Frequently Asked Questions Part I | Part II | Part III

What To Expect After Angioplasty?
After angioplasty, you will be moved to a recovery room or to the coronary care unit. Your heart rate, pulse, and blood pressure will be closely monitored and the catheter insertion site checked for bleeding. You will have a large bandage or a compression device at your groin and the catheter insertion site to prevent bleeding. You will be instructed to keep your leg straight if the insertion site is at your groin.

You usually can start walking within 12 to 24 hours after angioplasty. The average hospital stay is 1 to 2 days for uncomplicated procedures. You may resume exercise and driving after several days.

You are usually given aspirin after angioplasty with stenting to help prevent the formation of blood clots. When a stent is also used, you may be given aspirin and another platelet inhibitor (such as clopidogrel [Plavix]). You will usually take the aspirin long-term; the second platelet inhibitor usually is given for up to 3 months after the stent is placed.

Why Is Angioplasty Done?
Although many factors are involved, angioplasty with or without stenting is usually used if you have:

• Frequent or severe chest pain (angina) that is not responding to medication.
• Evidence of severely reduced blood flow (ischemia) to an area of heart muscle caused by one or more narrowed coronary arteries.
• An artery that is likely to be treated successfully with angioplasty whether or not stenting is also used.
• You are in good enough health to undergo the procedure.

Angioplasty may not be a reasonable treatment option when:

• There is no evidence of reduced blood flow to the heart muscle.
• Only small areas of the heart are at risk, and you do not have disabling chest pain (angina).
• You are at risk of complications or dying during angioplasty due to other health problems.
• The anatomy of the artery makes angioplasty or stenting too risky or will interfere with the success of the procedure.
• The surgeon or hospital does not perform enough procedures to ensure competency.
• The hospital does not have access to emergency cardiac surgical facilities.

How well does Angioplasty work?
Angioplasty relieves chest pain and improves blood flow to the heart. If restenosis occurs, another angioplasty or bypass surgery may be needed.

Angioplasty combined with stenting and certain medications (glycoprotein IIb/IIIa platelet receptor antagonists, such as abciximab) show improved long-term outcomes compared to angioplasty alone, with short-term success rates of 96% to 99%.1, 2 Long-term outcomes of angioplasty on single-vessel disease are similar to those of coronary artery bypass surgery.2

Angioplasty is considered very effective for reestablishing blood flow during a heart attack.2 Angioplasty is at least as effective as (and possibly superior to) thrombolytics in the treatment of heart attack in medical centers where many procedures are performed.3

Bypass surgery may yield greater benefits than angioplasty for people with diabetes or those with extensive coronary atherosclerosis.2 Additionally, bypass surgery may be the best option when there are blockages in the coronary arteries that cannot be reached during angioplasty or if angioplasty is tried but did not sufficiently widen the blood vessel, or when heart valve disease is present.

Stents are now used routinely during angioplasty and other revascularization procedures. Restenosis is less likely when compared to angioplasty without stenting.1 However, additional medications (glycoprotein IIb/IIIa receptor inhibitors) are usually needed to help thin the blood and prevent blood clots following the placement of a stent.4

• Coated stents are being used at some large medical centers to help prevent restenosis after angioplasty and stenting. These stents are coated with sirolimus, a medication that prevents the growth of new tissue that often causes the treated artery to close up again. These stents almost completely prevent restenosis and will replace other stents in the future.5
• Intracoronary radiotherapy. This is a newly approved therapy in which radiation is applied to the stented portion of the artery to treat restenosis that has already occurred. Although this technique has shown positive results for preventing restenosis, the long-term effectiveness of the approach needs further research.6, 7 Intracoronary radiation, also called brachytherapy, is performed mostly on those who are at high risk of restenosis after angioplasty.
  

What are the risks of Angioplasty?
Risks of angioplasty may include:

• Bleeding at the puncture site.
• Sudden closure of the artery.
• Heart attack.
• Need for additional procedures. Angioplasty may increase the risk of needing urgent bypass surgery. In addition, the repaired artery can renarrow (restenosis) and a repeat angioplasty may need to be performed.
• Reclosure of the grafted blood vessel (restenosis).
• Death. The risk of death is higher when more than one artery is involved.

What to think about before going to Angioplasty?
Early invasive treatment (such as angioplasty or bypass surgery) reduces symptoms and promotes early discharge from the hospital but does not reduce rates of death and heart attack.

Angioplasty does not require open-chest surgery and has less risk of immediate complications than bypass surgery. Evidence suggests that the long-term outcomes of bypass surgery and angioplasty are similar.9

Coronary artery bypass surgery appears to be a better option than angioplasty for people with diabetes, especially when multiple coronary arteries are affected.9

The benefits of angioplasty are much greater for a smoker if he or she quits smoking. A smoker's quality of life after angioplasty usually improves significantly after the procedure only if the smoking stops.

What Happens During Angioplasty?
First, a cardiac catheterization is performed. You will receive medication for relaxation and sedation, and then the doctor will numb the site with local anesthesia.

Next, a sheath (a thin plastic tube) is inserted into an artery -- usually in your groin. A long, narrow, hollow tube, called a catheter, is passed through the sheath and guided up the blood vessel to the arteries in your heart.

A small amount of contrast material is injected through the catheter. This allows the doctor to see the blood vessels, valves and chambers of the heart on a TV screen.

Once the catheter engages the artery with the blockage, the doctor will perform one of the interventional procedures described below.

The procedure usually lasts about 1 1/2 to 2 1/2 hours, but the preparation and recovery time add several hours. Usually, you will stay in the hospital overnight to be observed by the medical staff.

What Types of Interventional Procedures Are Used in Angioplasty?
Balloon angioplasty. During this procedure, a specially designed catheter with a small balloon tip is guided to the point of narrowing in the artery. Once in place, the balloon is inflated to compress the fatty matter into the artery wall and stretch the artery open to increase blood flow to the heart.

For most people, coronary balloon angioplasty increases blood flow to the heart, diminishes chest pain and reduces the risk of heart attack. For some people, however, the expanded artery may abruptly close. This can be treated with retreatment or emergency bypass surgery. However, the risk of this complication is reduced if a stent (see below) is also implanted during the angioplasty.

Stent. A stent is a small stainless steel mesh tube that acts as a scaffold to provide support inside your coronary artery. A balloon catheter, placed over a guide wire, is used to insert the stent into the narrowed coronary artery. Once in place, the balloon tip is inflated, and the stent expands to the size of the artery and holds it open. The balloon is deflated and removed, and the stent stays in place permanently. Over a several-week period, your artery heals around the stent.

It is now standard for stents to be used in combination with other procedures, such as angioplasty, to help keep the coronary artery open. Stents also reduce the need for emergency open-heart surgery when blockages in medium- to large-sized arteries do not respond to balloon angioplasty.

Rotoblation. A special catheter, with an acorn-shaped, diamond-coated tip, is guided to the point of narrowing in your coronary artery. The tip spins around at a high speed and grinds away the plaque on your artery walls. The microscopic particles are washed safely away in your blood stream and filtered out by your liver and spleen. This process is repeated as needed to allow for better blood flow. This procedure is rarely used today because balloon angioplasty and stenting has much better results and are technically easier for the cardiologist to perform.

Atherectomy. The catheter used in this procedure has a hollow cylinder on the tip with an open window on one side and a balloon on the other. When the catheter is inserted into the narrowed artery, the balloon is inflated, pushing the window against the fatty matter. A blade (cutter) within the cylinder rotates and shaves off any fat that protruded into the window. The shavings are caught in a chamber within the catheter and removed. This process is repeated as needed to allow for better blood flow. Like rotoblation, this procedure is rarely used today.

Brachytherapy. Brachytherapy is the use of radiation during angioplasty to prevent the artery from narrowing again.

What Can I Expect Before the Procedure?
Most people will need to have a routine Chest X-ray, blood test, electrocardiogram and urinalysis before the procedure. These tests may require separate appointments and are usually scheduled the day before the procedure.

You will not be able to eat or drink after midnight the evening before the procedure.

If you normally wear dentures or a hearing assistive device, plan to wear them during the procedure to help with communication. If you wear glasses, bring them also.

Please tell your doctor or nurse if you are taking Coumadin (warfarin), diuretics (water pills) or insulin. Also let them know if you are allergic to anything, especially iodine, shellfish, X-ray dye, latex or rubber products (such as rubber gloves or balloons) or penicillin-type medications.

You will need to take aspirin before the procedure. Please tell your doctor or nurse if you did not take aspirin.

You will remain awake during the procedure, but you are given medication to help you relax.

What Happens After the Procedure?
You will have to lay flat (without bending your legs) while the groin sheath is in place. A sheet may be placed across your leg with the sheath to remind you to keep it straight.

After the groin sheath is removed, you must lay flat for six to eight hours to prevent bleeding, but your nurse can raise your head (about two pillows high) after two hours. Your nurse will tell you when you can get out of bed with assistance six to eight hours after the groin sheath is removed (or sooner if a collagen "plug" was placed in your artery).

You should not eat or drink anything except clear liquids until the groin sheath is removed because nausea can occur during this time. Once you are allowed to eat, you will be advised to follow a low-cholesterol and low-sodium diet. You may be admitted to the hospital overnight for observation after the procedure.

Notify your doctor or nurse immediately if you have a fever or experience chest pain, swelling or pain in your groin or leg. If you have bleeding from your groin site, call 9-1-1 and lie down immediately. Remove the dressing and push down on your pulse in the affected area.

If a stent was placed during the angioplasty procedure, you will need to take platelet-blocking medications to reduce the possibility of a blood clot forming near the newly implanted stent.

When you have recovered sufficiently from the procedure and have talked with your doctor about your follow-up care, you will be able to go home.

Can Angioplasty Cure Coronary Artery Disease?
While the procedures performed during coronary angioplasty will open a blocked artery, they will not cure coronary artery disease. Lifestyle factors that can worsen coronary artery disease, such as smoking and diet, will still need to be modified. An exercise program will also be prescribed to improve your cardiac health.

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 leads and a pulse generator. The lead monitors the heart rhythm and delivers energy used for pacing, cardioversion 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.

There are different types of ICDs, including:

• 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.

How Does an ICD Work?
The ICD is an amazing little computer. It monitors the heart rhythm, identifies abnormal heart rhythms, and determines the appropriate therapy to return your heartbeat to a normal rhythm. Your doctor programs the ICD to include one or all of the following functions:

• Anti-tachycardia Pacing (ATP). When the heart beats too fast, a series of small electrical impulses are delivered to the heart muscle to restore a normal heart rate and rhythm.
• Cardioversion. A low energy shock is delivered at the same time as your heartbeat to restore a normal heart rhythm.
• Defibrillation. When the heart is beating dangerously fast, a high-energy shock is delivered to the heart muscle to restore a normal rhythm.
• Bradycardia pacing. When the heart beats too slow, small electrical impulses are sent to stimulate the heart muscle to maintain a suitable heart rate.

Who Should Use an ICD?
ICDs are used for:

• People who have had an episode of sudden cardiac death or ventricular fibrillation.
• People who have had a heart attack and are at high risk for sudden cardiac death.
• People who have hypertrophic cardiomyopathy and are at high risk for sudden death.
• People with at least one episode of ventricular tachycardia, an abnormal heart rhythm.

How Should I Prepare for the ICD Procedure?
Ask your doctor what medications you are allowed to take. Your doctor may ask you to stop certain medications one to five days before the procedure (such as aspirin).

If you are diabetic, ask your doctor how you should adjust your diabetic medications.

Do not eat or drink anything after midnight the evening before the procedure. If you must take medications, drink only with a sip of water.

When you come to the hospital, wear comfortable clothes. You will change into a hospital gown for the procedure. Leave all jewelry and valuables at home.

What Happens During the ICD Procedure?

You will lie on a bed and the nurse will start an intravenous line (IV) into your arm or hand. This is so you may receive medications and fluids during the procedure.

You will be given an antibiotic to prevent infection and a medication through your IV to relax you and make you drowsy, but it will not put you to sleep.

The nurse will connect you to several monitors. The monitors allow the doctor and nurse to check your heart rhythm, blood pressure and other measurements during the implantation.

Your left or right side of your body, from your neck to your groin will be shaved and cleansed with a special soap. Sterile drapes are used to cover you from your neck to your feet. A strap will be placed across your waist and arms to prevent your hands from coming in to contact with the sterile field.

The ICD may be implanted in two ways, but the endocardial (transvenous) approach is most common.

A small incision is made under the collarbone. The lead is placed into a vein and guided inside your heart chamber. The generator is placed under skin in your upper chest and attached to the lead(s).

On rare occasion, it may be necessary for your doctor to implant your ICD using the epicardial approach (outside your heart). This requires open-heart surgery. Instead of placing the lead through a vein and guiding it to the heart, it is sewn onto the heart. Your doctor will decide if this approach is necessary for you.

The ICD implant takes about two to five hours to perform.

What Happens After the ICD Procedure?
You will be admitted to the hospital for about one to three days. The nurses will monitor your heart rate and rhythm. The length of your hospital stay depends on the type of ICD procedure you have.

The morning after your implant, you will have an EKG, blood tests and a chest X-ray to ensure the leads and/or patches and the ICD are in the proper position. You will also go to the electrophysiology lab to have your ICD checked. This will involve testing the ICD and programming it to your needs.

You will be given information about the type of ICD and leads you have, the date of implant, and the doctor who implanted them. In about three months after the procedure, you will receive a permanent card with this information. It is important that you carry this card with you at all times in case you need medical attention.

You can do most activities when you return home. Avoid lifting objects that weigh more than 20 pounds or pushing or pulling heavy objects. If you had heart surgery, it may take longer to get back to some activities. Your doctor or nurse will discuss specific activities with you before you leave the hospital.

How Should I Care for the Wound After an ICD?
Keep the wound clean and dry. After five days, you may take a shower. Look at your wound every day to make sure it is healing.

Call your doctor if you notice:

• Redness
• Swelling
• Drainage from the wound
• Fever
• Chills

You will have a slight bulge under the skin where the generator is located. It will not be noticeable under clothes. If the ICD implant is in your abdomen, avoid wearing tight fitting clothing or tight belts so your wounds will not be irritated.

Should I Avoid Certain Electrical Devices?
Most electrical devices, such as microwave ovens, do not interfere with ICD function. You need to avoid strong electric or magnetic fields such as: Some industrial equipment, high output ham radios, high intensity radiowaves (found near large electrical generators, power plants or radiofrequency transmission towers), and arc or resistance welders

Stay at arm's length away from less powerful electric or magnetic fields such as: Large magnets, stereo speakers, airport security wands, antennas used in ham or CB radios. Cellular phones should be kept at least 6 inches from your ICD and not on the same side as your ICD.

Do not undergo any tests that require magnetic resonance imaging (MRI). You may have CT scans done if necessary.

If you have concerns about your job or activities, ask your doctor.

Will I Know When the ICD Is Working?
You may or may not be aware of when your ICD detects and corrects your heart rhythm. Often it depends on the type of therapy you receive.

• Pacing. You may or may not feel the impulses - usually they are not detectable.
• Cardioversion. The shock feels like a thump on the chest, but discomfort does not linger.
• Defibrillation. You may be unconscious (passed out) and not feel the shock. If you are awake, the shock feels like a kick in the chest, but the pain is felt for only a moment.

What Should I Do if I Get Shocked After an ICD?

• Stay calm.
• Sit or lie down. Ask someone to stay with you.
• If you do not feel well after the shock, call your doctor or an ambulance (Dial 911 in most areas).
• If you feel fine after the shock, you do not need to seek immediate medical attention.
• Call your doctor within 24 hours.

If someone is touching you when the ICD fires, they may feel a tingling feeling; this is not harmful to them.

How Often Do I Need to See My Doctor After an ICD?
Regular follow-up is important after an ICD implant. Your doctor will tell you how often you will need to have the ICD checked. During ICD checks, the doctor will determine if the ICD had detected or treated any abnormal heart rhythms and will check the ICD battery. These visits are very important. You will also need to see a cardiologist at least once a year.

What Happens During Brachytherapy?
First angioplasty is performed, and a "ribbon" of radioactive isotopes is placed through the catheter to the site of blockage. The ribbon stays in place for about 4 to 15 minutes, and the catheter is removed.

Are There Risks Associated With Brachytherapy?
Yes. In some cases, blood clots (thrombosis) may occur at the site of radiation months after the procedure is performed. Antiplatelet medications are given after the procedure to decrease the risk of late blood clot formation.

Because brachytherapy is a new treatment, the long-term effects are still unknown. Studies are still underway to evaluate its effects. Two forms of brachytherapy - gamma radiation and beta radiation - were approved by the FDA in 2002.

Who Should Get Brachytherapy?
Brachytherapy is not appropriate for everyone. Those who seem to benefit most from this type of therapy for in-stent restenosis include people at higher risk for re-stenosis, for example, those with diabetes or long stenotic areas (long areas of narrowing).

Since blood clot formation is a side effect of brachytherapy for restenosis, people who have had recent heart attacks, poor heart function and blood clots may not be eligible for this treatment.

Should I Have Brachytherapy?
If you are at high risk for in-stent restenosis, with careful monitoring, brachytherapy may be a treatment option for you. It is best to discuss this with your doctor and an interventional cardiologist with experience in radiation therapy to see if brachytherapy is right for you.

Who Is a Candidate for a Biventricular Pacemaker?
Biventricular pacemakers improve the symptoms of heart failure in about 50% of patients that have been treated maximally with medications but still have severe or moderately severe heart failure symptoms. Therefore, to be eligible for the biventricular pacemaker, heart failure patients:

• Must have severe or moderately severe heart failure symptoms
• Must be taking medications to treat heart failure
• Must have delayed electrical activation of the heart (for example: intraventricular conduction delay or bundle branch block) as seen on ECG
  Note that the biventricular pacemaker can also perform traditional pacemaker functions and can treat slow heart rhythms.

Some heart failure patients may need an additional device called an internal cardioverter defibrillator (ICD), which prevents cardiac arrest in a person at high risk for the condition.

How Do I Prepare for the Biventricular Pacemaker Implant Procedure?

• Ask your doctor what medications you are allowed to take. Your doctor may ask you to stop certain medications several days before your procedure (such as blood thinners and aspirin). If you have diabetes, ask your doctor how you should adjust your diabetes medications.
• Do not eat or drink anything after midnight the night before the procedure. If you must take medications, drink only small sips of water to help you swallow your pills.
• When you come to the hospital, wear comfortable clothes. You will change into a hospital gown for the procedure. Leave all jewelry and valuables at home.

What Should I Expect During the Pacemaker Implant Procedure?
Pacemakers can be implanted two ways:

Endocardial (transvenous) approach: Two leads are placed into a vein and then guided to the right atrium and right ventricle of your heart. The lead tips are attached to your heart muscle. The other ends of the leads are attached to the pulse generator, which is placed under the skin in the upper chest. The third, left ventricular lead is guided through your vein to a small vein on the back of the heart called the coronary sinus to pace the left ventricle. This approach is done under local anesthetic (you will not be asleep). This technique is technically challenging and is unsuccessful about 10% of the time due to the size, shape, or location of the patient's vein.

Epicardial approach during heart surgery: Biventricular pacemaker leads are often placed at the time of heart surgery. This surgical approach may be required if the endocardial approach was not successful. The left ventricular lead is placed on the back of the outside of the left ventricle. This technique requires general anesthesia (you will be asleep). A second procedure is done several days later after surgery to connect the leads to the pacemaker.

Your doctor will decide which approach is best for you.

What Happens After the Biventricular Pacemaker Implant?
Hospital stay
After the pacemaker implant, you will be admitted to the hospital overnight. The nurses will monitor your heart rate and rhythm. You will also have a Holter monitor (a small recorder that is attached to your chest by small electrode patches) placed. It will record your heart rhythm for twelve hours. This is another way to check proper pacemaker function. The morning after your implant, you will have a chest X-ray to check your lungs and the position of your pacemaker and leads. Your Holter monitor will be removed. The results of the Holter monitor will be reported to your doctor.

Final pacemaker check
Before you go home, a nurse specializing in managing pacemakers will check your pacemaker. The nurse will place tiny electrodes onto your chest that are attached to a computer monitor by a cable. A small machine known as a programmer is used to check your pacemaker. It has a wand that is placed directly over the device. This machine allows the nurse to read your pacemaker settings and make changes during testing. With these changes, the function of the pacemaker and leads can be evaluated. You may feel your heart beating faster or slower. This is normal; however, report all symptoms to the nurse. Results of the pacemaker check are discussed with your doctor, who will then determine your pacemaker settings.

After your pacemaker check, an echocardiogram (echo) will be done. The pacemaker nurse will be there during your echo and will change your pacemaker settings at least three times. The echo will be repeated with each change to evaluate heart function. The pacemaker will keep the settings that demonstrated your best heart function.

When Will I be Able to Go Home?
Usually, you will be able to go home the day after your pacemaker was implanted. Your doctor will discuss the results of the procedure and answer any questions you may have. A nurse will go over specific instructions for your care at home.

Wound Care
Keep the area where the pacemaker was inserted clean and dry. After five days, you may take a shower. Look at your wound daily to make sure it is healing. Call your doctor if you notice:
• Unusual redness
• Swelling
• Drainage from your wound
• Fever
• Chill

Activity
You may move your arm normally and do not have to restrict its motion during normal daily activities. Avoid extreme pulling or lifting motions (such as placing your arm over your head without bending at the elbow). Activities such as golf, tennis, and swimming should be avoided for six weeks after the pacemaker was implanted. Microwave ovens, electric blankets, and heating pads may be used. Cellular phones should be used on the side opposite your pacemaker. Ask your doctor or nurse for more specific information regarding what types of equipment may interfere with your pacemaker.

Pacemaker Identification
You will receive a temporary ID card that tells you what type of pacemaker and leads you have, the date of implant, and the doctor who implanted it. In about three months, you will receive a permanent card from the company. It is important that you CARRY THIS CARD AT ALL TIMES in case you need medical attention at another hospital.

Follow-up care
A complete pacemaker check should be done six weeks after your pacemaker is implanted at your cardiologist's office. This check is CRITICAL because adjustments will be made that can prolong the life of your pacemaker. After that, your pacemaker should be checked every six months using a telephone transmitter to evaluate battery function. The nurse will explain how to check your pacemaker using the telephone transmitter. When the battery function gets low, it will be necessary to change the pacemaker.

You should see your doctor for a pacemaker analysis every six months. This check differs from the telephone check because the leads are also tested. Leads cannot be checked thoroughly over the telephone.

How Long Will My Pacemaker Last?
Pacemakers usually last two to four years.

How Will I Know if My Pacemaker Needs to Be Changed?
After getting a pacemaker, you will need to follow up with the cardiologist and nurses who care for your pacemaker at their office and through regular phone checkups. This will allow them to monitor your pacemaker's function and anticipate when it needs to be changed.