon various projections by administering contrast agent and images are recorded and saved to CD.

The procedure generally lasts 20-30 minutes. Following the completion of the procedure, the cannula is removed from the inguinal region and compression is applied on the site for 10 minutes. After it is observed that bleeding is controlled, a tight bandage is applied to the region. However, under some medical requirements, it may be necessary left the cannula in the region for longer time. Other than exceptions, the patient is allowed to return to normal daily life at 24 hours following the procedure.

During angiography, procedure-related problems (complications) can rarely occur. Pain, mild swelling and bruising (hematoma, ecchymosis, pseudo-aneurysm) may occur in the procedure site. However, the occurrence rate of complications requiring repair in the procedure site is 2 percent. Although rare, it is possible to observe stroke and myocardial infarction (around 2 in every 1000 subjects). It is also known that life-threatening risks are below 2 per thousand. Others include perforation of cardiac vessels and chambers, hypotension secondary to severe allergic reaction, some cardiac rhythm disorders and need for temporary pacemaker implantation, but they are now extremely rare. In patients with elevated levels of creatinine and urea, renal dysfunction may occur secondary to the iodine-containing contrast agent used. However, the condition is usually temporary.

Mitral Stenosis and Balloon Valvuloplasty

Mitral valve is located between left atrium and the left ventricle. Stenosis occurs in the valve secondary to previous acute joint rheumatism.  In conclusion, sufficient blood cannot be supplied from the atrium to the left ventricle. Blood passing the stenotic valve during rest is sufficient for needs of the body. However, the blood supplied will not be adequate during exercise and thus, dyspnea occurs.
Treatment options vary depending on the degree of stenosis in the valve. Medical treatment is adequate is mild stenosis, but the two options for moderate and severe stenosis are mitral balloon valvuloplasty and open heart operation.

Advantages of mitral balloon valvuloplasty include local anesthesia and ability to return work the day following the operation. However, valvuloplasty is a temporary method. Nevertheless, it is an advantage that it postpones the operation of mitral valve replacement.

Intracoronary Stent

Coronary Stent (steel wire cage) is a treatment method used for removing problems such as inability to restore complete opening in coronary arteries by balloon dilatation and/or for patients who had experienced intra-arterial perforation following balloon treatment. The stent, which is placed over the balloon by the manufacturing company, will be assembled on interior wall of the vessel when the balloon is inflated. After the stent is placed, patient is transferred to the inpatient clinic or coronary intensive care unit. Hospitalization period is generally around 1-2 days. It is very important to keep the leg straight, where the procedure is performed, for first 6-12 hours following the completion of the procedure.

One or more than one stent may be required depending on the length of atherosclerotic region. Within weeks, those stents are covered by a thin membrane layer and the stent is left on vessel wall throughout remaining life of the patient. Ability to develop better quality stent due to technological advances had caused somewhat decrease in bypass surgery. Success rate in balloon and stent approaches is over 90-95 percent. Along the 6-month period, restenosis can occur at rate of 20-30 percent. This rate is decreased to the range of 8 – 15 % in drug-coated stents. If stenosis occurs within the stent lumen, balloon dilatation or stent treatment can be re-applied. Restenosis rate is higher in diabetic patients. If drug coated stent is placed, the patient should receive aspirin and clopidogrel containing drugs for mean one year or for more years, if possible.

The complication risk [heart attack (1-2%), need for emergency bypass surgery (less than 1%)] of balloon angioplasty and stent procedure is very low. Acute occlusion occurs due to the obstruction in the region treated using balloon dilatation during the procedure or within 24 hours following the procedure. However, if stent is implanted during angioplasty, this risk will be lower.

Pacemaker implantation

Pacemaker implantation Did you know before that our heart has a power network similar to that of a city? In fact, stimuli leaving the main center (sinus node) located at right atrium passes from intermediary station (atrioventricular node) located between atriums and ventricles following a short latent time will spread to ventricles again via specialized conduction means and thus, electrical stimulation generated in the main center is conducted to all cardiac muscular (myocardial) cells. Following electrical stimulation of the heart, the contraction occurs.

If cardiac rhythm decelerates due to inability of stimulation center (sinus node) to generate adequate stimulations and due to any obstruction along conduction paths, artificial pacemakers implanted into the body are required for ensuring sufficient heart beat rate in order to allow patient continue a normal life. Permanent pacemakers are products of cutting-edge technology that they are activated whenever they are needed by continuously sensing the operation of the heart. In some types of pacemakers, they respond to conditions requiring acceleration of cardiac rhythm by accelerating operation of the device. Thus, not only complaints of the patient based on deceleration of cardiac rhythm including syncope, dizziness and dyspnea disappear, but also the life quality of the patient is improved.   

Valvuloplasty Procedure

Inguinal region of the patient is anesthetized by administering local anesthetic substance. Later, inguinal vein is accessed via venipuncture. A plastic tube (catheter) is placed. The curtain between right atrium and the left atrium is passed through using a special needle advanced through the catheter. The guidewire is advanced under fluoroscopy to the left atrium. The balloon is advanced over the wire and placed into the stenotic valve. The balloon is inflated in the stenotic section of the valve. Thus, the valve is dilated as much as possible. The process can be repeated several times. The balloon is removed and the patient is discharged to home the next day.

A serious perforation may occur in the valve during the procedure (the possibility is below 2 %) and a heart operation may be required to repair the perforation. The risk including emergency heart operation and stroke is extremely rare.   

The Procedure of Pacemaker Implantation

The Procedure of Pacemaker Implantation In general, the procedure is performed under local anesthesia by inserting tiny wires, also referred as electrode, into the one or both atriums or ventricles via large veins lying from thorax to the heart and the electrode is connected to a generator fixed to the subcutaneous layer of the thorax. This procedure generally lasts 30-60 minutes. Hospitalization period may be 2-5 days.   

Adverse events related with pacemaker implantation

Adverse events related with pacemaker implantation Permanent pacemaker implantation is a minor surgery. Therefore, adverse events, also referred as complication, may occur in the procedure. However, risk of complications related to the procedure is very low and they are mostly not of vital importance. Conditions that may occur during the implantation include perforation of pleura, bleeding caused by unintentional insertion of needle into artery instead of vein and rhythm disorders. Although inflammation of the wound site is within range of possible events, it is very rarely observed. Protective antibiotic therapy will be started to avoid the inflammation.

You may be required to rest at bed for 24 hours following the completion of the procedure. Sutures will be removed at 6-10 days following the procedure. Overall, no changes will occur in your daily life following the implantation of permanent pacemaker. However, your physician will clearly inform you the behaviors and environmental conditions with negative influence on your cardiac pacemaker.

In patients with vital requirement of permanent pacemaker implantation, there is no alternative treatment method of this procedure. When the useful life of the battery expires in approximately 5-6 years following the procedure, only the generator of the battery will be replaced and wires will not be intervened. You will be required to be regularly controlled by your physician following the implantation of the pacemaker.

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