Cardiac Imaging Department of Liv Hospital provides advanced services in the field of cardiac imaging by a team consisting of 3 physicians specialized on cardiac imaging, interventional cardiology and cardiac rhythm disorders, 2 cardiology nurses assisting polyclinic services, 3 catheter nurses in the catheter laboratory (one was trained as electrophysiology technician) and officers for guest relations.

4-Dimensional Imaging With Advanced Echocardiography

The department has a standard to perform all advanced diagnostic echocardiography methods such as transthoracic and transesophageal echocardiography, stress echocardiography, 4-dimensional echocardiography, “strain” tissue imaging and carotid doppler imaging.

Different from 2-dimensional echocardiography systems used today, all transthoracic (applied via chest) and transesophageal (through esopahgus) echocardiography procedures may be performed as 4-dimensional. (The picture on right-upper side was taken during visit of rector of Alabama University, Birmingham Prof. Dr. Navin C. Nanda)

Risk for Heart Attack Is Determined

In addition to current screening tests to detect atherosclerosis, vascular imaging provides important information about atherosclerosis of heart vessels even the individual seems healthy with low risk in terms of cardiovascular diseases. For this purpose, two of methods proven to be safe for use for atherosclerosis screening by clinical researches worldwide are used in SHAPE screening system.

Liv Hospital both performs measurement of interior layer of the vessel wall through carotid doppler and coronary calcium scoring through CT.

Heart Diseases are Diagnosed Early by CIMT Test

CIMT test is a atherosclerosis diagnosis and vascular age determination test which is suggested by European and American Heart Guidelines for diagnosis of atherosclerosis and prediction of cardiovascular diseases. The value appeared as a result of the test shows vascular age of the individual and indicates if there is atherosclerosis.  This painless ultrasonographic imaging for about 10 minutes may be used even for pregnant women since it does not contain any radiation.

Main Cardiac Imaging Methods In the Department

• Echocardiography
• Transesophageal Echocardiography (through esophagus)
• 4-Dimensional Echocardiography
• Stress Echocardiography
• Carotid Doppler Examination
• SHAPE : Advance Cardiac Screening Program
• Facts to be known about developent of heart attack.

In the Coronary Angiography and Cardiac Catheterization Laboratory of Liv Hospital, interventional procedures such as angiography, balloon and stent placement are performed successfully through modern therapy methods.

Procedures Performed in Interventional Cardiology Clinic of Liv Hospital

• Coronary Angiography
• Peripheral Angiography
• Right and left heart catheterization
• Vascular resistance measurement for pulmonary hypertension
• Diagnostic procedures such as renal angiography
• Complex percutaneous coronary procedures
• Carotid artery procedures
• Renal stent
• Alcohol septal ablation in hypertrophic obstructive cardiomyopathy
• Percutaneous closure of atrial and ventricular septal defects
• Renal denervation in persistent hypertension
• TAVI (Transcatheter aortic valve implantation) in the patients with risk for operation

Comfort of Angiography from the Wrist

The angiography procedure performed from the femoral artery forces the patient to lie on the bed for 6 hours and has the risk of bleeding. In the Interventional Cardiology Clinic of Liv Hospital, balloon and stent placement procedures are performed from the artery of the wrist. These patients may be mobilized just after angiography and discharged shortly without any risk of bleeding.

Risk of bleeding significantly decreases after angiography procedures from the wrist. The rate of risk for procedures from the femoral artery is observed around 5% and the risk rate for radial artery procedures is 0.2%.

In the procedures and percutaneous interventions which have been performed in the Interventional Cardiology Clinic of Liv Hospital, the radial artery (wrist) was preferred as insertion site in 95% of the patients. This rate is over the world standards.

No complication of bleeding due to insertion site of angiography was observed in the clinical practice.  Discharge of the patients who have diagnostic procedure through the radial artery may be provided within 2 to 3 hours. On the other hand, the patients whom femoral artery is preferred for insertion, immobilized lying period for 6 to 12 hours was reduced to 2 hours by groin closure devices and implementations such as sand bags are not needed.

Atherosclerosis Does not Appear Again by Specific Stents

In our laboratory, rate for use of drug eluting stent and soluble stent is 90%. This rate is significantly over general standard which is 60%. The drug eluting stents used are approved by FDA and they provide important advantages to reduce reappearance of stenosis in the artery.

Accurate Diagnosis by Advanced Technology

Along with advanced intra-coronary imaging techniques such as intravascular ultrasound (IVUS) and Optic Coherence Tomography (OCT), FFR measurements integrated to current angiography system via wireless pressure-wire procedure which is the first and only in our country may be performed routinely and allow more sensitive decision into the correct coronary lesion for stent procedure. The laboratory was organized in accordance with security and quality standards determined by SCAI. Intra-aortic balloon pump support for the patients admitted to the laboratory due to cardiogenic shock always exists in the catheter laboratory. Set-up conforms with complex procedures like TAVI and was approved by the teams from abroad.

Main Procedures Performed in Interventional Cardiology Clinic of Liv Hospital

Coronary Angiography

Coronary Angiography is visualization of the coronary arteries (vessels providing blood circulation and feeding to the heart) by administrating a stained fluid.  Angiographic procedures may be performed for all vessels of the body. Eye vessels, brain vessels, heart and leg vessels are generally the most common vessel systems for research. The procedure performed to examine heart vessels is called coronary angiography.

Coronary angiography (also called cardiac catheterization or angiography) is an interventional imaging method to evaluate heart vessels and their functions.

Diseases That Cardiac catheterization is used for Diagnostic and Therapeutic Purposes

• To diagnose coronary artery disease, valvular heart disease or aorta disease and to determine the severity.
• To assess the function of the heart muscle.
• To determine advanced therapy (coronary balloon angioplasty and stent, coronary bypass surgery, interventional or surgical procedure for heart valve) methods

Coronary Angiography

A thin, flexible plastic sheath is placed into the femoral or brachial artery during coronary angiography. A soft, thin, and cavernous plastic catheter is inserted into this sheath and forwarded to exit of the cardiac arteries. The catheter is referred to the coronary arteries through a special x-ray machine.

A contrast material (angiography stain) is injected through a catheter and mobile x-ray films are recorded in a digital environment. This part of the procedure is called coronary angiography. In addition to these images, advanced imaging and evaluation methods such as intravascular ultrasound (IVUS), optic coherence tomography (OCT) or fractional flow reserve (FFR) may be necessary. IVUS enables to obtain detailed images of the coronary artery via ultrasound. OCT provides comprehensive data about interior wall of the artery through a special light source. FFR provides information about severity of the stenosis monitored by measuring the blood flow characteristics. These advanced imaging techniques are recommended to be performed by experienced centers and operators via very special devices.

Balloon Angioplasty and Stent (Coronary Interventional Procedure) Placement

The coronary interventional procedure is a non-surgical treatment method to open narrowed coronary arteries to increase the blood supply to the heart. When a narrowed or obstructed coronary artery(ies) is detected during coronary angiography, it may be treated by angioplasty and stent method by common decision of the physician and the patient within same session or another session as planned. This decision may differ according to clinical status of the patient.  The coronary interventional procedure starts same as a coronary angiography. After a catheter is inserted into the exit of the coronary arteries, balloon angioplasty and stent are performed to open the coronary arteries.

Balloon Angioplasty

By blowing a balloon which dilates with fluid on the end of a thin catheter, narrowed coronary arteries may be opened.  The technique used for balloon angioplasty is called percutaneous coronary angioplasty (PTCA) or percutaneous coronary procedure (PCP). when the balloon is blown, the fatty plaque is compressed against the obstructed arterial walls and blood flow increases.

Balloon Angioplasty With Stent

In most cases, stent placement is combined with balloon angioplasty procedure. Stent is a small tube consisting of a metal mesh which acts like a skeleton to provide support inside the artery. To place a stent inside the narrowed artery, a balloon catheter forwarded over a guidewire is used. When the stent is forwarded into the narrowed site, the balloon is inflated and stent dilates according to the diameter of the artery and adheres onto the arterial wall. After the balloon is deflated, stent is left in the site permanently. The stent is covered by normal vessel cells (endothelium) and heals within a couple of weeks.

Stent and angioplasty is generally recommended for the patients with stenosis or obstruction in single or two coronary arteries. If obstruction is present in more than two arteries, coronary artery bypass surgery may be in question.

Drug Eluting stents (DES):

Drug eluting stents include drugs which are released in the placement site for a certain period and reduce stenosis again. Drug eluting stents have a metal stent skeleton structure; however, a thin, drug-coated layer which has the controlled release characteristic exists on their surface.

Many studies show that reoccurence of stenosis is lower in drug-eluting stents when compared with normal stents. Drug eluting stents have certain advantages especially for thin vessels, longer sick area, fully obstructed vessels and on bifurcation points. Since availability of the drug eluting stent depends on the clinical progress and vessel structure of the patient, it is recommended to discuss this case with your interventional cardiologist. Use of double anticoagulant drug and avoiding discontinuation without consent of the physician are very important for the patients who had drug eluting stent procedure in accordance with suggestions of the cardiologist.

Because cardiac catheterization and interventional procedures are performed without opening the chest and no scar appears, they are not accepted as surgical procedures. The procedure period is quite shorter than the surgery. In some cases, coronary interventional procedure may be advices to the patient depending on the outcomes of the surgical procedure.

In Rhythm Disorder Clinic of Liv Hospital, diagnosis and treatment of cardiac rhythm disorders are planned and executed. For diagnosis of the rhythm disorder, instant ECG record is required; devices called Rhythm Holter are used to record the event. The tilt table testing used to search the cause for dizziness is also performed in Rhythm Disorder Clinic. Moreover, follow-up and pacemaker control of the patients with pacemaker are performed in our clinic.

A Pacemaker Lasting For 8 Years

These are developed technological devices used for heart rate deceleration or intracardiac electric transmission disorder called block. Stimulates the heart and prevent deceleration. It is placed under the skin through local anesthesia. It operates approximately for 8 years. The device should be replaced at the end of this period. Patients with pacemaker are evaluated on regular intervals, generally every 6 months. The pacemaker may be programmed externally by a computer. The battery life and rhythm records obtained by the pacemaker can be observed.

Life is Easier With Novel Pacemakers

The pacemaker is affected from magnetic field and electric parasites. Therefore, there are some issues that the patients with pacemaker should follow. MRI should not be performed and patients with pacemaker should not pass the gates with security screening. Novel pacemakers are not affected by use of cell phones. Use of electric houseware is safe.

Implantable Cardioverter Defibrillator (ICD)

The Implantable Cardioverter Defibrillator is a kind of pacemaker used to prevent sudden death due to a rhythm disorder called ventricular fibrillation. Electric shock is applied if necessary and the life-threatening rhythm disorder is treated. It is generally used for severe heart diseases which have the risk of ventricular fibrillation.

It is an efficient therapy method for the patients who had sudden heart arrest and survived after interventions. It is placed under the skin through local anesthesia. The battery life is shorter than other pacemakers. Electric shock is larger because a higher energy is required.

Pacemaker Therapy for Heart Failure

Heart failure appears when pumping power of the heart decreases. These patients present some findings such as quick exhaustion, shortness of breath, swelling on the feet.  Complaints may not get better even with medical therapy. Quality of life is severely affected. In a significant part of the patients with heart failure, the coordination between heart chambers spoils. Three-cable pacemakers provide the coordination and increases the pumping power; relieve the complaints.  These pacemakers are placed under the skin through local anesthesia. Differently from other pacemakers, mode of operation should be adjusted through special echocardiography techniques.

Electrophysiology and Catheter Ablation

Different types of rhythm disorders cause tachycardia. These disorders originate from electric abnormalities on different areas of the heart.  In general, a tissue which should not exist on the heart is responsible from abnormal electric activity. Like coronary angiography, these tissues are found by inserting the wires called catheter forwarded from femoral vessels to the heart. This procedure is called catheter ablation.

Radiofrequency or cooling system are used to eliminate abnormal tissue.  An electrophysiology device is necessary for catheter ablation. This procedure requires hospitalization for one night for follow-up. It is performed under local anesthesia.  It is performed with an achievement rate of 100% for many rhythm disorders.