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Endomyocardial
Biopsy
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| An
endomyocardial biopsy is a biopsy of the heart tissue inside the
heart. This is done in most cases as a follow up for heart transplantation.
Medical Center Cardiologists, P.S.C. has been involved in the heart
transplantation program at Jewish Hospital in Louisville, Kentucky
since its inception. We follow many patients who have had cardiac
transplantation and these patients are followed with endomyocardial
biopsies as a means to adjust their anti-rejection medicines following
their heart transplantation. The procedure involves placement of
a catheter through a vein in either the neck or groin area. The
area is scrubbed with a cleaning solution and a drape is placed.
A plastic tube is placed and through this tube a biopsy catheter
is placed and positioned inside the heart with the aid of x-ray.
Samples of the heart tissue are removed and examined for evidence
of rejection or evidence of abnormalities that could cause a weakening
of the heart muscle. This weakening is called cardiomyopathy. The
procedure takes 15 minutes and is associated with little or no discomfort.
There may be a pushing sensation in the neck or groin with manipulation
of the catheter and there may be some perception of extra heart
beats when the biopsy samples are taken. At the completion of the
test, the catheter is removed and pressure is held to stop bleeding.
This takes ten minutes or less and the patient is allowed to ambulate
immediately if the procedure is done through the neck and after
1-2 hours if the procedure is done through the groin. The patient
is allowed to go home on the same day of the procedure. There are
no limitations following the procedure. Medical Center Cardiologists,
P.S.C. performs approximately 100 endomyocardial biopsies per year
and these are performed primarily by two of the twelve physicians
in the group. |
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Catheter
Based Intervention
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| Catheter
based intervention is a means of opening blocked arteries that surround
the heart muscle. Initially this procedure was performed with a
balloon and referred to as Percutaneous Transluminal Coronary Angioplasty
(PTCA). Since the inception of that procedure in the late 1970s
other means of opening up arteries have developed to include atherectomy
which is the removal of fatty material from inside the coronary
arteries by either scrapping which is referred to as directional
coronary atherectomy, ablation with a high speed drill which is
referred to as rotational atherectomy and extraction of the material
with cutting which is referred to as TEC-atherectomy. There has
also been the evolution of scaffolding devices referred to as stents.
These are another means of opening up blocked coronary arteries.
Each one of these procedures will be described in more detail in
the following paragraphs. |
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Angioplasty
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| Angioplasty
is a procedure that has many similarities to cardiac catheterization.
The procedure can be performed through the femoral artery in the
groin or brachial artery in the arm. A plastic tube is placed in
either the groin or arm. A second tube is then inserted into either
the left or right coronary artery. A small wire is placed across
the area of narrowing in the right or left coronary artery. Over
the wire a tube is placed with a balloon. The balloon is then expanded
in the area of blockage and the artery is stretched opened both
inside and outside to allow improved blood flow to the area of the
heart where the narrowed artery was located. During the time that
the balloon is inflated, patients usually experience some of their
pain or symptoms that cause them to present to their doctor. These
symptoms last approximately 30-60 seconds. When the balloon is deflated
and withdrawn, the symptoms are eliminated. The procedure takes
approximately 60 minutes to perform. Following the procedure the
tubes in either the arm or leg remain in place and your doctor may
have you remain on a blood thinner which would require prolonged
bed rest with the tubes in place. More commonly, if the tubes are
removed in 4-6 hours, and following a further 6-8 hours of bed rest
the patient will then be able to ambulate. Most patients are ready
for discharge to home on the day following the procedure. Most patients
can be back to an active life style within 1 week. We usually ask
the patients to follow up with their cardiologists within 1-3 weeks.
The success rate for coronary angioplasty is 90-95%. There is a
less than 1% risk of death. There is a 1-3% risk of emergency bypass
surgery if the blood vessel cannot be successfully opened or is
opened and threatens to close. There is a 30-40% re-narrowing of
the artery where the balloon angioplasty was performed in the first
3-6 months following the procedure. If patients have no symptoms
after 6 months it is unlikely for them to have a recurrence at the
site of the original angioplasty.
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Atherectomy
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| Atherectomy
is another procedure that relieves symptoms of coronary artery disease
by improving blood flow to the heart by treating blockages in the
arteries that feed the heart. An atherectomy catheter removes the
cholesterol build up from inside the heart by cutting, grinding
or aspirating the cholesterol build-up from the body. The procedure
is performed in the same way as balloon angioplasty. The only difference
is the mechanism from which the artery is opened and the blood flow
is improved.
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Rotational
Atherectomy
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| Rotational
atherectomy is the use of a high speed drill that ablates or grinds
up the cholesterol inside the artery to very fine particles which
pass uneventfully down stream from the blockage. The drill spins
at between 160,000 and 200,000 revolutions per minute. The tip of
the drill is impregnated with industrial diamonds which form a very
hard and sharp cutting surface. The procedure is ideally suited
for patients that have very hard cholesterol deposits and especially
those that have calcium. Like other catheter based procedures, the
risk and success rates are similar with success rates between 90-95%
and reoccurrence rates between 30-40%. The risk of emergency bypass
surgery is again 1-3% with the risk of death of less than 1%. We
found rotational atherectomy is a very good procedure for re-narrowed
Stents as well as arteries that have heavy calcification which is
very common in more elderly patients. If further information is
required about rotational atherectomy, please contact our website
and we would be happy to send you a brochure.
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TEC-Atherectomy
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| Transluminal
Extraction Atherectomy: The TEC-atherectomy procedure is one that
is ideally suited for blockages that have blood clot and blockages
that occur in old bypass grafts. This procedure allows the plaque
to be cut up and aspirated. This prevents any particle from going
down stream in the blood vessel involved or the bypass graft involved
and thus minimizing the risk of heart attack during the procedure.
This procedure has evolved primarily for the treatment of previous
bypass grafts from coronary artery bypass surgery and less commonly
in the treatment of myocardial infarction. The risks and benefits
are the same as in other catheter based intervention and if further
information is required on TEC-Atherectomy, please contact our website.
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Directional
Atherectomy
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| Directional
atherectomy was the first atherectomy procedure that was approved
by the federal government. This is a shaving procedure that collects
the cholesterol build up inside the cutting chamber which allows
its removal from the body. This prevents any particles from going
down stream and therefore minimizes the risk of heart attack. Directional
atherectomy is an ideal procedure for patients that have big arteries
with somewhat asymmetric cholesterol build up. It has also been
used in patients that have cholesterol build up at a branch point
in their arteries. Like all atherectomy procedures, directional
atherectomy has the same risks of heart attack, death and recurrence
in the first 3-6 months. It is again a very successful procedure
with success rates in the 90-95% range. If further information about
directional atherectomy is required, please contact our website.
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Coronary
Stents
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| Coronary
stents are metal scaffolding devices that hold open the artery after
it has been enlarged with a balloon catheter or an atherectomy catheter.
Coronary stents are the first devices to show dramatic improvements
in the re-narrowing rates from earlier procedures primarily performed
by atherectomy catheters or balloon angioplasty catheters. Coronary
stents in appropriate patients have reduced the recurrence rate
from 30-40% to 20%. A coronary stent is a metal sleeve that is loaded
on top of conventional balloon angioplasty catheter. This is placed
through the groin or arm as previously described in the angioplasty
and atherectomy procedures. The metal stent, however is left behind
inside the artery as a scaffolding device. At present, there are
four coronary stents that are available for implantation in patients.
At Medical Center Cardiologists, P.S.C., we have been lucky enough
to participate in government and industry supported trials looking
at newer coronary stent designs which should prove beneficial to
all patients and especially to patients in our practice. It should
be noted, however, that coronary stents are not for all types of
blockages. They have not shown to be better than previous devices
in patients that have small coronary arteries with narrowing. They
also have problems in patients that have blockages at branch points
and patient that have blockages involving a long segment of a coronary
artery.
Whether coronary artery
stenting is right for you is best discussed with your cardiologist.
Four out of the twelve cardiologists in Medical Center Cardiologists,
P.S.C. perform catheter based intervention of which coronary stenting
is one type of intervention. If you wish more information about
coronary stents, please E-mail us a message and we will be happy
to accommodate your request.
Medical Center Cardiologists,
P.S.C. perform approximately 3,200 invasive cardiology procedures
per year. Of these, approximately 2,500 are cardiac catheterizations
with 700 catheter based interventions and 100 endomyocardial biopsies.
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