Most common heart-related
conditions
- provided by America's leading
cardiologists
Cardiovascular Procedures
As the number of people with heart disease increases,
so too does the need for cardiovascular procedures.
Whether a patient needs a pacemaker, balloon angioplasty
or stent placement, cardiovascular procedures can
help people with serious heart problems live longer
lives. Select a program below to learn more about
the large variety of these procedures.
What is Bypass Surgery?
Coronary bypass is a form of heart surgery
that uses new arteries to "bypass" and
replace clogged heart arteries. Tune in to learn
more about this important type of heart surgery.
Participants:
Lawrence I. Bonchek MD
Webcast Transcript:
ANNOUNCER: A coronary bypass is a type of heart
surgery that re-routes blood vessels around heart
arteries that have become clogged with cholesterol
build-up.
LAWRENCE I. BONCHEK, MD: Bypass surgery is done
in order to route blood around obstructions in the
coronary arteries, which are the arteries that supply
blood to the heart. They're actually very small
arteries, so it doesn't take a lot of cholesterol
buildup in the wall of the artery to block an artery
that size.
Surgeons will take a healthy blood vessel like
an artery from the chest wall or a vein from the
leg, and then connect the blood vessel above and
below the blockage to bypass it.
LAWRENCE I. BONCHEK, MD: There are two major ways
that bypass surgery is done nowadays, and people
will hear the terms off-pump and on-pump bypass
surgery. Traditionally, bypass surgery has always
been done with a heart-lung machine so that the
heart could be stopped and the lungs are not being
inflated, and the heart-lung machine is doing those
functions while the heart is absolutely stationary
to allow very precise, meticulous sewing while the
bypasses are being attached.
But in recent years, with advances in technology,
there have been pieces of equipment developed that
allow you to stabilize a small area of the heart
that you're working on, and to do the bypass operation
without the heart-lung machine. And that's known
as off-pump bypass surgery.
ANNOUNCER: Lifestyle modifications are important
after surgery so that the new blood vessels don't
become blocked as well.
LAWRENCE I. BONCHEK, MD: The most common lifestyle
modifications are correcting all the bad things
that people have been doing beforehand, such as
not smoking. They should lose weight. They should
watch the salt in their diet. They should eat a
healthier diet.
ANNOUNCER: Bypass surgery is still a major procedure,
but most people can be fully recovered and active
in as little as two months.
LAWRENCE I. BONCHEK, MD: My advice to anyone who
has had bypass surgery is to enjoy life, because
that's the purpose of having the surgery so that
they can get back to full and normal activity.
What is a Pacemaker?
A pacemaker is a battery-powered device that
sends signals to the heart to help it beat properly.
Tune in to find out more about these life-saving devices.
Participants:
Melanie Gura, MSN
Douglas P. Zipes, MD
Webcast Transcript:
ANNOUNCER: Everyone has heard of pacemakers, but
most people don't know what an important role a
pacemaker can play in maintaining a healthy heart
and lifestyle.
MELANIE GURA, MSN, RN: An artificial pacemaker
is a small, battery-operated device that can actually
take over the role of the heart's electrical system
when needed. It consists of the wire, or the lead
electrode system, and the pacemaker or device itself.
The population for pacemaker implantation is not
limited to age, sex or race. There are approximately
100,000 pacemakers implanted yearly in the United
States, and they may be prescribed for a variety
of conditions.
Bradycardia is the most common rhythm problem that
is associated with pacemaker implantation. This
is when the heart becomes too slow, and patients
have symptoms such as shortness of breath, fatigue,
dizziness, or even fainting spells can occur.
Atrial fibrillation is a very common heart rhythm
disorder in which the upper chambers of the heart
beat erratically and chaotically and rather fast,
and sometimes it's also too slow.
Heart failure is a condition in which the heartbeat
cannot meet the normal volume of blood and oxygen
to supply all parts of the body.
Syncope, also known as a common faint or passing
out, is usually less severe, but can occur frequently
in patients.
ANNOUNCER: Surgery is usually the next step to
regaining a healthy heartbeat.
DOUGLAS P. ZIPES, MD: A pacemaker is put in under
local anesthesia. So we make a tiny incision in
the chest, and the actual procedure itself lasts
45 minutes to an hour and a half, depending upon
what is done. This is certainly not open-heart surgery.
It's very simply done.
MELANIE GURA, MSN, RN: Implanting a pacemaker has
very little risks associated. But however, whenever
there is a surgical procedure, complications can
arise. One of the complications that can happen
in the early postoperative phase can be bleeding
at the incision and sometimes it will cause a hematoma
or a little blood clot over the pulse generator
and some bruising.
Rarely, a lead can become dislodged or displaced,
and the patient would have to go back to have the
lead repositioned by the physician
DOUGLAS P. ZIPES, MD: The complication rate is
very, very acceptable, considering the tradeoff
of the wonderful things the pacemaker does.
What are the Different Types of Pacemakers?
A pacemaker is an implanted device that helps
the heart beat more regularly. Learn more about the
different kinds of pacemakers and the heart problems
they are used for.
Participants:
Jamie B. Conti, MD
Webcast Transcript:
ANNOUNCER: A pacemaker is a battery-operated device
that is implanted in the chest to help the heart
pump blood more effectively. There are different
kinds of pacemakers, and it's important to know
what they are and what conditions they are used
for.
JAMIE B. CONTI, MD: There are a variety of pacemakers
that are available. There are single-chamber pacemakers,
which means a pacemaker with one wire. Those are
used in patients who rarely have a problem, but
occasionally need a little bit of extra help keeping
their heart rate up.
There are two-chamber pacemakers, which are used
for people who in general need considerable support
of their heart rate with a pacemaker, and one of
those wires goes in the top chamber, the atrium;
the other wire goes in the bottom chamber, the ventricle.
There are also three-lead pacemakers that are relatively
new. Those are used to treat congestive heart failure.
One of those leads goes in the atrium, the top chamber.
The second lead goes in the right ventricle, which
is one of the bottom chambers. And the third lead
goes through a vein that wraps around the heart
and can pace the left ventricle and thus help us
with our treatments of congestive heart failure.
Once you have a pacemaker, it is important to follow
up with your physician on a routine basis. We need
to see our patients physically in our office at
least once a year, and then we check their pacemaker
over the telephone at a set schedule, depending
on how old the pacemaker is. The older it gets,
the more frequently we check it so that we know
when the battery needs to be changed.
How will Life Change with a Pacemaker?
After a pacemaker is implanted, a patient
may need to make some changes in his lifestyle to
prevent adverse effects. Tune in to learn more about
managing life with a pacemaker.
Participants:
Douglas P. Zipes, MD
Jamie B. Conti, MD
Webcast Transcript:
ANNOUNCER: After pacemaker implantation, there are
important steps and precautions patients must take
to ensure that their pacemakers continue to function
properly.
DOUGLAS P. ZIPES, MD: After the pacemaker is implanted,
the symptoms produced by the slow heartbeat or the
fast heartbeat should be taken care of by the pacemaker;
that's the reason for the implantation. And then
we follow the patient. Many of the follow-ups are
done electronically or over the telephone so the
patient does not have to come in physically to be
evaluated.
With other patients, they indeed do need to come
in. They may have what we call comorbidities. In
other words, they have another problem, heart failure
or coronary disease, that needs to be followed as
well as just having the pacemaker.
ANNOUNCER: And after several months of limiting
physical activity, patients can usually resume their
normal routines.
DOUGLAS P. ZIPES, MD: We generally restrict an
individual from major arm movements, such as lifting
your arms above your head, combing your hair, playing
golf, because that movement can make the wire in
the heart move and change its position. After several
months, that's no longer an issue, but until that
time we generally want an individual to just kind
of restrict their upper arm movement.
JAMIE B. CONTI, MD: People often ask, you know, "What
can I do after I have a pacemaker implanted? Will
I be limited in any way?" We have patients
whose heart rates were so slow because of being
marathon runners or extreme sports people. When
they get their pacemaker, they can go back to regular
activity.
ANNOUNCER: Although microwave ovens and other household
appliances no longer affect people with pacemakers,
there are still precautions to take in public places.
DOUGLAS P. ZIPES, MD: A couple of cautionary things.
One is when you go to the airport, notify the airport
security as you're going through the detector that
indeed you do have a pacemaker implanted, because
it can set off the alarm. The other is, there are
theft detector electronic equipments that are found
in department stores and bookstores and so on, and
they will have no impact on the pacemaker if the
individual just takes a leisurely stroll through
the theft detector equipment, but we would not want
the individual to stand right within that field
and be exposed to it
ANNOUNCER: In the end, a pacemaker will help a
patient live a more normal and active life, with
little to no inconvenience.
What are the Various Diagnostic Imaging Tests?
Cardiovascular medicine has a variety of
diagnostic imaging tests used by doctors to help identify
and diagnose abnormalities in your heart.
Participants:
Richard P. Lewis, MD, MACC
Professor of Internal Medicine, Ohio State University,
Columbus, Ohio
Jacqueline A. Noonan, MD, FACC
Pediatric cardiologist, University of Kentucky College
of Medicine,
Lexington, Kentucky
Webcast Transcript:
ANNOUNCER: For anyone with questions about the health
of their heart, there are a variety of diagnostic
tests available to physicians that can help provide
some answers.
RICHARD P. LEWIS, MD: Cardiovascular medicine has
more imaging tests than anybody else, by a long
ways. Actually, the first diagnostic imaging test
was a chest x-ray invented around the turn of the
20th century, so it's over 100 years old. It's still
helpful.
JACQUELINE NOONAN, MD: You know, in the olden days,
people used to use their stethoscope. And with the
stethoscope, if you had trained well, you could
diagnose rheumatic heart disease, what kind of valve
was involved, by listening. And this could be helped
by looking at an electrocardiogram, which would
tell you which side of the heart was thicker than
normal, whether the atrium was enlarged and use
certainly the chest x-ray.
Then cardiac catheterization came into vogue where
one could put a catheter into the heart and measure
pressures, put dye in and show defects, show whether
there was rheumatic heart disease, congenital heart
disease or whether the heart, which is not functioning
well. You could look at the coronary arteries with
coronary angiography.
RICHARD P. LEWIS, MD: The rest of the cardiac testing
has mostly been developed in the last 50 years,
and they fall into two basic categories: invasive
and non-invasive. And invasive means puncturing
the surface of the body. Non-invasive means not
having to do that.
The non-invasive tests consist of electrocardiogram
and chest x-ray; echocardiography, which is a widely
used test today; nuclear studies, where you inject
a radioisotope into the blood, and then look at
where it goes in the heart to see if there's areas
that aren't getting enough blood, that's a perfusion
scan. Or you can actually watch the heart contract
with the isotope that's inside the heart's blood
pool and watch the blood pool pass through the heart,
and you can define how well the heart's working.
That's a widely used test.
The echo is an extremely versatile test, because
it'll show you all of the heart valves and how they
work, the heart muscle, what kind of condition it's
in, whether there's fluid in the sac around the
heart, and a lot of other things that you could
do. And echo's an easy test to do, and you can do
it on really sick people in the intensive care unit,
emergency rooms.
Now, the invasive studies, diagnostic studies,
are mostly cardiac catheterization, which involves
putting a catheter in blood vessels, usually the
leg blood vessels, and advancing them into the heart.
And there we measure pressures inside the heart,
which is critical when you have abnormal heart valves,
and we can also inject contrast material, that you
can take an x-ray movie and see the outline of the
heart chambers and see how well the heart's working,
or you can see, most importantly, the heart arteries
and see how they're doing.
JACQUELINE NOONAN, MD: There are CAT scans, and
now there are improvements in the CAT scans, and
then there's the magnetic resonant imaging, MRIs.
So there are many different diagnostic tests that
can be used. There are also tests that can be used
to look for how good the oxygen in your heart is,
which reflects the coronary blood flow. Nuclear
scans, where one can do nuclear scans, both when
you're resting and when you're exercising, will
help us to understand whether your coronary arteries
are supplying the heart sufficient blood. So there
are many, many different kinds of diagnostic tests
available today.
What Medicines Do I Take After a Stent?
After a stent is placed in an artery, there
is a chance that a blood clot may develop. To help
prevent clots, antiplatelet drugs are often prescribed
after the stenting procedure.
Participants:
Spencer B. King, MD, MACC
Fuqua Chair of Interventional Cardiology, Fuqua
Heart Center, Piedmont Hospital, Atlanta, GA.
Adolph M. Hutter Jr, MD, MACC, FAHA, FESC
Past President and Editor-in-Chief Conversations
with the Experts American College of Cardiology
Webcast Transcript:
ANNOUNCER: A common question asked by people who
have stents is why they need to continue taking
drugs like Aspirin, Plavix or Coumadin.
SPENCER B. KING, III, MD: After stenting, the blood
platelets—these are little particles within
the blood that help us stop bleeding, if we cut,
they collect and form a clot—those platelets
can be detrimental after you have a stent placed.
They can actually build up on the stent and may
cause a clot to form there.
ADOLPH M. HUTTER, JR., MD: We need to use some
drugs that prevent blood clots from forming in the
stent or from restenosis. And the most effective
drugs have been shown to be the antiplatelet drugs:
That's Aspirin or clopidogrel, called Plavix. These
are the anti-platelet drugs. They work very well.
Coumadin, which is a blood thinner against clots
formed by thrombin doesn't work very well for stents.
So you need to be on aspirin and Plavix, but you
don't need to be on Coumadin just for a stent. You
might need Coumadin for another reason, but you
don't need it just because you have a stent.
SPENCER B. KING, III, MD: Coumadin is an anti-clotting
drug that people know about, but it is not routinely
used after stenting. It has different uses, in atrial
fibrillation and in preventing clots in the legs
and all sorts of things. But when stents are used,
it's the combination of aspirin and the clopidogrel
that is critical.
ANNOUNCER: Determining which drug a patient should
use depends on the type of stent they have.
ADOLPH M. HUTTER, JR., MD: If you have a bare metal
stent, then you should be on aspirin 325 mg/day,
and Plavix 75 mg/day, for a month. If you have a
drug-eluting stent, we know that those events can
occur many, many months after a month, and so most
people recommend that you be on aspirin 325 mg/day,
and Plavix 75 mg/day indefinitely, at least for
six months.
What Do I Do after I Have a Stent?
Stenting is a common procedure used to keep
clogged arteries open. To ensure long-term success
additional treatments are necessary after surgery.
Learn more about the options.
Participants:
Robert S. Schwartz, MD, FACC
Director of Preclinical Research, Minneapolis Heart
Institute, Minneapolis, MN
Spencer B. King, MD, MACC
Fuqua Chair of Interventional Cardiology, Fuqua
Heart Center, Piedmont Hospital, Atlanta, GA.
Editorial Consultant:
Suzanne Hughes, MSN, RN
Webcast Transcript:
ANNOUNCER: Stenting is a common procedure used to
keep clogged arteries open. Once a stent is inserted,
the treatment of the diseased artery doesn’t
stop there. In addition to the stent, lifestyle
changes and medications are necessary for long-term
success.
ROBERT S. SCHWARTZ, MD, FACC: What you do after
a stent has been placed is very important. It’s
almost as important as what the doctor does while
the stent is being placed. First and foremost, take
your medicines. There’s two very important
medicines that virtually all doctors prescribe after
a stent has been placed. One is just plain old aspirin.
The other is another drug called clopidogrel. Or
the common name is called Plavix. These drugs are
important because they stop the formation of blood
clots inside the stent.
A blood clot that forms inside the stent is very
important, because when it happens, it usually goes
complete, the artery is blocked off, the patient
has a heart attack. So first and foremost, take
those medicines. That’s very important. If
they doctor gives them to you, they sometimes are
difficult to take, but it’s a very important
thing to do.
SPENCER B. KING, MD, MACC: The other point is that
everybody who gets stents put in has atherosclerosis.
They’ve got coronary artery trouble, and therefore
they need to be on preventive therapy, and this
usually involves treatment of their cholesterol,
their lipids, their blood pressure, their diabetes,
if they have it. So even if a stent is put in, it
doesn’t mean that the patient is finished
with the treatment. Preventive therapy is critical
in those patients.
ROBERT S. SCHWARTZ, MD, FACC: The main thing from
your standpoint as a patient is to look and be certain
that you’re getting no more chest pain, no
more shortness of breath, if the symptoms that brought
you to the doctor in the first place have not returned.
If they do return, it’s usually not an emergency.
It’s not anything dangerous, typically. But
it is important to get back in to your doctor, because
it may mean that scar tissue has grown inside the
stent, and the stent may be gradually plugging up
with scar tissue something that can be fixed relatively
easily today.
The Different Ways to Unclog Arteries?
When an artery narrows in your heart, doctors
can fix the problem by inserting a small wire mesh
tube called a stent to hold the artery open. Which
type of stent works best for you?
Participants:
Adolph M. Hutter Jr, MD, MACC, FAHA, FESC
Past President and Editor-in-Chief Conversations
with the Experts American College of Cardiology
Robert S. Schwartz, MD, FACC
Director of Preclinical Research, Minneapolis Heart
Institute,
Minneapolis, MN
Spencer B. King, MD, MACC
Fuqua Chair of Interventional Cardiology, Fuqua
Heart Center, Piedmont Hospital, Atlanta, GA.
Editorial Consultant:
Suzanne Hughes, MSN, RN
Webcast Transcript:
ANNOUNCER: When an artery narrows in the heart,
one solution to fix the problem is to place a small
wire mesh tube called a stent in the artery to support
and hold it open. There are two types of stents,
a bare metal stent and a drug-eluting stent.
ROBERT S. SCHWARTZ, MD, FACC: Stenting came into
common practice in about 1995 or so. It was very
commonly used. The first stents were invented only
about 1986. Prior to this time, we only opened arteries
using balloons, and a major problem was, the artery
would often close down, either while the patient
was still having the procedure done, or later in
the six-month time frame. What the stent has done
has solved pretty much both of those problems.
ADOLPH M. HUTTER JR, MD, MACC, FAHA, FESC: A stent
is a wire, a type of wire that they actually put
into the coronary arteries and balloon up and dilate
so they keep the coronary artery open. And there
are bare metal stents that just have metal, and
then there are drug-eluting stents which have metal
and elute a certain drug that keeps the process
around the stent from progressing to cause restenosis.
Restenosis is a narrowing up inside that stent,
or maybe at the edge of the stent, from the tissue
of the coronary artery. And the bare metal stents
tend to have a higher restenosis rate than the drug-eluting
stents. So the drug in the stent that is eluting
helps prevent the restenosis.
ROBERT S. SCHWARTZ, MD, FACC: There's a big difference
between bare metal stents and medicated stents.
The first stents that we had available to us were
bare metal stents, meaning it was nothing but a
tube of metal expanded inside your coronary artery
on a balloon. A balloon is inflated with liquid,
usually water, under high pressure. It opens the
stent. The stent is placed in the artery.
While this is better than putting no stent in at
all, we soon discovered that if a stent is placed,
it in fact increases the likelihood that you'll
do well over the next six months to several years.
The reason you'll do well is because before this
the arteries would close down. Almost half of some
arteries would narrow back down due to scar tissue,
a process called restenosis.
The advent of the bare metal stent has markedly
reduced restenosis from about one in two to about
one in three patients. One in three patients is
not quite good enough. For this reason, many scientists,
engineers and companies have gotten together with
many physician researchers and discovered that by
putting medicine onto a stent, having the stent
actually give medicine to the artery around it after
it's been implanted over a long period of time,
can really stop in large part the growth of the
scar tissue to the point where it becomes a problem
SPENCER B. KING, MD, MACC: The re-narrowing is
largely wound healing. It's kind of a scar formulation
inside the vessel. You can think of it that way.
So if there is this kind of excessive scar formulation
that might narrow the artery, the drug-eluting stents
can inhibit that.
Now, in some situations, the bare metal stent is
perfectly good and as good as the drug-eluting stent,
but in other situations, particularly difficult
arteries to treat, the drug-eluting stent has offered
a big advantage in reducing the chance of re-narrowing.
ROBERT S. SCHWARTZ, MD, FACC: The restenosis rate
now with medicated stents is only about one in 10
to maybe even one in 20, depending on how big your
artery is and another series of patient factors
that are important when the stent is implanted.
The information
published on this page has been provided by the
Heart Authority
in collaboration with Cardiosource – American College of Cardiology
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