Resources - DrCRaghu

Introduction

Atrial Fibrillation means the upper chambers of the heart. These upper chambers of the heart start beating chaotically quiet irregularly that is what is called as Atrial Fibrillation. Normally a heart beats around 60-100 times per minute so the number of beats a heart should beat is determined by the sinus node and its function but at times when there is an enlargement of atria or sometimes there is an infection or inflammation of the atria what happens is these atria start beating chaotically so this chaotic beating of the atria is called Atrial Fibrillation. In this video Dr. C Raghu TAVR expert in India explains to you all about Atrial Fibrillation, What are the types in Atrial Fibrillation? What are the complications of Atrial Fibrillation? How to detect Atrial Fibrillation?

Atrial Fibrillation means the upper chambers of the heart. These upper chambers of the heart start beating chaotically quiet irregularly that is what is called as Atrial Fibrillation. Normally a heart beats around 60-100 times per minute so the number of beats a heart should beat is determined by the sinus node and its function but at times when there is an enlargement of atria or sometimes there is an infection or inflammation of the atria what happens is these atria start beating chaotically so this chaotic beating of the atria is called Atrial Fibrillation. In this Atrial Fibrillation in contrast to the 60- 100 beats per minute of the atrial contraction here the atrial rate is between 400-600 per minute so the atria start beating very fast and quiet irregularly.

So if the atria beat very fast and irregularly what does it mean?

It means that if a structure is beating at 400-600 per minute the beating is quiet ineffective so that is what we call as atrial paralysis or the atria is not effectively functioning so atrial fibrillation leads to dysfunction of the atrium

This atrium contributes to about 20% of heart output so when the atrium is dysfunctional the heart pumping is reduced by around 20%.

Onset of Atrial Fibrillation

Atrial Fibrillation can be either

sudden onset
chronic
paroxysmal.

Acute Atrial Fibrillation: Atrial Fibrillation sometimes it happens suddenly like in the scenario of an acute heart attack or in a scenario of an inflammation of pericardium or sometimes when there is a sudden pulmonary embolism that means there is a blood clot within the blood vessels supplying the lungs. In those circumstances there can be a sudden onset of Atrial Fibrillation so this is called an acute Atrial Fibrillation so once after the cause for the Atrial Fibrillation has been reversed there is a strong chance that this Atrial Fibrillation can revert back to normal sinus so the atrium will start contracting at a much lower rate.

Chronic Atrial Fibrillation: The other type of Atrial Fibrillation is a Chronic Atrial Fibrillation or a Chronic Persistent Atrial Fibrillation where the Atrial Fibrillation is present for more than a week in duration and continues to persist. So that means that the Atrial Fibrillation does not come back to sinus rhythm but in fact is present for beyond a week and continue to remain so for rest of the life so that is what we call as Chronic Atrial Fibrillation or a long standing Atrial Fibrillation.

Paroxysmal Atrial Fibrillation: There is another type of Atrial Fibrillation called Paroxysmal Atrial Fibrillation that means Atrial Fibrillation is present for certain duration of time and then reverts back to sinus rhythm and once again might come up again. It comes and goes that is what we call as Paroxysmal Atrial Fibrillation.

Which type of Atrial Fibrillation is dangerous?

All types of Atrial Fibrillation are dangerous.

Why they are dangerous?

Atrial Fibrillation as we understood reduces the pumping ability of the heart by 20% in addition a prolonged and fast rate of the heart fatigues the heart and reduces the heart pumping ability again that is called left ventricular dysfunction

The most dreaded complication of Atrial Fibrillation is brain stroke because the atria are chaotically contracting or they are inefficiently contracting there is pooling of blood within atrium and this pooling of blood or stasis or stagnation of blood in the atrium leads to promotion of blood clots in the atrial chambers. These blood clots which are present in the atrial chambers because the heart continues to beat every minute every second so what happens is these small clots which are present in the atrial chambers get dislodged and potentially lead to a brain stroke these dislodge and they gets lodged in the brain vessels so that is called a brain stroke. So a patient with Atrial Fibrillation can develop a heart dysfunction they can develop a brain stroke they can develop a sudden reduction in the cardiac output so these are the various complications of Atrial Fibrillation.

How can we detect Atrial Fibrillation?

We have seen that if the Atrial Fibrillation is chronic and persistent that can be easily detected by an ECG or an Electrocardiogram. This is the simplest inexpensive test to detect the presence of Atrial Fibrillation.

But if it is a Paroxysmal Atrial Fibrillation that means it comes and goes then we might have to use a long term ECG recording technology to identify or diagnose or detect the presence of Atrial Fibrillation. So there are numerous technologies to identify Atrial Fibrillation on a long standing basis. Some of them are external that means we put as a patch ECG outside or we connect multiple electrodes as in the form of a Holter monitoring or we have got a lot of novel devices like the Alivecor where you can just touch with the fingertips of the thumb to identify Atrial Fibrillation. So number of technological advances have appeared to detect the presence of Atrial Fibrillation. Even our Apple watch also has got an Atrial Fibrillation detection algorithm so an apple watch also can

detect the presence of Atrial Fibrillation. Quite a few of my patients tend to identify their Atrial Fibrillation from their apple watch so you have got simple technologies you have got complex technologies

The most complex technologies like where you can put an implantable loop recorder. A small device is implanted into the subcutaneous tissue that means beneath the skin and the muscle or the fat and then this recorder will continue to record the heartbeat.

So you have got the simple technology like the ECG and a moderately complex technology like the ECG patch or the Holter recording or a 14 day ECG patch is also available and finally for those patients where the Atrial Fibrillation is very rare you can put an implantable loop recorder that can last for about 2 years of the time.

So what happens is if these patients tend to have one episode of Atrial Fibrillation which is persistent for more than 30 seconds then we can say that this patient has got an Atrial Fibrillation which could be Paroxysmal in nature.

In conclusion lot of new technologies are there one of the easiest technology is the apple watch somebody who is a patient you can use a Alivecor type of monitor. If the patient is newly diagnosed or you want to confirm or make a diagnosis of Atrial Fibrillation you can use a Holter monitoring, a patch ECG for atleast 14 days. For one to diagnose Atrial Fibrillation atleast 14 days of recording is required before we can say that this patient does not have Atrial Fibrillation.

Let us know about Heart Failure

What is Heart Failure?

Heart failure is not a single disease instead it is a constellation of symptoms. In this disease the heart is unable to meet the requirements of the body by its inability to pump or be able to do so by increasing the filling pressures so that it might pump effectively.

Heart Failure is not a disease but a group of symptoms. It is the result of many diseases affecting not only the heart but other organs of body.

Heart Failure vs Heart attack vs Cardiac arrest

(heart attack and cardiac arrest images)

All the three terms refer to different medical issues.

Heart failure is consequent to inefficient functioning of heart.
Heart attack is due to the interruption of blood supply to the heart.

Cardiac arrest is a situation where the heart stops to beat.

Symptoms of heart failure

(heart failure image)

Inefficient functioning of the heart leads to fluid logging in the body

Fluid logging in the lungs – presents as breathlessness – Left Heart failure in medical parlance Early stages of heart failure – breathlessness can be present on walking.
Advanced stages of heart failure –Breathlessness can be present at rest or, Inability to lie flat or may be awakened from sleep.

Fluid accumulation in other organs of the body – Right heart failure in medical parlance Legs causing swelling of the feet, Swelling of face, abdomen, Pain in upper right abdomen.

Heart failure symptoms which are related to the lungs are called left heart failure symptoms, those symptoms which are related to other organs are called right heart failure symptoms.
Concept of left and right heart
failure is important in treatment

What causes heart failure?

Heart failure is a result of many disease processes in the body. Common among them being: Coronary artery disease:

The most common disease that is responsible for heart failure is coronary artery disease. • Coronary artery disease means accumulation of cholesterol in the blood vessels supplying the heart leading to interruption of blood supply to the heart.
This interruption of blood supply can either directly reduce the blood supply to the heart resulting in dysfunction or can cause heart attack which can also reduce the heart pumping ability.
Common diseases – such as diabetes, hypertension and sometimes abnormalities of the valves of the heart and fast beating of the heart of which most commonly atrial fibrillation can all result in reduced efficiency of the heart.

In addition, advanced age itself beyond the age of 65-70 the efficiency of the heart reduces leading to heart failure.

What tests are required for diagnosis of heart failure?

The tests for the diagnosis of heart failure are

Imaging test
ECG
Blood test

Blood tests in heart failure :

The most common blood test that is done is a pro-BNP test. If it is less than 125, we can safely exclude heart failure as the cause for breathlessness. (pro BNP figure)
In addition, we look at presence of Anaemia, Renal dysfunction and blood glucose elevation in a patient with heart failure.

Electrocardiogram (ECG) : This remains an important test ( add ECG figure)

Can detect the presence of previous heart attack.
Irregular heart beat – most common is atrial fibrillation.
Presence of any Bundle branch block.

Echocardiogram : The most common and important test for the diagnosis of heart failure is the echocardiogram where we estimate the left ventricular ejection fraction (measures the pumping ability of the heart) or in short called as EF.

Other test done to manage heart failure are cardiac MRI and nuclear test.

Angiography not only identifies blocks but allows them to be

What is the role of Angiography in heart failure?

(Add a figure of angiogram)

For every 3 patients with heart failure 2 have

removed as a continuation procedure – angioplasty and stent.

underlying blocks in the blood vessels of heart. These blood vessels supplying the heart are the coronary arteries and obstructions are called coronary artery disease. So, whenever there is a coronary artery disease, we can identify that only by performing a coronary angiography.

The major advantage of this investigation is apart from diagnosis in coronary artery disease, in case if any blocks in heart vessels are identified they can be treated by performing a balloon angioplasty and a stent procedure.

The benefit of removing the cholesterol plaques in the heart vessels is that – there can be a strong chance for the heart functioning to recover once the blood flow is restored back to the heart.

What is Aortic stenosis?

Aortic stenosis is a disease where the valve between left ventricle and aorta is narrowed. Normally the left ventricle is the chamber which pumps blood to the entire body through the aortic valve. So if the aortic valve is narrowed either due to infection or age related degeneration it is called aortic stenosis. This is a disease of the elderly people usually beyond 50 years of age.

What are the symptoms of aortic stenosis?

When the disease is severity is mild people usually do not experience any symptoms. But is the disease is severe – even though the disease is severe in early phases the patient might not have symptoms.

So, early stages of aortic stenosis patient might not have any symptoms. Where as in the advanced stage of severe aortic stenosis the patients can develop can develop chest pain also called angina in medical terminology. So chest pain which increases on walking or any other form of exertion and gets relieved on rest or stopping of that activity is called angina. So patients with aortic stenosis because is unable to pump as per the requirements of the body (due to aortic valve narrowing) they experience angina.

The other symptom is breathlessness – on walking or on lying down flat the patient develops difficulty in breathing. This is referred to as dyspnea in medical terminology. So when ever a patient is having a fixed blood supply to various organs without increasing as per their needs there is pooling of blood in the heart. This pooled blood in the heart “reverses back” into the lungs which is responsible of breathlessness.

Finally in advanced stages of aortic stenosis patients develop a sudden loss of consciousness with spontaneous recovery. These episodes of loss of consciousness are also called as syncope in medical terminology.

So the predominant symptoms of aortic stenosis are chest pain, breathlessness and sudden loss of cosnciousness.

At the same time patients with aortic stenosis will develop an impaired function of the heart also called heart failure. This heart failure need to necessarily present in severe heart failure but can also be seen in intermediate or moderately severe aortic stenosis.

Aortic stenosis and high blood pressure

Patients with aortic stenosis have reduced supply of blood to various organs of the body. Because of this it was believed that patients with aortic stenosis tend to have low blood pressure. This is not true regarding the current epidemic of aortic stenosis we are currently seeing. Currently most of the aortic stenosis patients are elderly in their 60s, 70s and 80s of age. So these patients because of the progression of the age and hardening of the blood vessels they develop high blood pressure or Hypertension in medical terminology. So patients with aortic stenosis are not spared from high blood pressure contrary to what we were believing till date and what we are seeing is a scenario of aortic stenosis patients having high blood pressure levels.

What is the impact of this high blood pressure on a patient with severe aortic stenosis?

Patients with high blood pressure and severe aortic stenosis develop a faster progression of the disease severity. So a patient of aortic stenosis with uncontrolled blood pressure can have a severe aortic stenosis at a much earlier age.

How can patients with aortic stenosis control their blood pressure?

People with aortic stenosis and high blood pressure need to control their blood pressure using 3-4 different types of medicines. A good control of blood pressure is one of the first steps in retarding the progression of aortic stenosis.

Can people with aortic stenosis do exercise?

People with aortic stenosis tend to have a fixed cardiac output. This means – the aortic valve is narrowed and this narrowing limits the blood supply to various organs of the body. When there is a reduction in blood supply to various organs of the body – the first to be affected is the brain. This causes syncope or sudden loss of consciousness.

So when a person with severe aortic stenosis exercises vigorously then there is a reduction of blood supply to the brain causing sudden unconsciousness. This problem happens in people with an advanced or severe aortic stenosis. So people with severe or advanced aortic stenosis are advised not to participate in vigorous physical activity such as running, jogging or weight lifting etc.

But at the same time as we all know for the control of BP, blood sugar and cholesterol and effective control of heart failure are important steps for retarding the progression of aortic stenosis. So a mild to moderate severe intensity exercise is advised for control of the various co-morbidities in aortic stenosis. But at the same time a vigorous or severe intensity exercise is definitely not to be performed. Severe intensity exercise or competitive sports is a contra indication for aortic stenosis patients in medical terminology.

Aortic Stenosis Symptoms (Telugu)

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Women especially at young age are experiencing an unprecedented increase in heart attacks and strokes. We attempt In this article to make the reader aware of the reasons for this.

How are women different from men for developing heart attack?

Women tend to develop cardiac disease 7-10 years later compared to men that is attributed to the protective effect of estrogen hormone, which is present till menopause.

What are the traditional risk factors for developing heart disease?

Both men and women are prone to develop cardiac problems if they have one or multiple risk factors listed below. They are called traditional because they have been in practice for the past 6 decades.

Non-modifiable risk factors

Modifiable risk factors

· Age

· Male gender

· Family history of cardiac disease (< 60 years)

· Smoking

· Diabetes

· Hypertension

· Hyperlipidemia

· Obesity

Despite the absence of many of these risk factors, women worldwide are increasingly dying due to cardiac ailments.

Do traditional risk factors confer a disparate risk for developing cardiac problems in women?

Women are sensitive than men for the development of heart diseases when they have associated traditional risk factors.

For example:

Diabetes: Women with diabetes have a 7-fold increase in cardiac events compared to only 3-fold increase in diabetic men.
Smoking and tobacco use has been shown to enhance the risk by an additional 25% in women compared to men for development of heart attacks. In fact tobacco use has been responsible for 50% of cardiac events in women and confers a 3-fold increased events. Normally women develop heart attacks 7-10 years later than men due to the protective benefits of estrogen hormone. This protective effect is lost with tobacco use and if they develop diabetes.

Unique risk factors for cardiac problems in female gender include:

Pre-eclampsia (High BP during pregnancy associated with complications)
Diabetes during pregnancy
Polycystic Ovary syndrome
Early menopause
Autoimmune diseases

Early menopause and risk of heart attack:

About 10% of women experience menopause naturally before the age of 45 years. This is called early menopause. Because of lack of estrogen in post menopausal women, it predisposes to cardiac events.

Compared to women of similar age, those who attain natural or surgical menopause (removal of uterus – Hysterectomy) less than 45 years are at 50% higher risk of developing heart attack and 20% increased risk of death. Those women who attained surgical menopause tend to have higher cardiac events compared to natural menopause. So women should be dissuaded to undergo uterus removal surgery unless there is a clear evidence that the procedure is definitely required. Hormone replacement therapy has been tried to mitigate this risk but in vain. Current guidelines are against hormone replacement therapy for early menopause.

What can we do to prevent these cardiac events in women?

Targeting traditional risk factors – diabetes, hypertension, lipids, sedentary life styles, inappropriate food choices and obesity form the bedrock strategy for reducing the risk of developing heart attacks.

But for women further measures are needed to address the unique risk factors for women. The American College of Cardiology in its 2019 guidelines notified pre eclampsia, early menopause and autoimmune disease as “risk enhancers” for cardiac disease. They also added that physicians should have a low threshold to treat those patients with risk enhancers by life style measures and cholesterol lowering drugs to reduce the risk of developing heart attacks.

Finally women should realize that they are no longer at low risk for developing cardiac ailments and need to understand there are new risk factors that put them at “enhanced risk” for developing heart attacks.

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

Mitral Valve Replacement Surgery

Whenever the mitral valve is damaged and most of the times when it is leaky mitral valve or mitral regurgitation in those circumstances we replace this entire mitral valve structure with an artificial valve. So that procedure is called mitral valve replacement. Mitral stenosis can be eminently treated with a balloon. Instead of replacing the valve we repair the valve with a balloon and open up the valve so this procedure is called a balloon mitral valvotomy.

In this video Dr. C Raghu TAVR expert in India explains to you all about Mitral Valve replacement surgery, When should a patient undergo it? What are the types of valves used in this surgery? When this surgery cannot be performed? What are the options for the patients who are high risk for this Mitral Valve replacement surgery?

As we have seen already there are two different types of mitral valve problems.

One is a narrowing of the mitral valve also called as mitral stenosis. So when the valve is only narrowed without any leaking of the valve, this type of mitral stenosis can be eminently treated with a balloon. Instead of replacing the valve we repair the valve with a balloon and open up the valve so this procedure is called a balloon mitral valvotomy. So whenever there is a narrowing of the valve if the valve is suitable we can do a balloon mitral valvotomy. So the balloon mitral valvotomy is usually performed when the valve area is less than 1.5 cm square. So if the valve is narrowed below 1.5 cm square we perform a balloon mitral valvotomy. At the same time if there is any features of heart failure or there is evidence of severe increase in the blood pressure in the lungs also called as pulmonary hypertension then we ask the patient to undergo a balloon mitral valvotomy at a early stage.

If the valve is leaking that is called mitral regurgitation. So in a patient with mitral regurgitation as we have already understood that there will not be any symptom in the early phases of disease. So we need to do a periodic echocardiogram to understand whether there is an enlargement of the heart, whether there is any reduction of the pumping ability of the heart then we have to send these patients for a mitral valve replacement procedure.

When is a mitral valve replacement done in mitral regurgitation?

severe mitral valve leaking associated with the enlargement of the heart • increase in the blood pressure in the lungs
there is a failure of the right heart

For a leaky valve we cannot do balloon for a leaky valve we have to only perform a replacement of the mitral valve.

Types of artificial mitral valves:

When a mitral valve is replaced this valve can be of two types

Mechanical or a metallic valve
Tissue valve or bio-prosthetic valve

Mechanical or a metallic valve

So normal valve tissue is a fibrous and it is made of muscular tissue. It’s not truly muscle but similar to a muscular tissue. So when we have this mitral valve, you remove this valve and replace with a metallic alloy valve. So this valve is called a mechanical valve or a metallic valve.

A mechanical valve needs the use of blood thinners or anticoagulants.

Mechanical valve lasts for decades generally two to three decades or even four decades.

When a mechanical valve is damaged the person has to undergo a repeat open heart surgery and replace the valve which is a high risk procedure.

A mechanical valve even though it is durable it has got a risk of bleeding because of blood thinner use life-long.

Tissue valve or bio-prosthetic valve

At times because this mechanical valve has got a lot of complications, if the person is more than 60 years of age we replace this valve with a tissue valve. Instead of a mechanical valve we have a tissue means these tissue valves are similar to that of a valve which is given by the god or present naturally. So this mechanical valve is made up of alloy whereas the tissue valve is made up of bovine that means from the buffalo or from the heart of a pig these valves are constructed. So this tissue valves are akin to that of normal tissue and they do not have so many complications.

A tissue valve does not need blood thinners.

A tissue valve might last anywhere between ten to fifteen years of duration.

If a tissue valve is damaged then we can replace the tissue valve with a Trans-catheter that means without surgery we replace the valve going through the groin.

A tissue valve even though it works for a shorter duration is preferred especially in the elderly people (more than 60 years) because these patients do not require lifelong anticoagulation or blood thinner usage.

Mitra-clip therapy or Trans catheter edge to edge repair

Patients with mitral regurgitation if the patient has got a severe mitral valve leaking associated with dysfunction of the heart or the patient is very elderly let’s say more than 75 years of age the surgery is considered high risk. So heart pumping dysfunction, elderly age group or if the patient had a previous mitral valve replacement either by tissue valve then these are the patients who are

considered to be high risk for undergoing a repeat mitral valve procedure or sometimes the patient can undergo a surgery to the heart like a bypass surgery.

In those conditions doing a repeat repeat surgery for the mitral valve after a bypass surgery is also considered high risk.

Similarly people who have got kidney problem, people who have got advanced age, people who have got a previous brain stroke those are all the patients whom replacement of the mitral valve with an artificial valve is considered high risk.

For those patients who have to undergo a mitral valve therapy or treatment and not considered suitable because of their age, kidney failure or brain stroke or poor heart pumping ability, previous bypass surgery, previous mitral valve surgery in those cases we have to consider other ways where this mitral valve can be repaired or replaced.

Due to new technological advances we can repair the mitral valve because if the valve leaflets are leaky because there is a gap between those two valve leaflets for example you consider these two are mitral leaflets and there is a gap you can bring the leaflets together by putting a clip so the valve leaflets are getting closer and they can be fastened with a clip.

So this clip can reduce the leaking or sometimes completely abolish the mitral valve leaking. So this procedure is called mitra-clip or a transcatheter end to end repair.

At the same time patients who have got a mitral valve stenosis that means there is no inadequate or leaking valve but instead the valve is narrowed if it happens after a damage to the tissue valve then we can replace the valve using a catheter procedure that is what we call as the Transcatheter Mitral Valve Replacement.

These two advances like a mitra-clip or similar type of surgery and transcatheter mitral valve replacement are a boon for the elderly patients with mitral valve disease who are considered not suitable candidates for getting the mitral valve replacement surgery.

This is an important advance in those patients with end stage heart failure and a leaking of the mitral valve.

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

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

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