Procedures

EKG

An electrocardiogram or ECG (also called an EKG) is a common, painless test that records the electrical activity of the heart and converts it into lines called "waveforms" that can be seen on a monitor or printed out on paper. The waveforms created by the ECG can be divided into time segments to measure the rate of movement of the heart's electrical impulses.The patient lies down and "electrodes" at the end of wires (or leads) are attached to each arm, leg and the chest. There are no needles used and the test is painless. The ECG takes about ten minutes from start to finish, but the actual recording of the heart's electrical activity usually is done in a matter of seconds. Patients are required to remain still, and are sometimes asked to hold their breath for short periods of time.There is little preparation necessary for an ECG, and you may eat or drink fluids before and after the test. You may be asked to wear a hospital gown for the test, and all jewelry should be removed. Also, be sure to tell your doctor or the person who performs the ECG if you are taking any medications. Some medications can affect the electrical activity of the heart, and this information is important in order for the doctor to interpret the exam correctly.

Echocardiogram

An Echocardiogram is a non-invasive, safe and effective test to study the anatomy of the heart. It uses sound waves (ultrasound) to form images of the structures of the heart. The ultrasound and electrocardiography (ECG) signals are recorded on a videotape or digitally simultaneously to be reviewed by the cardiologist. The test can evaluate the size of the different chambers of the heart, the quality of the valves, measure the heart's pumping ability and identify other problems of the heart that may increase a person's risk for dangerous arrhythmias. A specially trained cardiologist or a technologist at the hospital or in a physician's office does the test. There is no preparation for this test and a patient may eat or drink prior to the study. A patient gown will be put on and the patient will be asked to lie down on an examination table. The lights in the room are dimmed to allow for better viewing of the monitor by the technologist or cardiologist performing the test. Electrodes (adhesive stickers that are attached to wires called leads) are placed on the patient's skin on the chest so that an ECG can be recorded with the ultrasound recordings during the test. Where the electrodes are placed is usually cleansed and possibly shaven to assure a good recording. A clear gel is applied to the chest and a transducer (a microphone-type device) is placed on the chest over the gel. It is moved around the chest so the technologist can record different views of the patient's heart. The patient may be asked to move from back to side, breathe slowly or hold their breath for a few seconds during the test. This helps improve the quality of the pictures recorded. The technologist is constantly monitoring the pictures on a television screen. He may also record a Doppler (speed of the blood running through the heart) echocardiogram and you will hear a swooshing sound correlating to your heartbeat. The whole test takes 30-60 minutes.

An Echocardiogram is performed to:
• Determine the size of the chambers of the heart, which can change with conditions such as hypertension, heart damage with a myocardial infarction or congestive heart failure.
• Determine the heart's pumping ability.
• Identify the structure, thickness and movement of the heart valves.
• Determine if there is fluid, blood clots or tumors in specific areas of the heart.

RCPG performs echos at the Parnell Office Building (POB) and Linden Oaks Medical Park, as well as our Newark office in Wayne County. The test takes about a half hour or less from start to finish. Wearing comfortable clothing is helpful.

Cardiac Stress Test

A cardiac stress test is a test that is performed in order to determine the amount of stress that your heart can manage before it develops an abnormal rhythm or evidence of ischemia (not enough blood flow to the heart). A stress test is also used to test for heart disease. The test provides information on how a patient’s heart responds to exertion. Typically a stress test will involve walking on a treadmill or pedaling on a stationary bike while an EKG monitors the heart rate and blood pressure. Other types of stress testing include Adenosine Stress Test, Stress Echocardiogram, and a Nuclear Stress Test. The adenosine stress test is performed while a patient is unable to exercise, and a drug is administered to stimulate the heart to respond as if the patient were exercising. A stress echo is a graphic outline of the heart’s movement and can accurately visualize the motion of the heart’s walls and pumping action when the heart is stressed. Nuclear stress testing helps to determine which parts of the heart are healthy and functioning correctly. A small amount of radioactive contrast is injected, and the cardiologist uses a special camera to identify the rays emitted from the contrast. These images are taken both at rest and during exercise.

Cardiac Catheterization

A Cardiac “Cath” is an Angiogram. Cardiac angiography is the most commonly performed procedure in the United States. Many hospitals in the Florida area have cardiac cath laboratories. An angiogram is performed to detect coronary artery disease. Coronary artery disease occurs when blockage or plaque occludes the blood vessels which supply the heart with blood. A partial occlusion can cause chest discomfort otherwise known as angina while a complete occlusion can cause a heart attack. The tests to detect blockage are stress tests, non-invasive scans (CT or MRI) or coronary angiograms (cath).

A coronary angiogram directly evaluates the patency of the arteries by injecting x-ray dye into them while performing x-rays. At this time it is the most definitive and most accurate test to evaluate for coronary artery disease and blockages; however it is invasive and involves the use of x-rays and contrast dye.

The procedure begins after an IV is inserted into a patient who is then brought into the cath lab and placed on the x-ray table. After a local anesthetic is given, a small catheter (2 mm in diameter) is placed into the artery. A two mm catheter is then advanced in the aorta under x-ray guidance and is used to engage the coronary arteries. X-ray dye is injected into the arteries and pictures are then obtained and analyzed by the physician. At the completion of the test the catheter and equipment are removed and the site is compressed to prevent bleeding. Except for the slight pain during administration of the local anesthetic it is usually a painless procedure.

Other reasons to perform a heart cath are to evaluate the pressures and the structures of the heart. A picture of the heart and its pumping function is often also performed which provides the ejection fraction, or strength of the heart.
The potential complications of a heart cath include but are not limited to bleeding, infection, kidney problems, blood vessel injury, stroke, heart attack, urgent bypass surgery or even death. The risk of serious complications are very low with the risk of death < 1/1000 and the risk of heart attack or stroke <1/500.

Is the Procedure Done in the Leg or the Arm?
The procedure can be performed in either the leg artery (femoral artery) or the wrist artery (radial artery.) In the past years, in past years, the procedure was most often performed in the leg, or femoral artery. But now, for majority of patients, the procedure can be performed safely and easily in the small artery of the wrist, the radial artery. Either way, most patients will go home within 4 hours of the procedure.

Radial or Wrist Approach for Cath
The benefit of using the radial artery is that there is increased patient comfort for the procedure, and there is less bleeding risk because of smaller equipment and artery size. Patients that have the cath using the radial approach can sit up and ambulate soon after the procedure and need less pain medications or recovery time. Often, patients with a radial cath can go home sooner than if the leg was used. There is a small minority of patients that cannot have the cath done through the radial artery because the artery is too small or too tortuous. The University of South Florida is one of the few programs in Florida that perform the majority of its outpatient procedures through the radial artery.

Cardiac Catheterization is performed on the third floor of Tampa General Hospital and the Pepin Heart Institute. A patient should follow instructions about medications, diet and when to arrive as already provided. Family and friends accompanying a patient may wait in the patient waiting area. A cell phone number is helpful for the physician to contact family members when the procedure is finished.

The staff at the desk in the waiting area is happy to provide any assistance needed. Expect the procedure to take at least 1 hour from when it started. Patients that go home the same day usually can go home after 2-4 hours of observation and driving is not allowed for a specified time.

All coronary procedures are performed by Dr. Michael Berlowitz, who is a Board Certified Interventional Cardiologist for the University of South Florida. He is also the Associate Cath Lab Director at Tampa General Hospital, and the Medical Director of the Cardiovascular Unit. Dr. Berlowitz is the University Director of Coronary Services and started the radial program at Tampa General Hospital.

Angioplasty and Stent

There are many ways to treat a blockage in the cardiac catheterization laboratory. For many years, the procedure was called “plain balloon angioplasty” because only balloons were used to “crush” blockage; later metal stents were developed to hold the blood vessel open, keep the treated plaque stable and prevent the blockage from immediately coming back. Now, interventional cardiologists have many different tools available to open blockage.

Some of these tools to treat blockage include cutting balloons (small balloons with tiny razor sharp blades on it edges to help cut the blockage if it is hard or too firm to crush,) rotational atherectomy (small diamond coated burrs that actually drill through the blockage,) and thrombectomy catheters (tubes in the artery that allow suction of clot and debris.) Sometimes, blockages can be further studied with tiny ultrasound cameras or special pressure wires. For the most part, however, balloons and stents are still the mainstay of therapy.

If a blockage is determined to be severe enough for angioplasty the procedure is normally performed immediately after the angiogram. During angioplasty a small wire (0.014 inch) is placed into the affected artery and across the blockage. A balloon is then advanced over the wire and inflated at the site of the blockage to open a passage way for blood flow. Normally a stent is then inserted to provide a scaffold to prevent the plaque or blockage from recoiling and re-narrowing the blood vessel.
The two types of available stents are either drug eluting or non-drug eluting. The drug eluting stents are imbedded with a medication to prevent scar tissue from growing inside the stent. These stents may be more likely to clot and therefore require long term treatment with a blood thinner in addition to aspirin. Non drug eluting stents are less likely to clot but are prone to scar tissue formation and the need for another procedure may be higher than drug eluting stents within six months. Your physician will decide what type of stent is best for you depending upon your other medical issues and the characteristic of the blockage.
The potential complications include those listed in the angiogram section. If the angioplasty stent procedure fails sometimes emergent bypass is recommended. This occurs in less than 1% of cases.

Angioplasty and stenting is performed on the third floor of Tampa General Hospital the Pepin Heart Institute. A patient should follow instructions about medications, diet and when to arrive as already provided. Family and friends accompanying a patient may wait in the family waiting area. A cell phone is helpful for the physician to contact family members when the procedure is finished.

The staff at the front desk in the lobby is happy to provide any assistance needed. Expect the procedure to take at least 1 hour from when it started. Patients that have angioplasty or stenting will often stay overnight in the hospital. Same day discharge may be possible with patients that had the procedure performed from the radial or wrist approach.
Angioplasty, stenting and all other coronary procedures are performed by Dr. Michael Berlowitz, who is a Board Certified Interventional Cardiologist for the University of South Florida. He is also the Associate Cath Lab Director at Tampa General Hospital, and the Medical Director of the Cardiovascular Unit. His is the University Director of Coronary Services.

Intravascular Ultrasound (IVUS)

IVUS is an imaging procedure used to look at a patient’s arteries from the inside out. It is most commonly performed to confirm the proper placement of a stent, or to determine where a stent should be placed. IVUS can also be performed to view the aorta and structure and structure of artery wall where plaque tends to build up, and to identify which specific blood vessels are involved in aortic dissection. It uses a specifically designed catheter with a small ultrasound probe attached at the end. The catheter is inserted into an artery in the patient’s groin area, and moved up the heart. A computer measures how the ultrasound waves reflect off of the blood vessels and produces an image. After the test is performed the catheter is completely removed and a bandage is placed over the area. The patient will be asked to lie flat on their back and apply pressure to the groin area for a few hours following the test to prevent bleeding. If the test is used during cardiac catheterization, the typical hospital stay is 3-6 hours. If it was done during angioplasty the stay is about 12-24 hours.

Ablation

An ablation is a procedure to treat arrhythmias (abnormal heart rhythms). In an ablation, a thin, soft tube (catheter) is placed into a vein in your groin or neck and brought to your heart. The catheter can be used to study the arrhythmia. The catheter can then be used to apply heat (radiofrequency) or cold (cryoablation) to the heart tissue that is causing the arrhythmia. Many arrhythmias can be effectively eliminated or suppressed with catheter ablation.

An ablation is generally safe. The recovery time is short because the procedure does not involve large incisions. Most of our patients leave the hospital within 24 hours.

Ablations are performed for:
• Atrial Fibrillation
• SVT (Supraventricular Tachycardia)
• Atrial Flutter
• VT (Ventricular Tachycardia)
• PVC (Premature Ventricular Contraction)
• WPW (Wolff-Parkinson-White)

MRI Scan

An MRI scan is an imaging test using radio waves to create three-dimensional images of organs and tissues. It is a non-invasive method for observing the organs, tissues, and skeletal system of the body. An MRI that focuses on the heart and blood vessels can determine the size and function of the heart’s chambers, the thickness and movement of the walls of the heart, the extent of any damage caused by a heart attack or disease, structural problems such as aneurysms or dissections, and any accumulation of plaque or blockage in the blood vessels.

The MRI machine looks like a tunnel. The patient lies down on a table that can move about within the tunnel, and the images are monitored from another room. The machine creates a strong magnetic field around the patient, and the test is painless. The whole test will last just about an hour and it is important to hold very still while the images are being captured.

PET Scan

A pet scan is an imaging test performed to observe the functioning of a patient’s organs and tissues, and uses a small amount of radioactive material. The type of radioactive material used is determined by the organ or tissue under scrutiny and it can be injected or swallowed. The principal behind a PET scan is that more radioactive material builds up in the areas of the body with higher levels of chemical activity, and this often corresponds to areas of disease. The accumulation of radioactive material shows up very bright on a PET scan image. Cardiologists perform a PET to detect areas of decreased blood flow in the heart, and to see which areas of the heart may benefit from angioplasty or surgery. These scans are most commonly done as an outpatient procedure, and there is really no preparation that needs to be done. As a general rule, patients should not eat anything up to several hours before the test.

Even though a radioactive material is administered to the body during this test, the amount of radiation is very low, and will not affect the processes of your body. However, it is harmful to women who are pregnant.