Gleneagles Hospital

Parkway Group Healthcare Mount Elizabeth Hospital

A Cardiac Care Brochure Parkway Group Healthcare
CONTENT
Introduction
Screening Procedures
Diagnostic (non-invasive) Procedures
Diagnostic (invasive) Procedures
Interventional (non-surgical) Procedures
Surgical Procedures
Introduction 6

Screening Procedures 8
- Chest X-ray
- Cardiac Calcium Scoring
- Electrocardiogram (ECG)

Diagnostic (non-invasive) Procedures 12

- Stress Test (exercise or pharmalogical)
- Nuclear Perfusion Test (exercise or pharmalogical)
- Transthoracic Echocardiography (TTE)
- Transoesophageal Echocardiography (TEE)
- Holter Monitoring
- Ambulatory Blood Pressure

Diagnostic (invasive) Procedures 20

- Coronary Angiogram

Interventional (non-surgical) Procedures 22

- Biventricular Pacemaker
- Percutaneous Transluminal Coronary Angioplasty (PTCA)/Balloon Angioplasty/Stenting
- Ablation
- Transcatheter Closure of ASD

Surgical Procedures 28
- Coronary Artery Bypass Grafting (CABG)

3
Gleneagles Hospital is established as a leading centre for the care and treatment
of cardiac patients. The highly skilled nursing team, together with the experience
and expertise of the physicians and surgeons, continually advance the standards of
Gleneagles’ cardiac care.
Cardiac care is one of the cornerstones of Mount Elizabeth Hospital’s sterling
reputation as a leading private healthcare facility of choice. The first open-heart
surgery in private practice in Singapore was performed in Mount Elizabeth. The
Hospital has always maintained her cutting-edge lead in the disciplines of cardiology
and cardiothoracic surgery.
INTRODUCTION
Coronary Heart Diseases Prevention and Treatment Services
Coronary heart disease is one of the top killers in Asia and in many developed
countries throughout the world. Parkway Group Healthcare, which owns East Shore,
Gleneagles and Mount Elizabeth hospitals in Singapore, and seven hospitals in
the region, is the largest private healthcare organisation in Asia. It is committed to
providing comprehensive and quality care to the prevention and treatment of coronary
heart diseases.

With more than 30 cardiologists and cardiothoracic surgeons, our depth and breadth
of medical, clinical and surgical experience is focused on giving cardiac patients the
latest treatment options, supported by investment in state-of-the-art technology
and equipment.

With the largest concentration of cardiac specialist physicians under one roof, as well
as qualified and compassionate nursing care, Parkway Group Healthcare is the ideal
choice for patients with cardiac conditions.

7
SCREENING PROCEDURES
Chest X-ray
Cardiac Calcium Scoring
Electrocardiogram (ECG)
 SCREENING PROCEDURES
CHEST X-RAY

Chest X-ray
Although considered a basic and routine investigation, a simple chest x-ray provides valuable information
on the general condition of the patient’s heart as well as the thoracic cavity.

The chest x-ray can indicate the size and position of the heart, any gross abnormalities and changes in the
heart size, which can serve as a primary indicator of heart failure or obvious congenital abnormalities.

The lung fields can indicate changes occurring as a result of heart failure such as collections of fluids in
addition to any lung pathology that might be evident.

As a basic screening procedure, the chest x-ray helps a clinician to detect signs indicative of a heart
condition and also serve as a useful guide in pursuing more sophisticated means of investigations to ascertain
the patient’s health status.

Even if no gross abnormalities are detected, the captured ‘image’ serves as a very reliable base line, which
can be archived for future reference.

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Cardiac calcium scoring
is a test to detect the presence
of calcium deposits in the arteries.
If calcium deposits are present,
it is an indication of a hardening
of the arteries.

An ECG is quick, safe and

painless. The process takes
about five to ten minutes.
 SCREENING PROCEDURES
CARDIAC CALCIUM SCORING
ELECTROCARDIOGRAM (ECG)

Cardiac Calcium Scoring

Cardiac calcium scoring is a screening procedure
to detect calcium build-up in the coronary arteries.

The test is non-invasive and can be performed in

approximately ten minutes and is completely painless.

Coronary artery calcium is a definite marker for the

presence of artheroscleroris, i.e. the hardening of
the arteries. The results of this screening test allows
the physician to make accurate clinical decisions in
the treatment of coronary artery disease, taking into
consideration the number of calcified vessels, the
patient’s age, gender, symptoms and risk factors.

The calcium scoring chart ranges from zero to over

400. The ‘normal’ score for any age is ideally zero.
The calcium score has greater significance if it
exceeds the 75th percentile of the patient’s age and
sex group, or if calcium is detected in more than two
blood vessels.

Electrocardiogram (ECG)
An Electrocardiogram (ECG) is a recording of the heart’s electrical activity as a graph or a series of wave
lines on a moving strip of paper or video monitor. In this way, one is able to evaluate the heart’s rate, rhythm
and detect the presence of cardiac problems.

The highly sensitive ECG machine helps to detect various heart irregularities, disease and damage.

An ECG is routinely used when heart disease or damage is suspected in a patient who may be experiencing
symptoms such as angina (chest pain), palpitations, shortness of breath, lightheadedness or loss
of consciousness.

How is an ECG performed?

An ECG is quick, safe and painless. It is non-invasive. The patient has to remove his clothes from the
waist up and is then asked to lie down comfortably. The nurse or technician will thoroughly clean a total
of ten areas on the patient’s chest, arms and legs, over which will be attached ten small metal devices
(electrodes). These will be connected by wires to the ECG recorder.

The patient needs to lie still for about one minute while the heart activity is measured and recorded.
Each electrode produces a ‘tracing’ of a particular area of the heart. The entire ECG takes about five to
ten minutes.

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DIAGNOSTIC
(NON-INVASIVE) PROCEDURES
Stress Test (exercise or pharmalogical)
Nuclear Perfusion Test (exercise or pharmalogical)
Transthoracic Echocardiography (TTE)
Transoesophageal Echocardiography (TEE)
Holter Monitoring
Ambulatory Blood Pressure
 DIAGNOSTIC (NON-INVASIVE) PROCEDURES
STRESS TEST

Stress Test (Exercise or Pharmalogical)

A stress test is a diagnostic test that allows the physician to understand a patient’s heart activities both at
rest and with exertion.

The stress test can be administered in two ways:

a. through physical exercise,

b. through the administration of medications, to simulate the ‘stress’, or pharmalogical stress test

All stress tests are performed with ECG electrodes attached to the body to monitor the heart’s activity and
allows the physician to compare the ECG patterns at rest and during stress.

How is an exercise stress test performed?

An exercise stress test requires a patient use a standard treadmill while the ECG electrodes are attached
to the body.

The test requires two phases: the resting phase and the exercise phase.

During the resting phase, the patient lies still while the ECG is taken.

During the exercise phase, the exercise begins at a slow rate and progressively increases his speed
and incline, while the patient’s ECG is recorded periodically, until the patient’s maximum heart rate is
reach when the patient signals discomfort.

13
Results of a Nuclear Perfusion Scan
 DIAGNOSTIC (NON-INVASIVE) PROCEDURES
NUCLEAR PERFUSION TEST

The nuclear perfusion

test measures how the
heart is performing at rest
and during exertion, with
the help of radioactive
elements seen through
a device called a
gamma camera.

Nuclear Perfusion Scan (Exercise or Pharmalogical)

A nuclear perfusion scan is similar to the stress test, which requires two phases – resting and exertion.

The nuclear perfusion scan adds another diagnostic tool for the physician: allowing him to determine the
perfusion (blood flow) to the heart muscle. It is similar to the stress test and requires both resting as well
as stress phases. The images are produced by injecting a small amount of radioactive but harmless substance
(tracer) into a vein at the peak of exercise.

A second injection of the tracer is injected for the resting phase of the test, and further images will be taken
with the gamma camera. This tracer is detected by the gamma camera as it flows through the blood vessel
to the heart muscle. It can show where blood flow has been reduced or restricted.

The physician will compare the results of the heart’s activity at resting phase and at exertion phase.

15
Patient undergoing an ‘echo’
 DIAGNOSTIC (NON-INVASIVE) PROCEDURES
TRANSTHORACIC ECHOCARDIOGRAM (TTE)

Transthoracic Echocardiogram (TTE)

Also known simply as an ‘echo’, an echocardiogram is a painless test that uses high-frequency sound waves
(ultrasound) to obtain images of the heart and its various structures.

Echocardiograms are used to evaluate the structure and function of the heart, including:

a. Status of the heart valves

b. Status and strength of the heart muscle
c. Identifying the presence of blood clots or growths within the heart chambers
d. Detecting the causes of abnormal heart sounds (murmurs)

Because the test does not involve any of the radiation that an x-ray does, it is a very safe test. The sound
waves bounce back from the various components of the heart, producing images and sounds that can be
used by the physician to detect any abnormalities.

How is a TTE performed?

The physician prepares the chest area by applying a conductive, water-soluble gel. A small device, the
‘transducer’ is then placed on the patient’s chest, and this is rotated and positioned at various angles
to obtain images of the heart, which can be seen on a video monitor.

The TTE can be used in conjunction with various forms of stress to detect the presence of coronary
artery disease.

a. an exercise, or stress echocardiogram

b. pharmalogical, or drug-enhanced, stress echocardiogram

How is a chemical or pharmalogical stress test performed?

There may be cases when a patient cannot perform the exercise necessary to an exercise-based
stress test.

In these instances, the physician can still examine the heart by simulating the effects of stress and
exertion by an injection of medication, such as dobutamine. These chemicals stimulate the heart and
mimic the effects of vigorous physical activity.

17
A Holter monitor being attached onto a patient
 DIAGNOSTIC (NON-INVASIVE) PROCEDURES
TRANSOESOPHAGEAL ECHOCARDIOGRAM (TEE)
HOLTER MONITORING
AMBULATORY BLOOD PRESSURE MONITORING (ABPM)

Transoesophageal Echocardiogram (TEE)

This is a form of echocardiogram that involves inserting a transducer down the patient’s throat into the
oesophagus (the long tube that connects the throat with the stomach).

Because the oesophagus is located closely behind the heart, clearer images of the heart structures and
valves can be obtained from inside the body instead of the outside.

Holter Monitoring
A Holter monitor is a portable device that continually monitors the electrical activity of an ambulatory (freely-
moving) patient’s heart over a period of time.

The physician will recommend this test most often when it is suspected that the patient experiences abnormal
heart rhythm, i.e., arrhythmia, or that the patient experiences times when the heart is not getting enough
oxygen-rich blood, i.e., cardiac ischemia.

How is Holter monitoring performed?

Wires (electrodes) from the Holter monitor are taped to carefully-prepared areas of the patient’s body.
The patient is sent home to go about his daily activities (except bathing and showering) and the patient
is asked to keep a diary of his activities and any symptoms he may experience.

Ambulatory Blood Pressure Monitoring

Ambulatory Blood Pressure Monitoring (ABPM) is a method of measuring blood pressure readings of a
patient over a 24-hour period. A special blood pressure monitor is used, and the patient is asked to keep a
diary of his activities during the monitoring period.

19
DIAGNOSTIC
(INVASIVE) PROCEDURES
Coronary Angiogram
 DIAGNOSTIC (INVASIVE) PROCEDURES
CORONARY ANGIOGRAM

Coronary Angiogram
A coronary angiogram is a x-ray procedure to detect the presence of blockages within the coronary arteries.
These blockages are usually the result of the progressive build-up of materials within the walls of the blood
vessels that lead to the development of coronary heart disease.

How is a coronary angiogram performed?

The physician will inject a special dye into the
coronary arteries. A thin tube (catheter) is
inserted through a blood vessel, usually in the
upper thigh. This catheter is then carefully
manipulated through the patient’s main artery
(the aorta) until it is positioned at the opening of
the coronary arteries.
Once the catheter is in place, a special dye is
injected through the catheter and into the arteries.
Then the x-ray is taken. X-ray pictures are taken
while the dye is being injected to obtain images,
showing the coronary arteries and the presence
or absence of any blockages within them.
The patient is usually given a mild sedative before
the procedure but is aware of his surroundings
throughout the procedure.
A coronary angiogram is the most accurate test
in the diagnosis of coronary artery disease.
Depending on what the angiogram shows, the
physician will recommend treatments such as
medication, interventional (non-surgical)
procedures such as balloon angioplasty, or
bypass surgery.

21
INTERVENTIONAL
(NON-SURGICAL) PROCEDURES
Biventricular Pacemaker
Percutaneous Transluminal Coronary Angioplasty (PTCA)/Balloon Angioplasty/Stenting
Ablation
Transcatheter Closure of ASD
 INTERVENTIONAL (NON-SURGICAL) PROCEDURES
BIVENTRICULAR PACEMAKER

A pacemaker
regulates the pumping
action of the heart,
when it cannot do so
on its own.

Biventricular Pacemaker
In many heart failure patients, the walls of the left ventricle - the heart’s main pumping chamber - are no
longer synchronised, or pumping together as they normally would. A biventricular pacemaker is designed
to resynchronise the pumping action of the heart.

How is a biventricular pacemaker insertion performed?

After a local anaesthesia is applied, a small
incision is made in the chest wall just above the
collarbone. Another cut is made in the vein just
under the collarbone.
One of the two wires is threaded through the
vein and positioned in a vein that drains the left
ventricle.
The second wire is threaded through the vein
and embedded into the right ventricle.
The wires are secured by tiny screws which
ensure that the electrode at the tip of each wire
is in direct contact with the inner surface of the
heart chamber. The other ends of the wires are
connected to a generator, which is inserted into
the tissue under the collarbone. The incision is
then closed.
The procedure may take one to two hours, and
can be performed as an inpatient or outpatient
procedure.

23
 Balloon
Angioplasty

Heart

The path
of the tube

Femoral artery

Figure 1

BALLOON IN POSITION
Coronary
Aorta

Tube
Balloon

BALLOON INFLATED
Left coronary
artery
Right coronary
artery

BALLOON WITHDRAWN
Partial
blockage

The path of the tube

Figure 2
 INTERVENTIONAL (NON-SURGICAL) PROCEDURES
PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)/BALLOON ANGIOPLASTY/STENTING

Percutaneous Transluminal Coronary Angioplasty (PTCA)/

Balloon Angioplasty/Stenting
Balloon angioplasty or Percutaneous Transluminal Coronary Angioplasty (PTCA) is a widely-used technique
for opening blocked arteries. The procedure flattens the plaque against the artery wall to open a channel
through which more blood may flow.

How is a PTCA or balloon angioplasty performed?

The patient will be fast overnight for the
procedure.
Before the procedure, intravenous (IV) access
is obtained to allow drugs to be administered to
the patient.
A guiding catheter is then inserted, usually
through the groin, and through which the devices
used in the angioplasty procedure are placed.
(see Figure 1)
Once the physician has located the blockage, a
guide wire is advanced down the artery and
across the blockage. The smaller balloon-tipped
catheter is then threaded across the wire until it
is positioned across the blockage, where it is
then inflated for one to three minutes. After
deflation of the balloon, the process can be
repeated at other areas. (see Figure 2)
Another procedure known as coronary stenting
often accompanies balloon angioplasty. The stent
is a small wire-mesh tube delivered to the artery
mounted as a balloon-tipped catheter and
provides a stronger, reinforced framework at the
site of the blockage. Stents help to keep the artery
open and reduces the changes that the blockage
might recur (restenosis).
The balloon is inflated, deflated and removed,
leaving behind the stent to reinforce the
artery wall.
Balloon angioplasty is a relatively quick
procedure, taking one or two hours. The patient
is usually kept under observation and monitored
for one to two nights.

Drug-coated stents

Drug-coated stents are coated with very small amounts of various chemicals and medication that help
improve the way the body reacts to the placement of the stent.

Medicated stents, in particular those coated with an immunosuppressant called sirolimus, limit the amount
of scar tissue that can form and improve the stent’s ability to stay open in the long-term.

25
When the heart is not beating
in a smooth regular rhythm,
the irregular heartbeats are called
arrhythmia. This condition can
be dangerous.
 INTERVENTIONAL (NON-SURGICAL) PROCEDURES
ABLATION
TRANSCATHETER CLOSURE OF ASD

Ablation
When the heart is not beating in a regular rhythm, the irregular heartbeats are called arrhythmia. When the
heart is beating very rapidly, this type of arrhythmia is known as tachycardia. Some forms of tachycardia
may be due to an abnormal collection of conduction fibres within the heart. There are types of tachycardia
that may be treated by a procedure called ‘ablation’.

How is ablation performed?

There are two ways that ablation can be done: non-surgical and surgical.

The non-surgical method uses radiofrequency energy to eliminate the abnormal conduction pathways.

At the tip of the tube is a small wire, which delivers radiofrequency energy to burn away the abnormal
areas of the heart, allowing the heart to beat normally again.

In surgery, there are three ways that ablation can be performed:

a. The Maze procedure is where the surgeon makes small cuts in the heart to re-direct healthy
electrical rhythms

b. Cryoablation is where a very cold substance is introduced to freeze the cells that are creating the
problems so that these cells cannot function anymore

c. Endocardial resection is when the surgeon removes a section of the thin layer of the heart where
the abnormal rhythms come from

Transcatheter Closure of Atrial Septal Defect (ASD) in Adults

Atrial Septal Defect, or ASD, is a congenital anomaly of the heart. It is a condition commonly known as
‘hole-in-the-heart’. It refers to a hole between two upper chambers of the heart, the atria. If left untreated,
ASD may affect the lungs. Those who suffer from the condition tend to tire easily, have poor effort tolerance
or even heart failure. They may also experience irregular heartbeat.

What is the Amplatzer Septal Occluder?

This is an occlusive device to treat ASD, as a viable alternative to traditional open-heart surgery. Parkway
Group Healthcare is the first in Singapore to perform the transtheter closure of ASD in adults using the
Amplatzer Septal Occluder.

How is it performed?

During the procedure, a folded occluder is delivered through a catheter to ‘plug’ the hole in the heart.
First performed on children in Singapore in 1997, the method has been used to correct ASD successfully
in adults as well the following year.

It can be performed in about two hours with excellent results.

27
SURGICAL PROCEDURES
Coronary Artery Bypass Grafting (CABG)
 SURGICAL PROCEDURES
CORONARY ARTERY BYPASS GRAFTING (CABG)

Coronary Artery Bypass Grafting (CABG)

Coronary Artery Bypass Grafting (CABG) or often simply known as bypass surgery is the surgical method
of treating coronary artery disease. The aim here is not to repair or remove blocked arteries but
to create a detour around the blockage: in other words, to bypass the blockage since the normal route
has been blocked. Depending on how many arteries are blocked, one, two or more bypasses may be created
at surgery.

During surgery, the surgeon takes a segment of healthy blood vessel (vein or artery) from another part of
the body and uses it as the new bypass channel.

With today’s expertise and technology, bypass surgery carries very little risks. Hospitals performing large
numbers of open-heart operations have risks of death of about 1 to 2%. Risks may vary from patient to patient
depending on factors such as old age, long-standing diabetes, previous heart attacks and strokes, kidney
failure etc. Patients who are unsure of their own risks, are advised to discuss this with their doctors.
Whatever the risk, however, they may be worth taking considering the fact that CABG significantly improves
and lengthens the quality of the patient’s life.

29
Bypass or ‘open heart’ surgery
 SURGICAL PROCEDURES
CORONARY ARTERY BYPASS GRAFTING (CABG)

How is a bypass surgery performed?

Surgery is performed under a general
anaesthetic; hence the patient will not be aware
of the procedure.
When the patient arrives in the operating theatre,
he will already be sedated so that he will be
relaxed and calm. The anaesthetist will insert
several needle-sized tubes into the vein under
local anaesthesia. Once these are in, the patient
will be anaesthetised.
The patient will then be connected to a ventilator
via a tube inserted through the mouth or nose
into the windpipe.
An incision is made down the middle of the front
of the chest. Through this incision, the heart will
be exposed for connection to the heart lung
machine. While this is going on, another team
will be harvesting the patient’s veins from his
legs or arteries from the arm, to use as bypass
channels.
Once both teams are ready, the patient’s heart
will be stopped and the function of the heart and
lung will be taken over the heart-lung machine.
The harvested blood vessels will then be sewn
in such a way that one end is connected to the
aorta (the large artery arising from the heart)
while the other rend is connected to the coronary
artery below the level of blockage.
On completion of this part of the operation, the
patient’s heart will be made to resume its function.
When the surgeon is satisfied that the heart is
beating normally, the patient will be disconnected
from the heart-lung machine and the surgery
completed. The patient will then be taken to the
Intensive Care Unit (ICU) for monitoring.

Recovery

Patients are normally monitored and managed in the ICU for one to two days. On the second day after
surgery, patient will be transferred back to an ordinary ward for recuperation. In the ward, they will be
taught how to breathe effectively and to gain confidence in their recovery process.

Most patients will be discharged from hospital in about a week and be ready to return to work in approximately
six weeks to three months.

31
 WHERE WE ARE
Cluny Road

Taman Serasi
Jln Elok

Botanic GLENEAGLES
Gardens HOSPITAL MOUNT
Nutmeg Road
Nassim Hill
ELIZABETH
Mount
HOSPITAL Elizabeth
Link
Marriott Hotel
Napier Road
Mount
Lucky Plaza Elizabeth
Middlesex Road
Road
Embassy of Orchard Road
Tanglin Tong Bideford Road
the United States Post Office Building
Australian of America
High Commission Wisma Atria
British Shopping Centre The
Council Paragon
British High
Commission Crown Prince
Ngee Ann City Hotel

Map not drawn to scale.

Medical Referral Centre Hotline: (65) 6735 5000 (Local Toll Free)
e-mail: mrc@parkway.com.sg
Website: www.parkwaygrouphealthcare.com