Currently, a number of heart diseases can be accurately diagnosed by echocardiographic examination or other non-invasive imaging methods. However, if surgical or interventional treatment is necessary, it is usually necessary to perform a heart catheterization examination. It means inserting special catheters through a vein or artery into the heart. These catheters can be used to measure blood pressure, oxygen concentration, temperature, blood flow velocity in individual heart compartments, they can be used to stimulate heart action and measure the speed of propagation of electrical impulses through the heart. Individual heart sections or blood vessels can be filled with contrast material using catheters and then visualized with an X-ray machine. The choice of catheters and examination procedure depends on the type of heart or lung disease. The arteries and veins on the wrist are most often used as access vessels. The veins can also be entered by an injection in the groin or neck.

Types of catheterization examinations

The most common type of catheterization examination is coronary angiography. The aim is to determine the extent of atherosclerotic involvement of the coronary arteries in patients with ischemic heart disease or in patients with heart defects. It makes it possible to decide on the optimal method of treatment, i.e. whether it is necessary to operate the heart, whether it is possible to treat with catheterization or whether it is necessary to proceed conservatively with drugs. In patients with heart defects, a so-called large catheterization is sometimes performed in addition, in case the conclusions of the echocardiographic examination are not clear, or there is a contradiction between the result of the echocardiographic examination and the degree of the patient's difficulties. In many cases, the catheterization examination is immediately followed by interventional treatment, when with the help of catheters we are able to remove the heart problem, or to completely or partially cure the patient. This is mainly coronary angioplasty (see below), but we are also able to close a heart septal defect or expand a narrowed heart valve.

Coronary angiography

Coronary angiography is an X-ray examination in which the doctor uses catheters (thin hollow tubes) to inject an X-ray contrast agent into the coronary arteries.
The X-ray images are stored in digital form, which the doctor can later show to, for example, a cardiac surgeon, in order to get advice on which other treatment method is most suitable for the patient. Coronary arteries are usually shown in several projections. Therefore, part of the X-ray machine moves around the patient during the procedure. Imaging in multiple projections is important so that no significant narrowing of the coronary arteries can be missed. Based on this examination, doctors can see exactly all affected areas and can determine their severity. By obtaining this information, they can then make a better decision about the best course of treatment for a particular patient.

Performing coronary angiography

Coronary angiography is performed in the so-called catheterization laboratory. The main part of this laboratory is an angioline - a special X-ray machine. During the examination, the patient is fully conscious and cooperates with the doctor the entire time. He is in the supine position, covered with sterile drapes. The doctor will begin the examination by applying local anesthesia to the injection site. This is most often the patient's groin. However, the manual approach is increasingly used. To ensure that everything is done in a completely sterile environment, it is important to shave the injection area well. As a rule, the patient does it himself, possibly with the help of a nurse the evening before the procedure. When the injection site is already numb, the doctor punctures the femoral artery with a thin needle. He introduces a special thin and soft wire with a needle, through which he then introduces the catheter itself, which is a plastic thin and soft tube made of a special material.

PTCA

• Percutaneous
  • this word indicates that this procedure is performed by an injection through the skin
• Transluminal
  • indicates that the doctor is working inside the vessel
• Coronary (English Coronary)
  • says that this procedure involves the coronary arteries
• Angioplasty
  • is a technique that can be used to expand (dilate) narrowed or closed blood vessels

The basic idea of PTCA is to place a small inflatable balloon in the narrowed area of the coronary artery. The inflatable balloon pushes the sclerotic plaques against the coronary artery wall, allowing the narrowed area to widen.

Course of PTCA

PTCA is a non-surgical procedure performed under X-ray control in a catheterization laboratory. Similar to coronary angiography, a special thin-walled plastic catheter is introduced through the wrist artery to the mouth of the coronary artery. Another special catheter equipped with a balloon is then introduced inside this catheter. The doctor who performs the procedure repeatedly checks the position of the balloon using a contrast agent. Similar to coronary angiography, the patient may be repeatedly asked to inhale and hold their breath for a while during the procedure. This is so that the movie recording is of good quality.

When the doctor places the balloon precisely in the center of the narrowest point in the artery, he inflates it. During the inflation period, the general condition of the patient, including blood pressure and pulse, is monitored very carefully. It is possible that a typical tight pain behind the sternum will appear during the inflation period. During inflation, the sclerotic plaques are pushed against the wall of the coronary artery and thus the inner lumen of the vessel is expanded. At the end of the procedure, the doctor checks again by applying a contrast agent whether he succeeded in dilating the affected blood vessel. Depending on the result, a decision is made on the eventual repetition of the balloon inflation or the possible introduction of a "stent" - a tiny spring that keeps the blood vessel expanded.

At the end of the procedure, the short introducer tube inserted into the artery on the wrist is immediately pulled out and a "bracelet" with an inflatable cuff is placed on the wrist, which compresses the injection site for 4 hours.

After performing PTCA

After the procedure, the patient returns to the room or to the intensive care unit, where his general condition is closely monitored by the nursing team. If the wrist is used to introduce the catheter, the patient can get out of bed after 12 hours. If an arm has been used, it must usually remain in bed for 24 hours after the last catheter is withdrawn. If the patient feels moisture, heat or cutting pain at the injection site, he should immediately notify the nurse. Although it is very rare, delayed bleeding from the injection site may occur.

Throughout the day, and especially the first hours after the procedure, it is good if the patient presses his fingers on this place when straining the groin (sneezing, coughing). On the day of PTCA, the patient should drink more fluids than usual so that the contrast material can be easily flushed out of the body through the kidneys. After PTCA, chest discomfort is common for 1-2 hours after the procedure. If the heart pain increases or returns, the patient must notify the nursing staff. About 24 hours after the catheter is removed, the patient is usually encouraged to start walking. However, the nurse should help him leave the bed for the first time.

Release home

After a successful PTCA, the patient usually goes home within 3-4 days. He should be transported home by ambulance or car by relatives. He definitely shouldn't be driving the car alone. But before he goes home, he should check with his attending physician about his diet, physical activity and other medication use, or when he can return to work. Because the drugs will continue to be an important part of the treatment, the patient must go home safe with these drugs. Medicines will help to prevent the formation of a clot in the dilated blood vessel, as well as the spasm (convulsion) of the coronary arteries. The doctor should also tell the patient the date of the next check-up.

Stent

A stent is a spring made of noble metals. Using a dilating PTCA balloon, it is introduced into the narrowing of the coronary artery. Here, when the balloon is inflated, this spring is expanded and pressed into the vessel wall. After the balloon is deflated, the balloon is pulled out of the artery, but the stent remains in the artery wall permanently. Within 4 weeks it is covered with a vascular lining. Thanks to stents, acute problems arising during PTCA can be successfully solved and the incidence of serious complications after PTCA can be significantly reduced. The stent enables a better final effect of procedures on the coronary arteries. The introduction of stents significantly reduced the incidence of restenosis.

The biggest danger of stent implantation is blockage by a blood clot in the first month after the procedure. Fortunately, it currently occurs in less than 1% of cases. In the event of severe chest pain in the first two weeks after the procedure, it is therefore necessary to seek an internal or cardiology examination immediately. To reduce the risk of this serious complication, it is necessary to take antiplatelet drugs for the recommended time. Two drugs are usually used 6-12 months after the operation, one (most often Anopyrin) then for life.

Outpatient examination of arteries on the heart

Catheterization examination of the coronary arteries can also be performed in the so-called stationary mode. The patient comes to the procedure on the day of the examination in the morning, on an empty stomach, when he only takes his regular medication in the morning. The examination is performed as described above in the catheterization room through the wrist. After the procedure, the patient remains in the clinic sitting in a chair for 4-5 hours and is then discharged home. It is necessary to be taken from the hospital by an accompanying person. On the day of the procedure, it is necessary to spare the hand through which the procedure was performed, and not to do heavy work with this hand for a week after the examination.

This type of short hospitalization is not suitable for patients who are taking blood-thinning drugs (Warfarin, Pradaxa, Xarelto, Eliquis) and for patients after heart bypass surgery.

Catheter replacement (non-surgical insertion) of the aortic valve (TAVI — from the English Transcatheter Aortic Valve Implantation) is intended for patients with shortness of breath, chest pains or syncope (sudden loss of consciousness), which are caused by severe narrowing (stenosis) of the aortic valve (the valve between the left heart chamber) and the aorta – the main vessel that carries blood from the left heart chamber to the body). As a result, this leads to overloading of the heart, the emergence of the aforementioned difficulties and also to a significant worsening of the life prognosis (expected life expectancy) of the affected. Until now, the standard treatment has been and is heart surgery with the opening of the chest and the use of extracorporeal circulation, during which the degenerated valve is removed and replaced with an artificial valve. For patients in whom this surgical solution was impossible or carried a disproportionate risk, drug treatment remained the only option, but it is not very effective and does not lead to a significant change in the unfavorable prognosis of these patients.

Technological progress in recent years has led to the development of an artificial valve that can be implanted in place of a degenerated aortic valve using catheterization techniques (techniques using thin tubes inserted into the heart - so-called catheters). These techniques make it possible to insert (implant) an artificial valve without opening the chest and using extracorporeal circulation, and are therefore gentler for the patient than classic surgery. They therefore allow replacement of the aortic valve even in patients for whom the operation would be very risky, either because of associated diseases, old age, or an overall unfavorable condition. Considering that this is a recently developed method, the long-term effectiveness of which has not yet been fully verified, this procedure is intended for the time being only for patients with a high risk or infeasibility of standard surgical treatment. However, the results so far show that it is at least as safe for these patients as classical surgical treatment, while at the same time less demanding for the patient in terms of the postoperative course and with significantly faster recovery and return to normal life. According to current findings, the effect on improving difficulties and reducing heart load is comparable to standard surgical valve replacement.

Performance progress

The performance is basically performed using the same techniques as other catheterization examinations of the heart, i.e. with the help of catheters introduced through the arterial and venous channels into the heart under X-ray control. However, it requires access from at least two arteries and the catheters for its implementation are larger than those commonly used. It is therefore performed under general anesthesia (sleep) with artificial ventilation (artificial respiration) or with the use of drugs that remove pain and reduce perception (so-called analgosedation). Even before the insertion of the artificial valve, the narrowed own valve is expanded with a balloon so that the artificial valve can be inserted more easily. The balloon is then withdrawn and a long sheath is inserted into the area of the aortic valve along the wire, in which the artificial valve is folded. This valve is placed under X-ray control exactly in the place of the original aortic valve. The valve is either made of a material that automatically takes the desired shape after it is released from the case (a metal with shape memory, called Nitinol), or it is folded on another balloon, which is inflated and fixed at the destination. The case in which the valve was folded is then withdrawn and measurements and imaging are performed to verify its correct function. Subsequently, the points of entry into the arterial bed are treated. After the procedure, the patient is monitored for approximately 2-4 days in the intensive care unit, and in the case of an uncomplicated course, he can be discharged to home treatment after 5-7 days.

In some patients with significant involvement of the femoral arteries, it is necessary to insert a larger sheath after surgical preparation (opening) of the artery from an incision in the groin under direct visual control. In patients whose femoral or pelvic arteries are so severely affected that insertion of a large sheath is not possible, the procedure can be performed through the subclavian artery or through a small incision on the right side of the chest. Also in this case, surgical preparation of the access site is necessary. For these patients, the hospital stay is somewhat extended until the surgical wound heals.

In adulthood, the heart is divided into 4 compartments: the right and left atria and the right and left ventricles. Atria and ventricles are physiologically separated from each other by an impermeable septum (the so-called septum). In a healthy adult, deoxygenated blood flows from the body (more precisely, from the organs) into the right atrium, then into the right ventricle and lungs, where it is oxygenated. The oxygenated blood then returns through the left atrium and ventricle to all organs. Under normal circumstances, there is no mixing of oxygenated and non-oxygenated blood through the flow between the atria or chambers, and this ensures the efficient transport of oxygen to the organs. Under certain circumstances, most often on the basis of a congenital disorder, the communication between the atria can be preserved (so-called defect). Abnormal communication through this membrane then occurs. The defect can have different forms, size and clinical significance. It is most accurately diagnosed using an echocardiographic examination (ultrasound examination). In some cases, the defect needs to be closed.

When is it appropriate to close the atrial septal defect?

Closure of the atrial septal defect is recommended to the patient if there is evidence of systemic (e.g. to the brain) embolization (confirmed by neurological examination and brain CT) with suspected or found inter-atrial communication. In order for the defect to be closed, other conditions must be met, which are determined by a detailed cardiology examination (size, effect on blood flow and character). A specially trained team of doctors participates in the indication for a performance of this nature.

What are the options for closing the atrial septal defect?

1. Surgical patch - operation under general anesthesia on an open heart using extracorporeal circulation. This is a highly invasive procedure. It requires at least one week of hospitalization and approximately 3 to 4 weeks of rehabilitation.
2. Catheter closure of the atrial septal defect – a minimally invasive approach, with a single injection into the inguinal vein – is more advantageous for less invasiveness (3 to 4 days of hospitalization) and early recovery. A special closing system, the so-called Amplatzer occluder, is used, which is made especially for this procedure. It consists of 2 discs (umbrellas) with which the defect is closed. It is made of a metal called Nitinol (a metal with shape memory, well adaptable in the body), which is covered by the body's own tissue within 3 months and thus becomes an integral part of the atrial septum. Due to the nature of the procedure, the catheter closure is only suitable for certain types of defects.

Amplatzer occluder implantation procedure

The patient is most often admitted to the hospital one day before the actual procedure (checking of laboratory tests, patient's condition - reduction of complications, or the possibility of additional detailed examinations). No special preparation is needed. On the day of the procedure, the patient is fasting (from midnight). A thin plastic intravenous cannula is inserted into a vein in his arm, which is used to administer drugs and infusions before, during and after the procedure. The procedure itself is performed in the catheterization room under light analgosedation and under sterile conditions. Everything is managed by an experienced team of doctors and nurses. The duration of the performance is around 20 to 40 minutes.

After arriving at the catheterization room, the nurse places the patient on a movable bed under the X-ray machine. The inguinal vein (90% right) is used to access the venous system. First, local anesthesia is performed in the groin area. Then, an injection is made into the access inguinal vein with a stronger needle and a stronger plastic tube (the so-called introducer or sheath) is inserted into the vein. Through this introducer, a special system is subsequently introduced into the right atrium and then through the defect into the left atrium (the introduction is not painful, the inner part of the blood vessels and the inner part of the heart do not have nerves, and therefore the passage of the system is not perceived by the patient). Finally, the coiled Amplatzer occluder is introduced through the whole system into the left atrium, where it is opened - first the disc for the left atrium is unfolded, and then the catheter is retracted a little into the right atrium and the second disc is unfolded (the atrial septum is caught between the discs). Finally, the complete disconnection of both disks is carried out, which allows us to definitively connect both disks to each other. Both the X-ray method and esophageal echocardiography are used to check the exact positioning of the occluder.

After the procedure, the patient is transferred back to the bed in the ward, the sheath is removed from the groin here in about 3 to 6 hours, after the anticoagulant drugs administered in the catheterization room have worn off. Removal of the introducer is performed by a doctor. After pulling out the introducer, the injection site is first firmly pressed for 15 minutes to prevent bleeding (so-called compression). Subsequently, bed rest with an outstretched limb and compression at the injection site is necessary for about 4 to 8 hours. Ending bed rest is only possible after the groin has been checked by a doctor. All these measures are necessary to prevent complications at the injection site (primarily bleeding).

What is the next procedure after occluder implantation?

In the case of an uncomplicated procedure, the patient can go home the next day after implantation of the Amplatzer occluder (total hospitalization time is 3 to 4 days in an uncomplicated procedure). Uncomplicated closure of the atrial septal defect does not result in limitations in the usual way of life or a change in work ability or competence. After the procedure in the following week, we recommend not putting too much stress on the limb in question (the limb on which the occluder system was introduced) - heavy physical load should be avoided, especially lifting heavy loads or other static exertion and rapid bending of the limb (cycling, swimming). If the groin is fine, the patient is fully included in normal life.

Is additional special therapy necessary?

After the introduction of the Amplatzer occluder, it is necessary to take two "blood thinning" drugs (so-called dual antiplatelet therapy) as therapy for 3 months — anopyrin (trade name e.g. Godasal, Anopyrin, Stacyl) and clopidogrel (trade name e.g. Trombex, Clopidogrel, Plavocorin ). After that, anopyrin alone is administered long-term. The therapy aims to prevent the formation of blood clots on the occluder. This risk decreases after the occluder is covered by the inner lining of the heart (endothelium), which corresponds to the recommended period of use (3 months). Due to the nature of the effect of the combined treatment in the first 3 months, it is not advisable to plan any procedure or surgery for this period due to the increased risk of bleeding in the given period.

Is further monitoring necessary at our workplace?

As a standard, 3 months after the implantation of the occluder, we perform an esophageal echocardiographic examination to evaluate the effect of the procedure. The patient will be given the date of this check-up upon discharge from hospital, including a telephone connection in case of any questions from the parties regarding this issue. If the finding is favorable, further monitoring at the place of residence is possible.

Angiography is an examination of the arteries with a contrast agent injected into the artery through an inserted catheter. Arteries are blood vessels in the body that carry blood away from the heart. Arteries can be affected by a number of diseases, and due to the fact that they are inaccessible to the human eye, angiographic examination plays a significant role in the diagnosis and treatment of their diseases. Using this method, the doctor can examine the arteries both in the limbs and in other organs (e.g. the brain, kidneys, lungs and elsewhere).

When is an angiographic examination indicated?

The examination is indicated by a doctor who is fully familiar with the issue of vascular diseases. This doctor should use all available non-invasive examination methods to determine the degree of involvement of the patient's vascular bed. If the disease cannot be treated conservatively, an angiographic examination is recommended. Most often, it is a so-called ischemic disease of the limbs (narrowing or blockage of the arteries supplying the limbs), damage to the arteries supplying the brain, kidneys, intestines, examination of the deep venous system. In addition, vascular malformations are often examined, e.g. aneurysm (bag-like enlargement of an artery) or venous-arterial shunt. Carriers of vascular malformations are particularly at risk of bleeding.

Is it necessary to worry about the examination?

The examination is carried out during short-term hospitalization. Before the examination, it is necessary not to eat or smoke for at least 6 hours, then to limit fluids up to 3 hours before the procedure, before that it is advisable to take them in larger quantities. Before the angiographic examination, it is also necessary to carry out basic tests evaluating blood clotting parameters. If the patient is taking medications that reduce blood clotting (Warfarin or new anticoagulants - Eliquis, Lixiana, Pradaxa, Xarelto), these must be temporarily discontinued. If these principles are not followed, there is a higher risk of bleeding at the site of the injection into the artery. The last necessity before angiography is to shave the hair in the area of both groins, which are the most common access route to perform the examination. Shaving is performed by medical staff at the hospital.

Before the examination, you will be given a medicine to thin the blood. If you have already experienced an allergic reaction (it is important to report all experienced allergic reactions to the attending physician, especially in connection with the administration of contrast agents), you will be given medication to reduce the risk of another allergic reaction.

What is the course of the examination, medical procedure?

The examination is carried out in the angiography room. In front of him, the patient puts down all his clothes, including underwear, possibly even jewelry and dentures. During the examination, he usually lies on his back. The nurse will disinfect the place where the vein will be inserted (usually the groin). Next, he covers the patient with sterile drapes. The doctor will then numb the injection site. The examination is usually painless. After applying local anesthesia, the doctor inserts a catheter into the artery, which will be used to examine the vascular bed. The application of the contrast material through the coil can be accompanied by a feeling of perceived warmth of varying intensity. During the entire examination, the doctor is in contact with the patient, who gives instructions on when to hold the breath, how and when to change position, etc. In case of difficulties or if the patient has questions, he can contact the examining staff at any time.

Based on the result of the angiographic examination, the doctor informs the patient about treatment options. If he suggests a conservative or surgical procedure, then at this point the examination will end, the doctor will withdraw the catheter from the groin, and then there will be careful manual compression of the groin until the bleeding from the artery stops.

A bandage and a sandbag are then placed on the injection site for several hours. You can usually get out of bed after 8 to 24 hours, unless your doctor tells you otherwise. With the development of modern instrumentation, special devices are now being used more and more often, with which the examining doctor can tape or sew the examined area. The period of rest in bed is then significantly shorter. The examining doctor will inform you about the use of this method at the end of the procedure. If the course is uncomplicated, you can eat and drink after the examination. Your attending physician will inform you of the progress of the examination and will guide your further treatment accordingly.

As part of the angiographic examination, the doctor can propose a treatment procedure that he will carry out immediately. It is mostly a so-called percutaneous transluminal angioplasty (PTA – dilation of an artery with a balloon) with the possible introduction of a metal reinforcement (a so-called stent). Sometimes it is necessary to perform the procedure later due to the need for another arterial access. If the procedure is to follow immediately, the doctor will insert a wire into the groin, with which he will insert a catheter with a balloon into the narrowed area, which expands the narrowed area, or reinforces the affected area with a metal reinforcement (stent). In this case, during the examination, you will be given medication to prevent blood clotting at the site of the placed stent. The procedure is followed by the same procedure and rest regime as after simple angiography. The medical staff will measure your blood pressure and pulse at regular intervals and check the injection site. If you notice any abnormality from your normal state of health or have any other physical discomfort, report it to the nursing staff immediately.

A pacemaker is a device that is usually introduced into the human body when the heart rate slows down significantly, or when the generation or conduction of the heart's own impulses ceases (i.e. in the case of bradyarrhythmia). A cardioverter-defibrillator is a device that is implanted to interrupt life-threatening arrhythmias, when the heart beats too fast and stops pumping blood (tachyarrhythmias). Some devices are also designed to stimulate both chambers of the heart to improve their pumping function in cases of heart failure. The entire introduced system is a system of its own "alarm clock" and electrodes that connect the device to the heart.

The actual insertion is performed in the operating room under local anesthesia, after which a small skin incision is made under the collarbone on the left or right side and then a pocket is dissected to place the device in the subcutaneous tissue. Access to the venous bed is then ensured by pricking the subclavian vein with a needle (approximately the same mechanism as when taking blood), through which one or more special introducers are introduced, introducing one or more electrodes (depending on the type of arrhythmia) into the vascular system and further into the heart. Electrodes are inserted under X-ray control. One electrode is usually inserted into the right ventricle and the other into the right atrium. When implanting a cardioverter-defibrillator, the introduced electrode is stronger. In some cases, for example, when the contraction of both heart chambers is out of sync, an additional stimulation electrode is inserted into one of the veins that bring blood to the right atrium from the rest of the heart. Because these veins run along the surface of the left ventricle, simultaneous stimulation of the left and right ventricles is achieved. A special long sheath is used to probe these veins and then inject a contrast material (angiography) to visualize them. After introducing the electrodes and measuring their electrical parameters, a pacemaker or cardioverter-defibrillator is connected to them, placed in the created pocket, and the wound is sutured and covered with a sterile bandage. This concludes the performance. In the case of implantation of a cardioverter-defibrillator, it is usually necessary to test at the end of the procedure whether the device can interrupt the most serious arrhythmia - ventricular fibrillation. During a short general anesthesia, ventricular fibrillation is induced, which is interrupted by a discharge from the device. After the procedure, the patient remains hospitalized, as bed rest (typically 24 hours) is very important to ensure proper healing of the electrodes and prevention of their loosening. The position of the electrodes is further checked with a classic X-ray image.

Stitches after the insertion of the device are removed ten days after the introduction of the pacemaker/defibrillator in the cardiostimulation clinic (building II. internal clinic, entrance A12B, 1st floor at the end of the corridor). Patients continue to be monitored in special cardiostimulation clinics II. VFN internal clinics. During the first inspection, the device is thoroughly adjusted with regard to the individual needs of the patient.

After the internal battery is exhausted, the device must be replaced. If it is not necessary to replace the established electrode or add another electrode, which is usually not necessary, then it is only a simple outpatient procedure.

Patients are placed on a waiting list when the procedure is indicated (by the attending cardiologist at the place of residence, internist, doctor in the arrhythmia clinic). The exact date of the procedure along with specific instructions are then communicated to the patient by phone or e-mail approximately three weeks before starting hospitalization. This system was introduced with regard to long waiting times and the need to guarantee flexibility when referring acute patients or during extraordinary events.

The waiting period for individual procedures depends on both the type of procedure and the acuteness of the patient's condition. In the case of indications for lighter performances, performance can be expected in 2 to 3 months. When indicated for catheter ablation of atrial fibrillation and some other more complex procedures, the waiting time varies between 3 and 6 months.

What do the terms electrophysiological examination and catheter ablation of arrhythmias mean and who are these procedures intended for?

Electrophysiological examination and catheter ablation are intended for patients with certain heart rhythm disorders (arrhythmias). The term electrophysiological examination refers to establishing a diagnosis, the mechanism of the occurrence of arrhythmia, and determining its dangerousness. Catheter ablation is a procedure in which, with the help of radiofrequency energy, the places in the heart responsible for the occurrence and maintenance of arrhythmia are affected - this is a medical procedure. Catheterization ablation is indicated for patients with documented, significant arrhythmia that can be treated by this method. On the other hand, patients who have not yet been proven to have an arrhythmia, but there is a significant clinical suspicion of its presence, can be sent for an electrophysiological examination, especially if there is a fear that it is dangerous for the patient.

Difficulties that are suspected of having an arrhythmia and which, even without documentation of an arrhythmia, may lead to an indication for an examination, are primarily some short-term disturbances of consciousness or feelings of fainting. Other, less significant difficulties are the perception of fast heartbeat, slow heartbeat or irregular heart activity. In the case of the most frequently treated arrhythmia - atrial fibrillation - the diagnosis and likely procedure are known practically from the beginning. For other arrhythmias, the basic step before ablation is to first determine the exact type of arrhythmia by examination, the mechanism of its occurrence and the degree of its danger to the patient. Based on such an examination, further treatment is determined, including catheter ablation.

Preparation for examination

The referring physician should always provide accurate information about the preparation before the examination. The information is repeated by the income coordinator at the moment of determining the exact performance date. In general, a few principles can be stated: Previously, before the examination, blood thinners - anticoagulant therapy - were discontinued for all patients. This strategy has undergone significant changes. At the present time, it is not necessary to interrupt Warfarin therapy if purely intravenous access is assumed. On the other hand, for some procedures, it is desirable not to interrupt anticoagulation with Warfarin. The optimal INR (Quick) on the day of the procedure is 2-2.5. If you are going to have a procedure with uninterrupted Warfarin therapy, then it is advisable to perform the INR one week before entering the hospital. If the INR is below 2.5, then the dose of the drug is not changed. If it is above 2.5, it is advisable to slightly reduce the dose, but not stop it. Sufficient experience with new drugs during procedures is not yet available (refers to preparations: Pradaxa, Xarelto, Eliquis, Lixiana). However, we only plant these substances ourselves on the day of the performance. In general, we advise the patient to take his usual dose in the morning on the day of admission (we assume the procedure the next day). There is no need to stop taking Anopyrin (Godasal, Stacyl), antihypertensive drugs and most cardiac drugs. Medicines introduced with the aim of suppressing the occurrence of arrhythmia, on the other hand, should be discontinued before the procedure according to the doctor's instructions.

It is not suitable to perform procedures during another acute illness or during an acute worsening of a chronic illness. In case of ambiguities, it is advisable to inform yourself by telephone about the suitability of postponing the performance before the start date. The telephone contact for income coordinator L. Spěváčková is 22496 3249. The contact for the Antiarrhythmic Unit, where patients are hospitalized, is 22496 2603. It is also not advisable to perform examinations on women during menstrual bleeding. Pregnancy is a contraindication to the procedure.

Before the actual examination, the patient must be on an empty stomach - optimally he does not eat or drink from midnight before the procedure planned for the morning. A light breakfast is allowed if the performance is in the afternoon. The places where the catheters enter need to be shaved - this is only done in the inpatient department. No other preparation is necessary. If the patient takes some less common medicines, it is advisable to take them with him to the hospital. For some procedures, an esophageal echo or CT heart is performed on the day of admission - then it is necessary to arrive on an empty stomach. Specific information is given to patients when the appointment is confirmed.

Performance progress

We perform the examination and treatment of arrhythmia with catheter ablation during a short stay in the hospital. There are a variety of rhythm disorders, so the procedure is different for each patient. Some parts of the procedure are the same for all arrhythmias, others are different. Admission to the hospital is usually set for the day before the procedure, when the patient is examined by a doctor and laboratory tests are performed. Before the examination itself, a short preparation is necessary. On the day of the examination, the patient must be fasting. Sometimes it is necessary to interrupt the administration of some drugs before the procedure, on the contrary, we leave other drugs unchanged (see below). During the procedure itself, the patient lies on a movable examination table in a supine position. Physical rest of the patient is necessary. The entire procedure is performed under local anesthesia, or in mild attenuation. The principle of the examination is the sensing of signals from the inside of the heart, where so-called catheters are placed. Recording of an ordinary EKG is based on the same principle, but the sensing electrodes are placed on the surface of the body. Catheters emit energy that is able to burn the area responsible for the development of the arrhythmia and thereby neutralize the rhythm disorder. One catheter can be inserted, more often it is necessary to insert several catheters. Catheters access the heart via the vascular system: most often through veins, but sometimes it is also necessary to use arterial access. Catheters are most often inserted into the vessels in the right groin area, but it is not an exception to introduce catheters via the left groin or veins located in the neck. The choice of catheter access to the heart is up to the doctor and depends mainly on the type of arrhythmia and the location from which the arrhythmia originates. The inserted catheters are then placed by the doctor in defined positions in the heart cavity, which is directly checked by X-ray.

For more complex examinations, the position of the catheter is also controlled using three-dimensional so-called electroanatomical mapping systems. The heart is then examined in several ways. On the one hand, the so-called transmission intervals of the electrical impulse between individual parts of the heart are measured. The heart is an electrically active organ and is controlled by a system of electrical impulses. Therefore, the heart can be examined by measuring electrical signals, and arrhythmias can also be induced by electrical stimulation of heart tissue. This method is widely used. With the help of electrical stimulation, the function of the heart's transmission system is more thoroughly verified, and the investigated rhythm disorder is often triggered, which is further precisely identified and specifically localized. In addition to direct electrical stimulation of the tissue, in some cases an intravenous infusion (drip) of drugs that increase the excitability of the heart tissue and accelerate the heart rate is used to induce arrhythmia. Stimulation maneuvers can be perceived by patients as unpleasant heart palpitations, a feeling of warmth, pressure on the chest or shortness of breath. These symptoms are common. Nevertheless, it is always advisable to inform the medical staff about an unpleasant feeling. Depending on the type of detected rhythm disorder, the treatment procedure is further determined.

If the type of arrhythmia allows its treatment with catheter ablation, the rhythm disorder is treated in the vast majority of cases in one session. In a smaller percentage of cases, it is necessary to plan the ablation procedure for another date, especially if it is necessary to use other technologies. For disorders that are sufficiently documented on the basis of non-invasive examinations, radiofrequency ablation is performed even without the need for extensive invasive examination of arrhythmias. As a rule, the patient perceives the treatment of arrhythmia similarly to the introduction of the examination. In some cases, e.g. for arrhythmias originating from the left atrial region, it is necessary to use a so-called transseptal approach to reach the key area, where a puncture of the atrial septum is performed, with which the ablation catheter is introduced into the left atrium. Puncture of the atrial septum is painless and is performed under ultrasound control to guarantee maximum safety of the procedure.

The ablation procedure can be accompanied by a feeling of pressure on the chest, which we try to influence with painkillers. It is therefore important to inform the doctor about the pain so that he can decide on the administration of these drugs. In order to evaluate the effect of ablation, it is necessary to demonstrate the inducibility of the arrhythmia, the completeness of the burn, and the inability of the signal to spread in the area of the arrhythmia's origin with stimulation maneuvers at the end of the procedure. Only when such a goal is met is it possible to end the procedure and take the patient to the inpatient ward. Inserted catheters are mostly removed in the room, but always on the day of the procedure. Throughout the examination, patients are in contact with the doctor, who gives them clear instructions and informs them about the progress of the procedure. The duration of the entire performance is different due to the difference in arrhythmias. It ranges from a few tens of minutes to many hours of intervention.

In the department, absolute bed rest is usually required for several hours, so that the points of entry of the catheters into the vascular system are "retracted". For lighter procedures, it is possible to be discharged to home treatment the next day. Hospitalization for several days is necessary for more complex procedures. Depending on the type of arrhythmia, the patient is further monitored in the Arrhythmology Clinic. After discharge from the hospital, it is advisable to limit physical exertion for a week to a fortnight in order to spare the punctured areas of the groin or neck. Normal household exertion and walks are usually possible. The return to full load and to work depends on the difficulty of the work performed and is individual. With office work, it is usually possible to return to work within a few days, with physically demanding work later.

What is the benefit for the patient and what are the results of these procedures

With the right decision on the method of treatment of arrhythmia using catheter ablation, this method is very effective. Its probability of success depends on the type of rhythm disorder. In the case of simple interventions, the chance of permanently eliminating the arrhythmia is up to 95%. For more complex procedures such as atrial fibrillation or ventricular tachycardia, the success rate is generally lower. The success rate of the first performed procedure for atrial fibrillation ranges between 70-80% for a paroxysmal form of arrhythmia and is significantly lower (even below 50%) in the case of a longer-lasting arrhythmia. The effect of performance in atrial fibrillation can be reliably assessed only after 3 to 6 months have passed, when the burned areas have healed and the heart atria have fully recovered, and after stopping all drugs that suppress arrhythmia. There are also rhythm disorders that can be treated with catheter ablation, but this treatment is still only a supplement to comprehensive patient care (e.g. ventricular arrhythmias after a myocardial infarction). Information about the potential effect of therapy in specific cases should be consulted with a doctor familiar with the issue of arrhythmology. In general, if the patient is indicated for such a procedure, the profit from this treatment always outweighs the risks of this procedure.

How to behave after the procedure in home treatment, when you can return to work

After the procedure, the patient is monitored in the hospital until the next day for lighter procedures, for more complex procedures or if drug therapy needs to be adjusted or for complications, the hospitalization is longer. The patient is usually instructed about the next procedure and regimen when being discharged to home treatment. Specific instruction is a common part of a dismissal report. If further monitoring of the patient in the Arrhythmology Outpatient Clinic or further examination is necessary, the patient is informed of the date of the visit or examination upon discharge. In the home environment, it is advisable to limit activities that strain the injection sites in the groin for approximately one week - sports, cycling, carrying heavy objects are therefore not suitable, it is recommended to limit walking up stairs. However, it is possible to carry out ordinary light housework, walking around the apartment or taking walks is allowed. After a week, it is usually possible to return to normal life. Returning to work depends on the type of work. In the case of office work and sedentary work, longer incapacity for work is usually not necessary. With heavy physical work, depending on the type and course of work, it is advisable to expect at least two weeks of incapacity for work. It is advisable to take the drugs used during the hospital stay as recommended. Some preparations are temporary and can be discontinued over the course of weeks or months. For others, longer-term use should be expected. In the event of confusion, the development of complications — especially larger bruises in the area of injections, but also in the event of shortness of breath, chest pain, loss of consciousness, reappearance of arrhythmia after the procedure — it is necessary to contact a doctor. If you have any questions, you can call 224 962 603 - Antiarrhythmic unit with 24-hour service.

Electrical cardioversion is a procedure used to correct an incorrect heart rhythm, most commonly atrial fibrillation or flutter. The principle is the application of an external electric current.

Performance progress

Before electrical cardioversion, a cannula is inserted into the patient to administer drugs. So that the patient does not feel the electric shock, he is put to sleep for a few minutes during the procedure. After falling asleep, the doctor places two surface electrodes in the area of the sternum and on the left side of the chest, between which the above-mentioned electric pulse passes. The entire procedure, including sleep, takes around 15 to 20 minutes. After complete recovery (about 1 hour), the patient can eat and drink after being checked by a doctor or nurse.

Before performance

On the day of the electrical cardioversion, the patient must be fasting, i.e. not eating or drinking (at least 4 hours before the procedure). The presence of arrhythmia is always verified before the procedure. If the patient is taking Warfarin, they should bring the results of the Quick test (INR), with the last result not older than 3 days.

After performance

After cardioversion, the patient is monitored for at least 2 to 4 hours, until the effect of the drugs administered for short-term sleep wears off. Due to the nature of the drugs administered for short-term anesthesia, it is advisable to have an escort when leaving the hospital and it is not advisable to drive motor vehicles or engage in activities requiring high attention.