Resources - DrCRaghu

Background
Management of Heart Failure (HF) continues to be challenging despite the formidable advances in medical and intervention therapy. Establishment of the four pillars – Angiotensin Converting Enzyme (ACE) inhibitors/Angiotensin Receptor Blockers (ARB)/Angiotensin Receptor blocker-Neprilysin inhibitor (ARNi), Beta blockers, Mineralocorticoid Receptor Antagonist (MRA) and Sodium Glucose Co-Transporter2 inhibitors (SGLT2i) in the recent decade has paved way for the effective management of HF. The adaptation of these drugs into clinical practice continues to be low despite the robust evidence in clinical trials. Agents that increase cardiac contractility (inotropes) for the treatment of Heart Failure with reduced Ejection Fraction (HFrEF) – defined as left ventricular ejection fraction (LVEF) of less than 40%, have paradoxically increased the mortality rates instead of improving1. This is due to the increase of myocardial oxygen consumption as well as myocardial injury whilst increasing contractility. The established four pillars of HFrEF management improve the efficiency of heart function through indirect mechanisms rather than directly improving the cardiac contractility.

The Drug
Omecamtiv Mecarbil belongs to a new class of cardiac positive inotrope agents called “myotropes” that improve cardiac contractility without increasing the myocardial oxygen consumption. Phase 2 trials – COSMIC HF and ATOMIC HF with this agent have established the efficacy of this agent. Considering the adverse effects observed previously with other inotrope agents a phase 3 study, is essential for this molecule to be adapted into clinical practice. The recently published Global Approach to Lowering Adverse Cardiac Outcomes through Improving Contractility in Heart Failure (GALACTIC-HF) trial, conducted on 8266 patients demonstrated a modest but significant benefit with this agent.

GALACTIC HF analysis
Patients with LVEF less than 35% who are on established medical therapies received Omecamtiv Mecarbil versus placebo in this study. The study agent showed an 8% reduction in the combined event rate of cardiac mortality and HF hospitalization over and above that achieved with the four pillars. At the same time, this agent did not increase myocardial injury or infarction or arrhythmia rates. The benefit of this agent was observed predominantly in those with LVEF <28% in the primary analysis2. Patients admitted into Intensive Care units were also benefitted despite their predicted poor expected outcomes. In a recent sub group analysis, the benefit was most pronounced when the LVEF < 25% and for those in sinus rhythm without increasing sudden cardiac death3. Improvement in LVEF in modest numbers was also found. The use of SGLT2i in only 2% of patients is the limitation for this trial – SGLT2i were not proven to be beneficial in the management of HF when GALCTIC HF trial was conducted.

Take Home Message
Omecamtiv Mecarbil is an important addition rather than an alternative to the established therapies for HFrEF4. Marked benefit seen in patients with LVEF <25% and sinus rhythm highlights the importance of using this agent in select groups leading to a personalized approach to HF therapy5.

References:

Ahmad T, Miller PE, McCullough M, et al. Why has positive inotropy failed in chronic heart failure? Lessons from prior inotrope trials. Eur J Heart Fail 2019; 21: 1064-78.
Swedberg K. Stimulation of Contractility in Systolic Heart Failure. N Engl J Med. 2021; 382: 178-179.
Teerlink JR, Diaz R, Felker GM et al. GALACTIC-HF Investigators. Effect of Ejection Fraction on Clinical Outcomes in Patients Treated With Omecamtiv Mecarbil in GALACTIC-HF. J Am Coll Cardiol. 2021 Jul 13; 78: 97-108.
Teerlink JR, Diaz R, Felker GM, et al. Cardiac myosin activation with omecamtiv mecarbil in systolic heart failure. N Engl J Med 2021; 384:105-16.
Ferreira JP. Omecamtiv Mecarbil: A Personalized Treatment for Patients With Severely Impaired Ejection Fraction. J Am Coll Cardiol. 2021 Jul 13; 78: 109-111.

Key Words:

Heart Failure
Inotropes
Myotropes
GALCTIC HF trial
Personalized Heart Failure treatment

The aortic valve guards flow of blood from the heart to the rest of the body. The major blood vessel that carries blood to the various organs of the body is the aorta and hence this valve is named aortic valve.
Aortic stenosis is a condition where the aortic valve narrows due to various causes. Most commonly ageing consequent degeneration of aortic valve causes the narrowing thus restricting blood flow to other organs.
Transcatheter Aortic Valve Replacement (TAVR or TAVI) is a procedure where the damaged valve is replaced by an artificial valve.
TAVR is a minimally invasive procedure and does not require splitting open of chest or general anaesthesia.
Through an incision, in the groin, an aortic valve mounted on a catheter will be introduced into the heart.
- Aortic valve degenerates with ageing due to wear and tear. This happens usually beyond the age of 65 years. Many at that age have associated issues like previous heart surgery, kidney dysfunction, blocks in blood vessels supplying heart and brain, age-related frailty, lung problems etc. These issues make them a high risk for open-heart surgery.
- Initially, TAVR was indicated for high-risk patients but for the past 5 years is being used in intermediate-risk and selected low-risk cases also.
- Then, an artificial valve is directed into the aortic valve, where it can be expanded and further takes over the function of a diseased valve resulting in improved blood flow.TAVR became a revolutionary popular procedure?
- - High riskforopen-heart surgery
  - History of kidney or lung diseases and cannot undergo invasive procedures/surgery
  - Having previous valve replacement surgery that gets narrowed again.
  Who are not eligible to undergo TAVR procedure?
  - Previous mechanical valve surgery at the aortic valve location.
  What are the risks of the TAVR procedure?
  
  Generally, the TAVR procedure is safe and effective. However, some problems may occur in 1-3% of cases based on an individual’s characteristics which include:
  - Bleeding due to damage of blood vessels
  - Brain stroke
  - Infection
  - Heart attack
  - Kidney failure
  - Failure of the new artificial valve
  What are the potential complications of the TAVR procedure?
  - Paravalvular regurgitation
  - Pacemaker implantation
  - Valve thrombosis
  - Bleeding
  - Infective endocarditis
  - Death
  These can potentially affect 0.5-7% of patients.
  
  What are diagnostic tests to undergo before the TAVR procedure?
  - Electrocardiogram
  - Echocardiogram
  - Transesophageal echocardiogram
  - Carotid Ultrasound
  - CT aortogram
  What happens during TAVR procedure?
  - Small incisions are made in the groin for catheter insertion. Ongoing X-ray imaging will guide the catheter towards the aortic valve and the balloon at the end of the catheter may be inflated to open the aortic valve.
  - Then an artificial aortic valve will be directed through the catheter and placed over the diseased valve and deployed.
  - Echocardiography will be done to check for the functioning of the new aortic valve.
  What happens after the TAVR procedure?
  - Vitals such as Blood pressure, heart rate, temperature, respiration rate, blood oxygen level will be monitored, the patent is restedin the ICU for 24 hours.
  - Patient hospital stay will be 2 to 4 days.
  - If the catheter insertion is at the groin area, you may ask for not bend or cross your legs
  - Infections and bleeding manifestations are checked at the insertion site
  - You will be instructed to keep hydrated that will help you in washing off the contrast dye
  - Blood tests, Chest X-ray,Electrocardiogram(ECG), Echocardiogram will be done
  How long does my TAVR procedure last?
  - TAVR is a durable procedure and lasts for 10 to 20 years in the absence of complications.
  - Compared to surgical replacement of the aortic valve, TAVR provides a larger valve area and hence chances for re-narrowing are less.
  What is the uniqueness of treatment of TAVR by Dr C Raghu?
  - Availability of multimodality imaging leading to accurate diagnosis of the problem and associated co-morbidities.
  - One of the earliest cardiologists in India to have performed TAVR.
  - The first operator in South India to have performed TAVR in a patient with a previous mitral valve replacement.
  - Excellent pre-procedure planning leading to a highly successful result.
  Keywords:
  
  Open heart surgery
  
  Mechanical valve
  
  Pacemaker
  
  Valve Thrombosis
  
  Infective endocarditis
  
  Echocardiograms
  
  Carotid ultrasound
  
  Ct Aortogram
  
  Artificial aortic valve
  
  TAVR procedure
  
  Fast recovery rate
  
  Small incision
  
  Cardiologist
  
  Mitral valve replacement
  
  Who are eligible to undergo TAVR procedure?

The heart has 3 layers of tissue:

Pericardium – The thin outer layer that protects the heart
Myocardium – a thick muscular middle layer that contracts and pumps out blood
Endocardium – a thin inner lining

Inside the heart, there are four chambers- the upper two are right and left atria and lower two are right and left ventricles. The atria receive the blood that comes to the heart and the ventricles pump blood out from the heart. The right and left side of the heart is separated by a septum.

The heart also has 4 valves which allow unidirectional flow of blood every time the heart beats.

the tricuspid valve is between the right atrium and right ventricle.
The pulmonary valve is between the right ventricle and the pulmonary artery.
The mitral valve is between the left atrium and left ventricle.
The aortic valve is between the left ventricle and the aorta.

The electrical system of heart:

The pumping action of the heart is controlled by the heart’s electric system. As an electrical impulse moves through the heart muscles, the various chamber of heart coordinate and pump out blood.

An electrical stimulus is generated by the sinus node (also called the natural pacemaker) which is located in the right atria of the heart. This stimulus activates the atrial muscles. The electrical stimulus then travels down through the conduction pathways and causes the heart’s ventricles to contract and pump out blood. The atria contract first, just a few milliseconds before the ventricles. This allows the blood from the atria to enter into the ventricles which is pumped out later.

Mitral stenosis is the narrowing of the valve present between the left chambers of the heart (mitral valves), thereby blocking the blood flow. This condition usually develops several years after a person had a rheumatic fever. Mitral stenosis is treated with balloon valvotomy, when the medications do not reduce the symptoms. If left untreated, mitral stenosis can result in various heart complications.

Mitral valvotomy (or valvuloplasty), also known as percutaneous balloon dilation, is a minimally invasive procedure that involves widening a mitral valve using a balloon catheter, a thin, flexible tube with a balloon at the tip. This procedure improves the overall function of the heart.

What are the risks of mitral valvuloplasty?

The risks associated with percutaneous balloon dilation include:

Blood clot formation or tears in the heart
Backward flow of the blood (mitral valve regurgitation) due to damaged valve
Restenosis of the mitral valve

What happens before the procedure?

Your doctor will explain the procedure in detail and provide you the opportunity to ask any questions; do not hesitate to ask any questions related to the procedure.

Your healthcare team will give you certain instructions to prepare for the procedure:

You will be asked not to eat or drink anything after midnight, on the previous night of the procedure; you can drink water up to 4 hours of the procedure.
A blood test may be done to evaluate the time required for the blood to clot; other blood tests may also be performed.
You may be asked to stop taking certain medicines that may involve with the blood clotting process.

Notify your doctor if you:

Had an allergic reaction to any contrast dye, iodine or seafood.
Are sensitive to any medications, tape, latex, or anaesthetic agents.
Have a pacemaker.
Have any body piercings on the abdomen or chest.
All the medications you are taking, including over-the-counter drugs, herbal supplements, blood thinners, etc.
Have heart valve disease, as antibiotic drugs may be given before this procedure.
Have a history of bleeding disorders
Are or may be pregnant

Before the procedure, the area near the catheter insertion site (the groin area) may be shaved. Your physician may order other preparations for the procedure based on your medical condition.

How is mitral valvuloplasty performed?

On the day of the procedure, you should remove your jewellery and other objects that may interfere with the procedure. You will be asked to change into a hospital gown and empty your bladder before the procedure.

An intravenous (IV) line will be attached to your arm or hand to inject medications and administer IV fluids, if needed. You may receive a sedative to help you relax.

The following are the steps generally involved in a balloon valvuloplasty:

A local anaesthetic is injected at the insertion site.
Once the anaesthesia sets in, a sheath or an introducer (a plastic tube) will be inserted into the blood vessel.
A valvuloplasty catheter is inserted through the sheath into the blood vessel. The catheter is advanced through the aorta into the heart valve. The catheter may be guided by a fluoroscopy (a special x-ray).
Once the catheter reaches the precise location, a contrast dye is injected into the valve to get a clear image of the area.
The balloon is then inflated and deflated several times.
The catheter is then removed.
The catheter insertion site is closed using a sterile bandage.

What happens after the procedure?

After the procedure, you will be moved to the recovery room. You should remain flat on bed for several hours after the procedure. Your vital signs, and circulation and sensation in the affected arm or leg, the insertion site will be monitored regularly.

Medicines may be given for pain or discomfort near the insertion site. You will be asked to drink water and other fluids to eliminate the contrast dye from your body. You can return to your regular diet after the procedure.

Mostly, you may have to spend the might in the hospital, based on your medical condition and recovery.

Your healthcare team will give you instructions to be followed after leaving the hospital:

Keep a check on the insertion site for unusual pain, bleeding, swelling, or discoloration.
Keep the insertion site clean and dry.
Do not participate in any strenuous activities. Your doctor will inform you when you can resume normal activities and return to work.

Call your doctor immediately if you have any of the following:

Fever or chills
Severe pain, swelling, redness, bleeding or other leakage from the insertion site
Numbness, coolness or tingling sensations in the affected extremity
Pain or pressure in the chest, nausea or vomiting, sweating, or dizziness
Reduced urination
Swelling of the abdomen or extremities
Over 3 pounds weight gained in a day

Cardiac disease is the common cause of death throughout the world. Among these, 85% of death are due to heart attack and stroke.

A heart attack occurs when the cholesterol plaque accumulates in the walls of the coronary arteries (blood vessels that deliver blood to the heart). People with the possible symptoms of a heart attack can confirm the diagnosis by coronary angiography. Coronary angiography is a procedure that combines contrast dye and X-rays to identify the blockages in the coronary arteries.

When is coronary angiography done?

Coronary angiography is an important part of clinical evaluation in patients who have:

Persistent angina despite full medications
Ischemic heart disease
Cardiomyopathy
An abnormal heart stress test
Unexplained congestive heart failure
Acute myocardial infarction
Large ventricular septal defects, which may increase the risk of heart failure

It is also used as a pre-operative procedure in individuals with scheduled heart surgery, who have a high risk of coronary artery disease.

Risks of coronary angiography:

The following are the possible complications associated with coronary angiography:

Bleeding at the site of incision
Blood clots
Infection
Irregular heart rhythms
Kidney damage
Risk of stroke

What happens before the procedure?

Coronary angiography is usually performed on an emergency basis. If the procedure is scheduled in advance, then the person may need to follow these instructions:

Inform about all the past and present medical conditions.
Tell about the current medications.
Notify the doctor regarding any allergies.
Eight hours before the surgery avoid eating or drinking anything.

How is Coronary Angiography performed?

Before initiating the procedure, a sedative is given through the IV line to calm the person. Local anaesthesia is administered either on the arm or groin region.

Once the anaesthesia sets in, an incision is made to insert the catheter into the artery. By using the X-rays, the catheter is guided to reach the coronary artery. Once the catheter reaches the artery, a contrast dye is injected to highlight the blockage. This blockage is observed on the X-ray monitor.

What to expect after the procedure?

Once the catheter is removed, the incision will be closed with a manual clamp. For the first few hours, you will be in a recovery room, where your vitals are checked. You need to lie straight for a few hours to avoid bleeding from the incision site.

Before discharge, the doctor may give you the following instructions:

Consume plenty of fluids to flush out the contrast dye from the body.
Take the prescribed medications.
Do not lift heavy weights for a few days
Avoid strenuous activities for a couple of days.
Have a healthy and well-balanced diet.
Maintain healthy body weight.

When to seek medical attention?

Visit the doctor immediately on noticing any of the following symptoms:

Bleeding
Infection at the site of catheter insertion
Pain, discomfort, and inflammation at the incision site
Change in the colour or temperature at the operated area (arm or leg)
Weakness or dizziness
Chest pain
Shortness of breath

Carotid artery disease is a condition that arises when the fat deposits accumulate and block the blood vessels that deliver blood to the brain. People with carotid artery disease are at higher risk of developing stroke. So, to determine the risk and prevent the associated complications, a procedure known as cerebral angiography is recommended.

Cerebral angiography is a diagnostic procedure that uses X-rays to evaluate the blockage or any brain abnormalities in the carotid arteries (blood vessels in the brain and neck).

When is cerebral angiography recommended?

Cerebral angiography is recommended if the doctor suspects any of the following abnormalities within the brain:

An aneurysm
A dilated blood vessel in the brain
Brain tumour
Brain clot
Stroke

It is also used to evaluate arteries in the head and neck before undergoing any surgery; to provide additional information regarding any abnormalities that are not visible on other imaging tests, and as a minimally invasive procedure to treat vessel abnormalities.

In some cases, it is done to determine the underlying cause of the following symptoms:

Severe headache
Memory loss
Dizziness
Blurred vision
Loss of balance or coordination
Weakness or numbness

Before the procedure:

Specific instructions are given before undergoing the procedure. These instructions may include:.

Any allergies
The use of current medicines, vitamins, and mineral supplement
The current medical conditions
Any food or dietary restrictions before the procedure.

What happens in the procedure?

Before initiating the procedure, the patient’s head is stabilized by using a strap, tape, or sandbags. Based on the age of the person, either local or general anaesthesia, is administered. Once the anaesthesia sets, the doctor will sterilize the groin region and make an incision. Under the guidance of X-rays, the catheter is passed into an artery in the neck.

Once the catheter is placed in the correct position, the contrast dye is injected to highlight the blockage. After the X-rays are done, the catheter is removed, and the incision is closed.

What to expect after the procedure?

Once the procedure is done, the vitals are monitored in a recovery room. The person would be instructed to keep the leg straight if the catheter is administered through the groin region. Pain and inflammation at the site of incision are common, which can be relieved by applying ice packs and taking the prescribed medicines.

What considerations should be taken after the test?

Cerebral angiography is a diagnostic procedure, so there are not much considerations. However, following the below-given tips may ease the discomfort associated with the test:

Have a healthy and well-balanced diet.
Do not lift heavyweight for a few days or as suggested by the doctor.
Perform normal activities 8 to 12 hours after the procedure.

Talk to the doctor:

Call the doctor immediately on noticing any of the following symptoms:

Chest pain
Dizziness
Infection at the catheter site
Shortness of breath
Skin rash
Slurred speech
Vision problems
Numbness in the face, arms, or leg muscles

Hemodialysis is a preferred treatment option for patients with chronic kidney disease. In this t procedure, the blood is filtered outside the body by a dialyzer or “artificial kidney”. For hemodialysis, a vascular access is created to insert the needles that connect the dialyzer, thereby allowing the blood to move out and return to the body at a high rate. An arteriovenous fistula is the preferred vascular access for hemodialysis.

An arteriovenous (AV) fistula is created by connecting an artery to a vein, usually in the wrist or upper arm. But sometimes, the fistula can become infected, blocked or narrowed. The blocked fistula can be treated by a balloon fistuloplasty.

What is balloon fistuloplasty?

Balloon fistuloplasty is a procedure in which any blockage or narrowing in the fistula is located by using a dye, and the blockage is relieved by stretching the blood vessels with a special balloon.

In this procedure, a small balloon is inflated for several times at the narrowed regions of a fistula; if required a stent may also be placed. This technique widens the lumen and facilitates the process of dialysis.

Why perform fistuloplasty?

A fistula can age and cause problems like clotting and scarring, thereby decreasing its function and effectiveness of dialysis. Clots can decrease the rate of blood flow or block the fistula completely. If these problems are left untreated, it may lead to the failure of fistula.

Thus, it is important to treat the narrowing or blockage at an early stage, so that the fistula works well, and dialysis occurs without any complications.

What are the risks of dialysis fistuloplasty?

Fistuloplasty is usually a safe procedure, but some complications may occur rarely. The common risks and complications associated with fistuloplasty include:

Bruising around the site of insertion of the needle, which may become large and uncomfortable (rarely).
Infection of large bruises, which may need antibiotic treatment or surgical intervention.
Allergic reaction to the dye, which may present as a skin rash
Circulatory problems due to the damage to the artery or fistula caused by catheter or balloon
Treatment failure, which will require surgical intervention

How to prepare for the procedure?

Your healthcare provider will give you instructions to prepare for the procedure, which may include:

You may be asked not to eat or drink anything for six hours before the procedure; you can drink water up to two hours before.
Some blood tests may be performed before the procedure to evaluate the risk of bleeding.
If you are diabetic, ask your doctor to alter the treatment regimen.
Ask your doctor which medicines you can continue to take, and which ones you should stop.
If you are taking any antiplatelets or anticoagulants, you may have to stop taking these medicines a few days before.
Ensure that you have an adult to drive you home and accompany you overnight.

Inform your healthcare provider if you:

Are allergic to iodine, or have any other allergies
Have a history of reaction to the dye used for CT scan or X-rays
May be or are pregnant
Are a diabetic

What happens during the procedure?

The following are the steps usually performed in a fistuloplasty:

You will be asked to lie on your back on an x-ray table. Some monitoring equipment will be attached to measure your heart rate and blood pressure.
The interventional radiologist will observe the fistula by using an ultrasound, which provides a clear picture of the fistula.
A small needle is inserted in the fistula, and a contrast dye is injected. This provides an image of the blood vessels, which helps to locate the narrowing or blockage.
A catheter (a small, flexible tube) with a balloon at the tip is then inserted in the blood vessel to reach the precise location.
Once the catheter reaches the site of the blockage or narrowing, the balloon is inflated and deflated several times from outside the body.
Sometimes, if the balloon does not improve the fistula, a permanent stent may be used to widen the narrowing.
Then the catheter is removed from the blood vessel, and the puncture site is stitched to prevent bleeding.

Usually, fistuloplasty takes about one hour, but the duration may vary in different patients.

What happens after the procedure?

You will have to stay in the hospital after the procedure for three to four hours for observation. Your pulse, blood pressure and oxygen levels in the body will be monitored regularly. You may return to your normal diet. The fistula is ready to use immediately after the procedure.

Your nurse will tell you when you can go home. You will need a friend or a family member to drive you home; using public transport is not recommended.

Your fistula should be ready for use immediately after the procedure.

What measures do I take after going home?

The following measures will help you recover better after a fistuloplasty:

Rest well on the day of the procedure and the next day. Then, you can return to your normal activities.
You can follow your normal diet.
Take the pain killers as prescribed r instructed.
Continue to take you regular medicines, as prescribed.
Do not take metformin until two days after the procedure.
You can have a bath or shower the next day.

Call your doctor immediately

if you have any of the following symptoms:

A lot of swelling and bruising
Severe pain at the puncture site that does not get better with painkillers
Bleeding at the puncture site
Change in the colour of your arm
Fever or chills
A lump, pus or discharge at the puncture site
Difficulty breathing or chest pain

Cardiac catheterization is one of the most extensively performed cardiac procedures. If you have chest pain or irregular heartbeat, your doctor may recommend cardiac catheterization.

Cardiac catheterization is a minimally invasive procedure used to detect and treat cardiovascular diseases. This procedure involves the insertion of a catheter (a thin hollow tube) into the large arteries or veins present in the neck, arm or groin, which is then guided to the heart using a special X-ray. Once the catheter reaches the location, diagnostic tests or treatment procedures are carried out.

Why perform Cardiac Catheterization?

Cardiac catheterization is done to find the cause of the signs and symptoms of a heart problem or to treat or repair the heart damage.

This procedure is performed to:

Determine the pressure levels in the chambers of the heart.
Determine the heart function after a cardiac intervention.
Detect blockages in the coronary arteries (coronary angiography) or valve dysfunction.
Perform procedures such as angioplasty, ablation therapy or valve repair.
Obtain a small piece of heart tissue to examine under a microscope for detecting conditions affecting the heart muscle (cardiac biopsy).

What is the difference between Cardiac Catheterization and Coronary Angiography?

Catheterization is a procedure used to diagnose and treat various conditions. It involves the insertion of a catheter into the arteries and veins to reach the heart and to measure how much blood the heart pumps out, the pressure in each heart chamber, and to detect any defects in the heart. Also, various small instruments can be inserted into the catheter to view the interior of the blood vessels, to remove a tissue sample from the heart for further examination, etc.

Coronary angiography is a type of catheterization procedure, which involves analysing the arteries that supply the heart with oxygen-rich blood. This procedure involves the insertion of a catheter in the arm or the groin, which is threaded to reach the coronary arteries. During insertion, fluoroscopy (a continuous x-ray procedure) is used to guide the catheter to reach the precise position. After the catheter tip is at the right location, a contrast dye is injected into the coronary arteries. This dye can be seen on x-rays, and the outline of the arteries is viewed on a video screen.

How do I prepare for the procedure?

Inform your doctor about:

The medications that you are taking, especially blood-thinners or anti-inflammatory medications
Any medical conditions that you have
Allergies to any dyes or specific medications

Before the procedure:

Fast for at least 6 hours, as food and liquid increase the possibility of complications with general anaesthesia.
Empty your bladder before heading to the procedure.
Remove dentures and jewellery, as they may interfere with the imaging procedures.
Your general health status and vital signs will be monitored.

What happens during the procedure?

During cardiac catheterization, an IV cannula is inserted in your arm to administer medications. You will be given a mild sedative to help you relax during the procedure.

The general procedure of cardiac catheterization is given below:

The site of catheter insertion (usually the groin) is cleaned and shaved.
Usually, local anaesthesia is administered. General anaesthesia may be given before surgical procedures such as valve repair or ablation.
When the site of catheter insertion becomes numb, an incision is made, and the catheter is inserted using a catheter sheath.
Once the catheter reaches the heart, a dye is administered which outlines the vessels, valves and chambers of the heart.
The diagnostic tests or surgical procedures will then be performed for treating the condition.

Vital signs and electrocardiogram will be continuously monitored during the procedure.

Cardiac catheterization usually lasts for about 30 minutes. It may be longer if you are undergoing any other test or intervention using this procedure.

After the procedure is done, the catheter will be removed, and the incision will be closed by stitches. A sterile dressing will be used to prevent infection in the incision site.

What happens after the procedure?

Once the procedure is done, you will be asked to lie flat on the bed for 2-6 hours after the procedure. Your heart rate and blood pressure will be continuously monitored.

Once the anaesthesia wears off, you will be given pain medications. You will be asked to drink plenty of water to eliminate the dye that was administered. Usually, you will be asked to stay in the hospital for a few hours or a day.

After leaving the hospital, follow all the post-procedural instructions given by your doctor. You may resume your normal activities in a day’s time. Some soreness at the incision site is normal; it may reduce within a week.

What are the risks of Cardiac Catheterization?

Cardiac catheterization is a relatively safe procedure. However, like any other invasive procedure, some uncommon risks of this procedure are:

Infection
Blood clotting
Bruising at the incision site
Allergic reaction to dye
Arrhythmia
Air embolism
Stroke

Call your doctor if you experience:

Severe pain at the incision site
Signs of infection: redness, warmth, pus oozing or excessive swelling around the incision site
Numbness or tingling sensation in your limbs

Peripheral arteries are the blood vessels that deliver blood to the lower limbs. When the cholesterol accumulates in these blood vessels, the blood flow to the lower limbs gets blocked. Peripheral angioplasty is a minimally invasive procedure. It is done to restore the blood flow by opening the blocked peripheral arteries.

When is peripheral angioplasty performed?

Peripheral angioplasty is mostly indicated in the treatment of Peripheral Vascular Disease (the circulatory disorder caused by the blocked or narrowed blood vessels outside the heart).
Peripheral artery disease is the common condition, in which peripheral angioplasty is recommended.

Are there any risks with peripheral angioplasty?

Peripheral angioplasty is associated with the following risks:

Breathing problems
Bleeding
Blood clots
Infection
Kidney damage
Damage to the blood vessel

How to prepare for the procedure?

Before initiating the procedure, a physical examination and imaging tests are done to determine the overall health condition. Additionally, the following steps would help in a successful procedure and quicker recovery:

Inform the use of current medications, vitamin or mineral supplements.
Tell the doctor about any underlying disease condition.
Take the prescribed medicines.
Notify the doctor if you have any allergies.
Six to eight hours before the surgery do not eat or drink anything.

What happens during the procedure?

Local anaesthesia is administered in the upper thigh region. Once the anaesthesia sets, an incision is made on the upper thigh to insert the catheter. By using a high-resolution fluoroscopic, the catheter is guided to the blocked artery. When the catheter reaches the obstructed artery, the balloon is inflated to widen the blood vessel. Once the blood flow is restored, a stent is placed to prevent the risk of further blockage. Finally, the incision is closed and covered with a sterilized bandage.

What to expect after the procedure?

You will be placed in a recovery room and the vital parameters would be checked. For at least 3-6 hours, you need to remain still, to prevent bleeding from the incision site. Depending on the patient’s condition, the doctor will decide whether the person requires a hospital stay or not.
Before discharge, you will receive the following instructions:

Keep the wound clean and dry.
Do not lift heavyweights.
Avoid strenuous exercises for at least 24 hours after the procedure.
Drink plenty of fluids to help flush out the contrast dye from the body.

Care after peripheral angioplasty:

Although peripheral angioplasty clears the blockage, it does not treat the underlying cause of the blockage. So, to prevent the further risk of blockage, the following steps should be taken:

Maintain a healthy body weight.
Quit smoking.
Exercise regularly.
Take the prescribed medicines to prevent re-narrowing of the blood vessels.
Manage stress.
Avoid fatty-foods.
Have a low-salt and low-fat diet to prevent the risk of fluid retention.

Seek medical attention:

The following symptoms are the warning signs that require immediate medical attention:

Swelling in limbs
Chest pain
Shortness of breath
Fever associated with chills (over 101oF)
Weakness
Dizziness

Critical limb ischemia (CLI) refers to severe compromise of blood flow to alimb (hands or legs) which causes severe limb pain at rest or even loss of limb. It is the most advanced form of peripheral artery disease.

CLI numbers:

Prevalent in 2% patient over 70 years of age.
Within 1 year of diagnosis, 40-50% patientshave an amputation and 25% die.

How CLI leads to amputation?

Amputation occurs when there is marked ischemia of the limb owing to reduction of blood flow and increase demand in the limb.

Factors that reduce blood supply:

Diabetes mellitus
Severe Renal or Heart failure
Vasospastic diseases
Smoking

Factors that increase demand for blood flow:

Infection (cellulitis)
Skin breakdown
Trauma
Osteomyelitis

Diagnosis of CLI:

Characteristic	Duplex Ultrasound	Digital – Subtraction Angiography	Magnetic Resonance Angiography (MRA)	Computed Tomographic Angiography (CTA)
Advantages	Noninvasive Can Visualize & Quantitate severity	Gold Standard High Resolution Can guide intervention	Noninvasive No radiation No contrast 3 D	Noninvasive Higher Resolution than MRA 3 D
Disadvantages	Operator dependent Limited by dense calcification	Invasive Radiation Contrast 2Dimensional	Lower Resolution than CTA Claustrophobia Contrast Image artifact if stent present	Radiation (25% of dose with DSA) Contrast Limited by calcification

Management plan for critical limb ischemia:

Critical Limb Ischemia Non-Healing Ulcer Rest Pain

MRA, CTA or invasive argiography shows lesion treatable by endovascular approach

Endovascular revascularization ->Wound care and atherosclerosis risk factor modification
Lesion treatable by open sugery at acceptable operative risk
- Surgical revascularization ->Wound care and atherosclerosis risk factor modification
- Consider primary amputation ->Wound care and atherosclerosis risk factor modification

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