Cardiac Care Brochure

8/9/2019 Cardiac Care Brochure

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Gleneagles HospitalMount Elizabeth HospitalParkway Group Healthcare


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Parkway Group HealthcareA Cardiac Care Brochure


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IntroductionScreening ProceduresDiagnostic (non-invasive) ProceduresDiagnostic (invasive) ProceduresInterventional (non-surgical) ProceduresSurgical Procedures

CONTENT


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Introduction

Screening Procedures- Chest X-ray- Cardiac Calcium Scoring- Electrocardiogram (ECG)

Diagnostic (non-invasive) Procedures- Stress Test (exercise or pharmalogical)- Nuclear Perfusion Test (exercise or pharmalogical)- Transthoracic Echocardiography (TTE)- Transoesophageal Echocardiography (TEE)- Holter Monitoring- Ambulatory Blood Pressure

Diagnostic (invasive) Procedures- Coronary Angiogram

Interventional (non-surgical) Procedures- Biventricular Pacemaker

- Percutaneous Transluminal Coronary Angioplasty (PTCA)/Balloon Angioplasty/Stenting- Ablation- Transcatheter Closure of ASD

Surgical Procedures- Coronary Artery Bypass Grafting (CABG)

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Gleneagles Hospitalis established as a leading centre for the care and treatment

of cardiac patients. The highly skilled nursing team, together with the experienceand expertise of the physicians and surgeons, continually advance the standards of

Gleneagles cardiac care.


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Cardiac care is one of the cornerstones ofMount Elizabeth Hospitalssterling

reputation as a leading private healthcare facility of choice. The first open-heartsurgery in private practice in Singapore was performed in Mount Elizabeth. The

Hospital has always maintained her cutting-edge lead in the disciplines of cardiology

and cardiothoracic surgery.


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Coronary Heart Diseases Prevention and Treatment Services

INTRODUCTION


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Coronary heart disease is one of the top killers in Asia and in many developed

countries throughout the world. Parkway Group Healthcare, which owns East Shore,

Gleneagles and Mount Elizabeth hospitals in Singapore, and seven hospitals in

the region, is the largest private healthcare organisation in Asia. It is committed toproviding comprehensive and quality care to the prevention and treatment of coronary

heart diseases.

With more than 30 cardiologists and cardiothoracic surgeons, our depth and breadth

of medical, clinical and surgical experience is focused on giving cardiac patients the

latest treatment options, supported by investment in state-of-the-art technology

and equipment.

With the largest concentration of cardiac specialist physicians under one roof, as well

as qualified and compassionate nursing care, Parkway Group Healthcare is the ideal

choice for patients with cardiac conditions.


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Chest X-rayCardiac CalciumScoringElectrocardiogram(ECG)

SCREENING PROCEDURES


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SCREENING PROCEDURESCHEST X-RAY

Although considered a basic and routine investigation, a simple chest x-ray provides valuable informationon the general condition of the patients heart as well as the thoracic cavity.

The chest x-ray can indicate the size and position of the heart, any gross abnormalities and changes in the

heart size, which can serve as a primary indicator of heart failure or obvious congenital abnormalities.

The lung fields can indicate changes occurring as a result of heart failure such as collections of fluids inaddition to any lung pathology that might be evident.

As a basic screening procedure, the chest x-ray helps a clinician to detect signs indicative of a heartcondition and also serve as a useful guide in pursuing more sophisticated means of investigations to ascertainthe patients health status.

Even if no gross abnormalities are detected, the captured image serves as a very reliable base line, whichcan be archived for future reference.

Chest X-ray


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An ECG is quick, safe andpainless. The process takes

about five to ten minutes.

Cardiac calcium scoringis a test to detect the presenceof calcium deposits in the arteries.If calcium deposits are present,it is an indication of a hardeningof the arteries.


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SCREENING PROCEDURESCARDIAC CALCIUM SCORINGELECTROCARDIOGRAM (ECG)

Electrocardiogram(ECG)

An Electrocardiogram (ECG) is a recording of the hearts electrical activity as a graph or a series of wavelines on a moving strip of paper or video monitor. In this way, one is able to evaluate the hearts rate, rhythmand detect the presence of cardiac problems.

The highly sensitive ECG machine helps to detect various heart irregularities, disease and damage.

An ECG is routinely used when heart disease or damage is suspected in a patient who may be experiencingsymptoms such as angina (chest pain), palpitations, shortness of breath, lightheadedness or lossof consciousness.

How is an ECG performed?

An ECG is quick, safe and painless. It is non-invasive. The patient has to remove his clothes from thewaist up and is then asked to lie down comfortably. The nurse or technician will thoroughly clean a totalof ten areas on the patients chest, arms and legs, over which will be attached ten small metal devices(electrodes). These will be connected by wires to the ECG recorder.

The patient needs to lie still for about one minute while the heart activity is measured and recorded.Each electrode produces a tracing of a particular area of the heart. The entire ECG takes about five toten minutes.

Cardiac calcium scoring is a screening procedureto detect calcium build-up in the coronary arteries.

The test is non-invasive and can be performed inapproximately ten minutes and is completely painless.

Coronary artery calcium is a definite marker for thepresence of artheroscleroris, i.e. the hardening ofthe arteries. The results of this screening test allowsthe physician to make accurate clinical decisions inthe treatment of coronary artery disease, taking intoconsideration the number of calcified vessels, thepatients age, gender, symptoms and risk factors.

The calcium scoring chart ranges from zero to over400. The normal score for any age is ideally zero.The calcium score has greater significance if itexceeds the 75th percentile of the patients age andsex group, or if calciumis detected in more than twoblood vessels.

Cardiac CalciumScoring


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Stress Test (exercise or pharmalogical)Nuclear Perfusion Test (exercise or pharmalogical)Transthoracic Echocardiography (TTE)Transoesophageal Echocardiography (TEE)Holter MonitoringAmbulatory Blood Pressure

DIAGNOSTIC(NON-INVASIVE) PROCEDURES


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DIAGNOSTIC (NON-INVASIVE) PROCEDURESSTRESS TEST

How is an exercise stress test performed?

An exercise stress test requires a patient use a standard treadmill while the ECG electrodes are attachedto the body.

The test requires two phases: the resting phase and the exercise phase.

Duringthe resting phase, the patient lies still while the ECG is taken.

Duringthe exercise phase, the exercise begins at a slow rate and progressively increases his speedand incline, while the patients ECG is recorded periodically, until the patients maximum heart rate isreach when the patient signals discomfort.

Stress Test (Exercise or Pharmalogical)

A stress test is a diagnostic test that allows the physician to understand a patients heart activities both atrest and with exertion.

The stress test can be administered in two ways:

a. through physical exercise,b. through the administration of medications, to simulate the stress, or pharmalogical stress test

All stress tests are performed with ECG electrodes attached to the body to monitor the hearts activity andallows the physician to compare the ECG patterns at rest and during stress.


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Results of a Nuclear Perfusion Scan


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DIAGNOSTIC (NON-INVASIVE) PROCEDURESNUCLEAR PERFUSION TEST

Nuclear Perfusion Scan (Exercise or Pharmalogical)

A nuclear perfusion scan is similar to the stress test, which requires two phases resting and exertion.

The nuclear perfusion scan adds another diagnostic tool for the physician: allowing him to determine theperfusion (blood flow) to the heart muscle. It is similar to the stress test and requires both resting as wellas stress phases. The images are produced by injecting a small amount of radioactive but harmless substance(tracer) into a vein at the peak of exercise.

A second injection of the tracer is injected for the resting phase of the test, and further images will be takenwith the gamma camera. This tracer is detected by the gamma camera as it flows through the blood vesselto the heart muscle. It can show where blood flow has been reduced or restricted.

The physician will compare the results of the hearts activity at resting phase and at exertion phase.

The nuclear perfusiontest measures how theheart is performing at rest

and during exertion, withthe help of radioactiveelements seen througha device called agamma camera.


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Patient undergoing an echo


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DIAGNOSTIC (NON-INVASIVE) PROCEDURESTRANSTHORACIC ECHOCARDIOGRAM (TTE)

Transthoracic Echocardiogram(TTE)

Also known simply as an echo, an echocardiogramis a painless test that uses high-frequency sound waves(ultrasound) to obtain images of the heart and its various structures.

Echocardiograms are used to evaluate the structure and function of the heart, including:

a. Status of the heart valvesb. Status and strength of the heart musclec. Identifying the presence of blood clots or growths within the heart chambersd. Detecting the causes of abnormal heart sounds (murmurs)

Because the test does not involve any of the radiation that an x-ray does, it is a very safe test. The sound

waves bounce back from the various components of the heart, producing images and sounds that can beused by the physician to detect any abnormalities.

How is a TTE performed?

The physician prepares the chest area by applying a conductive, water-soluble gel. A small device, thetransducer is then placed on the patients chest, and this is rotated and positioned at various anglesto obtain images of the heart, which can be seen on a video monitor.

The TTE can be used in conjunction with various forms of stress to detect the presence of coronaryartery disease.

a. an exercise, or stress echocardiogram

b. pharmalogical, or drug-enhanced, stress echocardiogram

There may be cases when a patient cannot perform the exercise necessary to an exercise-basedstress test.

In these instances, the physician can still examine the heart by simulating the effects of stress andexertion by an injection of medication, such as dobutamine. These chemicals stimulate the heart andmimic the effects of vigorous physical activity.

How is a chemical or pharmalogical stress test performed?


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A Holter monitor being attached onto a patient


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DIAGNOSTIC (NON-INVASIVE) PROCEDURESTRANSOESOPHAGEAL ECHOCARDIOGRAM (TEE)

HOLTER MONITORINGAMBULATORY BLOOD PRESSURE MONITORING (ABPM)

Transoesophageal Echocardiogram(TEE)

This is a form of echocardiogram that involves inserting a transducer down the patients throat into theoesophagus (the long tube that connects the throat with the stomach).

Because the oesophagus is located closely behind the heart, clearer images of the heart structures and

valves can be obtained from inside the body instead of the outside.

A Holter monitor is a portable device that continually monitors the electrical activity of an ambulatory (freely-moving) patients heart over a period of time.

The physician will recommend this test most often when it is suspected that the patient experiences abnormalheart rhythm, i.e., arrhythmia, or that the patient experiences times when the heart is not getting enoughoxygen-rich blood, i.e., cardiac ischemia.

Ambulatory Blood Pressure Monitoring (ABPM) is a method of measuring blood pressure readings of apatient over a 24-hour period. A special blood pressure monitor is used, and the patient is asked to keep adiary of his activities during the monitoring period.

Holter Monitoring

How is Holter monitoring performed?

Wires (electrodes) from the Holter monitor are taped to carefully-prepared areas of the patients body.The patient is sent home to go about his daily activities (except bathing and showering) and the patientis asked to keep a diary of his activities and any symptoms he may experience.

Ambulatory Blood Pressure Monitoring


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DIAGNOSTIC (INVASIVE) PROCEDURESCORONARY ANGIOGRAM

Coronary Angiogram

A coronary angiogramis a x-ray procedure to detect the presence of blockages within the coronary arteries.These blockages are usually the result of the progressive build-up of materials within the walls of the bloodvessels that lead to the development of coronary heart disease.

How is a coronary angiogramperformed?

The physician will inject a special dye into thecoronary arteries. A thin tube (catheter) isinserted through a blood vessel, usually in the

upper thigh. This catheter is then carefullymanipulated through the patients main artery(the aorta) until it is positioned at the opening ofthe coronary arteries.

Once the catheter is in place, a special dye isinjected through the catheter and into the arteries.Then the x-ray is taken. X-ray pictures are takenwhile the dye is being injected to obtain images,showing the coronary arteries and the presenceor absence of any blockages within them.

The patient is usually given a mild sedative beforethe procedure but is aware of his surroundingsthroughout the procedure.

A coronary angiogram is the most accurate testin the diagnosis of coronary artery disease.Depending on what the angiogram shows, thephysician will recommend treatments such asmedication, interventional (non-surgical)procedures such as balloon angioplasty, orbypass surgery.


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Biventricular PacemakerPercutaneous Transluminal Coronary Angioplasty (PTCA)/Balloon Angioplasty/StentingAblationTranscatheter Closure of ASD

INTERVENTIONAL(NON-SURGICAL) PROCEDURES


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INTERVENTIONAL (NON-SURGICAL) PROCEDURESBIVENTRICULAR PACEMAKER

A pacemakerregulates the pumpingaction of the heart,when it cannot do soon its own.

Biventricular Pacemaker

In many heart failure patients, the walls of the left ventricle - the hearts main pumping chamber - are nolonger synchronised, or pumping together as they normally would. A biventricular pacemaker is designedto resynchronise the pumping action of the heart.

How is a biventricular pacemaker insertion performed?

After a local anaesthesia is applied, a smallincision is made in the chest wall just above thecollarbone. Another cut is made in the vein justunder the collarbone.

One of the two wires is threaded through thevein and positioned in a vein that drains the leftventricle.

The second wire is threaded through the veinand embedded into the right ventricle.

The wires are secured by tiny screws whichensure that the electrode at the tip of each wireis in direct contact with the inner surface of theheart chamber. The other ends of the wires areconnected to a generator, which is inserted intothe tissue under the collarbone. The incision isthen closed.

The procedure may take one to two hours, andcan be performed as an inpatient or outpatientprocedure.


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Aorta

Left coronaryartery

Partialblockage

Right coronaryartery

The path of the tube

BALLOON WITHDRAWN

BALLOON IN POSITION

Coronary

TubeBalloon

BALLOON INFLATED

Heart

The pathof the tube

Femoral artery

BalloonAngioplasty

Figure 1

Figure 2


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INTERVENTIONAL (NON-SURGICAL) PROCEDURESPERCUTANEOUS TRANSLUMINAL CORONARY ANGIOPLASTY (PTCA)/BALLOON ANGIOPLASTY/STENTING

Percutaneous Transluminal Coronary Angioplasty (PTCA)/

Balloon Angioplasty/Stenting

Balloon angioplasty or Percutaneous Transluminal Coronary Angioplasty (PTCA) is a widely-used techniquefor opening blocked arteries. The procedure flattens the plaque against the artery wall to open a channelthrough which more blood may flow.

Drug-coated stents are coated with very small amounts of various chemicals and medication that helpimprove the way the body reacts to the placement of the stent.

Medicated stents, in particular those coated with an immunosuppressant called sirolimus, limit the amountof scar tissue that can form and improve the stents ability to stay open in the long-term.

How is a PTCA or balloon angioplasty performed?

The patient will be fast overnight for theprocedure.

Before the procedure, intravenous (IV) access

is obtained to allow drugs to be administered tothe patient.

A guiding catheter is then inserted, usuallythrough the groin, and through which the devicesused in the angioplasty procedure are placed.(see Figure 1)

Once the physician has located the blockage, aguide wire is advanced down the artery andacross the blockage. The smaller balloon-tippedcatheter is then threaded across the wire until itis positioned across the blockage, where it isthen inflated for one to three minutes. After

deflation of the balloon, the process can berepeated at other areas. (see Figure 2)

Another procedure known as coronary stentingoften accompanies balloon angioplasty. The stentis a small wire-mesh tube delivered to the arterymounted as a balloon-tipped catheter and

provides a stronger, reinforced framework at thesite of the blockage. Stents help to keep the arteryopen and reduces the changes that the blockagemight recur (restenosis).

The balloon is inflated, deflated and removed,leaving behind the stent to reinforce theartery wall.

Balloon angioplasty is a relatively quickprocedure, taking one or two hours. The patientis usually kept under observation and monitoredfor one to two nights.

Drug-coated stents


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When the heart is not beatingin a smooth regular rhythm,the irregular heartbeats are calledarrhythmia. This condition canbe dangerous.


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INTERVENTIONAL (NON-SURGICAL) PROCEDURESABLATION

TRANSCATHETER CLOSURE OF ASD

Ablation

When the heart is not beating in a regular rhythm, the irregular heartbeats are called arrhythmia. When theheart is beating very rapidly, this type of arrhythmia is known as tachycardia. Some forms of tachycardiamay be due to an abnormal collection of conduction fibres within the heart. There are types of tachycardiathat may be treated by a procedure called ablation.

Atrial Septal Defect, or ASD, is a congenital anomaly of the heart. It is a condition commonly known ashole-in-the-heart. It refers to a hole between two upper chambers of the heart, the atria. If left untreated,ASD may affect the lungs. Those who suffer fromthe condition tend to tire easily, have poor effort toleranceor even heart failure. They may also experience irregular heartbeat.

This is an occlusive device to treat ASD, as a viable alternative to traditional open-heart surgery. ParkwayGroup Healthcare is the first in Singapore to perform the transtheter closure of ASD in adults using theAmplatzer Septal Occluder.

How is ablation performed?

There are two ways that ablation can be done: non-surgical and surgical.

The non-surgical method uses radiofrequency energy to eliminate the abnormal conduction pathways.

At the tip of the tube is a small wire, which delivers radiofrequency energy to burn away the abnormalareas of the heart, allowing the heart to beat normally again.

In surgery, there are three ways that ablation can be performed:

a. The Maze procedure is where the surgeon makes small cuts in the heart to re-direct healthyelectrical rhythms

b. Cryoablation is where a very cold substance is introduced to freeze the cells that are creating theproblems so that these cells cannot function anymore

c. Endocardial resection is when the surgeon removes a section of the thin layer of the heart wherethe abnormal rhythms come from

Transcatheter Closure of Atrial Septal Defect (ASD) in Adults

How is it performed?

What is the Amplatzer Septal Occluder?

During the procedure, a folded occluder is delivered through a catheter to plug the hole in the heart.First performed on children in Singapore in 1997, the method has been used to correct ASD successfullyin adults as well the following year.

It can be performed in about two hours with excellent results.


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Coronary Artery Bypass Grafting (CABG)

SURGICAL PROCEDURES


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SURGICAL PROCEDURESCORONARY ARTERY BYPASS GRAFTING (CABG)

Coronary Artery Bypass Grafting (CABG)

Coronary Artery Bypass Grafting (CABG) or often simply known as bypass surgery is the surgical methodof treating coronary artery disease. The aim here is not to repair or remove blocked arteries butto create a detour around the blockage: in other words, to bypass the blockage since the normal routehas been blocked. Depending on how many arteries are blocked, one, two or more bypasses may be created

at surgery.

During surgery, the surgeon takes a segment of healthy blood vessel (vein or artery) from another part ofthe body and uses it as the new bypass channel.

With todays expertise and technology, bypass surgery carries very little risks. Hospitals performing largenumbers of open-heart operations have risks of death of about 1 to 2%. Risks may vary frompatient to patientdepending on factors such as old age, long-standing diabetes, previous heart attacks and strokes, kidneyfailure etc. Patients who are unsure of their own risks, are advised to discuss this with their doctors.Whatever the risk, however, they may be worth taking considering the fact that CABG significantly improvesand lengthens the quality of the patients life.


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Bypass or open heart surgery


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SURGICAL PROCEDURESCORONARY ARTERY BYPASS GRAFTING (CABG)

How is a bypass surgery performed?

Surgery is performed under a generalanaesthetic; hence the patient will not be awareof the procedure.

When the patient arrives in the operating theatre,

he will already be sedated so that he will berelaxed and calm. The anaesthetist will insertseveral needle-sized tubes into the vein underlocal anaesthesia. Once these are in, the patientwill be anaesthetised.

The patient will then be connected to a ventilatorvia a tube inserted through the mouth or noseinto the windpipe.

An incision is made down the middle of the frontof the chest. Through this incision, the heart willbe exposed for connection to the heart lungmachine. While this is going on, another team

will be harvesting the patients veins from his

legs or arteries from the arm, to use as bypasschannels.

Once both teams are ready, the patients heartwill be stopped and the function of the heart and

lung will be taken over the heart-lung machine.

The harvested blood vessels will then be sewnin such a way that one end is connected to theaorta (the large artery arising from the heart)while the other rend is connected to the coronaryartery below the level of blockage.

On completion of this part of the operation, thepatients heart will be made to resume its function.When the surgeon is satisfied that the heart isbeating normally, the patient will be disconnectedfrom the heart-lung machine and the surgerycompleted. The patient will then be taken to the

Intensive Care Unit (ICU) for monitoring.

Patients are normally monitored and managed in the ICU for one to two days. On the second day aftersurgery, patient will be transferred back to an ordinary ward for recuperation. In the ward, they will betaught how to breathe effectively and to gain confidence in their recovery process.

Most patients will be discharged fromhospital in about a week and be ready to return to work in approximatelysix weeks to three months.

Recovery


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GLENEAGLESHOSPITAL

NassimHill

Napier Road

Middlesex Road

British HighCommission

BritishCouncil

TanglinPost Office

Embassy ofthe United States

of AmericaAustralianHigh Commission

BotanicGardens

MOUNTELIZABETHHOSPITAL

Ngee Ann City

Wisma AtriaShopping Centre

Lucky Plaza

Marriott Hotel

Nutmeg Road

MountElizabeth

Road

J ln Elok

TongBuilding

TheParagon

Crown PrinceHotel

Orchard Road

Taman Serasi

Cluny Road

MountElizabeth

Link

Bideford Road

WHERE WE ARE

Map not drawn to scale.


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Medical Referral Centre Hotline: (65) 6735 5000 (Local Toll Free)e-mail: [email protected]

Website: www.parkwaygrouphealthcare.com

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