The Heart Is a Pump

The heart is a muscle that pumps blood around the body through a series of pipes. These pipes are called arteries. The left side of the heart receives fresh, oxygen-rich blood from the lungs and then pumps it out a large artery called the aorta that branches into smaller arteries that go to all parts of the body.

The various parts of the body then take the oxygen out of the blood and the now stale, oxygen-poor blood is returned to the right side of the heart through pipes called veins. The right side of the heart pumps this stale blood to the lungs where it picks up more oxygen and the cycle begins again.

The Coronary Arteries

The heart muscle, like every other part of the body, needs its own oxygen-rich blood supply. Arteries branch off the aorta and spread over the outside surface of the heart. The Right Coronary Artery (RCA) supplies the bottom part of the heart. The short Left Main (LM) artery branches into the Left Anterior Descending (LAD) artery that supplies the front of the heart and the Circumflex (Cx) artery that supplies the back of the heart.

There are several tests that can check if plaques are blocking the coronary arteries to the heart. These include: treadmill test (fast walking on a treadmill while attached to an ECG machine), nuclear scans such as SPECT or PET scan, stress echocardiogram, CT angiography scan, or angiogram.

Angiogram

With this test, a small tube or catheter is inserted into an artery in the groin or wrist and guided to the heart. A dye is injected through this tube and into the coronary arteries so that they can be seen by an X-ray. This shows if there is plaque blocking the arteries and whether the blockages should be treated just with medications or if there is also need for an angioplasty or coronary artery bypass grafting (CABG) surgery. Sometimes dye is injected into the pumping chamber of the heart to check how strong the heart is and if there was any damage to the heart muscle. This is called a ventriculogram. The catheter is then removed.

Angioplasty and Stents

Sometimes blockages in the coronary arteries can be fixed with angioplasty. A small tube or catheter is inserted into an artery in the groin or wrist and guided to the heart as with the angiogram. In this procedure, a small balloon at the end of the catheter can be inflated for a short period of time to push the plaque back against the wall of the artery so that blood can flow better.

In many patients, a small metal mesh tube or stent, is placed over the balloon. When the balloon is deflated and removed, this stent stays permanently where the blockage was and lowers the risk of this area narrowing again. Some stents are metal alone (bare metal stents). Others have a medication coating on them (drug eluting stents).

Advantages of Angioplasty

Over 90% of angioplasties are successful immediately. Blood flow through the artery returns to normal or near normal. Some people may not have complete relief, but their symptoms are improved, allowing them to be more active and comfortable.

There is no incision as this is not surgery and you are not put to sleep (general anesthesia). Most people are up and walking on the same day. Some people go home the same day, but some patients are required to stay overnight and go home the following morning.

Disadvantages of Angioplasty

An artery may become narrow again after angioplasty. This is called restenosis. If the artery narrows enough, you may feel angina again. The use of stents has reduced the restenosis rate. Restenosis is usually treated with a second angioplasty, but occasionally bypass surgery is needed or medical therapy is used.

Risks of Angiogram and Angioplasty

Angiogram and angioplasty (with or without stent implantation) are common procedures. Your physician has carefully considered your clinical condition and believes that the benefits of the procedure outweigh the risks. However, since these procedures are invasive there are risks associated with them.

Common risks include:

• Bleeding at the catheter insertion site or other organs due to blood thinning medication (antiplatelet or anticoagulant)

Less common but potentially more serious risks include:

• Heart attack
• Stroke
• Unknown dye allergy
• Kidney problems, including kidney failure requiring dialysis
• Emergency heart surgery
• Death
• Other rare and unpredictable complications

In 1% to 2% of angioplasty cases, the artery collapses or is damaged by the wire or balloon. A stent can often fix this, but sometimes patients need emergency coronary artery bypass surgery. At the Heart Institute, our operating rooms are close by if a patient needs surgery.

Coronary Artery Bypass Grafting

Sometimes the blocked arteries cannot be fixed with angioplasty/stents and may require coronary artery bypass grafting (CABG) which is surgery that requires opening the chest. Arteries inside the chest, an artery from the wrist, or pieces of vein from the leg are used to go around the blockages in the coronary arteries. This surgery requires a recovery time of five to seven days in hospital and one to two months at home.

What to Expect During an Angiogram

Before Your Procedure

After a brief discussion with the nurse you will be taken into the Catheterization Lab and asked to
lie on a special X-ray table. The temperature in the room will be very cold. You will be attached to a heart monitor.

As this is a teaching hospital there may be other physicians, nurses and lab technologists involved in your procedure. All staff will be wearing gowns, masks and special aprons.

Your groin/wrist will be washed with a cold solution and sterile sheets will be placed over you. It is important that you neither move nor touch the top of the sheets once they are in place. You may be asked to lie with your arms above your head for a period of time. A nurse will be available to assist you.

During Your Procedure

You will be given medication to help you relax, but you will be awake during the procedure so that
you can follow instructions from the doctor and nurses. The doctor will administer freezing to your groin/wrist. A small catheter will be threaded through a blood vessel up to the heart. A contrast dye will be injected through this catheter to highlight the coronary arteries. Most patients experience a sensation of body warmth or the urge to empty their bladder as the dye is injected.

X-ray pictures will be taken throughout the procedure. The X-ray machine will move over you very close to your body.

During the procedure, you may be asked to take a deep breath and hold it for a few seconds, or to cough. It is not unusual to experience some chest pain. Inform the nurse if you experience any discomfort or have concerns.

The time for the procedure in the lab is usually between 30 to 90 minutes. If your condition is complex, your procedure will be longer.

Due to unforeseen circumstances there may be a lengthy wait in the lab waiting area or you may be
returned to your room until the lab is available.

After Your Procedure

You will leave the Catheterization Lab on a stretcher, and one of the following will happen:

• After an angiogram: The catheter will be removed and a special clamp or manual pressure will be applied.
• After an angioplasty: You will be transferred to a unit which specializes in catheter (sheath) removal if a groin insertion was used, or back to the sending unit if the wrist was used.

The nurse will frequently check your pulse, blood pressure, pulses in your feet or wrist, and the puncture site. If you are a patient in the Day Unit area, due to space constraints, only one family member or friend should be with you at a time. They may be asked to leave periodically in order for the staff to deliver care and allow the patient to rest.

Following a groin insertion:

• If the doctor used your groin (femoral artery), you must remain on bed rest for up to 6 hours after the procedure.
• It is important to keep your head on the pillow and your affected leg straight. You will be reminded frequently to do these two things to avoid bleeding from the puncture site.
• If you experience back discomfort, you can be repositioned with the help of a nurse, keeping your affected leg straight. The head of your bed may be elevated slightly.
• During this time you may sleep, read or rest. You will be given a snack.

Following a wrist insertion:

• If the doctor used your arm (radial artery) you will have a clamp applied to your arm in the lab to prevent bleeding.
• You will be on bed rest for approximately one hour after the procedure.
• It is important to keep your arm on the pillow and refrain from twisting your wrist. You may move your fingers. Your nurse will be available to assist you while the clamp is in place.
• During this time you may sleep, read or rest. You will be given a snack.

Ask your nurse for assistance as soon as you need to go to the bathroom. It is important not to sit up. The nurse will assist you in getting up once your bed rest is complete. You will be encouraged to walk around during the hour before discharge.

Activity

Following a groin (femoral) insertion:

• Limit the amount of stair climbing as much as possible. Try to climb the stairs only once on the day of your procedure.
• Do not lift anything heavy—greater than 10 lbs (4.5 kg) —for 48 hours.
• Apply pressure to your groin if you have to sneeze or cough hard for 48 hours. The easiest way to apply pressure is to make a fist and place it firmly on the groin area over the band-aid.

Following a wrist (radial) insertion:

• Do not lift anything greater than 10 lbs (4.5 kg) with the affected arm for 48 hours after the procedure. Avoid vigorous wrist movements of the affected arm.
• You may elevate your arm on a pillow to help prevent swelling.

Dressing

• You may remove the clear dressing or band-aid the day after the procedure, and replace it with a new band-aid.
• A small amount of dried blood on the old dressing and puncture site is normal.
• You may take a shower the day after your test, but do not allow the dressing to stay wet.
• Do not take a tub bath or cleanse the arterial puncture site for 48 hours after your test.
• You may re-apply a dry band-aid for a few more days in order to keep the skin clean and reduce the risk of trauma or infection. The band-aid may be removed 72 hours after the procedure.
• Try to avoid wearing tight or restrictive clothing over the puncture site.

Puncture Site

Examine the site every day and notify your nurse or physician if any of these problems develop:

• An expanding lump or persistent area of redness and warmth
• Yellow drainage from the wound site
• Worsening numbness in the leg, hand, wrist, or arm
• Severe discomfort at the puncture site

Bleeding

If any bleeding occurs while in hospital, please ring for your nurse immediately. If a small amount of bleeding occurs at the puncture site at home:

• For a wrist site, sit down immediately and apply firm pressure to your wrist with your fingers for ten minutes.
• For a groin site, lie down and apply pressure to your groin using a fist placed firmly on the groin area over the band-aid.

If the bleeding stops, remain quiet and keep your procedure leg/wrist immobile for two hours.