Interventional cardiology is a branch of cardiology that deals specifically with the catheter based treatment of structural heart diseases. Procedures are performed by specifically trained cardiologist. Since there is no surgery performed, the leading doctors are not cardiovascular surgeons, but cardiologists.

Which procedures are included in the context of Interventional Cardiology?

• Right-left heart catheterization,
• Coronary angiography,
• Coronary angioplasty (PTCA),
• Stent Procedures (Balloon and stent; drug-eluting Stents; melt-away stents)
  Mitral Valve, Balloon Valvotomy,
• Pulmonary Valve, Balloon Valvotomy,
• Percutaneous Aortic Valve Replacement (TAVI),
• Renal Denervation in Hypertension,
• Closure of PDA and ASD in children,
• Percutaneous Coronary Intervention (PIG) in Acute Myocardial Infarction (PCI) ,

Also pacemaker implantation is a commonly performed invasive cardiology procedure at Electrophysiology Pacemaker Laboratory of our Center.

Electrophysiological cardiac work-ups are;

• Pacemaker Implantation,
• Pacemaker implantation in heart failure,
• Lead extraction,
• Placement of loop recorder,
• Electrophysiological studies (EFS) in arrhythmias,
• Ablation (in arrhythmias).

Commonly performed procedures of our Heart Center team:

• Cardiac Catheterization and Angiography

Vessels that supply heart’s muscle tissue are called “coronary vessels”. Atherosclerosis is formation of plagues (produced by fatty accumulation and calcification) in the blood vessel wall. These plagues may result in obstruction or stenosis of the vessels. Stenosis or obstruction of coronary arteries might cause chest pain and heart attack (myocardial infarction) in the patient.
The basic principle to prevent stenosis of coronary arteries is to improve risk factors.

Measures are the essential for treatment, e.g. regular checks of diabetes mellitus, loss of weight, treatment of hypertension, improvement of high cholesterol and triglyceride values, cessation of smoking, and regular exercises.

• Coronary Angiography and Cardiac Catheterization

Despite preventive measures taken, if complaints are present suggesting stenosis of coronary arteries, or if any abnormalities are detected by pre-tests (e.g. effort test, thallium test, etc.), cardiac catheterization and coronary angiography are performed to identify location and size of this stenosis. In case the stenosis is critical, the treatment options can be balloon angioplasty-stent or bypass operation. Both of these treatment options are performed safely in our day.

Cardiac catheterization is a diagnostic method that has been used for people since 1930s, and has been widely utilized since 1953. At the present time femoral artery is often used while arm vessels are rarely used. Cardiac catheterization and coronary angiography are diagnostic methods not treatment. It is based on imaging of cardiac cavities and coronary arteries with injection of contrast material and also measuring the pressure of the cardiac cavities and associated vessels.

The patient is delivered a tranquilizer and transferred to catheter laboratory after signing informed consent form. Femoral or arm section is anaesthetized to place a cannula in the vessel. The thin catheter made of plastic-like material is guided through cardiac cavities first to record the pressure then contrast material is injected for taking pictures. Then coronary arteries are displayed and recorded. This procedure takes approximately 15 -30 minutes.

• Percutaneous Mitral Balloon Valvuloplasty

Mitral valve is located between the left atrium and the left ventricle. It has two leaflets. Mitral stenosis occurs when two leaflets of the valve thicken and attach to each other, and is characterized by narrowed valve as a result of thickened and shrunk muscles and fibers holding the mitral valve. Mitral stenosis is a heart valve disease developed associated with acute rheumatic fever suffered in the childhood.

Mitral stenosis prevents oxygenated blood coming from the lungs from passing from the left atrium to the left ventricle. Therefore, the left atrium is the first to enlarge then the blood begins accumulating in the lungs. Intrapulmonic pressure is increased by accumulated blood in the lungs, and the patients will have complaints of shortness of breath, cough, heart-throb, and in the advanced stages hemoptysis (pulmonary edema or pulmonary congestion) may occur.

Treatment of mitral stenosis varies depending on the severity of stenosis. Pharmacotherapy should be enough for mild stenosis. Diuretics will be helpful to prevent accumulation in the lungs and beta blockers will be useful for heart-throb. With progressed stenosis, percutaneous mitral balloon valvuloplasty (PMBV) or open heart surgery (surgical repair or replacement of mitral valve) is performed.

Mitral balloon valvuloplasty is used to enlarge narrowed mitral valve by a balloon. When performed on appropriate patients, mitral balloon valvuloplasty has many advantages over open heart surgery.

The most important advantage is that the patient does not receive general anesthesia, and the rib cage is not opened. Thus, the patient is conscious during the procedure and does not require intensive care after the procedure.

In addition, patients are able to recover in short time and mostly discharged the following day.

Another important advantage is that a large number of patients, who has received a mitral balloon valvuloplasty, does not need to use anticoagulant drugs if no arrhythmia occurs while the patients, who have undergone an open heart surgery and implanted an artificial (prosthesis) valve, need to use anticoagulant drugs (coumadin-warfarin) for a lifetime.

How do we perform mitral balloon valvuloplasty?

Mitral balloon valvuloplasty procedure is performed by interventional cardiologists at angiography laboratory.

• Inguinal region is cleaned with an antiseptic solution to apply a local anesthetic prior to procedure.
• A cannule is placed in the inguinal artery and vein and guided to the heart’s right atrium by a catheter then the wall between the heart’s right and left atria is perforated by a specific needle to get to the left atrium.
• The balloon catheter is guided from the left atrium to left ventricle by a specific wire then inflated at the mitral valve to enlarge the valve as much as possible.
• The wire and balloon catheter is removed after the procedure and a bandage is applied on the inguinal region.
• The patient is advised a bed rest and discharged the following day if no problem occurs during follow-up.
• The success rate of mitral balloon valvuloplasty is higher than 90%.
• Most patients will have a well-being for about 20 years.
• Mitral balloon valvuloplasty procedure may be repeated, if necessary, when mitral valve becomes narrowed again.

Mitral balloon valvuloplasty procedure has been performed for years at our hospital. We are the leading hospital with a serious of 1200 cases in the world and in the country. We perform mitral balloon valvuloplasty safely.

How do we perform TAVI?

• Transcatheter aortic valve implantation (TAVI) has been developed for elderly patients with aortic stenosis associated with wear, and patients in high-risk group because of coexisting diseases and for who an open heart surgery is considered risky, and started to use widely in the world after 2005.
• The valve used in line with the developed technology, and the application of implant system become easier each year.
• It is currently applied on over 10.000 patients across the world.
• There are two valves mostly used through catheter, Sapien XT (Edwards) and Corevalve (Medtronic). This valves are similar to bioprosthesis valves which are surgically implanted.
• TAVI procedure is performed at catheter laboratory by team work of invasive cardiology, cardiovascular surgery, echocardiogram, and anesthesia staff.
• Inguinal region is mostly accessed when the patient is under anesthesia. The heart is reached through aorta and calcified aortic valve is enlarged by a balloon then biological tissue prosthesis valve is implanted.
• The entire procedure is monitored by echocardiogram through esophagus so that precise measurements can be provided.

Based on more than 30-years’ experience in each field of cardiology and cardiological interventions, Group Florence Nightingale Hospitals, Heart Center team easily and effectively tackle cardiac problems from different levels of severity.

What is a Cardiac Pacemaker?

A Cardiac Pacemaker is an electronic device implanted in the body to correct heart’s rhythm and transmission system disorders.

It is vital to correct transmission system disorders, especially bradycardia. A device called pacemaker is implanted in the body to correct bradycardia and for better performance of daily activities. A pacemaker is an electronic device with two parts.

Pulse Generator: the part producing stimulus

Lead or Electrode: The part transmitting

Pulse generator consists of a battery and electronic circuit. Battery is usually lithium. Electronic circuit is a miniature computer with various programs installed in. The programs can be changed when required by a magnet. The power from the battery is converted to small electronic pulses and transmitted to the heart by lead. The electronic circuit controls the timing and intensity of electric stimuli transmitted to the heart.

Lead (electrode) provides the transmission between the heart and the pulse generator. It is usually an insulated wire from polyurethane.

A pacemaker has two important functions:

• Stimulation:Producing a stimulus at a required rate when the heart doesn’t produce one or when it is slow,
• Detection or Sensation: Detecting and monitoring the heart’s natural activity; producing a stimulus when required. So, a pulse generator will not produce a stimulus when the heart has its rhythm.

How is a Cardiac Pacemaker Implanted?

There are two types of a cardiac pacemaker.

• Temporary Cardiac Pacemaker: In some cases, temporary blocks or bradycardia may occur in the heart. Such cases will naturally recover. However, a temporary cardiac pacemaker is implanted to maintain patient rhythm and life until it get backs to normal.

It consists of a pacemaker box and special lead. The lead is placed inside the heart through a vascular access (from neck, arm or groin). The other end of the wire is connected to the pacemaker box. Such pacemakers implanted temporarily are easy to remove when the patient recovers.

• Permanent Pacemaker:Implanted in the body permanently.

There are two methods of implantation:

• Endocardial method:The electrode is guided through a blood vessel to be placed in the heart. The procedure required local anesthesia.
• Epicardial method:The electrode is directly stitched on the heart muscle. This procedure requires general anesthesia. It is rare in cases where it is impossible to perform endocardial method.

Endocardial Implantation of Permanent Pacemaker

This procedure is performed in a special catheter lab with a radioscopy device and under full sterilization, administering local anesthesia. During the procedure, the surgeon and assisting staff will wear a sterile dress, bonnet, and mask as in the operating theatre. The front side of the chest is cleaned with a special solution and covered with a sterile blanket. The pacemaker is usually implanted in the left chest (may be in the right side) below the clavicula.

The site is incised in 8-10 cm. Depending on the type of the pacemaker implanted 1-2-3 leads are guided through the vessels exposed by incision to be placed in the required cavity of the heart. Measurements we call threshold measuring are performed to see the state of the lead to detect and produce a stimulus. The leads are then attached to tissues and vessel at the site of incision. The other end of the lead is connected to the pulse generator which is placed in the pocket specially prepared under the skin, and the skin is sutured.

Depending on the condition of the heart, the heart chamber to be stimulated must be determined before.

• One-chamber stimulation: The right atrium and the right ventricle are selected for this stimulation. Only one lead is used.
• Two-chamber stimulation: Both the right atrium and the right ventricle of the heart are stimulated. Two leads are placed in the right atrium and right ventricle.
• Three-chamber Bi-Ventricular stimulation: A special type of stimulation used in heart failure. Three leads are placed in the right atrium, right ventricle, and coronary sinus. In this case, the right atrium, right ventricle and left ventricle will be stimulated.

The procedure usually takes 1-2 hours for implantation of a permanent pacemaker. In implantation of three-chamber pacemakers, it may take time to find the coronary sinus and implant the lead, resulting in prolonged time for the procedure around 3-4 hours.

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