Coronary angiography is the process of taking images of the coronary “heart” arteries by passing a thin tube called a catheter through an arm artery to the top of the heart. A small amount of contrast is injected and an x-ray camera outside the body takes images.

Coronary angioplasty and stenting are procedures to reopen blocked or significantly narrowed coronary arteries. This may involve inflating a balloon or placing a stent (an expandable metal scaffold) into the artery to restore blood flow.

Angiography and stenting are commonly performed under local anaesthetic without the need for a general anaesthetic.

Where is this procedure performed?

Procedures are performed in a dedicated X-ray area called an Angiography Suite, similar to a small operating room. This area is equipped with an X-ray Image Intensifier, television screens and a heart monitoring system.

CTCA uses computed tomography (CT) scanning to take detailed images of the heart. It is a quick and easy test (scanning takes 15 seconds), without the need for invasive procedures, to determine if there are any significant narrowing in the heart arteries.

Coronary bypass surgery, otherwise known as coronary artery bypass graft (CABG) surgery is a procedure that uses another artery or vein to restore blood flow to your heart muscle by bypassing the area of blockage or narrowing.

Our guide to Undergoing Cardiac Surgery at Norwest provides you with information about what to expect before surgery, the surgery process and recovery after surgery.

To find out more click HERE.

For severely narrowed or leaking valves these may be repaired or replaced. This can be achieved with standard surgery, less invasive surgery or via minimally invasive catheter-based procedures. To replace a heart valve, your doctor may remove the heart valve and replace it with a mechanical valve or a biological tissue valve.

DC cardioversion (DCCV) is used to treat irregular heart rhythms - commonly atrial fibrillation. The procedure involves a general anaesthetic and placement of electrodes on the chest. An electrical impulse or shock is delivered to return the heart rhythm to normal.

What is an electrophysiological study?

An electrophysiology study (EPS) is a series of tests that examine the heart’s electrical activity and is used to diagnose and treat cardiac rhythm disturbances. EPS involves mapping the electrical paths in the heart to determine if significant electrical abnormalities exist.

By using special pacing wires, the doctor is able to identify any rhythm disturbance and then choose the best method of treatment which may be an oral medication, a pacemaker, an implantable cardioverter defibrillator or a cardiac ablation procedure to restore the heart rhythm.

The electrical conduction system controls the heart rate. This system generates electrical impulses and conducts them throughout the muscle of the heart, stimulating the heart to contract and pump blood.

What is a cardiac rhythm disturbance?

There are conditions where the normal electrical conduction of your heart becomes disrupted causing abnormal heart rhythms (arrhythmia). Many different reasons may cause this to occur, so ask your doctor to explain your condition with you.

What happens before an EPS?

Before EPS, the doctor will discuss the test with you and your family, and answer any questions you may wish to ask as well as discuss potential risks and complications.

What preparation is needed before an EPS?

• Electrocardiogram (ECG) and blood tests will be performed. Nurses will check your vital signs, peak flow, height, weight including extremity observations. Chest X-ray is not routinely done unless requested by your doctor
• Your right/left groin will be shaved
• An intravenous cannula will be inserted into a vein in your arm. This may be used to give medication during the test
• You will be required to fast for solids and fluids for six hours before the test.

What happens during an EPS?

The procedure is performed in a special laboratory under local anaesthetic so you will be awake. You may be given medication through your intravenous cannula to help you relax and a local anaesthetic injection into the groin. The catheters or pacing wires are introduced through the groin into the leg vein and guided, with the use of the X-ray camera, into the right position in your heart.

Between one and four pacing electrodes are used and placed in different positions in the heart. The doctor will give small electrical impulses through the electrodes, which will cause your heart to beat at different rates. Medication may be administered to control your heart rhythm and effectiveness of the medication will be monitored. In some cases, a rapid heart rhythm disturbance may cause you to pass-out for an extremely short period of time, and a small electric shock may be required to restore your normal rhythm.

When the EPS is completed, the doctor will remove the catheters and apply pressure to the insertion site to prevent bleeding. A small sterile dressing will be applied which may be removed after 48 hours.

What happens after EPS?

• On your return to the ward, the nurse will check your vital signs, extremity observations and wound site. ECG will be performed
• You will be cardiac monitored until the following day or as per your doctor’s instructions
• Eat and drink when fully awake and alert
• Rest in bed after the procedure
• Your doctor will advise when you can go home. If no further intervention is required and all assessments and monitoring parameters are within normal limits, you may be able to go home.

Cardiac ablation uses heat (radio frequency) or cold (cryo) energy to create tiny scars in your heart to block abnormal electrical signals that cause rhythm disturbances. This procedure is used to correct heart rhythm problems such as atrial fibrillation.

An implantable loop recorder is a convenient and easy way to obtain long term ECG recording by implanting a tiny paperclip sized device under the skin. This device can record ECGs for 3 plus years and is generally suited for patients with unexplained fainting and strokes/mini strokes of unknown cause. Your doctor can remotely monitor your heart rhythm via a mobile link that you keep in your home.

What is a pacemaker?

An artificial pacemaker is a small device that is inserted under the skin of your chest to help heart muscles pump blood regularly. It is designed to mimic the heart’s natural pacemaker.

A pacemaker uses small amounts of electrical current to stimulate your heart muscle to make it contract. The device consists of a long lasting battery and electronic circuits, inside a metal case.

There are 3 types of artificial pacemakers

• Single chamber pacemakers set the pace of only one of the heart chambers, usually the left ventricle, and needs just one lead
• Dual chambers pacemakers set the pace of two of the heart chambers and needs two leads
• Biventricular pacemakers use three leads, one in the atrium (one of the top pumping chambers in your heart) and one in each of the ventricles (left and right bottom chambers).

Do I need a pacemaker?

Certain diseases or conditions may damage the heart’s electrical system, causing the heart to beat too fast or too quickly. If your heart pumps poorly but not necessarily slowly, such as with heart failure, a biventricular pacemaker may be needed. This helps the heart to beat more efficiently and reduces heart failure.

What can I expect?

Before the procedure

The entire procedure usually takes about an hour, although this can vary. Do not eat or drink anything for 6 hours before the procedure. Your nurse will perform an ECG and will check vital signs such as blood pressure, temperature, heart and respiratory rate.

An intravenous cannula will be inserted in each arm. The procedure/surgery is performed either in the catheter laboratory (Cath Lab) or an operating theatre.

During the procedure

Light sedation may be given to help you relax. The pacemaker leads are inserted into a vein below the collarbone and passed through this vein into the heart. The leads are then attached to the inside of the heart wall and after tests are performed, the leads are connected to the pacemaker. The pacemaker is then implanted under the skin, below the left or right shoulder.

A chest x-ray will be performed after the procedure to check lungs, as well as the position of the pacemaker and leads.

After the procedure

You will be moved to the recovery area for close monitoring and then to the ward to stay overnight. A pressure bandage is applied at the wound site which will be removed prior to going home.

Structural heart procedures include:

• Patent foramen ovale closure (PFO)
• Atrial septal defect (ASD)
• Ventricular Septal Defect closure (VSD closure)
• Left Atrial Appendage Occlusion or Closure

What is a minimally invasive mitral valve replacement?

A minimally invasive mitral valve replacement is a procedure to replace a poorly working mitral valve with an artificial valve without the need for open heart surgery. The surgery is called “minimally invasive” because it uses a single small incision and specialized instruments rather than a larger incision for the traditional open repair. This may lead to easier and faster recovery from surgery.

The heart has four valves. These valves help blood flow through the heart and out to the body by promoting forward flow and preventing backflow. The mitral valve lies between the two chambers of the heart on the left side. These two chambers are the left atrium and the left ventricle. The valve allows blood to flow from the left atrium to the left ventricle in the heart. An artificial valve may be used to replace your poorly working mitral valve. This will make sure that blood can flow into the left ventricle and then flow out to the body normally, without putting extra stress on the heart.

Why might I need a minimally invasive mitral valve replacement?

If the mitral valve is working poorly, you may need it repaired or replaced. Repair of the mitral valve is often possible. However, sometimes replacement is necessary.

Mitral valve stenosis and mitral valve regurgitation (also known as mitral valve insufficiency) are two different types of problems that might need valve replacement.

In mitral valve stenosis, the valve is unable to open fully. This means less blood is able to move from the left atria into the left ventricle. In mitral valve regurgitation, the valve is leaky. Some blood leaks back into the left atrium instead of moving forward into the left ventricle.

These problems can lead to such symptoms as fatigue, shortness of breath, fluid build-up in the legs (oedema), fluid build-up in the lungs (pulmonary oedema), and heart palpitations. If these symptoms are severe, and/or the valve is severely damaged, you may need valve repair or replacement.

Both mitral stenosis and mitral regurgitation can result from general aging of the valve. Other causes of mitral valve disease include:

• Coronary artery disease
• Infection of the heart valves
• Heart failure
• Rheumatic fever
• Congenital heart defect (something you are born with)

MitraClip is a medical device used to treat mitral valve regurgitation.

Cardiac Services Accreditation Practitioner at Norwest

Cardiac Accreditation Services credentials suitably qualified practitioners to perform cardiac procedures including Transcatheter Aortic Valve Implantation (TAVI) and Transcatheter Mitral Valve Repair (TMVr).

Dr Peter Fahmy, Interventional and Structural Cardiologist is a Cardiac Services accredited practitioner for TMVR and TAVI. He is head of the Heart Valve program at Norwest Private Hospital.

What is TAVI?

Transcatheter Aortic Valve Implantation (TAVI) is a new way of replacing the aortic valve in your heart. In the past, the aortic valve could only be replaced with open heart surgery.

Transcatheter means that a catheter (a small flexible and hollow tube) is used to place a new aortic valve in the heart. This is done by making a small opening in an artery, then threading the catheter and the new valve into the right position (replacing the valve).

Unlike open heart surgery, there is no need to open the chest for this procedure. TAVI is generally performed under conscious sedation known as twilight sedation.

Why you may need your aortic valve replaced?

The aortic valve is one of the four valves in your heart that ensures blood flows through your heart in the right direction. When blood leaves the heart, it flows through your aortic valve. Stenosis means a narrowing of the aortic valve opening. Aortic stenosis usually occurs as people age. Over time, the valve stiffens and cannot open enough to let blood through. This may cause feeling short of breath, chest pain, or feeling faint or very tired.

Until now, the usual treatment for severe aortic stenosis has been open heart surgery. Open heart means the person’s chest and the heart itself are opened so the doctor can operate directly on the heart. The doctor removes the diseased valve and replaces it with a new valve. While this surgery is being done, the person’s blood is circulated outside the body through a special machine, called a heart-lung bypass machine. This is called Surgical Aortic Valve Replacement and may be the best option for most people.

A Surgical Aortic Valve Replacement may not be the best option if:

• You are older
• You have other diseases like kidney or lung disease
• You have had one or more open heart surgeries in the past
• You are not well enough for a major surgery
• You have had radiation to your chest.

Is TAVI the best option?

In order for us to decide whether TAVI would be the best option for you, we need a lot of information about you, your heart, and general health. Also, it is not just our decision. If we recommend TAVI, you can choose to continue with your current treatment instead, or talk to your doctor about other options. But it is important to make your decision after we have seen you and given you information about your options.

Every person undergoes a thorough review before deciding if TAVI is an option. If you decide that you want to know if TAVI is an option, you will need to come to the hospital for at least two visits.

To find out more about the procedure, click HERE.

What is Transoesophageal Echocardiography?

A transoesophageal echocardiogram (TOE) is a special type of echocardiogram (heart ultrasound) that takes images from behind the heart. This is achieved by passing the probe down the back of the throat (very similar to an endoscopy or gastroscopy procedure). The images obtained are of better quality than a normal echocardiogram due to the lack of lung (air) between echo probe and heart.

What happens during the procedure?

The procedure will be performed in your room or in the Cardiac Cath Lab holding bay. The nurse caring for you during your procedure will explain what to expect and record your blood pressure, monitor your heart rate and oxygen level in your blood.

The nurse will set up the required equipment and will assist your Cardiologist during the procedure. A cannula (needle) will be inserted into the back of the right hand. The doctor will spray the back of your throat with an anaesthetic spray and ask you to gargle then swallow. This may be repeated. You will be positioned onto your left side and the nurse will give you some sedation through the cannula.

Once you are sedated, your doctor will insert the TOE probe and ask you to swallow. Once in place, you will just doze until the end of the procedure which takes about 15-30 minutes.

What happens after the procedure?

After the procedure, you will be transferred to your room once you are awake and responding to the nurse’s questions. Your doctor may have already spoken to you about the result.

Your blood pressure and heart rate will continue to be monitored for several hours.

What is Cardiac Rehabilitation?

Cardiac Rehabilitation (cardiac rehab) is a medically supervised program designed to improve your heart health if you have experienced a heart attack, heart failure, angioplasty or heart surgery.

The program will help you and your families to understand the heart problem, achieve a healthy lifestyle and help to maintain any changes that have been made to your heart. Cardiac rehabilitation should be lifelong to ensure a healthy heart.

Why does Cardiac Rehabilitation help?

Cardiac rehabilitation can have many benefits for your health in both the short and long-term and help recovery to normal activities sooner. You’ll get personalised support, including:

• Learning more about your heart condition and treatment
• Increasing your energy and strength to make daily activities easier such climbing stairs
• Getting back to your usual activities e.g. work, driving, having sex
• Changing your lifestyle to improve your heart health
• Managing your medicines
• Stop smoking
• Warning signs and knowing what to do in an emergency

You’ll be able to ask questions about things that may worry you and get support if you feel stressed, anxious or depressed.

When do I begin Cardiac Rehabilitation?

Cardiac rehabilitation begins before you come to hospital if you are planning a heart procedure or surgery. Your doctor may have suggested some lifestyle changes such as quitting smoking, eating healthier foods and losing weight. New medications may have also been started. In hospital, you will be given further advice from our Coronary Care Team and your doctor. You may also meet our Cardiac Rehabilitation Coordinator.

Why should I attend Cardiac Rehabilitation?

Cardiac Rehabilitation is highly recommended if you have had a heart attack (myocardial infarction), heart procedure (stents) or cardiac surgery. Cardiac rehabilitation will help you to:

• Recover more quickly
• Reduce anxiety and depression
• Increase your ability to do physical activity
• Meet other people in a similar situation and increase your support network.

How does a Cardiac Rehabilitation program work?

Cardiac rehabilitation usually runs for 6-10 weeks. It often starts in hospital and continues when you go home.

Cardiac Rehabilitation at The Hills Private Hospital

Our affiliated hospital, The Hills Private Hospital in Baulkham Hills offers Cardiac Rehabilitation programs designed for those who have experienced a heart attack, heart failure, heart procedure or heart surgery.

The program aims to maximise physical, psychological and social recovery following a cardiac event. It provides participants with the tools to minimise the progression of cardiac illness by presenting information about a healthy lifestyle, and aims to return individuals back to their normal daily activities. The program at The Hills Private includes education by healthcare professionals, physiotherapy, exercise physiology and Tai Chi sessions.

For more information about Cardiac Rehabilitation at The Hills Private Hospital, call 02 9639 3333 or the Day Program Co-ordinator on 02 9686 0454 or click HERE.