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PROCEDURES

Exercise Treadmill Test || Echocardiogram || Holter Monitor || Event Monitor || Nuclear Scans || 256 slice CT Angiography || Radial Artery Catherizations || Cardiac Electrophysiology

The Gentler Approach to Cardiac Catheterization and Stent Placement

(Provided by Transradialuniversity.com)
For many patients who undergo cardiac catheterization (angiogram) and/or angioplasty/stent placement, the worst part of the procedure actually occurs after the entire process is over.  Traditionally, transfemoral catheterization involves insertion of a thin tube, or catheter, into the major artery in the groin and threading it into the heart.  After procedure completion, forceful pressure is applied (either manually or with a large clamp) for awhile on the puncture site to prevent bleeding.  Subsequently, the patient must remain in bed, with the leg straight, for several hours.  Many complain of significant muscle cramps and backaches.  Safety-wise, there is an ever-present risk of bleeding associated with this approach, especially in larger individuals.  Since the groin, or femoral, artery is deeply embedded in layers of tissue, even significant internal bleeding may not be readily apparent.  Furthermore, external pressure may not be transmitted sufficiently to control the bleeding in all situations.  In cases of severe bleeding complications, transfusions and potentially vascular surgery may be required.
            There is good news, however.  Northside Cardiology, P.C. is the only cardiology group in the greater Atlanta area to routinely offer a more comfortable and safer alternative.  Transradial catheterization and/or angioplasty/stent placement is performed through the wrist.  Post-procedurally, individuals wear a small wrist compression device and are free to sit up or ambulate, without the need to lie recumbent in bed.  Patients uniformly prefer this approach, as it is much more comfortable and allows for greater mobility and freedom.  Additionally, there is no intrusion into sensitive and private body areas; and patients consider it less invasive.  Most patients can typically be discharged much earlier.  Most importantly, multiple large-scale studies have confirmed the greater safety of this technique, as compared with the aforementioned transfemoral approach.  There is essentially no risk of bleeding, and the potential for artery damage is likewise markedly minimized.1-5   This enhanced safety is due to the very superficial position of the wrist, or radial, artery; any bleeding issue is easily visible and can be readily controlled by firm external pressure.  Additionally, nerve damage is minimized by this strategy, as the major nerve is located far from the radial artery.  The opposite is true for the transfemoral approach.
The technical training and skills required for this approach, however, have limited its prevalence locally.  Dr. Chen has performed the most transradial catheterizations and angioplasty/stent procedures of any other physician in the metropolitan Atlanta area.  In addition to having written and published extensively on this topic, to help train other doctors, he also runs a course whereby cardiologists from around the country come to learn this technique. 
Moreover, stent implantation currently requires an overnight admission in many cases; however, Dr. Jack Chen recently co-authored a study demonstrating the safety of same-day discharge for patients undergoing transradial stent deployment.5  Since patients can walk immediately after the procedure, there is no need to lie still on an uncomfortable stretcher.  Accordingly, Dr. Chen has designed for St. Joseph’s Heart and Vascular Institute a post-procedural Transradial Lounge which was showcased at the American College of Cardiology Annual Scientific Sessions in Atlanta in March, 2010.  The first of its kind in this country, the wood-paneled Lounge resembles more an airport lounge or café than a hospital recovery room.  There are no stretchers; patients relax in reclining lounge chairs and are free to walk about.  Patients enjoy individual high-definition televisions (you can bring in your favorite DVD to play) and Wi-Fi internet to check emails or surf online.  We have created a relaxing, non-clinical environment to help reduce the patients’ anxieties and apprehensions.
            The vast majority of patients undergoing cardiac catheterization will qualify for the transradial approach.  However, it may not be applicable to some individuals with suboptimal circulation in the hand or those with history of bypass surgery.  This technique is especially beneficial in larger patients (higher risk of bleeding from the groin), those with peripheral artery disease (leg artery blockages), those with back or spine problems (problems with prolonged recumbency), or those with restless legs syndrome (cannot keep leg still).  Nonetheless, all patients will enjoy the comfort and mobility of transradial coronary intervention. 
            We have been routinely performing this procedure for over 6 years.  If you may need a cardiac catheterization or angiogram, please inquire with your personal physician or cardiac care provider regarding this procedural innovation.  Our physicians and staff at Northside Cardiology, P.C. (www.nscatl.com) welcome any questions you may have on this or other areas of care for your heart.
            Also see other related websites:


image2

After Transradial stent placement, patient walks off catheterization table, completely mobile, with only a small bandage around the wrist (arrow).

image4image6

After Transfemoral catheterization, force is applied to the groin to stop bleeding; and the patient must lie completely still in bed for several hours, usually resulting in significant back, hip, and leg cramps.  The “Clamp” to the right is often substituted for manual pressure.

References:

  1. Chen JP. Repeat right transradial coronary intervention in a patient with dextrocardia:  the right approach to the right-sided heart. Catheterization and Cardiovascular Interventions 2007; 69(2): 223-226.
  2. Kiemeneij F, Laarman GJ. Percutaneous transradial artery approach for coronary Palmaz-Schatz stent implantation. American Heart Journal 1994;128:167-174.
  3. Jonas E, Horlick E, Ivanov, Seidelin PH, Ross JR, Ing D, et al. Decreased complication rates using the transradial compared to the transfemoral approach in percutaneous coronary intervention in the era of routine stenting and glycoprotein platelet IIb/IIIa inhibitor use: a large single-center experience. American Heart Journal 2008;156(5):864-870.
  4. Jabara R, Gadesam R,  Pendayala L, Chronos N, Crisco LV-T, Chen JP. Same-day Trans-Radial Intervention and Discharge Evaluation (the STRIDE Study). American Heart Journal (In press).

Exercise Treadmill Test (ETT)
The exercise treadmill test is done while you walk on a treadmill. During the test, an electrocardiogram (EKG) records the electrical activity of your heart. There are many different treadmill protocols available. We use the Bruce protocol. This is the standard protocol used in cardiology practices to evaluate the heart and its response to exercise. The test has many stages, each of which are three minutes in duration, with each advancing stage, the speed and degree of incline increases, causing your heart rate, respiratory rate, and systolic blood pressure to rise. In general, exercise testing is very safe, but because all tests, by nature, carry a small risk, the test will be supervised and interpreted by a cardiologist. If you develop chest pain, or shortness of breath during the test, let the physician know.

Echocardiogram
The echocardiogram is an ultrasound study which allows us to visualize the heart, its size, valves, and chambers to more adequately evaluate their functions. There is no discomfort associated and no preparation involved. Your echocardiogram takes approximately 30 to 60 minutes.

Holter Monitor
The holter monitor is an ambulatory electrocardiogram. You will wear five electrodes attached to a recorder (about the size of a walkman). This recorder will record every beat that your heart makes, while attached to you. You may not take a bath or shower while you are being recorded. We recommend you bathe that morning. Holter monitors are scheduled first thing in the morning or afternoon and must be promptly returned the next day about the same time you received the monitor. Failure to do so may result in the loss of recorded information by the monitor.

Event Monitor
This is an extended duration ambulatory monitor which is worn for approximately one week. Events/symptoms may be transmitted via telephone. This is given for transient episodes at the discretion of the physician.

Nuclear Scans
Myocardial perfusion imaging, Thallium scans

Myocardial refers to the heart. Perfusion is the passage of blood through the circulatory system and imaging refers to computer generated pictures. The test is done in two parts. In the first part, the heart is stressed (the heart's arteries are expanded using a special medication). Healthy or "normal" coronary arteries dilate more than unhealthy or partially blocked arteries. Once the blood vessels are dilated, a small amount of radioactive imaging agent is injected. The imaging agent tends to concentrate in those parts of the heart that have the best blood flow. The imaging agent emits signals that can be detected by a special type of camera. Images taken by the camera show if any part of your heart is not getting enough blood. In the second part, two sets of pictures are taken. The first set shows the arteries of the heart when the blood vessels are dilated. The second set shows the heart during normal functioning, referred to as "rest". The two sets of images are compared. A relatively healthy heart shows little or no difference between images taken during stress and those taken at rest. In a heart with partially blocked arteries, images taken during stress are different from those taken at rest.

256 slice Computed Tomography Angiography (64 slice CTA)
256 slice CTA is a new, state-of-the-art, non-invasive, diagnostic tool that allows cardiologists to image the heart, blood vessels (coronary arteries) and other cardiac structures non-invasively. The 256 slice CTA can produce three dimensional, high quality diagnostic images of the heart, aorta, lungs, and coronary circulation. Prior to the advent of CTA, we needed an invasive angiogram (cardiac catheterization) in order to see the coronary arteries but since 2005, we have been able to offer this test  and in many cases avoid the risks of an invasive procedure. Further, we have diagnosed many cases of significant coronary blockages missed by stress testing.

At the time of the patient’s arrival in the CT suite, the patient will be fully assessed by a cardiac trained nurse (BLS/ACLS certified).  The patient’s heart rate, blood pressure, ECG, and history will be reviewed.  An intravenous line will be placed into the patient’s arm for fluids and medication. Patients are often given beta-blockers for a few days prior to the procedure to slow the heart rate; this allows better image quality. IV Contrast is used so be sure to tell your physician and nurse if you have an allergy to dye or contrast. When the patient’s heart rate is slow and stable, the CT examination is performed which only takes a few minutes including the placement onto the table and the actual image acquisition takes about 18 seconds to perform and the patient can leave immediately after. Test results are usually available within 24 hours

This is a picture of a normal coronary artery imaged with CTA:

We can even see Coronary bypass grafts to determine if they are open:

The procedure is very safe and accurate; in fact, we can be 98% sure someone doesn’t have heart disease which means this test which is better than current stress testing modalities. Essentially, 64 slice CTA can quickly and non-invasively exclude coronary artery disease, as well as diagnose its presence.

Dr. Balk has been performing CTAs in Atlanta since 2005 and is one of North Atlanta’s highest volume operators and is currently working with colleagues to develop an ER program for rapid diagnosis of chest pain syndromes using CTA.

Cardiac Electrophysiology
Device implementation allows physicians to insert small mechanisms into the patient's body to treat a variety of symptoms. A pacemaker, which helps a heart function properly, is just one example of the tools now available to electrophysiologists.

Pacemaker
A pacemaker is a small, battery-powered device that is implanted permanently into the body. The pacemaker monitors the electrical impulses in the heart and, when needed, delivers electrical stimuli to make the heart beat (contract) in a more normal rhythm.

This device is used when the heart beats too slowly (bradycardia) or has other abnormal rhythms (arrhythmias). In some cases, pacemakers are also used to treat the symptoms of heart failure.

A pacemaker consists of a battery and electrical circuitry (pulse generator). The battery powers the pacemaker. The circuitry checks the heart rate and produces tiny electrical pulses that keep the heart beating at the correct pace.

A pacemaker is connected to the heart through one to three insulated wires (leads) that are attached directly to the heart's chambers

Implantable Cardioverter Defibrillator (ICD)
An implantable cardioverter defibrillator (ICD) is a device that monitors heart rhythms and delivers shocks when dangerous rhythms are detected.

Many ICDs record the heart's electrical patterns whenever an abnormal heartbeat occurs. Doctors can review this record during regular check-ups to help plan future treatment options.

ICDs are used to treat patients whose lower heart chambers (ventricles) beat too quickly (tachycardia) or quiver ineffectively (fibrillation). They are also used in patients who are at risk of these conditions due to previous cardiac arrest, heart failure or ineffective drug therapy for abnormal heart rhythms.

An ICD consists of a battery and electrical circuitry (pulse generator) connected to one or more insulated wires. The pulse generator and batteries are sealed together and implanted under the skin, usually near the shoulder. The wires are threaded through blood vessels from the ICD to the heart muscle.

The ICD continuously checks the heart rate. When it detects a heartbeat that is irregular or too rapid, it delivers a shock that resets the heart to a more normal rate and electrical pattern (cardioversion).

Implantation of an ICD can be a life-saving measure in people prone to developing fast heart rhythms, such as some individuals with heart failure or a history of heart attacks.

Cardiac Resynchronization Therapy (CRT)
Cardiac resynchronization therapy (CRT), also referred to as biventricular pacing, is used for patients with congestive heart failure. Unlike typical pacemakers, special pacemakers that coordinate the beating for both the left and right ventricles are used for CRT.

CRT can benefit patients with moderate to severe congestive heart failure symptoms, weakened and/or enlarged heart muscles, or a significant electrical delay in the lower pumping chambers of the heart. It has been shown to improve a person's energy level and quality of life.

Atrial Fibrillation Ablation
Atrial fibrillation is a disorganized rhythm originating in the upper chambers of the heart that can contribute to palpitations (fast heart rates), worsening of heart failure or stroke. While medical therapy offers some relief, therapy fails many patients eventually or they cannot tolerate it because of side effects. Recent advances have allowed physicians to perform ablations to eliminate atrial fibrillation.

Atrial fibrillation ablation is a specialized technique that requires expertise, specialized technology, careful patient selection and close follow-up.

Prior to the procedure, the physicians utilize the Department of Cardiology’s specialized cardiac MR (magnetic resonance) scanner to visualize the left atrium and pulmonary veins. This is where much of this rhythm disturbance originates. The physician uses these images to more precisely plan and guide the placement of catheters and ablation lesions during the procedure.

The procedure is performed under conscious sedation to maximize the patient’s comfort. Patients can expect to spend one night in the hospital after the procedure. Most patients resume their normal activities within a few days. The physicians use extensive outpatient event monitoring before and after the procedure to document all symptomatic episodes and as a surveillance measure to document possible asymptomatic episodes. An in-depth consultation can be arranged to see if ablation therapy is suitable for you.

Ablation
Cardiac catheter ablation, which is a relatively non-invasive procedure, is used to treat abnormally rapid heartbeats that cannot be controlled with medication, or in patients that cannot tolerate these medications. This procedure can restore a normal heart rhythm and eliminate the need for open-heart surgery or long-term drug therapies During a cardiac catheter ablation, a long, thin tube is threaded into or onto the heart to cauterize (ablate) the area of heart tissue that is causing abnormal heart rhythms.

Cardiac ablation catheters are used most often to treat abnormal rhythms that begin in the upper heart chambers (atria) including:
­ - Supraventricular tachycardia (SVT)
­ - Atrial tachycardia
­ - Atrial flutter

Ablation can also be used to treat heart rhythm disorders of the lower heart chambers (ventricles) such as ventricular tachycardia

Other Tests
Other tests we offer include:

  • Stress Echo
  • Carotid Doppler Studies
  • Ankle-brachial Index Measurements

In the hospital we perform a number of diagnostic and therapeutic procedures including:

  • Cardiac Catheterization
  • Percutaneous Coronary Interventions
  • Pacemaker Implantation
  • CT angiography

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  5670 Peachtree Dunwoody Road Suite 880 Atlanta, GA 30342    
Phone: 404-256-2525

Accredited Echocardiography
Laboratory
ICANL  
  3400 Old Milton Parkway Building C, Suite 360 Alpharetta, GA 30005 Phone: 404-256-2525  
1505 Northside Forsyth Drive, Suite 3600
Cumming, Georgia 30041
 
 

Location

Our Dunwoody location is conveniently located on the north side of Atlanta at the highway intersection of I-285 and GA 400 in the The Tower at Northside adjacent to Northside Hospital.

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Our Alpharetta office is Located off of Old Milton PKWY

 

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8:30 am to 5:00 pm M-F
During normal office hours, our staff is available for appointment scheduling, clinical inquiries, and prescription refills. Please call 404-256-2525 to reach one of our staff members.

 

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