CARDIOLOGY


Cardiac Angioplasty and Stent

 

Cardiac Angioplasty and Stent Placement

Overview

Coronary angioplasty, also known as percutaneous coronary intervention, balloon angioplasty and percutaneous transluminal coronary angioplasty, is used to open the clogged heart vessels (coronary arteries).

A catheter is usually inserted into an artery in the groin area and advanced to the clogged segment of the coronary artery tree. A plan is made by using the images. Afterwards, a balloon is advanced over the catheter and inflated at the clogged part. Thus, the occlusion is opened and blood flow is restored.

In a cardiac angioplasty, a thin tube or artificial vessel, called stent, is inserted and placed to prevent recurrence of the occlusion and to maintain the blood flow. Two types of stents are inserted into the coronary arteries: Drug eluting stents and non-drug-eluting bare metal stents. Stents with elute drug constantly release certain doses of a drug to the stenotic segment to prevent recurrence of the narrowing or occlusion.

When the clogged coronary artery is opened by angioplasty and the flow of the blood is maintained by stent, chest pain and dyspnea regress or disappear that are typical symptoms of coronary artery disease.

Why is this procedure done?

Fat particles begin to accumulate in the arteries that feed heart due to particular reasons, such as unhealthy nutrition, accumulation of excess fat in the body, high blood pressure, and diabetes mellitus. These structures, called plaques, grow over time as long as the risk factors are not eliminated. As a result, a condition, called atherosclerosis, develops, resulting in narrowing of coronary arteries followed by completely blockage.

Since coronary arteries are the vessels that feed the heart, narrowing and occlusions cause damage to the heart tissue, resulting in loss of cardiac functions over time.

Angioplasty is the first option, if medication treatment, diet and lifestyle changes do not help coronary artery disease that is manifested by chest pain and shortness of breath.

When angioplasty eliminates the stenosis of the coronary artery and, if necessary, a stent is inserted, the blood flow to the heart will be restored and the symptoms will regress over time.

However, if a major coronary artery is clogged or more than one coronary artery is narrow or occluded, coronary artery bypass surgery, a major surgery, may be required.

 

Risks

The risks that may be faced in coronary angioplasty - a minimally invasive procedure - include:

Sudden occlusion: The blood vessel is re-occluded by a clot or plaque, after patency is achieved. To overcome this problem, the clogged segment is dilated again and a stent is placed.

Re-stenosis: If a stent is not inserted after the flow of blood in the blocked coronary artery is restored, the occlusion may recur. Re-stenosis usually depends on the persistence of risk factors (blood sugar, blood lipids and blood pressure).

In-stent stenosis: Plaque formations may develop in the lumen of the stent, resulting in a stenosis. This risk is lower in drug-eluting stents.

Other risks of coronary angioplasty include heart attack, stroke, organ problems, and cardiac rhythm disorders.

Our specialists will employ all practices to minimize the risk of complications and our doctors will preoperatively inform you about risks listed above and all other potential complications and will address all your concerns.

 

Preparation

Your doctor will review your health history and asses your overall health before the procedure.

Flat angiography device is available in our Cardiology and Cardiovascular Surgery Units and the heart and coronary arteries can be quickly images by MRI and CT.

In the second stage, coronary angiography will be performed to locate the stenosis and whether it can be treated with angioplasty or not. In the coronary angiography, a thin tube, called catheter, is inserted into an artery of groin or arm. Your coronary arteries are imaged by instilling a contrast agent through this tube.

Once the stenosis is located, your doctor can perform the angioplasty and stent placement in the same session, and if necessary, the procedure is postponed to a future session. However, if conditions allow, combination of angiography and angioplasty in the same session is preferred and it is also advantageous for the patient.

Excluding emergencies, an appointment is scheduled for coronary angiography and angioplasty, and you should stop eating and drinking for a certain period of time (six to eight hours) before the procedure. You will have blood tests, chest X-ray, ECG and other necessary examinations to have your overall health assessed.

Moreover, prescription and over-the-counter medications will be reviewed and you will be informed about medications that you should stop taking.

Surgery and early postoperative period

Coronary angioplasty is a minimally invasive procedure that does not necessarily require general anesthesia.

The patient is awake during the procedure, but sedative agents are used to calm down.

A small incision is made after local anesthesia is administered to the puncture site. An artery of your groin or your arm is most commonly preferred. After a guide wire is inserted into the artery, a catheter is advanced over this guide wire.  Contrast agent delivered through the catheter helps locating the stenosis or the occlusion of the coronary artery(ies). The thin balloon at the tip of the catheter is inflated at the stenotic segment and thus, stenosis is eliminated and the blood flow is restored. Your doctor may decide to place a stent to prevent recurrence of blockage.

If it is decided to insert a stent, the stent that is found in collapsed form in the catheter is advanced to the clogged coronary artery. Once the balloon is inflated, the stent is advanced, expanded and left at the site of stenosis.

After these processes are completed, images (angiograms) are captured again to see the final status of the coronary arteries. After the catheter is removed and the small incision is stitched, the procedure is completed.

After angioplasty, you usually stay in the hospital for one night and you are discharged after it is confirmed that your overall health is stable.

If a stent is placed, you should take medications that are prescribed by your doctor in the rest of your life.

Your doctor will inform and instruct you about what you should pay attention at home after the angioplasty, lifestyle changes and exercises.

You should immediately call your doctor or visit the closest healthcare facility or call state emergency service if you recognize bleeding or swelling of you feel pain at the catheter puncture site or if you recognize signs of local infection, such as redness, swelling and warmth or if you feel fever, shortness of breath or chest pain, after you are discharged.

 

Results

Coronary angioplasty opens the clogged or stenotic coronary artery and restores blood flow to the heart tissue. Thus, symptoms caused by the stenosis, such as chest pain, poor exercise capacity and shortness of breath regress or disappear.

However, since the stenosis or clogging is caused by risk factors, including but not limited to smoking, blood pressure, high blood lipids, cholesterol, diabetes mellitus and unhealthy nutrition, these risk factors should completely eliminated or reduced after the angioplasty period. Otherwise, recurrence of a stenosis or clogging in the unforeseeable future is inevitable

 

Pacemaker – Implantation of Pacemaker

 

Overview

Our heart is an almost entirely muscular organ that has four chambers with heart valves between the chambers. Our heart contracts to pumps blood to the body, while it relaxes to receive the venous blood to the heart. Contraction and relaxation occurs synchronously. On the other hand, the pumping rate or the heart rate is balanced against the oxygen and nutrient requirements of the body.  In a healthy individual, the heart rate is 60 to 100 beats per minute. It beats at a lower limit of this range at resting, while it accelerates above this range in situations that increase the body's oxygen need, such as exercise.

 

An electrical system within the heart tissue regulates the heart rate and the rhythm. Electrical impulses generated by the sinus node and the sinoatrial node are transmitted to the heart through the atrioventricular node followed by the own transmission system (electrical system) of the heart. Thus, upper two chambers of the heart, the atria, contracts and pumps blood to the lower two chambers, the ventricles. Then, ventricles contract to pump the blood to the body and lungs. This coordinated pumping function is accurately preserved. When a problem occurs in the heart's electrical system, disturbances are observed in the heart rate and/or rhythm. The impaired electrical system may be the usual consequence of aging, but genetic factors and certain medications may also affect the heart rate and the rhythm. In addition, the diseases that damage the heart muscle, such as coronary artery disease, also lead to a similar clinical picture.

 

The pacemaker is a device consisting of two parts: a generator (battery) and wires (electrodes). The generator contains a small electric circuit that functions to send signals to the heart. Electrical signals generated in the generator are sent or transmitted to the heart by means of these electrodes.

 

Why is this procedure done?

If the heart cannot regulate the heart rate and the rhythm, pacemakers undertake the function of regulating the heart rate and the rhythm by producing low-energy electrical signals and sending to the heart.

 

When synchronized, coordinated beat of the heart fails and the heart beats at a rate above or below the physiological ranges, the pacemaker synchronize and coordinate the rhythm and the rate by producing impulse. While the pacemaker is fulfilling this function, body's need for oxygen and nutrients is taken into consideration.

 

There are three types of pacemakers: single chamber, double chamber and biventricular pacemakers. You may seek details about pacemakers from your cardiologist.  Your cardiologist will determine the most suitable pacemaker for your problem and explain it to you.

 

The pacemaker is used to treat the following conditions:

  • Acceleration of low heart rate (bradycardia)
  • Regulation of abnormal or rapid heart rhythm
  • Control of rhythm disorders such as atrial fibrillation
  • Coordination of signal transmission between the ventricles, between the atria and between the ventricles and the atria

 

The coordination of the conduction between the ventricles is called cardiac synchronization therapy (CRT) and it is used in the treatment of heart failure. Pacemaker alone or implantable cardioverter defibrillators can be used in cardiac resynchronization therapy. Implantable cardioverter defibrillator (ICD) plays a role in the treatment of the life-threatening arrhythmias. The ICD uses high-energy electric currents to treat the fatal rhythm disorder, referred to as fibrillation.

 

Risks

Although pacemaker implantation is an invasive procedure, potential risks are low. The life-threatening complications are very rare.

 

In the pacemaker laboratory, where the pacemaker is implanted, any and all necessary instrument, equipment and other means to manage the possible risks and complications are available.

 

The risks that can be faced while implanting the pacemaker are listed below:

  • Infection
  • Bleeding
  • Injury or tear of blood vessels
  • Anesthesia-related complications
  • Allergic reaction against contrast agent

 

Our specialists will employ all practices to minimize the risk of complications and our doctors will preoperatively inform you about risks listed above and all other potential complications and will address all your concerns.

 

Preparation

The first phase of preoperative preparation is same in all Our Hospitals. Once your doctor determined that the most appropriate treatment option for your disease is placement of a pacemaker, your general health is checked to see if you may undergo a surgery. If necessary, you will be started on life style changes and diet to prepare you better for the surgery. At the same time, the concomitant diseases, which will increase the likelihood of complications in the surgery, are also treated.

 

After it is verified that the surgery does not pose risk, you will be asked to quit smoking, if you are a smoker, and to stop taking certain medications that increase risk of bleeding. All other prescribed and over-the-counter medications, herbal products and supplements will also be questioned and you will be informed to continue or stop taking them.

 

When these preparations are completed and you reach the pre-operative phase, the following procedures are performed.

 

  • Review of health history
  • A detailed physical examination
  • Evaluation of cardiac functions and structures by ECG, Echocardiography and Holter monitoring.
  • Evaluation of the heart’s electric system with an electrophysiology study, if required
  • Necessary laboratory tests and radiology studies

Assessment by anesthesiologist and other laboratory tests and radiology studies to minimize anesthesia-related complications

 

You will also be instructed to stop eating and drinking at a particular time before the surgery and you should strictly follow this instruction in order to undergo the surgery at the scheduled date.

 

Moreover, it is reasonable to plan discharge, post-discharge accommodation and travel at this phase in order to manage postoperative period better.

 

Surgery and early postoperative period

After you have been taken to the pacemaker implantation laboratory for the procedure, you will be positioned on the procedure table. According to the method determined by the doctor, the procedure may also be performed in the operating room.

 

An IV line is inserted to allow intravenous treatments and administered medications, if necessary. At this stage, a sedative agent is administered to make you fall into a nap.

 

All your vital signs will be closely monitored using ECG, pulse oxymeter and anesthesia monitor.

 

General anesthesia is usually not required to place pacemaker. In other words, you will be conscious throughout the procedure, but you can feel slightly sleepy.

 

The skin is cleaned at location, where the generator will be implanted. A local anesthetic agent is administered before the incision is made. The pacemaker is placed beneath the skin by making an incision on the skin of the rib cage. Electrodes to be connected to the pacemaker are advanced to the heart through a vein. Meanwhile, fluoroscopic imaging is done, a modality similar to the angiographic imaging. One end of the electrodes is connected to the heart, while the other end is connected to the generator placed in the upper part of the rib cage. The incision made to place the generator is closed.

 

This method is an endocardial approach and a minimally invasive procedure. This is the most common method. The pacemaker and electrodes are placed on the rib cage. There is no need to general anesthesia in this procedure.

 

In the epicardial approach that is less frequently used, the pacemaker is placed beneath the abdominal skin and the electrodes are again advanced to the heart through a vein. This procedure is carried out in the operating room and requires general anesthesia.

 

After the pacemaker and electrodes are placed, the surgical part of the procedure is completed.

 

First, your doctor tests the electrodes. After the signal transmission is verified, the pacemaker is programmed in the light of the pre-operative tests (ECG, Echocardiography, Holter, Cardiac Stress Test) and the symptoms of your illness.

 

Placement of a pacemaker takes about 2 to 5 hours.

 

You will be transferred to the observation room, after the pacemaker is placed. Before you are transferred to the patient room, you should be observed here for a while and it should be verified that all your vital signs are stable or within acceptable limits. If you need critical care, you may be admitted to the intensive care unit.

 

You will be asked to stay at the hospital for one night after the pacemaker is placed. You will be discharged when your general health is stabilized and your pacemaker's settings are completed.

 

Before you are discharged, your medications will be planned and prescribed and, suggestions will be made that you need to take into account after the surgery (time to start work, engage in daily life activities and do exercise and sex life etc).

 

Before being discharged, your doctor will inform you about security systems, magnetic resonance imaging, radiation therapy, and other electrical and electronic devices that may affect the operation of your pacemaker. Security systems, such as ones equipped at airports, will alert because of your pacemaker. You may be given a medical report that your body has a pacemaker implanted in order not to have a problem with security personnel.

 

You should see your surgeon for follow-up visits that are scheduled before you are discharged.

 

If you experience warmth and redness in your incision line, or if you have a fever or any symptoms that you think are due to surgery after you are discharged, contact your surgeon immediately.

 

Results

After the pacemaker is placed and programmed, symptoms (fainting, shortness of breath, exhaustion, fatigue, chest pain) arising out of the fast or slow functioning of your heart or rhythm disorders will disappear.

 

You should take your medicines, as instructed by your doctor, and comply with health life style recommendations. Do not smoke or quit smoking, if you are a smoker, and you need to maintain optimal body weight and control your blood pressure, blood glucose and blood lipids well.

 

 

Coronary angiography

Overview

Coronary arteries are blood vessels that carry oxygen and nutrients to the heart tissue.

Angiography is a medical term that means the visualization of blood vessels.

Therefore, coronary angiography is an imaging study aimed to image coronary arteries.

Since coronary arteries are the vessels that feed the heart, narrowing and occlusions cause damage to the heart tissue, resulting in loss of cardiac functions over time.

To view the coronary arteries, a guide wire is first inserted into an artery of your body. Then, a thin tube, called a catheter, is inserted into the artery through the guide wire. The catheter is advanced over the guidewire to the heart. A contrast agent is administered through the lumen of the catheter and images of coronary arteries are obtained by an imaging device and viewed on a monitor, both available in the procedure room.

Cardiac catheterization implies all procedures carried out until the imaging phase. The room where coronary angiography is performed is the cardiac catheterization laboratory.

Nevertheless, since the primary goal is to minimize damage to the patient for all diseases, non-invasive imaging methods that do not require catheter placement are used before a coronary angiography is considered. Non-catheter Coronary Artery Angiography and MRI Angiography are available in order to be used by our Cardiology and Cardiovascular Surgery Clinics, and these imaging modalities do not require preliminary preparation and catheterization.

Besides, the need for coronary angiography should be supported by non-invasive tests that provide important information about functions of the heart, such as ECG and echocardiography.

 

Angiography in 4 Seconds

What is Coronary Angiography in Four Seconds? What are indications?

Coronary artery disease is the most common cause of death in developed and developing countries, like our country. Unfortunately, almost half of patient dies while they are transferred to the hospital. This fact had motivated doctors to diagnose the condition early in order to reduce deaths.

Until recently, we had some methods to make early diagnosis, such as cardiac stress test, Echocardiography and Heart Scintigraphy. An insidious disease can be diagnosed by 80% with these methods. Diagnostic value of these methods can sometimes be below 50% in some conditions. Conventional coronary angiography is an invasive method that is used for the definitive diagnosis of the disease, but it requires penetration in coronary arteries and poses some risks, albeit low.

Now, thanks to the developing technology, there is a method that can identifiy the patients especially who are in risk group with almost 100% accuracy. It is a tomography-based method that does not require puncture into cardiac vessels. Accuracy is almost 100 percent and it is a very short lasting procedure; on the contrary to conventional angiography, patient should not stay on bed for 6 hours. Since medications are administered into veins, no problem is faced that is related to the vessel, where medication is administered.

It is even more frequently used by cardiologists since more detailed information is provided about the plaque, the mixture of fat and calcium that occludes the coronary arteries and this information is more useful when treatment is planned for the patient.

There are some factors that determine safety of this valuable technique; and patients should be informed about those factors.

The first one is about the technology of the device. Heart is a moving organ and a device that is supposed to examine the coronary arteries measuring approximately 2-3 mm in diameter in this moving organ should process images very fast. Number of slices is the main factor that determine the process rate. While number of slices was 4, 8, 16 and 40 in old fashioned devices – too low to image a moving organ-, 64 slices are used by new generation devices. Therefore, both patients and doctors should know the number of slices and prefer devices with higher number of slices. One another issue is the experience of the doctor or the team of doctor who review the procedure. Patients should prefer more specialized centers that are further focused in the field of cardiology.

This is an easy method for patients and the procedure lasts only for four seconds after radio-opaque substance is intravenously administered and the patient holds breath.

This method is safely used to determine whether there is an insidious coronary artery disease especially in patients with diabetes, hypertension and family history notable for coronary artery disease as well as smokers even if there is no cardiac complaint. However, patients should necessarily be assessed by a cardiologist before this examination is considered. Because not every patient is eligible for this method and some medications should be given and some measures should be taken before the procedure.

 

Why is this procedure done?

Since coronary arteries are the vessels that feed the heart, narrowing and occlusions cause damage to the heart tissue, resulting in loss of cardiac functions over time. This condition that is manifested by chest pain, shortness of breath (dysepnia) and poor exercise capacity can lead to serious problems, even including death, if it is left untreated.

Coronary angiography is performed for imaging coronary arteries in patients with typical findings of a heart disease, such as chest pain (angina),dyspnea, and chest pain spreading to left arm and jaw. It is also a method of identifying congenital heart defects, cardiac valve diseases and other problems in blood vessels and treating them in the same session, if possible.

 

Risks

Although the possibility of encountering a risk in coronary angiography is very low, there are still some potential risks. In cardiac catheterization laboratory - the room where coronary angiography is performed-, any and all necessary instrument, equipment and other means to manage the possible risks and complications are available.

  • Perforation of the artery imaged
  • Cardiac rhythm disorders
  • Allergic reactions against the contrast agent
  • Bleeding in the punctured artery or another artery located on the route of catheterization
  • Infection
  • Heart attack

Our specialists will employ all practices to minimize the risk of complications and our doctors will preoperatively inform you about risks listed above and all other potential complications and will address all your concerns.

 

Preparation

Coronary angiography is performed in two ways, planned (elective) or urgent.

For the urgent angiography, after the patient is admitted to the catheterization laboratory, the basic procedures are applied, such as cleaning the catheter puncture site and administering the necessary medications and the local anesthetic.

In planned or elective coronary angiography, an appointment is first scheduled for the coronary angiography.

A cardiologist and/or other healthcare professional will inform you about what you need to do before you visit the catheterization laboratory at the appointment date. The time you will stop eating and drinking will be instructed. Medications you take for diabetes, hypertension and other disorders are reviewed. You are informed about medications that you should take in the day of the procedure. Besides, you should also inform your doctor about all over-the-counter medications, herbal products and vitamin and mineral supplements.

Before the procedure is performed, your health history is reviewed and a comprehensive physical examination is done, in which all your vital signs (pulse, heart rate, breath rate, core temperature, etc.) are evaluated.

Surgery and early postoperative period

After you have been taken to the catheterization laboratory for the procedure, you will be positioned on the procedure table. This table allows various positions during the procedure. In addition, there are mobile imaging devices that can move around the table to capture images.

An IV line is inserted to allow intravenous treatments and administered medications, if necessary. At this stage, a sedative agent is administered to make you fall into a nap.

All your vital signs will be closely monitored using ECG, pulse oxymeter and anesthesia monitor.

Although an artery located in your groin area is more commonly used for coronary angiography, it is possible to use an artery of your arm.

 

Radial Angiography (angiography with puncture of radial artery)

The radial artery (an artery in wrist) was first punctured for coronary angiography and PTCA (Balloon dilatation) – stent implantation in 1989. This approach was first adopted by a clinic as routine method for coronary angiography and coronary interventions in 1996. Next, other heart clinics around the world started to use this method. At global scale, almost 500 clinics puncture wrist artery (RADIAL Artery) for coronary angiography, balloon dilatation and stent implantation instead of femoral artery.

The main superiority of radial angiography (coronary angiography with the puncture of radial artery) to angiography with the puncture of femoral artery originates from reduced risk and boosted comfort for patients.

While the risks of vascular dilatation at the puncture site, abnormal links between the artery and the vein, inguinal swelling secondary to uncontrolled bleeding, severe pain and other problems that limit mobilization of the patient are high in angiography with the puncture of femoral artery, they are almost zeroed if radial artery is punctured. Moreover, the possible risk is much lower since radial artery is very thin and there is a second artery that lies parallel to it. Even the radial artery that is punctured occludes, the risk of facing a serious problem is low.

Considering comfort of the patient, radial angiography does not require lying completely immobile on the bed and meeting need to urinate and defecate in the bed – obvious problems for almost everyone. In radial angiography, patients walk to and leave the procedure room independently. They need no assistance for going to bathroom and they are not obliged to stay in bad for 6 hours unlike the angiography with the puncture of femoral artery. In radial angiography, patients are observed for 3 to 4 hours, while mobilization is not limited.

Radial angiography is a technique that is ever increasingly preferred worldwide for the past 7-8 years due to above mentioned advantages.

With novel cardiologic diagnostic and therapeutic methods;

Pediatric Cardiology team offers healthcare services, including diagnosis, invasive procedures and non-surgical repair of congenital cardiac septal defects, for all pediatric age ranges starting from neonatal period, Non-operative intervention to stenosis of heart valves with interventional angiography,

Electrophysiology method that enables interventional management of heart rhythm disorders,

The tissue echocardiography and stress echocardiography combined in a single device,

Thallium scintigraphy that shows the extent vessels supply blood to cardiac muscles,

Cardiac stress test with real-time analyses that produce mean values,

Rhythm Holter that monitors cardiac rhythm of patients for 24 to 48 hours,

Ambulatory Blood Pressure Holter that monitors blood pressure of patients for 24 hours,

Cardiac MRI runs heart scans to diagnose and follow up disorders of the cardiovascular system.

Flat Panel angiography device enables physicians to diagnose and manage cardiovascular diseases very successfully.

 

After the artery that the catheter will be inserted is determined, the local anesthetic is instilled beneath the skin to make sure you do not feel any pain.

Next, a small incision is made over the artery located at the catheter puncture site and the guide wire is inserted into the artery. Then, the catheter is advanced over the guide wire and contrast agent that helps to visualize the vessels is injected. After all cardiac structures and coronary arteries are visualized, if an abnormality is identified, it is treated in the same session, if possible. Possible treatments include embolectomy, stent placement, repair of congenital and acquired structural abnormalities, and a series of other procedures, mostly related to cardiac rhythm disorders.

Next, the catheters are removed and the procedure is terminated by stitching the small incision.

After the angiography, you will be taken to the observation room. Before you are transferred to the patient room, you should be observed here for a while and it should be verified that all your vital signs are stable or within acceptable limits.

Especially if the artery located in your groin is used, bleeding should be carefully monitored and managed after the angiography. For this purpose, it may be necessary to apply compression on the small incision made in the groin.

Discharge after coronary angiography is entirely related to your health status. If there is no any abnormality, you will usually be discharged on the same day. But, if an abnormality has been identified and intervened, your cardiologist will want you to stay in the hospital for one night or longer, if necessary.

After discharge from the hospital, if you experience signs of infection such as pain, redness and swelling at the incision site in the groin, significant swelling or bleeding at the catheter site, and if you experience chest pain or shortness of breath, it is a vital necessity to seek emergency medical treatment immediately.

 

Results

Coronary angiography images your heart and coronary arteries to explore an abnormality or a problem.

If any problem is identified, it is usually managed in the same session, if and whenever possible, and therefore, your complaints, such as chest pain and shortness of breath, will regress.

However, there may be a problem that requires a major surgery, and thus, your doctors will have the opportunity to prepare you for the major surgery at elective settings.

 

 

Pacemaker – Implantation of Pacemaker

 

Overview

Our heart is an almost entirely muscular organ that has four chambers with heart valves between the chambers. Our heart contracts to pumps blood to the body, while it relaxes to receive the venous blood to the heart. Contraction and relaxation occurs synchronously. On the other hand, the pumping rate or the heart rate is balanced against the oxygen and nutrient requirements of the body.  In a healthy individual, the heart rate is 60 to 100 beats per minute. It beats at a lower limit of this range at resting, while it accelerates above this range in situations that increase the body's oxygen need, such as exercise.

 

An electrical system within the heart tissue regulates the heart rate and the rhythm. Electrical impulses generated by the sinus node and the sinoatrial node are transmitted to the heart through the atrioventricular node followed by the own transmission system (electrical system) of the heart. Thus, upper two chambers of the heart, the atria, contracts and pumps blood to the lower two chambers, the ventricles. Then, ventricles contract to pump the blood to the body and lungs. This coordinated pumping function is accurately preserved. When a problem occurs in the heart's electrical system, disturbances are observed in the heart rate and/or rhythm. The impaired electrical system may be the usual consequence of aging, but genetic factors and certain medications may also affect the heart rate and the rhythm. In addition, the diseases that damage the heart muscle, such as coronary artery disease, also lead to a similar clinical picture.

 

The pacemaker is a device consisting of two parts: a generator (battery) and wires (electrodes). The generator contains a small electric circuit that functions to send signals to the heart. Electrical signals generated in the generator are sent or transmitted to the heart by means of these electrodes.

 

Why is this procedure done?

If the heart cannot regulate the heart rate and the rhythm, pacemakers undertake the function of regulating the heart rate and the rhythm by producing low-energy electrical signals and sending to the heart.

 

When synchronized, coordinated beat of the heart fails and the heart beats at a rate above or below the physiological ranges, the pacemaker synchronize and coordinate the rhythm and the rate by producing impulse. While the pacemaker is fulfilling this function, body's need for oxygen and nutrients is taken into consideration.

 

There are three types of pacemakers: single chamber, double chamber and biventricular pacemakers. You may seek details about pacemakers from your cardiologist.  Your cardiologist will determine the most suitable pacemaker for your problem and explain it to you.

 

The pacemaker is used to treat the following conditions:

  • Acceleration of low heart rate (bradycardia)
  • Regulation of abnormal or rapid heart rhythm
  • Control of rhythm disorders such as atrial fibrillation
  • Coordination of signal transmission between the ventricles, between the atria and between the ventricles and the atria

 

The coordination of the conduction between the ventricles is called cardiac synchronization therapy (CRT) and it is used in the treatment of heart failure. Pacemaker alone or implantable cardioverter defibrillators can be used in cardiac resynchronization therapy. Implantable cardioverter defibrillator (ICD) plays a role in the treatment of the life-threatening arrhythmias. The ICD uses high-energy electric currents to treat the fatal rhythm disorder, referred to as fibrillation.

 

Risks

Although pacemaker implantation is an invasive procedure, potential risks are low. The life-threatening complications are very rare.

 

In the pacemaker laboratory, where the pacemaker is implanted, any and all necessary instrument, equipment and other means to manage the possible risks and complications are available.

 

The risks that can be faced while implanting the pacemaker are listed below:

  • Infection
  • Bleeding
  • Injury or tear of blood vessels
  • Anesthesia-related complications
  • Allergic reaction against contrast agent

 

Our specialists will employ all practices to minimize the risk of complications and our doctors will preoperatively inform you about risks listed above and all other potential complications and will address all your concerns.

 

Preparation

The first phase of preoperative preparation is same in all Hospitals. Once your doctor determined that the most appropriate treatment option for your disease is placement of a pacemaker, your general health is checked to see if you may undergo a surgery. If necessary, you will be started on life style changes and diet to prepare you better for the surgery. At the same time, the concomitant diseases, which will increase the likelihood of complications in the surgery, are also treated.

 

After it is verified that the surgery does not pose risk, you will be asked to quit smoking, if you are a smoker, and to stop taking certain medications that increase risk of bleeding. All other prescribed and over-the-counter medications, herbal products and supplements will also be questioned and you will be informed to continue or stop taking them.

 

When these preparations are completed and you reach the pre-operative phase, the following procedures are performed.

 

  • Review of health history
  • A detailed physical examination
  • Evaluation of cardiac functions and structures by ECG, Echocardiography and Holter monitoring.
  • Evaluation of the heart’s electric system with an electrophysiology study, if required
  • Necessary laboratory tests and radiology studies

Assessment by anesthesiologist and other laboratory tests and radiology studies to minimize anesthesia-related complications

 

You will also be instructed to stop eating and drinking at a particular time before the surgery and you should strictly follow this instruction in order to undergo the surgery at the scheduled date.

 

Moreover, it is reasonable to plan discharge, post-discharge accommodation and travel at this phase in order to manage postoperative period better.

 

Surgery and early postoperative period

After you have been taken to the pacemaker implantation laboratory for the procedure, you will be positioned on the procedure table. According to the method determined by the doctor, the procedure may also be performed in the operating room.

 

An IV line is inserted to allow intravenous treatments and administered medications, if necessary. At this stage, a sedative agent is administered to make you fall into a nap.

 

All your vital signs will be closely monitored using ECG, pulse oxymeter and anesthesia monitor.

 

General anesthesia is usually not required to place pacemaker. In other words, you will be conscious throughout the procedure, but you can feel slightly sleepy.

 

The skin is cleaned at location, where the generator will be implanted. A local anesthetic agent is administered before the incision is made. The pacemaker is placed beneath the skin by making an incision on the skin of the rib cage. Electrodes to be connected to the pacemaker are advanced to the heart through a vein. Meanwhile, fluoroscopic imaging is done, a modality similar to the angiographic imaging. One end of the electrodes is connected to the heart, while the other end is connected to the generator placed in the upper part of the rib cage. The incision made to place the generator is closed.

 

This method is an endocardial approach and a minimally invasive procedure. This is the most common method. The pacemaker and electrodes are placed on the rib cage. There is no need to general anesthesia in this procedure.

 

In the epicardial approach that is less frequently used, the pacemaker is placed beneath the abdominal skin and the electrodes are again advanced to the heart through a vein. This procedure is carried out in the operating room and requires general anesthesia.

 

After the pacemaker and electrodes are placed, the surgical part of the procedure is completed.

 

First, your doctor tests the electrodes. After the signal transmission is verified, the pacemaker is programmed in the light of the pre-operative tests (ECG, Echocardiography, Holter, Cardiac Stress Test) and the symptoms of your illness.

 

Placement of a pacemaker takes about 2 to 5 hours.

 

You will be transferred to the observation room, after the pacemaker is placed. Before you are transferred to the patient room, you should be observed here for a while and it should be verified that all your vital signs are stable or within acceptable limits. If you need critical care, you may be admitted to the intensive care unit.

 

You will be asked to stay at the hospital for one night after the pacemaker is placed. You will be discharged when your general health is stabilized and your pacemaker's settings are completed.

 

Before you are discharged, your medications will be planned and prescribed and, suggestions will be made that you need to take into account after the surgery (time to start work, engage in daily life activities and do exercise and sex life etc).

 

Before being discharged, your doctor will inform you about security systems, magnetic resonance imaging, radiation therapy, and other electrical and electronic devices that may affect the operation of your pacemaker. Security systems, such as ones equipped at airports, will alert because of your pacemaker. You may be given a medical report that your body has a pacemaker implanted in order not to have a problem with security personnel.

 

You should see your surgeon for follow-up visits that are scheduled before you are discharged.

 

If you experience warmth and redness in your incision line, or if you have a fever or any symptoms that you think are due to surgery after you are discharged, contact your surgeon immediately.

 

Results

After the pacemaker is placed and programmed, symptoms (fainting, shortness of breath, exhaustion, fatigue, chest pain) arising out of the fast or slow functioning of your heart or rhythm disorders will disappear.

 

You should take your medicines, as instructed by your doctor, and comply with health life style recommendations. Do not smoke or quit smoking, if you are a smoker, and you need to maintain optimal body weight and control your blood pressure, blood glucose and blood lipids well.