Catheterization

What is Cardiac Catheterization?
Cardiac catheterization (also called cardiac cath) is a minimally invasive procedure that allows your doctor to “see” how well your heart is functioning and look for certain heart problems. Doctors usually do cardiac cath to understand how your heart is working or why you have symptoms such as chest pain.
Most people who have a cardiac cath have a test called “coronary angiography” done as part of the procedure. Doctors do coronary angiography to look at the arteries in a person’s heart. That way, they can see if there are any blockages in the arteries and how serious the blockages are.
During the test, a long, narrow tube, called a catheter, is inserted into a blood vessel in your arm or leg and guided to your heart with the aid of a special X-ray machine. Contrast dye is injected through the catheter so that X-ray movies of your valves, coronary arteries and heart chambers can be created.
How do I prepare for a cardiac cath?
You should not eat or drink anything after midnight the night before your test. Most patients are told to keep taking their medicines. However, ask your doctor if all medications are safe. Your doctor may ask you to do a blood test to check your kidney function and to ensure that you do not have a bleeding problem.
What happens during a cardiac cath?
A cardiac cath is done in the cardiac catheterization lab. You will be awake during the procedure, but your doctor will give you medicine to help you feel relaxed.
Your doctor will make a very small cut in the top, the inner part of your leg, or at your wrist. (He or she will numb this area first.) He or she will put a thin plastic tube, called a “catheter,” in a blood vessel which is just below the cut. Then he or she will advance the tube through your blood vessels to your heart. While this is happening, an X-ray will take pictures of the tube in your body. This helps your doctor know when the tube has reached the correct place in your heart.
When the tube is in place, your doctor will do tests. If you are having coronary angiography, your doctor will inject a dye into the tube that shows up on an X-ray. This dye can show if any of the arteries in your heart are clogged. Your body might feel warm during this part of the test.
If your arteries are clogged, your doctor might do a procedure to open them during the catheterization. If there is a chance you will have this procedure, your doctor will talk with you about it in his or her office before your cardiac cath.
What happens after a cardiac cath?
After the procedure, your doctor will remove the tube from your body and put pressure on the cut to prevent bleeding. You will need to rest in the hospital for a few hours. You will probably be able to go home after that, but someone else will need to drive you. If your doctor fixes any of your arteries, you will probably need to stay in the hospital overnight.
Before you leave, your doctor will tell you when you can drive and do your usual activities again. Someone on the medical staff will also discuss your medicines with you and set up a follow-up appointment to see you in about a week. At the follow-up, you will learn about the results of your cardiac cath.
What problems can happen after a cardiac cath?
The most common problems are bleeding, bruising, and soreness in the area where the tube was put in. These problems can last for a few days, especially if the tube was put in the leg.
Other problems can happen during or after a cardiac cath, but they are uncommon. They include heart attack, stroke (when a part of the brain is damaged because of a problem with blood flow), death, kidney damage.
A cardiac cath does involve a small amount of radiation. Too much radiation can cause serious health problems, such as cancer. The small amount of radiation from 1 cardiac cath will not cause any long-term problems in many people.
When should I call my doctor or nurse?
Call your doctor or nurse if any of the following happen after your cardiac cath:

• The area where the tube went in bleeds a lot.
• You get a fever or have pain, swelling, or redness where the tube went in.
• Your leg or hand is weak or numb.

What is an Angioplasty?
Angioplasty (Stenting) is a procedure used to treat some people with coronary heart disease. This procedure opens narrowed or blocked arteries in the heart.
Before the procedure, you will have a cardiac catheterization (see above). During this test, the doctor puts a thin plastic tube into a blood vessel in your leg or arm. Then he or she moves the end of the tube up to your heart. Next, the doctor puts a dye that shows up on X-ray into the tube. This part of the test is called “coronary angiography.” It can show how many of your heart arteries are blocked and how serious the blockages are.
Depending on the results, your doctor might do stenting right away. For this procedure, the doctor will advance another plastic tube to your heart. After it reaches the narrowed or blocked artery, the doctor will place a stent where the major blockage or blockages are. This opens up the artery at the place where it is blocked and helps restore blood flow to the heart.
A heart stent is a tiny metal tube (often coated with a medicine that helps keep the artery from getting narrow or blocked again) about one inch long that helps prop open an artery in the heart.
Reasons for doing an angioplasty
Your doctor might recommend a stent if you have coronary heart disease and have:

• Chest pain (“called angina”) that does not get better when you take medicines.
• One or more heart arteries that are very narrow.
• People who are having a heart attack or had a heart attack a short time ago also sometimes need stent placement.

How do I prepare for the procedure?
You should not eat or drink anything for 6 to 8 hours before the procedure. You might need to change your medicines or stop taking some of them beforehand. Follow all the instructions your doctor gives you. If you don’t feel well on the day of the procedure, tell your doctor.
What happens after the procedure?
After the procedure, your doctor will remove the tube from your body and put pressure on the small cut to prevent bleeding. You might need to stay in the hospital overnight. Before you leave, your doctor will tell you when you can drive and do your usual activities again.
Your doctor will prescribe aspirin and another medicine to help prevent clots inside the stent. It is very important that you take these medicines as directed and that you keep taking them unless your doctor says it’s OK to stop. People who stop taking these medicines too soon increase their risk of a heart attack or even death.
What problems can happen after the procedure?
The most common problems are bleeding, bruising, and soreness in the area where the tube was put in. These problems can last for a few days, especially if the tube was put in the leg.
Other problems can happen during or after stenting, but they are rare. They include:

• A small tear in the inside of a coronary artery, which usually heals by itself. Some people with this problem need another procedure or (in rare cases) surgery to fix the tear.
• Heart damage
• A blood clot inside the stent. This can block blood flow to the heart and cause a heart attack or even death. It can happen as early as 1 day or as late as 1 year or more after you get a stent.

When should I call my doctor or nurse?
Call your doctor or nurse if any of the following happen after your stenting:
You have chest pain that does not get better with 1 dose of sublingual (under the tongue) nitroglycerin
You get a fever or have pain, swelling, or redness where the tube went in.

What is carotid artery angioplasty?
Carotid artery angioplasty is a procedure done to open the clogged arteries (if significant) in your neck to prevent or treat stroke. The doctor uses a long, thin tube called a catheter that has a small balloon on its tip. They inflate the balloon at the blockage site in the carotid artery to flatten or compress the plaque against the artery wall.
Carotid angioplasty is often combined with the placement of a small, metal, mesh-like device called a stent. When a stent is placed inside of a carotid artery, it acts as a support or scaffold, keeping the artery open. By keeping the carotid artery open, the stent helps to improve blood flow to the brain. Carotid angioplasty and stenting are usually performed in patients either because they are not candidates for the traditional surgery (carotid endarterectomy) or because the procedure is felt to be less risky than the traditional surgery.
What can I expect during a carotid angioplasty or stent procedure?
The procedure is performed in the cardiac catheterization lab. You may be told not to eat or drink anything after midnight the night before the procedure, except for taking certain medicines. If you have diabetes, you should talk to your doctor about your food and insulin intake, because not eating can affect your blood sugar levels.
Talk to your doctor about any medicines (prescription, over-the-counter, or supplements) that you are taking, especially blood thinners or antiplatelet medication. You will most likely have blood tests, an electrocardiogram, and a chest x-ray taken before the procedure.
Once you are in the cath lab, you will lie on an examination table, which is usually near an x-ray camera and various monitors. Small metal disks called electrodes will be placed on your chest and hooked up to an electrocardiogram machine which monitors your heart rhythm during the procedure. You will rest your head in a cup-shaped area on the examination table, which will help you keep your head still while pictures of your carotid artery are taken.
A very small needle will be put in the vein of your forearm. This is called an intravenous line or IV. You will be given an anesthetic medicine to numb the area around where the catheter will be inserted. You should not feel pain during any part of the procedure.
After gaining entrance into the large artery of either your leg or arm, doctors will gently thread the catheter through that artery in your leg or arm and into the carotid artery itself. They use a video monitor to see the process. You will not feel the catheter passing through the arteries because the insides of arteries do not have nerve endings. Once the catheter reaches the blocked artery, a harmless dye (called contrast material) is injected, and the doctor will take a picture of the carotid artery. The dye may cause a warm feeling on one side of your face. Contrast material provides a detailed view of the narrowed artery and blood flow to the brain.
A filter that is shaped like an umbrella is then placed beyond the narrowed artery over a tiny wire to catch any plaque that may break away from inside the artery during the procedure. This filter device is called an embolic protection device (EPD) and is needed during most carotid artery procedures.
Once doctors know the exact location of the blockage in the carotid artery, the balloon-tipped catheter is slipped over this wire and advanced to the blockage. When this catheter reaches the blockage, the balloon is inflated. As the balloon expands, it presses against the plaque, compressing it against the artery wall. The balloon is then deflated. Doctors may inflate and deflate the balloon a number of times. A very small, flexible stent is then passed over the area of narrowing and is left inside the carotid artery. A new balloon is placed over the same wire and inflated inside the stent to open it up. The deflated balloon and EPD are removed, leaving the stent behind to hold the artery open.
Firm pressure will be applied to the site where the catheter was inserted to stop any bleeding. You will also be bandaged. To avoid bleeding at the catheter insertion site, you will need to lie very still for several hours, either in the recovery area or in your hospital room.
Duration: 30 to 90 minutes.
What happens after the procedure?
Most patients will spend the night in the hospital for observation. Nurses will watch you during the night to observe your heart rate and blood pressure.
After you leave the hospital, your doctor will give you specific instructions about drinking plenty of fluids, driving, and bathing. You should avoid standing or walking for long periods for at least 2 days after the procedure.
If you had angioplasty with or without stent placement, you will need to take aspirin and/or a blood-thinning medicine or antiplatelet therapy for a certain amount of time. Your doctor will tell you how and when to take these medicines.
Risks

• During angioplasty, blood clots that may form on the catheters can break loose and travel to your brain causing a stroke or ministroke (transient ischemic attack, or TIA. You’ll receive blood thinners during the procedure to reduce this risk.
• A stroke can also occur if plaque in your artery is dislodged when the catheters are being threaded through the blood vessels.
• A major drawback of carotid angioplasty is the chance that your artery will narrow again within months of the procedure. Special drug-coated stents have been developed to reduce the risk of restenosis.
• Blood clots can form within stents even weeks or months after angioplasty. These clots may cause a stroke or death. It’s important to take aspirin, clopidogrel (Plavix) and other medications exactly as prescribed to decrease the chance of clots forming in your stent.
• You may have bleeding at the site in your groin where catheters were inserted. Usually, this simply results in a bruise, but sometimes serious bleeding occurs and may require a blood transfusion or surgical procedures.

What is an Atrial Septal Defect?
An atrial septal defect (ASD) is a birth defect where there is a hole in the wall between the two upper chambers of your heart (atria). Small defects may never cause a problem and may be found incidentally. It’s also possible that small atrial septal defects may close on their own during infancy or early childhood. Large and long-standing atrial septal defects can damage your heart and lungs. An adult who has had an undetected atrial septal defect for decades may have a shortened lifespan from heart failure or high blood pressure that affects the arteries in the lungs (pulmonary hypertension). ASD closure may be necessary to repair atrial septal defects to prevent complications.
ASD Closure
ASD may not need treatment if there are few or no symptoms, or if the defect is small and is not associated with other abnormalities. Closure of the defect is recommended if the defect causes a large amount of shunting, the heart is swollen, or symptoms occur.
The procedure involves placing an ASD closure device into the heart through tubes called catheters. The Doctor provider makes a tiny cut in the groin, then inserts the catheters into a blood vessel and up into the heart.
The closure device is then placed across the ASD and the defect is closed.
Sometimes, open-heart surgery may be needed to repair the defect. The type of surgery is more likely needed when other heart defects are present.
Some people with atrial septal defects may be able to have this procedure, depending on the size and location of the defect.
Possible Complications
People with a larger or more complicated ASD are at an increased risk for developing other problems, including:

• Abnormal heart rhythms, particularly atrial fibrillation
• Heart failure
• Heart infection (endocarditis)
• High blood pressure in the arteries of the lungs
• Stroke

Mitral Valvotomy
This is a procedure in which a narrowed (stenotic) heart valve, between the two left chambers (mitral valve) is opened up using a balloon.
It is used for:

• Patients who have mitral valve stenosis with symptoms.
• Older patients who have aortic valve stenosis, but are not able to undergo surgery may undergo a similar procedure on the aortic valve.
• This balloon valvotomy procedure can be performed on the mitral, tricuspid, aortic or pulmonary valves.

What should I expect before the procedure?

• You will likely need to have blood tests, a chest x-ray, electrocardiogram, and an echocardiogram before the procedure.
• Ask your doctor what medications should be taken on the day of your test.
• If you are diabetic, ask your physician how to adjust your medications the day of your test.
• Tell your doctor or nurse if you are taking any blood thinning medications such as warfarin.
• You will not be able to eat or drink after midnight the evening before the procedure.
• Leave all valuables at home. If you normally wear dentures, glasses or a hearing assist device, plan to wear them during the procedure to help with communication.
• Tell your doctor and/or nurses if you have any allergies.

How is a balloon valvotomy performed?
Balloon valvotomy is a non-surgical procedure performed in the cardiac catheterization laboratory by a cardiologist and a specialized team of nurses and technicians.
Long, slender tubes called catheters are first placed into blood vessels in the groin and guided into the chambers of the heart. The doctor then creates a tiny hole in the wall between the upper two chambers of the heart. This hole provides an opening for to access the left atrium with a special catheter that has a balloon at the tip.
The catheter is positioned so the balloon tip is directly inside the narrowed valve. The balloon is inflated and deflated several times to widen the valve opening. Once the cardiologist has determined that the opening of the valve has been widened enough, the balloon is deflated and removed.
During the procedure, an ultrasound of the heart is often done to get a better picture of the mitral valve.
Duration
About 1 hour.
Please plan on staying all day for the procedure and remaining in the hospital overnight. Most patients are able to go home the next day.

What is Peripheral Artery Disease?
Peripheral artery disease (PAD) is a condition that can cause leg pain that gets worse with activity. Muscle pain that gets worse with activity and better with rest is called “claudication.” PAD affects the blood vessels (called arteries) that bring blood to the legs. PAD can also cause wounds to heal more slowly than usual.
Treatment involves modifying your lifestyle (diet, exercise and quitting smoking), use of medications and interventions (angioplasty, stenting or surgery) in some cases. These are in cases where you have severe symptoms despite trying medicines.
Angioplasty or Stenting
During angioplasty or stenting, the doctor sends a thin tube with a balloon at the end of it to the part of the artery that is blocked. Then the doctor inflates the balloon to open the blockage. Often the doctor props open the artery using a tiny mesh tube called a stent, which stays in the body. Some special balloons and stents also release medicine to help the artery stay open longer.

What is a Pacemaker?
The normal, healthy heart has its own pacemaker that regulates the rate that the heart beats.  However, some hearts don’t beat regularly. Often a pacemaker device can correct the problem. A pacemaker is a small device that sends electrical impulses to the heart muscle to maintain a suitable heart rate and rhythm. A pacemaker may also be used to treat fainting spells (syncope), congestive heart failure, and hypertrophic cardiomyopathy. It is implanted just under the skin of the chest during a minor surgical procedure.
The pacemaker has two parts: the leads and a pulse generator. The pulse generator houses the battery and a tiny computer, and resides just under the skin of the chest. The leads are wires that are threaded through the veins into the heart and implanted into the heart muscle. They send impulses from the pulse generator to the heart muscle, as well as sense the heart’s electrical activity.
Each impulse causes the heart to contract. The pacemaker may have one to three leads, depending on the type of pacemaker needed to treat your heart problem.
There are different types of pacemakers:

• Single chamber pacemaker uses one lead in the upper chambers (atria) or lower chambers (ventricles) of the heart.
• Dual chamber pacemaker uses one lead in the atria and one lead in the ventricles of your heart.
• Biventricular pacemaker uses three leads: one placed in the right atrium, one placed in the right ventricle, and one placed in the left ventricle (via the coronary sinus vein).

Your doctor will decide what type of pacemaker you need based on your heart condition.
The doctor programs the minimum heart rate. When your heart rate drops below that set rate, your pacemaker generates (fires) an electrical impulse that passes through the lead to the heart muscle. This causes the heart muscle to contract, creating a heartbeat.
Pacemakers are also used to treat the following:

• Pacemakers are used most commonly to treat bradyarrythmias, which are slow heart rhythms that may arise from disease in the heart’s electrical conduction system (such as the SA node, AV node or HIS-Purkinje system).
• Heart failure. This device is called cardiac resynchronization therapy (CRT) or biventricular pacing.
• Hypertrophic cardiomyopathy.
• Syncope (fainting spells).

What is an ICD?
An ICD, or implantable cardioverter defibrillator, is an electronic device that constantly monitors your heart rate and rhythm. When it detects a very fast, abnormal heart rhythm, it delivers energy to the heart muscle. This causes the heart to beat in a normal rhythm again.
The ICD has two parts: the lead(s) and a pulse generator. The lead(s) monitor the heart rhythm and deliver energy used for pacing and/or defibrillation (see below for definitions). The generator houses the battery and a tiny computer. Energy is stored in the battery until it is needed. The computer receives information from the leads to determine what rhythm is occurring.
Types of ICDs
Single chamber ICD. A lead is attached in the right ventricle. If needed, energy is delivered to the ventricle to help it contract normally.
Dual chamber ICD. Leads are attached in the right atrium and the right ventricle. Energy is delivered first to the right atrium and then to the right ventricle, helping your heart to beat in a normal sequence.
Biventricular ICD. Leads are attached in the right atrium, the right ventricle and the left ventricle. This technique helps the heart beat in a more balanced way and is specifically used for patients with heart failure.
Your doctor will determine which type of ICD is best for you.

What is Pacemaker and ICD Interrogation?
This is the process by which a programmer is used to get information about your device, in the office. This is done by placing a wand over your chest where the device is located.
What are the indications for the procedure?
We routinely evaluate the programming of your device and confirm that the battery and wires (leads) are functioning appropriately.
To assess if your device is malfunctioning.
How is it done?
We place a wand over your device that is linked to a special computer called a programmer. When the programmer and the device communicate, valuable information can be obtained from the memory of your device and we can change the programmed settings if needed.
We will evaluate the remaining lifespan of the battery and give you some idea about how long the battery will last. We test the function of the leads and make sure they conduct electricity both to and from your heart. We can also modify the programmed settings to better suit your heart’s individual needs.
Duration – 10 – 15 minutes
How do you prepare for the procedure?
No preparation is needed.
What are the risks of the procedure?
There are little or no risks of the procedure. During the interrogation, testing occasionally you can feel some mild lightheadedness.

What is Cardiac Resynchronization Therapy?
Cardiac resynchronization therapy (CRT) is a treatment for some types of heart failure. Heart failure is a condition in which the heart does not pump as well as it should.
When the heart pumps, the walls of the main pumping chamber of the heart (called the “left ventricle”) should pump at the same time. But in some people with heart failure, the walls of the left ventricle do not pump at the same time, making the heart failure worse.
CRT uses a special device called a biventricular pacemaker (BiV pacemaker). This device sends electrical signals to the heart to make the walls of the left ventricle pump at the same time.
CRT devices also can protect the patient from slow and fast heart rhythms.
How is CRT done?
Your doctor will do a procedure to put the pacemaker in your chest. He or she will make a small cut in your upper chest. He or she will put the wires in a blood vessel near the cut and thread them to your heart. Each of the 3 wires will sit in a different part of your heart. Your doctor will then connect the wires to the pulse generator. He or she will program the pulse generator and put it under the skin in your chest.
Depending on your heart condition, your doctor might use a “combined” device. A combined device has a BiV pacemaker plus an implantable cardioverter-defibrillator (ICD). An ICD can sense and treat abnormal heartbeats that could cause sudden death.
What are the Risks and Downsides?

• A wire can make a hole in a blood vessel, the heart, or the lungs.
• An infection can start around the pulse generator or wires.
• The wires might be put in the wrong place during the procedure or move out of place later on.
• You will need more surgery after 8 to 10 years to replace the battery.
• There is a chance that CRT will not work and that the BiV pacemaker will not improve your heart failure. If your heart failure does not improve with CRT, your doctor might change the settings of your BiV pacemaker. He or she will also talk with you about other possible treatments.

What is Cardioversion?
Cardioversion is a brief procedure where an electrical shock is delivered to the heart to convert an abnormal heart rhythm back to a normal rhythm.
Why do I need a Cardioversion?
Most elective or “non-emergency” cardioversions are performed to treat heart rhythm disturbances originating in the upper chambers (atria) of the heart. Cardioversion is used in emergency situations to correct a rapid abnormal rhythm associated with faintness, low blood pressure, chest pain, difficulty breathing, or loss of consciousness.
The normal heartbeat starts in the upper right chamber of the heart (right atria), the sinus node. The sinus node contains specialized cells that send an organized electrical signal through the heart resulting in a perfectly timed, rhythmic heartbeat. In patients with atrial fibrillation, however, the atria quiver due to chaotic electrical signals that circulate throughout both atria. This typically results in a fast and irregular heartbeat. While some patients have no symptoms, others may experience shortness of breath, lightheadedness, and fatigue. Depending on your specific medical history and symptoms, your physician may recommend a cardioversion to return your heart to a normal rhythm.
What are the different types of cardioversion?
Cardioversion can be “chemical” or “electrical”. Chemical cardioversion refers to the use of antiarrhythmic medications to restore the heart’s normal rhythm. Antiarrhythmia medications work by modifying the heart’s electrical properties to reduce the frequency of abnormal heart rhythms and to help restore a normal rhythm. Your doctor may decide to start your antiarrhythmic medication as an outpatient, or he or she may choose to admit you to the hospital to give you an intravenous (IV) or oral antiarrhythmic medication while your heart rhythm is closely observed. The decision of whether or not you need to be admitted to the hospital depends on your symptoms, the specific medication your doctor chooses, and your underlying heart disease.
Electrical cardioversion is a procedure whereby a synchronized (perfectly timed) electrical shock is delivered through the chest wall to the heart through special electrodes or paddles that are applied to the skin of the chest and back. The goal of the cardioversion is to disrupt the abnormal electrical circuit(s) in the heart and to restore a normal heartbeat. The shock causes all the heart cells to contract simultaneously, thereby interrupting and terminating the abnormal electrical rhythm (typically fibrillation of the atria) without damaging the heart. This split second interruption of the abnormal beat allows the heart’s electrical system to regain control and restore a normal heartbeat.
An electrical cardioversion is performed in a hospital setting such as an emergency room, intensive care unit, recovery room, special procedure room or Electrophysiology Laboratory. A cardiologist, a nurse and/or an anesthesiologist are present to monitor your breathing, blood pressure and heart rhythm. Special cardioversion pads are placed on your chest and back (or alternatively, both pads can be placed on the front of the chest). The pads are connected to an external defibrillator by a cable. The defibrillator allows the medical team to continuously monitor your heart rhythm and to deliver the electrical shock to restore your heart’s rhythm back to normal.
Since the shock can be painful, an anesthesiologist or specially trained nurse administers intravenous sedation. Once you are asleep (but still breathing on your own), the physician charges the defibrillator to a specified energy level and then delivers the shock by pressing a button on the defibrillator. The shock is transmitted along the cable to the pads on the chest where the energy is delivered across the chest wall to the heart muscle. Additional shocks at higher energy levels can be delivered if the first shock does not restore the rhythm back to normal. Rarely, minor skin redness can occur at the site of the cardioversion pads where the electrical energy was delivered.
After the Procedure
Patients typically awake quickly without any recollection of the shocks, due to the amnesic effects of the sedatives. Because of residual effects of the anesthetic medications used, patients are advised not to drive or make any important decisions for the rest of the day. A responsible adult should be available to provide transportation home. The anesthetic agents typically used for the procedure are short-acting; therefore most patients are able to go home an hour or so after the procedure. A normal heart rhythm can be restored more than 90% of the time, although abnormal rhythms may recur in about half the patients within a year. The success of electrical cardioversion often depends on the duration of atrial fibrillation and the underlying cause (heart disease). Cardioversion is not appropriate for every patient with atrial fibrillation.
Are there any other things I should know before my cardioversion?
Because the upper chambers of the heart are fibrillating (quivering) and do not squeeze uniformly in patients with atrial fibrillation, there is a potential risk that blood clots may form. The process of restoring a normal rhythm could potentially dislodge a blood clot from the heart resulting in a heart attack or a stroke. Fortunately, thinning the blood prior to cardioversion can prevent most blood clots. This is a process called “anticoagulation”. Anticoagulant medications include aspirin, heparin or warfarin. Warfarin is a pill taken daily and dosed according to blood test results. This test, referred to as the INR or International Normalized Ratio, monitors the “thinness” or “thickness” of the blood and typically should be in the 2.0-3.0 range (a normal INR in someone who is not on warfarin is typically around 1.0). If the INR is too low, there may be at an increased risk of forming a blood clot. If the INR is too high, there may be at an increased risk for bleeding. Heparin is a blood thinner that can be given as an intravenous solution or shots in the skin. It acts more quickly and its effects are reversed more rapidly than warfarin. Frequently, patients are placed on heparin until warfarin becomes effective, as this may take several days.
Prior to performing a cardioversion, your physician will determine your risk of blood clot formation (and thus, your risk of stroke or heart attack) and choose an anticoagulant medicine. In patients with atrial fibrillation or flutter that has been present for a while, the blood must be adequately thinned for at least 3-4 weeks prior to the cardioversion to reduce the risk of stroke. Because it takes many hours for blood clots to form, cardioversion can be safely performed without blood thinning medication in patients who have had their heart rhythm problem for less than 48 hours. Occasionally, your physician may recommend a special ultrasound of the heart (called a transesophageal echocardiogram or TEE). During a transesophageal echocardiogram, a special probe is placed in the esophagus. It allows your physician to directly visualize the atria to scan for potential blood clots. Typically, anticoagulation is continued after the cardioversion for an additional 4 weeks to 6 months, even if the cardioversion is successful.
What to Expect
You should have nothing to eat or drink for at least eight hours prior to the procedure.
Take your regularly scheduled medications the morning of the procedure unless your medical practitioner has told you otherwise. Your medications should only be taken with enough water to get the tablets down. If you are diabetic, you should discuss your insulin or other diabetes medication dosing with your medical practitioner.
Bring a list of all your medications with you.
Do not apply any lotions or ointments to your chest or back as this may interfere with the adhesiveness of the shocking pads.
After the Procedure
Patients typically awake quickly without any recollection of the shocks, due to the amnesic effects of the sedatives.
The anesthetic agents typically used for the procedure are short-acting; therefore most patients are able to go home an hour or so after the procedure. You should arrange a ride home that day.
A normal heart rhythm can be restored more than 90% of the time, although abnormal rhythms may recur in about half the patients within a year. The success of electrical cardioversion often depends on the duration of atrial fibrillation and the underlying cause (heart disease). Cardioversion is not appropriate for every patient with atrial fibrillation.
You may experience some minor chest discomfort and/or skin irritation following the procedure. An ointment can be applied to the area to reduce the discomfort.

What is An Electrophysiology study?
An electrophysiology (EP) study is a test performed to assess your heart’s electrical system or activity and is used to diagnose abnormal heartbeats or arrhythmia.
The test is performed by inserting catheters and then wire electrodes, which measure electrical activity, through blood vessels that enter the heart.
The Procedure
Depending on the length of your procedure, a catheter may be inserted to drain your bladder of urine during the procedure.
A small intravenous (IV) needle will be inserted into a vein in your arm to administer drugs, to make you feel sleepy. These medications help reduce your anxiety and relieve your discomfort.
The EP study is performed in the electrophysiology/ catheterization laboratory, where you’ll be placed on an X-ray table. Electrodes will be placed on your chest and back to connect you to the monitoring equipment. A blood pressure cuff will be placed on your upper arm to monitor your blood pressure.
To prevent infection, a nurse will shave and cleanse the groin and possibly neck area where the catheters will be inserted. The area will be cleansed with an antiseptic. Sterile sheets will be draped over your body. Please don’t touch the sterile areas on your neck and groin.
A local anesthetic will be administered with a tiny needle to numb the area where the catheters are inserted. You will feel a pinprick and possibly a stinging sensation for a few seconds.
One or more catheters, which are thin, long, flexible wires, will be inserted into a large vein in your groin or neck. The catheters will be guided to your heart. The positioning of catheters inside your heart will be monitored on a screen. You may feel pressure when the catheters are inserted. The incision site is less than a quarter of an inch.
There are two parts to the EP study:

• Recording the heart’s electrical signals to assess the electrical function
  Pacing the heart to bring on certain abnormal rhythms for observation under controlled conditions
• Medications are sometimes used to stimulate your arrhythmia. You may feel your heart racing or pounding. This may make you anxious, but you needn’t be alarmed. The doctors want to induce the abnormal rhythm causing your problem, so they can treat the arrhythmia. If you have any uncomfortable symptoms (such as chest pain, dizziness, shortness of breath, nausea, and pain) let the team know.

After the Procedure

• Catheters are removed and pressure applied to the groin and neck areas to prevent bleeding.
• You’ll lie still in bed for four to six hours to allow the catheter sites to seal. Don’t move or bend your leg.
• You will be checked frequently. If you feel sudden pain or see bleeding at the site, call the nurse immediately.
• Your doctor may share some of the preliminary findings after the test.
• If you feel well enough, you may be able to eat and drink.
• Before leaving the hospital, your doctor or arrhythmia nurse coordinator will provide instructions regarding medications and follow-up care and any restrictions in your normal activities.

Returning Home
After you’re discharged from the hospital and return home, please follow these guidelines:

• Limit your activity for the first 24 hours. Don’t strain or lift heavy objects more than 10 pounds for the first week.
• If traveling home takes several hours, stop every hour, stretch your legs and walk a few minutes to prevent the formation of blood clots in your legs.
• If you notice new blood on the dressing, press firmly on the incision site for about 20 minutes. If bleeding continues, call your doctor or go to the nearest emergency room while still applying pressure.
• Leave the dressing on until the day after the study. Your nurse will show you how to remove it.
• Don’t worry if you see a bruise or small lump under the skin at the insertion site. It will disappear within three to four weeks.

When to Call Us

• If the site, where catheters were inserted, becomes painful or warm to the touch.
• If you have chest pain, palpitations, shortness of breath or lightheadedness.

What is Radiofrequency Ablation?
Radiofrequency ablation is used to treat some types of rapid, irregular heart rhythms. During the procedure, your physician will guide a catheter with an electrode at its tip into the area of your heart that is creating the additional impulses. Then, a mild, painless radiofrequency energy (similar to microwave heat) is transmitted to the site, and heart muscle cells in a very small area (about 1/5 of an inch) die and the irregular beats stop.
It can also be used to “disconnect” the electrical pathway between the upper chambers and the lower chambers of the heart. If this is the case, you may also receive a pacemaker during the procedure. Your physician will diagnose the type of arrhythmia you have and then determine the type of RFA you need.
The procedure is now widely used because it has a very high success rate, low risk of complications and you can usually resume normal activities in a few days. It is performed under mild sedation with local anesthesia and most patients report little or no discomfort.
How do I prepare for my Radiofrequency Ablation?
Your physician will give you specific instructions for the night before your radiofrequency ablation procedure, depending upon your physical condition and other considerations. Some typical instructions include:
It is important for you to have an empty stomach for the ablation. Do not eat or drink any fluids after midnight before the procedure.
Regarding your daily medications, you may or may not need to take them. Additionally, your doctor may ask you to stop taking certain medications, like those that control your heart rate or aspirin products, one to five days before your procedure. Your physician will discuss this with you.
When you check in to the Heart Institute of the Caribbean, wear comfortable clothes and shoes. Don’t wear jewelry or bring valuables. Pack any personal care items you will want for an overnight or brief stay.
What happens during my radiofrequency ablation?
Your RFA will take place in the electrophysiology lab. You will be given a light sedative intravenously so you are relaxed, but not asleep during the procedure. Your physician may ask you to follow instructions, report symptoms and/or answer questions during the procedure.
You will be connected to monitors that let your physician monitor your heart rhythm and respond to arrhythmias.
The top of your leg near your groin will be numbed with a local anesthetic. Then, your physician will inject medication followed by several hollow flexible tubes called catheters into the large blood vessel(s) in your groin. A fluoroscopy (x-ray) machine will show the placement of the catheters so your physician can guide them into your heart.
Once your physician finds the correct area(s) of the heart, energy is applied through the catheter to destroy the area of muscle causing the irregular heartbeats.
The RFA procedure takes from two to six hours. After RFA you will be admitted to a room where your heart can be monitored. Typically, you will be discharged the next day and given follow-up instructions.
How common is this procedure?
Radiofrequency ablation is widely used. It’s the preferred treatment for many types of rapid heartbeats. It has a success rate of over 90 percent and a low risk of complications. Patients who have this done can resume normal activities in a few days. It causes little or no discomfort and is done under mild sedation with local anesthesia.