DIAGNOSTIC PROCEDURE OF

CARDIOVASCULAR SYSTEM

CARDIOVASCULAR SYSTEMCHEST X-RAY

A chest X-ray is a radiology test that involves exposing the chest briefly to radiation to produce an image of the chest and the internal organs of the chest. An X-ray film is positioned against the body opposite the camera, which sends out a very small dose of a radiation beam. As the radiation penetrates the body, it is absorbed in varying amounts by different body tissues depending on the tissue's composition of air, water, blood, bone, or muscle. Bones, for example, absorb much of the X-ray radiation while lung tissue (which is filled with mostly air) absorbs very little, allowing most of the X-ray beam to pass through the lung.

PROCEDURE

Patients obtaining a chest X-ray will often be requested to use an X-ray gown, and extra metallic objects such as jewelry are removed from the chest and/or neck areas. These objects can block X-ray penetration, making the result less accurate. Patients may be asked to take a deep breath and hold it during the chest X-ray in order to inflate the lungs to their maximum, which increases the visibility of different tissues within the chest. The chest X-ray procedure often involves a view from the back to the front of the body as well as a view from the side. The view from the side is called a lateral chest X-ray. Occasionally, different angles are added in order for the radiologist to interpret certain specific areas of the chest. The radiology technologist or technician is a trained, certified assistant to the radiologist who will help the patient during the X-ray and actually perform the X-ray test procedure. After the chest X-ray is taken and recorded on the X-ray film, the film is placed into a developing machine, and this picture (which is essentially a photographic negative) is examined and interpreted by the radiologist.

ELECTROCARDIOGRAM (ECG)

The electrocardiogram (ECG or EKG) is a noninvasive test that is used to reflect underlying heart conditions by measuring the electrical activity of the heart. By positioning leads (electrical sensing devices) on the body in standardized locations, information about many heart conditions can be learned by looking for characteristic patterns on the EKG.EKG leads are attached to the body while the patient lies flat on a bed or table. Leads are attached to each extremity (four total) and to six pre-defined positions on the front of the chest. A small amount of gel is applied to the skin, which allows the electrical impulses of the heart to be more easily transmitted to the EKG leads. The leads are attached by small suction cups, Velcro straps, or by small adhesive patches attached loosely to the skin. The test takes about five minutes and is painless. In some instances, men may require the shaving of a small amount of chest hair to obtain optimal contact between the leads and the skin.

HOLTER MONITOR

A ‘Holter monitor’ is a continuous tape recording of a patient's ECG for 24 hours. It is worn during regular daily activities under regular clothing. It helps your cardiologist compare symptoms of dizziness, palpitations or black outs with data gathered on the heart. Holter monitoring is used to detect an abnormal heart rhythm.

Preparation• The only requirement is that the patient wear loose-fitting clothes. Buttons

down the front of a shirt or blouse is preferable. This makes it convenient to apply the ECG electrodes, and also comfortably carry the monitor in a relatively discreet manner.

• Procedure• The chest is cleansed with an alcohol solution to ensure good attachment of the

sticky ECG electrodes. Men with hairy chests may require small areas to be shaved. The electrodes (circular white patches) are applied to various points of the chest. Thin wires are then used to connect the electrodes to a small recorder. The tape recorder is slung over the shoulder and neck. The recorder is worn for 24 hours and you are encouraged to continue your daily activities. You will not be able to shower whilst wearing the monitor. You will need to record your daily activity in a diary noting times of events such as ‘dance class’ or ‘fight with husband’. You should also record any symptoms you may experience such as skipped heartbeats, chest discomfort, shortness of breath and dizziness.

The Holter monitor has an internal clock which stamps the time on the ECGrecording. These can be used to correlate the heart rhythm with symptoms or complaints. After 24 hours, the Holter monitor needs to be returned. This can be removed by the staff.

EXERCISE TEST TREADMILLA test (sometimes simply called a treadmill test or exercise test) in which acontinuouselectrocardiogram(ECGor EKG) recording of theheartis made as thepatient performs increasing levels of exercise on the treadmill which is tilted to producethe effect of going up a small hill. The patient can stop the test at any time, if necessary.Afterwards the patient has heart and blood pressure checked.

Procedure• The patient is brought to the exercise laboratory where the heart rate

and bloodpressure are recorded at rest. Sticky electrodes are attached to the chest, shoulders andhips and connected to the EKG portion of the Stress test machine. A 12-lead EKG isrecorded on paper. Each lead of the EKG represents a different portion of the heart, withadjacent leads representing a single wall.

CARDIAC STRESS TESTING

The exercise cardiac stress testing (ECST) is the most widely used cardiac(heart) screening test. The patient exercises on a treadmill according to a standardized protocol, with progressive increases in the speed and elevation of the treadmill (typically changing at three-minute intervals). During the exercise cardiac stress testing (ECST),the patient's electrocardiogram (EKG), heart rate, heart rhythm, and blood pressure are continuously monitored.

Preparation• Prior to a stress test one should not eat or

drink for a couple of hours. You should however be very well hydrated before you begin. One may also be asked to refrain from smoking prior to the test. If you are undergoing some kind of medical treatments take all your medications prior to a stress test, unless told otherwise by the physician in charge

• . All individuals who use heart medications and inhalers for their asthma should bring them to the stress test center. Let the doctor know if you have diabetes; since exercise can lower blood sugar, he or she may want to check your blood sugar level before the test begins. Comfortable loose clothes for exercising and running shoes are the best clothing items to wear for such a test.

• .It is also recommended that you do warm up and extension exercises before you begin a cardiac stress test or any type of exercise routine. This will help prevent any cramping up of the muscles being used.

ECHOCARDIOGRAM

• An echocardiogram is an ultrasound of the heart which reveals heart valve problems and the overall muscle function. This common test allows our board certified cardiologists to see your heart in motion - ventricles squeezing and relaxing and valves opening and closing. These images are used to identify various abnormalities in the heart muscle and valves.

Procedure• Your technician will ask you to lie on your left side. An

ultrasound gel is applied to a microphone-like device called a transducer. The transducer sends and receives harmless ultrasound waves. The gel allows the the ultrasound beams to penetrate your chest wall so that it is possible to see your heart. Next, your technician will acquire ultrasound images by methodically and precisely moving the transducer around your upper chest creating different prospectives on a monitor. Test measurements will be recorded and diagnosed by our board certified cardiologists. This test is completely painless and will take about 5 minutes.

Nuclear Cardiology: THALLIUM

It is injected IV so that the scintillation camera can count radioactive uptake(areas of poor uptake indicate infarction). It is useful for assessing the extent of disease in a coronary artery and predict the effectiveness of bypass surgery or angioplasty.

Preprocedure• >start the IV line• >inform the client that an isotope is used only in a small diagnostic

amount and will lose radioactivity in a few hours.• >for stress test, thallium is injected 1 hour before the client exercises,5-

10 minutes after 2-4 hours.• >client should eat only a light meal during injection and testing period.• >inform the client that the arms wilL be extended behind the head in a

supine position.Postprocedure• >monitor vital signs• >assess for dyspnea or angina

DIPYRIDAMOLE THALLIUM (PERSANTINE)

• Dipyridamole thallium (Persantine) is injected to vasodilate coronary arteries so increased blood flow will make scanning with thallium more effective. It is used when the client is unable to tolerate exercise such as with severe peripheral vascular disease.

• Preprocedure• >instruct the client to hold all caffeine products for 12 hours in

advance.• >instruct the client on the purpose of dipyridamole(Persantine)• Postprocedure• >monitor vital signs• >assess for dyspnea or angina.

TECHNETIUM OR SETAMBI SCAN• Technetium or Setambi Scan has an IV injection of this isotope; high

uptake will be visualized in areas of MI (even 1-6 days post MI)• Preprocedure• >start the IV line• >inform the client that an isotope is used only in a small diagnostic

amount and will lose radioactivity in a few hours.• >for stress test, thallium is injected 1 hour before the client

exercises,5-10 minutes after 2-4 hours.• >client should eat only a light meal during injection and testing

period.• >inform the client that the arms wiLl be extended behind the head

in a supine position.

CARDIAC CATHETERIZATION• This is a procedure to examine blood flow to the heart and test how

well the heart is pumping. A doctor inserts a thin plastic tube (catheter) (KATH'eh-ter) into an artery or vein in the arm or leg. From there it can be advanced into the chambers of the heart or into the coronary arteries.

• Procedure• In the catheterization laboratory, the insertion area (usually the groin,

neck, or forearm)is cleansed with a sterilizing solution, shaved, and covered with sterile drapes. A small-needle injection of a local anesthetic is used to numb the area. A small incision is made and a pencil-sized plastic tube, called a sheath, is inserted into the artery (e.g., femoral artery, carotid artery) or vein. A catheter, which is usually 2 to 3mm In diameter, is passed via the sheath through the artery to the heart, and into a coronary artery.

ANGIOGRAPHY

Angiography or arteriography is a medical imaging technique used to visualize the inside, or lumen, of blood vessels and organs of the body, with particular interest in the arteries, veins and the heart chambers. This is traditionally done by injecting a radio-opaque contrast agent into the blood vessel and imaging using X-ray based techniques such as fluoroscopy. The word itself comes from the Greek words angeion, "vessel", and graphein, "to write or record". The film or image of the blood vessels is called an angiograph, or more commonly, an angiogram.

Procedure• In Angiography, a long wire called catheter is inserted inside the artery of

the leg, near the thigh crease. This catheter is then pushed against the blood flow towards the heart blindly. With a view of the tip of the catheter on the fluoroscopy monitor (which exposes the patient to very heavy radiation) this catheter is pushed onwards by trial and error method. If it gets stuck somewhere on the route, it is withdrawn a little and again pushed in. Not only it scratches the whole length of the arterial tubes of the body but it can also puncture any corner of the tubes. Once the tip reaches the heart area, further manipulation is done to push the tip in one of the coronary arteries. Once inside the coronary tube, after a lot of trial and error, a radioactive dye is injected through the hole in the catheter inside the coronary tubes and further fluoroscopy photographs are taken.

ELECTROPHYSIOLOGY STUDYAn electrophysiology study (EPS) of the heart is a test performed to analyze the electrical activity of the heart. The test uses cardiac catheters and sophisticated computers to generate electrocardiogram (EKG) tracings and electrical measurements with exquisite precision from within the heart chambers.Procedure• To begin your electrophysiology (EP) study at University of Wisconsin Hospital and Clinics,

you will be asked to lie down on an examination table and electrodes will be placed on your chest. These electrodes have wires that are connected to an electrocardiogram machine, which monitors your heart rhythm during the test. As an infection precaution, you will be shaved and cleansed around the area where the thin catheter tubes will be inserted, usually at the groin or neck area. You will receive a mild sedative through an intravenous line (IV) in your arm, which will help you relax during the test. To get inside the heart, EP catheters will be gently threaded into and through large veins accessible at the groin or neck. First, a small puncture is made in order to access the vein and a guide wire is inserted into the vein. A catheter sheath, essentially a hollow tube, is then guided over the wire. Thin catheters can then be inserted into the hollow sheath. Once in the vein, the catheters can be steered into the heart with the help of x-rays displayed on a monitor.

CENTRAL VENOUS PRESSURE MONITORING

Central venous pressure is considered a direct measurement of the blood pressure in the right atrium and vena cava. It is acquired by threading a central venous catheter (sub clavian double lumen central line shown) into any of several large veins. It is threaded so that the tip of the catheter rests in the lower third of the superior vena cava. The pressure monitoring assembly is attached to the distal port of a multi lumen central vein catheter.

Procedure• Central venous line placement is typically performed at four sites in the body: the right or left

internal jugular vein (IJV), or the right or left sub clavian vein (SCV).Alternatives include the external jugular and femoral veins. A long catheter may be advanced into the central circulation from the antecubital veins as well. The internal jugular vein follows a line from the inferior aspect of the external acoustic meatus to the medial aspect of the clavicle. It passes deep to the sternocleidomastoid muscle between the two heads and joins the subclavian vein to form the brachiocephalic vein, posterior to the clavicle closest to the sternum. The subclavian vein is a continuation of the axillary vein draining the arm. It begins at the lateral border of the first rib and ends at the thoracic inlet where it meets the IJV to form the brachiocephalic vein. The SCV passes over the first rib and apical pleura and runs along the underside of the clavicle parallel with the subclavian artery but is separated from the artery at the anterior scalene muscle, with the vein passing over the muscle. Central venous catheterization via the internal jugular vein has a lower incidence of pneumothorax compared to catheterization via the subclavian vein, and it can be easily compressed after catheter removal or after unintentional arterial puncture. Ultrasound can be a valuable adjunct for IJV cannulation, because the incidence of anatomical variants may be as high as 8.5%. Subclavian vein catheterization is more comfortable for awake patients and less prone to contamination from respiratory secretions, particularly in patients with tracheotomies.

PULMONARY ARTERY PRESSURE MONITORING

The process of pulmonary artery pressure monitoring in 50 consecutive patients in the surgical intensive care unit was analyzed to determine the number and types of problems that occurred in relation to the benefit obtained. This device is a balloon-tipped, flow-directed catheter that is inserted via central veins through the right side of the heart into the pulmonary artery. The catheter typically contains several ports that can monitor pressure or inject fluidsProcedure• The PAC is inserted through a special catheter in the subclavian or internal jugular vein

with the balloon deflated. Once the catheter tip reaches the superior vena cava, partial inflation of the balloon permits blood flow to guide the catheter. The position of the catheter tip usually is determined by pressure monitoring for intracardiac and great vessel pressures) or occasionally by fluoroscopy. Entry into the right ventricle is indicated by a sudden increase in systolic pressure to about 30 mm Hg; diastolic pressure remains unchanged from right atrial or vena caval pressure. When the catheter enters the pulmonary artery, the systolic pressure does not change, but diastolic pressure rises above right ventricular end-diastolic pressure or central venous pressure(CVP); ie, the pulse pressure narrows. Further movement of the catheter wedges the balloon in a distal pulmonary artery. A chest x-ray confirms proper placement.

INTRA-ARTERIAL BLOOD PRESSURE

Intra-arterial blood pressure (IABP) measurement is often considered to be the gold standard of blood pressure measurement. It is used to obtain direct and continuousBP measurements in critically ill patients who have severe hypertension or hypotension.

PACEMAKER• A pacemaker is a surgically implanted electronic device that regulates a

cardiac arrhythmia.Procedure• The procedure begins with the insertion of the wires that attach the

device to theheart. The wires are threaded through and into the heart where they are placed using atype of x-ray imagining that allows the doctor to see exactly where the wires are at alltimes. Once the wires are in place, an incision is made in the chest or abdomen, and theactual pacemaker device is placed under the skin. The wires, which are connected to theheart, are attached to the pacemaker. The pacemaker is then tested to make sure it isworking effectively.Once the physician determines that the wires are in the correct place and thepacemaker is functioning properly, the incision is closed withsuturesor adhesive stripsand medication is given to wake the patient.

CORONARY ARTERY BYPASS GRAFT

Coronary artery bypass graft surgery is a surgical procedure in which a blood vessel from another part of the body is grafted onto the occluded coronary artery below the occlusion in such a way that blood flow bypasses the blockage.

Procedure• After general anesthesia is administered, the surgeon removes the veins or prepares the

arteries for grafting. If the saphenous vein is to be used for the graft, a series of incisions are made in the patient's thigh or calf. If the radial artery is to be used for the graft, incisions are made in the patient's forearm. It is important to note that the removal of veins or arteries for grafting does not deprive the area of adequate blood flow. More commonly, a segment of the internal mammary artery is used for the graft, and the incisions are made in the chest wall. The internal mammary arteries are most commonly used because they have shown the best long-term results. Because they have their own oxygen-rich blood supply, the internal mammary arteries can usually be kept intact at their origin, then sewn to the coronary artery below the site of blockage. The surgeon decides which grafts to use, depending on the location of the blockage, the amount of the blockage, and the size of the patient's coronary arteries. In traditional coronary artery bypass surgery, the surgeon makes an incision down the center of the patient's chest, cuts through the breastbone, and retracts the ribcage open to expose the heart. The patient is connected to a heart-lung bypass machine, also called a cardiopulmonary bypass pump, that takes over for the heart and lungs during the surgery. During this "on-pump" procedure, the heart-lung machine removes carbon dioxide from the blood and replaces it with oxygen. A tube is inserted into the aorta to carry the oxygenated blood from the bypass machine to the aorta for circulation to the body. The heart-lung machine allows the heart's beating to be stopped, so the surgeon can operate on a still heart. Aortic clamps are used to restrict blood flow to the area of the heart where grafts will be placed so the heart is blood-free during the surgery. The clamps remain until the grafts are in place.

Adjunctive Modalities and Management CARDIOVERSION

Cardioversion refers to the process of restoring the heart's normal rhythm by applying a controlled electric shock to the exterior of the chest. Abnormal heart rhythms are called arrhythmias or dysrhythmias.Preparation• You will be given ‘Warfarin’, a blood thinning medication to take orally in the days prior to

the procedure. You should also take any other medications as instructed by your physician. You should fast for at least eight hours prior to the procedure. You will present at hospital on the morning of the procedure as a day patient.

Procedure• The procedure is administered in the ‘cath lab’ or coronary care unit. An anaesthetist

administers intravenous sedation. Once you are asleep, your cardiologist charges the defibrillator and delivers the shock. Usually a Trans-oesophageal Echocardiogram is performed with this procedure while you are asleep.

Post Procedure• You will probably feel slightly drowsy after the procedure. You will be allowed to leave the

hospital about three hours after the procedure and you will need someone responsible to take you home.

DEFIBRILLATIONDefibrillation is a process in which an electrical device called a defibrillator sends an electric shock to the heart to stop an arrhythmia resulting in the return of a productive heart rhythm.

• Cardiac Conduction Surgery MAZE ProcedureThe surgical procedure consists of creating a number of incisions in the atrium that disrupt the re-entrant circuits. Once the incisions are made, they are sewn together again. The atrium can then hold blood on its way to the ventricle and can squeeze or contract to push the blood in to the ventricle, but the electrical impulse cannot cross the incisions.

• CATHETER ABLATION SURGERYCatheter ablationis an invasive procedure used to remove a faulty electrical pathway from the hearts of those who are prone to developin gcardiac arrhythmias such as atrial fibrillation, atrial flutter, supraventricular tachycardias (SVT). It involves advancing several flexible catheters into the patient’ s blood vessels, usually either in• The femoral vein, internal jugular vein, or subclavian vein. The catheters are then

advanced towards the heart and high-frequency electrical impulses are used to induce the arrhythmia, and then ablate (destroy) the abnormal tissue that is causing it.

Procedure

• Usually you will be instructed to stop taking Coumadin (warfarin) three days before the procedure.

• Your doctor may also ask you to stop taking other medications, such as those that control your heart rate or aspirin products.

• Do not discontinue any of your medications without first talking to your healthcare provider. Ask your doctor which medications you should stop taking and when to stop taking them.

• If you have diabetes, ask the nurse how you should adjust your diabetes medications and/or insulin. .

• Eat a normal meal the evening before your procedure. However, DO NOT eat, drink or chew anything after 12 midnight before your procedure. This includes gum, mints, water, etc.

• If you must take medications, only take them with small sips of water. When brushing your teeth, do not swallow any water

• Remove all makeup and nail polish before coming to the hospital.• Wear comfortable clothes. You will change into a hospital gown before the procedure.• Please leave all jewelry (including wedding rings and watches) and other valuables at home.• The clothing you are wearing that morning will be returned to the person who accompanies

you or placed in a locker