CARDIOVASCULAR SYSTEM

CHEST X-RAY
A chest X-ray is a radiology test that involves exposing the chest briefly to
radiation to produce an image of the chest and the internal organs of the chest. An X-ray
film is positioned against the body opposite the camera, which sends out a very small
dose of a radiation beam. As the radiation penetrates the body, it is absorbed in varying
amounts by different body tissues depending on the tissue's composition of air, water,
blood, bone, or muscle. Bones, for example, absorb much of the X-ray radiation while
lung tissue (which is filled with mostly air) absorbs very little, allowing most of the X-ray
beam to pass through the lung.

Procedure

Patients obtaining a chest X-ray will often be requested to use an X-ray gown,
and extra metallic objects such as jewelry are removed from the chest and/or neck
areas. These objects can block X-ray penetration, making the result less accurate.
Patients may be asked to take a deep breath and hold it during the chest X-ray in order
to inflate the lungs to their maximum, which increases the visibility of different tissues
within the chest.

The chest X-ray procedure often involves a view from the back to the front of the
body as well as a view from the side. The view from the side is called a lateral chest X-
ray. Occasionally, different angles are added in order for the radiologist to interpret
certain specific areas of the chest.

The radiology technologist or technician is a trained, certified assistant to the

radiologist who will help the patient during the X-ray and actually perform the X-ray test
procedure. After the chest X-ray is taken and recorded on the X-ray film, the film is
placed into a developing machine, and this picture (which is essentially a photographic
negative) is examined and interpreted by the radiologist.
ELECTROCARDIOGRAM (ECG)
The electrocardiogram (ECG or EKG) is a noninvasive test that is used to reflect
underlying heart conditions by measuring the electrical activity of the heart. By
positioning leads (electrical sensing devices) on the body in standardized locations,
information about many heart conditions can be learned by looking for characteristic
patterns on the EKG.
EKG leads are attached to the body while the patient lies flat on a bed or table.
Leads are attached to each extremity (four total) and to six pre-defined positions on the
front of the chest. A small amount of gel is applied to the skin, which allows the electrical
impulses of the heart to be more easily transmitted to the EKG leads. The leads are
attached by small suction cups, Velcro straps, or by small adhesive patches attached
loosely to the skin. The test takes about five minutes and is painless. In some instances,
men may require the shaving of a small amount of chest hair to obtain optimal contact
between the leads and the skin.

HOLTER MONITOR
A ‘Holter monitor’ is a continuous tape recording of a patient's ECG for 24 hours.
It is worn during regular daily activities under regular clothing.It helps your cardiologist
compare symptoms of dizziness, palpitations or black outs with data gathered on the
heart. Holter monitoring is used to detect an abnormal heart rhythm.
Preparation
The only requirement is that the patient wear loose-fitting clothes. Buttons down
the front of a shirt or blouse is preferable. This makes it convenient to apply the ECG
electrodes, and also comfortably carry the monitor in a relatively discreet manner.

Procedure
The chest is cleansed with an alcohol solution to ensure good attachment of the
sticky ECG electrodes. Men with hairy chests may require small areas to be shaved. The
electrodes (circular white patches) are applied to various points of the chest. Thin wires
are then used to connect the electrodes to a small recorder. The tape recorder is slung
over the shoulder and neck. The recorder is worn for 24 hours and you are encouraged
to continue your daily activities.
You will not be able to shower whilst wearing the monitor. You will need to
record your daily activity in a diary noting times of events such as ‘dance class’ or ‘fight
with husband’. You should also record any symptoms you may experience such as
skipped heartbeats, chest discomfort, shortness of breath and dizziness.
 The Holter monitor has an internal clock which stamps the time on the ECG
recording. These can be used to correlate the heart rhythm with symptoms or
complaints. After 24 hours, the Holter monitor needs to be returned. This can be
removed by the staff.

EXERCISE TEST TREADMILL

A test (sometimes simply called a treadmill test or exercise test) in which a
continuous electrocardiogram (ECG or EKG) recording of the heart is made as the
patient performs increasing levels of exercise on the treadmill which is tilted to produce
the effect of going up a small hill. The patient can stop the test at any time, if necessary.
Afterwards the patient has heart and blood pressure checked.
Procedure
The patient is brought to the exercise laboratory where the heart rate and blood
pressure are recorded at rest. Sticky electrodes are attached to the chest, shoulders and
hips and connected to the EKG portion of the Stress test machine. A 12-lead EKG is
recorded on paper. Each lead of the EKG represents a different portion of the heart, with
adjacent leads representing a single wall.

CARDIAC STRESS TESTING

The exercise cardiac stress testing (ECST) is the most widely used cardiac
(heart) screening test. The patient exercises on a treadmill according to a standardized
protocol, with progressive increases in the speed and elevation of the treadmill (typically
changing at three-minute intervals). During the exercise cardiac stress testing (ECST),
the patient's electrocardiogram (EKG), heart rate, heart rhythm, and blood pressure are
continuously monitored.
Preparation

Prior to a stress test one should not eat or drink for a couple of hours. You should
however be very well hydrated before you begin. One may also be asked to refrain from
smoking prior to the test. If you are undergoing some kind of medical treatments take all
your medications prior to a stress test, unless told otherwise by the physician in charge
[4]
. All individuals who use heart medications and inhalers for their asthma should bring
them to the stress test center. Let the doctor know if you have diabetes; since exercise
can lower blood sugar, he or she may want to check your blood sugar level before the
test begins.

Comfortable loose clothes for exercising and running shoes are the best clothing items
to wear for such a test. [5].It is also recommended that you do warm up and extension
exercises before you begin a cardiac stress test or any type of exercise routine. This will
help prevent any cramping up of the muscles being used.

ECHOCARDIOGRAM

An echocardiogram is an ultrasound of the heart which reveals heart valve

problems and the overall muscle function. This common test allows our board certified
cardiololgists to see your heart in motion - ventricles squeezing and relaxing and valves
opening and closing. These images are used to identify various abnormalities in the
heart muscle and valves.

Procedure

Your technician will ask you to lie on your left side. An ultrasound gel is applied
to a microphone-like device called a transducer. The transducer sends and receives
harmless ultrasound waves. The gel allows the the ultrasound beams to penetrate your
chest wall so that it is possible to see your heart. Next, your technician will acquire
ultrasound images by methodically and precisely moving the transducer around your
upper chest creating different prospectives on a monitor. Test measurements will be
recorded and diagnosed by our board certified cardiologists. This test is completely
painless and will take about 5 minutes.
Nuclear Cardiology:
THALLIUM
It is injected IV so that the scintillation camera can count radioactive uptake(areas of
poor uptake indicate infarction). It is useful for assessing the extent of disease in a
coronary artery and predict the effectiveness of bypass surgery or angioplasty.

Preprocedure
>start the IV line
>inform the client that an isotope is used only in a small diagnostic amount and will
lose radioactivity in a few hours.
>for stress test,thallium is injected 1 hour before the client exercises,5-10 minutes
after 2-4 hours.
>client should eat only a light meal during injection and testing period.
>inform the client that the arms wil be extended behind the head in a supine position.

Postprocedure
>monitor vital signs
>assess for dyspnea or angina

DIPYRIDAMOLE THALLIUM (PERSANTINE)

Dipyridamole thallium(Persantine) is injected to vasodilate coronary arteries so
increased blood flow will make scanning with thallium more effective. It is used when the
client is unable to tolerate exercise such as with severe peripheral vascular disease.

Preprocedure
>instruct the client to hold all caffeine products for 12 hours in advance.
>instruct the client on the purpose of dipyridamole(Persantine)

Postprocedure
>monitor vital signs
>assess for dyspnea or angina.
TECHNETIUM OR SETAMBI SCAN
Technetium or Sestambi Scan has an IV injection of this isotope; high uptake will
be visualized in areas of MI (even 1-6 days post MI)
Preprocedure
>start the IV line
>inform the client that an isotope is used only in a small diagnostic amount and will
lose radioactivity in a few hours.
>for stress test,thallium is injected 1 hour before the client exercises,5-10 minutes
after 2-4 hours.
>client should eat only a light meal during injection and testing period.
>inform the client that the arms wil be extended behind the head in a supine position.
CARDIAC CATHETERIZATION

This is a procedure to examine blood flow to the heart and test how well the
heart is pumping. A doctor inserts a thin plastic tube (catheter) (KATH'eh-ter) into an
artery or vein in the arm or leg. From there it can be advanced into the chambers of
the heart or into the coronary arteries.

Procedure

In the catheterization laboratory, the insertion area (usually the groin, neck, or forearm)
is cleansed with a sterilizing solution, shaved, and covered with sterile drapes. A small-
needle injection of a local anesthetic is used to numb the area.

A small incision is made and a pencil-sized plastic tube, called a sheath, is inserted into
the artery (e.g., femoral artery, carotid artery) or vein. A catheter, which is usually 2 to 3
mm In diameter, is passed via the sheath through the artery to the heart, and into a
coronary artery.

ANGIOGRAPHY
Angiography or arteriography is a medical imaging technique used to visualize
the inside, or lumen, of blood vessels and organs of the body, with particular interest in
the arteries, veins and the heart chambers. This is traditionally done by injecting a radio-
opaque contrast agent into the blood vessel and imaging using X-ray based techniques
such as fluoroscopy. The word itself comes from the Greek words angeion, "vessel", and
graphein, "to write or record". The film or image of the blood vessels is called an
angiograph, or more commonly, an angiogram.
Procedure

In Angiography, a long wire called catheter is inserted inside the artery of the leg,
near the thigh crease. This catheter is then pushed against the blood flow towards the
heart blindly. With a view of the tip of the catheter on the fluoroscopy monitor (which
exposes the patient to very heavy radiation) this catheter is pushed onwards by trial and
error method. If it gets stuck somewhere on the route, it is withdrawn a little and again
pushed in. Not only it scratches the whole length of the arterial tubes of the body but it
can also puncture any corner of the tubes. Once the tip reaches the heart area, further
manipulation is done to push the tip in one of the coronary arteries. Once inside the
coronary tube, after a lot of trial and error, a radioactive dye is injected through the hole
in the catheter inside the coronary tubes and further fluoroscopy photographs are taken.

ELECTROPHYSIOLOGY STUDY
An electrophysiology study (EPS) of the heart is a test performed to analyze the
electrical activity of the heart. The test uses cardiac catheters and sophisticated
computers to generate electrocardiogram (EKG) tracings and electrical measurements
with exquisite precision from within the heart chambers.

Procedure

To begin your electrophysiology (EP) study at University of Wisconsin Hospital

and Clinics, you will be asked to lie down on an examination table and electrodes will be
placed on your chest. These electrodes have wires that are connected to an
electrocardiogram machine, which monitors your heart rhythm during the test. As an
infection precaution, you will be shaved and cleansed around the area where the thin
catheter tubes will be inserted, usually at the groin or neck area. You will receive a mild
sedative through an intravenous line (IV) in your arm, which will help you relax during the
test.

To get inside the heart, EP catheters will be gently threaded into and through
large veins accessible at the groin or neck. First, a small puncture is made in order to
access the vein and a guide wire is inserted into the vein. A catheter sheath, essentially
a hollow tube, is then guided over the wire. Thin catheters can then be inserted into the
hollow sheath. Once in the vein, the catheters can be steered into the heart with the help
of x-rays displayed on a monitor.
CENTRAL VENOUS PRESSURE MONITORING

Central venous pressure is considered a direct measurement of the blood

pressure in the right atrium and vena cava. It is acquired by threading a central venous
catheter (subclavian double lumen central line shown) into any of several large veins. It
is threaded so that the tip of the catheter rests in the lower third of the superior vena
cava. The pressure monitoring assembly is attached to the distal port of a multilumen
central vein catheter.

Procedure
Central venous line placement is typically performed at four sites in the body: the
right or left internal jugular vein (IJV), or the right or left subclavian vein (SCV).
Alternatives include the external jugular and femoral veins. A long catheter may be
advanced into the central circulation from the antecubital veins as well. The internal
jugular vein follows a line from the inferior aspect of the external acoustic meatus to the
medial aspect of the clavicle. It passes deep to the sternocleidomastoid muscle between
the two heads and joins the subclavian vein to form the brachiocephalic vein, posterior
to the clavicle closest to the sternum.The subclavian vein is a continuation of the axillary
vein draining the arm. It begins at the lateral border of the first rib and ends at the
thoracic inlet where it meets the IJV to form the brachiocephalic vein. The SCV passes
over the first rib and apical pleura and runs along the underside of the clavicle parallel
with the subclavian artery but is separated from the artery at the anterior scalene
muscle, with the vein passing over the muscle.

Central venous catheterization via the internal jugular vein has a lower incidence of
pneumothorax compared to catheterization via the subclavian vein, and it can be easily
compressed after catheter removal or after unintentional arterial puncture. Ultrasound
can be a valuable adjunct for IJV cannulation, because the incidence of anatomical
variants may be as high as 8.5%. Subclavian vein catheterization is more comfortable
for awake patients and less prone to contamination from respiratory secretions,
particularly in patients with tracheotomies.
PULMONARY ARTERY PRESSURE MONITORING

The process of pulmonary artery pressure monitoring in 50 consecutive patients in the

surgical intensive care unit was analyzed to determine the number and types of
problems that occurred in relation to the benefit obtained. This device is a balloon-tipped,
flow-directed catheter that is inserted via central veins through the right side of the heart
into the pulmonary artery. The catheter typically contains several ports that can monitor
pressure or inject fluids

Procedure

The PAC is inserted through a special catheter in the subclavian or internal

jugular vein with the balloon deflated. Once the catheter tip reaches the superior vena
cava, partial inflation of the balloon permits blood flow to guide the catheter. The position
of the catheter tip usually is determined by pressure monitoring for intracardiac and
great vessel pressures) or occasionally by fluoroscopy. Entry into the right ventricle is
indicated by a sudden increase in systolic pressure to about 30 mm Hg; diastolic
pressure remains unchanged from right atrial or vena caval pressure. When the catheter
enters the pulmonary artery, the systolic pressure does not change, but diastolic
pressure rises above right ventricular end-diastolic pressure or central venous pressure
(CVP); ie, the pulse pressure narrows. Further movement of the catheter wedges the
balloon in a distal pulmonary artery. A chest x-ray confirms proper placement.
INTRA-ARTERIAL BLOOD PRESSURE
Intra-arterial blood pressure (IABP) measurement is often considered to be the
gold standard of blood pressure measurement. It is used to obtain direct and continuous
BP measurements in critically ill patients who have severe hypertension or hypotension.

PACEMAKER
A pacemaker is a surgically implanted electronic device that regulates a cardiac
arrhythmia.

Procedure

The procedure begins with the insertion of the wires that attach the device to the
heart. The wires are threaded through and into the heart where they are placed using a
type of x-ray imagining that allows the doctor to see exactly where the wires are at all
times. Once the wires are in place, an incision is made in the chest or abdomen, and the
actual pacemaker device is placed under the skin. The wires, which are connected to the
heart, are attached to the pacemaker. The pacemaker is then tested to make sure it is
working effectively.

Once the physician determines that the wires are in the correct place and the
pacemaker is functioning properly, the incision is closed with sutures or adhesive strips
and medication is given to wake the patient.
CORONARY ARTERY BYPASS GRAFT
Coronary artery bypass graft surgery is a surgical procedure in which a blood
vessel from another part of the body is grafted onto the occluded coronary artery below
the occlusion in such a way that blood flow bypasses the blockage.

Procedure

After general anesthesia is administered, the surgeon removes the veins or

prepares the arteries for grafting. If the saphenous vein is to be used for the graft, a
series of incisions are made in the patient's thigh or calf. If the radial artery is to be used
for the graft, incisions are made in the patient's forearm. It is important to note that the
removal of veins or arteries for grafting does not deprive the area of adequate blood
flow.

More commonly, a segment of the internal mammary artery is used for the graft,
and the incisions are made in the chest wall. The internal mammary arteries are most
commonly used because they have shown the best long-term results. Because they
have their own oxygen-rich blood supply, the internal mammary arteries can usually be
kept intact at their origin, then sewn to the coronary artery below the site of blockage.

The surgeon decides which grafts to use, depending on the location of the
blockage, the amount of the blockage, and the size of the patient's coronary arteries.

In traditional coronary artery bypass surgery, the surgeon makes an incision

down the center of the patient's chest, cuts through the breastbone, and retracts the rib
cage open to expose the heart. The patient is connected to a heart-lung bypass
machine, also called a cardiopulmonary bypass pump, that takes over for the heart and
lungs during the surgery. During this "on-pump" procedure, the heart-lung machine
removes carbon dioxide from the blood and replaces it with oxygen. A tube is inserted
into the aorta to carry the oxygenated blood from the bypass machine to the aorta for
circulation to the body. The heart-lung machine allows the heart's beating to be stopped,
so the surgeon can operate on a still heart. Aortic clamps are used to restrict blood flow
to the area of the heart where grafts will be placed so the heart is blood-free during the
surgery. The clamps remain until the grafts are in place.

Adjunctive Modalities and Management

CARDIOVERSION
Cardioversion refers to the process of restoring the heart's normal rhythm by
applying a controlled electric shock to the exterior of the chest. Abnormal heart rhythms
are called arrhythmias or dysrhythmias.

Preparation
You will be given ‘Warfarin’, a blood thinning medication to take orally in the days
prior to the procedure. You should also take any other medications as instructed by your
physician.You should fast for at least eight hours prior to the procedure. You will present
at hospital on the morning of the procedure as a day patient.

Procedure
The procedure is administered in the ‘cath lab’ or coronary care unit. An
anaesthetist administers intravenous sedation. Once you are asleep, your cardiologist
charges the defibrillator and delivers the shock.

Usually a Trans-oesophageal Echocardiogram is performed with this procedure

whilst you are asleep.

Post Procedure
You will probably feel slightly drowsy after the procedure. You will be allowed to
leave the hospital about three hours after the procedure and you will need someone
responsible to take you home.
DEFIBRILLATION

Defibrillation is a process in which an electrical device called a defibrillator sends

an electric shock to the heart to stop an arrhythmia resulting in the return of a productive
heart rhythm.

Cardiac Conduction Surgery

MAZE Procedure
The surgical procedure consists of creating a number of incisions in the atrium
that disrupt the re-entrant circuits. Once the incisions are made, they are sewn together
again. The atrium can then hold blood on its way to the ventricle and can squeeze or
contract to push the blood in to the ventricle, but the electrical impulse cannot cross the
incisions.

CATHETER ABLATION SURGERY

Catheter ablation is an invasive procedure used to remove a faulty electrical
pathway from the hearts of those who are prone to developing cardiac arrhythmias
such as atrial fibrillation, atrial flutter, supraventricular tachycardias (SVT). It involves
advancing several flexible catheters into the patient's blood vessels, usually either in
the femoral vein, internal jugular vein, or subclavian vein. The catheters are then
advanced towards the heart and high-frequency electrical impulses are used to
induce the arrhythmia, and then ablate (destroy) the abnormal tissue that is causing
it.

Procedure

• Usually you will be instructed to stop taking Coumadin (warfarin) three days
before the procedure.
• Your doctor may also ask you to stop taking other medications, such as those
that control your heart rate or aspirin products.
• Do not discontinue any of your medications without first talking to your health
care provider. Ask your doctor which medications you should stop taking and
when to stop taking them.
• If you have diabetes, ask the nurse how you should adjust your diabetes
medications and/or insulin. .
• Eat a normal meal the evening before your procedure. However, DO NOT eat,
drink or chew anything after 12 midnight before your procedure. This includes
gum, mints, water, etc.
• If you must take medications, only take them with small sips of water. When
brushing your teeth, do not swallow any water
• Remove all makeup and nail polish before coming to the hospital.
• Wear comfortable clothes. You will change into a hospital gown before the
procedure.
• Please leave all jewelry (including wedding rings and watches) and other
valuables at home.
• The clothing you are wearing that morning will be returned to the person who
accompanies you or placed in a locker
Invasive Coronary Artery Procedures

PERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY

Percutaneous transluminal angioplasty (PTCA coronary) is a minimally invasive

procedure to open up blocked coronary arteries, allowing blood to circulate unobstructed
to the heart muscle.

CORONARY ARTERY STENT

Coronary Artery Stent is stainless tube with slots. It is mounted on a balloon
catheter in a "crimped" or collapsed state. When the balloon of is inflated, the stent
expands or opens up and pushes itself against the inner wall of the coronary artery. This
holds the artery open when the balloon is deflated and removed. Coronary artery stents
were designed to overcome some of the short comings of angioplasty.
Preprocedure
• NPO for 6-8 hours
• Verify written consent.
• Assess that laboratory values are within range.
• Review the client allergie and creatinine
• Inform the client that sedation will be given and a local anesthesia will be
administered at the catheter entry site,and a feeling of warmth and fluttering of
the heart may be experienced as the catheter is passed.
• Instruct the client to inhale when the catheter is inserted.
• Attach the ECG leads and monitorthe client during the 1-2 hour procedure.

Postprocedure
• Observe the insertion site for overt bleeding or hematoma (bleeding beneath the
skin).
 • Instruct the client to call immediately if there are signs of bleeding from then
insertion site.
• If bleeding or hematoma occurs,hold firm with with three fingers just above the
insertion site.
• Monitor ECG and vital signs
• Intruct the client on duration of bed (2-6 hours)

ATHERECTOMY
Atherectomy is a procedure to remove plaque from arteries. Plaque is the buildup of fat,
cholesterol and other substances in an artery's inner lining. It removes plaque from the
arteries supplying blood to the heart muscle. It uses a laser catheter, or a rotating shaver
("burr" device on the end of a catheter).

Preprocedure
• NPO for 6-8 hours
• Verify written consent.
• Assess that laboratory values are within range.
• Review the client allergie and creatinine
• Inform the client that sedation will be given and a local anesthesia will be
administered at the catheter entry site,and a feeling of warmth and fluttering of
the heart may be experienced as the catheter is passed.
• Instruct the client to inhale when the catheter is inserted.
• Attach the ECG leads and monitorthe client during the 1-2 hour procedure.

Postprocedure
• Observe the insertion site for overt bleeding or hematoma (bleeding beneath the
skin).
• Instruct the client to call immediately if there are signs of bleeding from then
insertion site.
• If bleeding or hematoma occurs,hold firm with with three fingers just above the
insertion site.
• Monitor ECG and vital signs
• Intruct the client on duration of bed (2-6 hours)
 BRACHYTHERAPY
Brachytherapy is one type of radiation therapy used to treat cancer. Radiation
therapy is the use of a type of energy, called ionizing radiation, to kill cancer cells and
shrink tumors.

Valve Repair and Replacement Procedures

VALVULOPLASTY
Valvuloplasty is a procedure in which a narrowed heart valve is stretched open
using a procedure that does not require open heart surgery.

Preparation

For at least six hours before balloon valvuloplasty, the patient will have to avoid eating or
drinking anything. An intravenous line is inserted so that medications can be
administered. The patient's groin area is shaved and cleaned with an antiseptic. About
an hour before the procedure, the patient is given an oral sedative such as diazepam
(Valium).
 VALVE REPLACEMENT
Valve Replacement is used to treat aortic valves and severely damaged mitral
valves. It is also used to treat any valve disease that is life-threatening. Sometimes,
more than one valve may be damaged in the heart, so patients may need more than
one repair or replacement.

Types of Valve Prosthesis:

MECHANICAL VALVES

Mechanical heart valves (MHV) are prosthetics designed to replicate the function of
the natural valves of the human heart. The human heart contains four valves: tricuspid
valve, pulmonic valve, mitral valve and aortic valve. Their main purpose is to maintain
unimpeded forward flow through the heart and from the heart into the major blood
vessels connected to the heart, the pulmonary artery and the aorta. As a result of a
number of disease processes, both acquired and congenital, any one of the four heart
valves may malfunction and result in either stenosis (impeded forward flow) and/or
backward flow (regurgitation). Either process burdens the heart and may lead to serious
problems including heart failure. A mechanical heart valve is intended to replace a
diseased heart valve with its prosthetic equivalent.

BIOLOGICAL VALVE
 Biological valves are valves of animals, like pigs, which undergo several chemical
procedures in order to make them suitable for implantation in the human heart. The
porcine (or pig) heart is most similar to the human heart, and therefore represents the
best anatomical fit for replacement. Implantation of a porcine valve is a type of
Xenotransplantation, or Xenograft, which means a transplant from one species (in this
case a pig) to another. There are some risks associated with a Xenograft such as the
human body's tendency to reject foreign material. Medication can be used to retard this
effect, but is not always successful.