Cardiac Rehabilitation

What is a Percutaneous Coronary Intervention (PCI) or Angioplasty?

Percutaneous Coronary Intervention is a procedure that widens a narrowed coronary artery, using specialized catheters. PCI can be performed as a planned procedure or as an emergency for someone who has an acute blockage/narrowing of the coronary arteries, such as a person suffering with severe angina or a heart attack. PCI can also be used if you have had coronary bypass surgery but a coronary graft has become narrowed.

The procedure is very similar to that of an angiogram. The cardiologist uses X-ray screening to guide a balloon mounted on a catheter to the narrowing in the coronary artery. The balloon is then gently inflated so that it compresses the fatty tissue responsible for the narrowing. This widens the artery and to hold the area open, a stent is usually left in place. As the balloon is inflated, angina symptoms may occur, but the pain eases very quickly when the balloon is deflated. A PCI will often take longer than an angiogram.

Prior to having a coronary angioplasty and for a defined period afterwards (which varies), certain 'anti-platelet drugs' will be prescribed to help both prevention of future coronary events and stent blockages.

If you have a stent and there is any question of the Clopidogrel/ Ticagrelor/Prasugrel being stopped by anyone, it must firstly be confirmed with your Cardiologist (Consultant at the hospital).

Sometimes, if the person has agreed to it beforehand, and the circumstances are right, the doctors may perform the PCI at the same time as the coronary angiogram.

Technical advances in PCI have led to the use of tools such as a laser or Rotablator (miniature diamond drill) and special balloon-only procedures. These can assist the interventionist in opening up an artery. However if PCI cannot be performed, or has been unsuccessful, the cardiologist may recommend a Coronary Artery Bypass Graft.

What is Rotablation?

What is Coronary Artery Bypass Grafting?

Coronary Artery Bypass Grafting is an operation where a blood vessel (an artery or vein) is removed from one part of the body and attached on to the heart’s coronary arteries to 'bypass' a blocked coronary artery.Several of these 'bypass' grafts may be needed and at least one of the donor blood vessels used as a graft will usually be an artery. The donor blood vessels used may be obtained from the inside of the chest wall, the leg or the arm.

Patients needing cardiac surgery will be referred to a cardiac surgeon at a specialist cardiac surgical centre, (for example, Southampton General Hospital).

Patients are usually admitted to the centre the day or the day before their operation. The length of stay varies, but is usually 4-7 nights following the surgery. In the initial 24-48 hours, following the surgery, patients require close monitoring in an Intensive Care or High Dependency Unit.

If you require Cardiac Surgery and are waiting in hospital for transfer, the ward staff and Cardiac Referrals Co-ordinator will be organising your transfer to the specialist cardiac centre. If you are waiting at home for the surgery, the Cardiac Referrals Co-ordinator will be assisting with your referral for Cardiac Surgery.

Cardiac Surgical Referrals Co-ordinator 01202 704404

What is Valve Disease?

The pumping action of the heart is assisted by four valves that control the flow of blood in one direction through the chambers of the heart. They are composed of thin tissue and despite being in constant use, are remarkably durable. On each side of the heart the valves form the only structural link between the chambers.

A valve can fail in two ways. The valve can leak (termed 'incompetence' or 'regurgitation') or narrow (called a 'stenosis'). Often a valve can be both leaking and narrowed. The following situations illustrate what may happen.

The first is a narrowing (stenosis) of one of the two valves on the left side of the heart. Narrowing of the Mitral Valve, nearly always a consequence of rheumatic fever as a child, produces damming up of blood within the left atrium which in turn causes fluid accumulation in the lungs. The consequence of this is shortness of breath. The heart's pacemaker is often upset and irregular fast rhythms are common in patients with advanced mitral stenosis. Narrowing of the other left heart valve, the Aortic Valve, means that not enough blood can be circulated to the body. This is especially noticeable during times of effort and patients frequently present with dizziness.

The second situation is one where a valve is leaking. Again, this is more common and more likely to be of importance when this involves the left side of the heart. Additional strain is put on the pumping chambers because for every heartbeat a variable proportion of blood is going in the wrong direction and has to be emptied out each time to try and maintain a normal circulation. The usual symptom of an overtaxed heart, in this situation, is breathlessness. If the right side of the heart is involved then fluid collects in the ankles or abdomen rather than the lungs.

Prevention of Infection

Before discussing those patients requiring some intervention, it is important to mention preventative measures. Anyone with Valvular Heart Disease runs a slight risk of infection of the valve. Whenever bacteria or other organisms get into the blood stream the body's defences rise up and kill these organisms. If however, the bacteria can hide away in a diseased valve or other abnormal lining structure of the circulation, then they can remain undisturbed and immune to one's natural defences. The organisms can then multiply and infect the heart leading to serious structural damage.

A small dose of bacteria invading the blood is of no consequence but during certain procedures such as dental work near the gums, some surgical procedures or an investigation of one of the passages, the amount of bacteria entering the blood can be considerable. In this situation there is a small risk of infection of the heart lining (called endocarditis). Such a risk can, in the case of dentistry, be reduced by good oral hygiene. It is important that you visit your dentist six monthly and take good care of your teeth and gums. In some circumstances your cardiologist may advise antibiotics before a dental procedure as a precaution.

Treatment

Those patients who develop symptoms related to their valvular insufficiency will require some form of treatment. In the majority of cases this is medical. Tablets used are to reduce fluid accumulation (diuretics) and to open up the circulation and prevent backward flow (vasodilators). Other drugs may be used to correct the heart rhythm if this has been disturbed. Patients with turbulent blood flow, particularly if linked to a persistently irregular heart rhythm, may need to go onto a blood thinning treatment to prevent clot formation. Such treatment can be life-long.

In a small proportion of patients, a surgical solution is necessary. This usually means an operation on a heart valve. Diseased valves can sometimes be repaired but more commonly require replacement.

Repair

The form of repair depends on which valve is involved and the type and severity of the abnormality. For example, a leaky mitral valve can sometimes be repaired. Valve replacement is however more common (and is the norm for the aortic valve).

Replacement

There are two main types of artificial heart valve. The first are artificial man-made valves (prosthetic/mechanical) and the second type are constructed from human or specially treated animal tissues (biological/bio-prosthetic valves). Each have their own attributes and both give excellent results. The decision as to which type to use depends on many factors. The surgeon may not be able to make a decision until the time of the operation. The main concern for the patient is that the prosthetic valves tend to last longer but require the indefinite use of a blood thinning drug (anticoagulant). Most patients who require a heart operation find their previous symptoms improve or disappear. Some drug treatment is reduced or withdrawn completely and for those, who prior to the operation were not able to work because of their symptoms, are often well enough to return to their previous occupation.

What is Atrial Fibrillation?

What is Heart Failure?

The term 'heart failure' is used when the heart muscle is impaired and failing to deliver as much blood and oxygen as the body requires. This can lead to breathlessness, tiredness and swollen ankles.

This may happen for a number of reasons, including, weakness or stiffness of the heart muscle, narrowed or leaking valves and abnormal heart rhythms. The most common causes of heart failure are heart attacks, high blood pressure and cardiomyopathy (a disease of the heart muscle). It may also be caused by, valve disease, congenital heart disease, uncontrolled irregular heart rhythms, alcohol and recreational drugs, and some chemotherapy.

Your consultant will tell you if you have heart failure, and may refer you to a Heart Failure Nurse specialist, who will contact you to offer support.

The British Heart Foundation produce a detailed booklet called "An everyday guide to living with Heart Failure". This can be found under their publication section at www.bhf.org.uk

Treatment for heart failure aims to control symptoms and manage the causes of heart failure. With the support of a heart failure nurse you will be shown what you can do to help you manage your heart failure. This includes, taking your medication, monitoring your weight and changes in your symptoms, eating healthily, reducing salt intake, controlling your fluid intake, limiting alcohol, stopping smoking and keeping active.

If you have heart failure, it is important to keep an eye on your weight. This is because, if your weight goes up, it may be that too much fluid is building up in your body. Weigh yourself every morning and tell your doctor or Heart Failure Nurse about any sudden weight change (for example, if your weight goes up by about 4 pounds – just under 2 kilograms – over two days), or if you start getting more breathless, or have more ankle swelling. It may be that a slight change in your medication (such as water tablets) can improve the symptoms you have.

Bournemouth Heart Failure Team: 01202 726079

Visit: www.cardiomyopathy.org / www.bhf.org.uk