List of Services

What is peripheral angiography?

Peripheral angiography is an X-ray examination of the blood vessels or chambers of the heart. A very small tube (catheter) is inserted into a blood vessel in your groin or arm. The tip of the tube is positioned either in the heart or at the beginning of the arteries supplying the heart, and a special fluid (called a contrast medium or dye) is injected. This fluid is visible by X-ray, and the pictures that are obtained are called angiograms.

Another name for this test is peripheral arteriography.

o EKG

Electrocardiogram (or Electrocardiography, ECG or EKG) — A quick, painless test that records the electrical activity of the heart. It may be taken at rest or during exercise. It is the standard clinical tool for diagnosing arrhythmias (abnormal rhythms) and to check if the heart is getting enough blood or if areas of the heart are abnormally thick. Small patches called electrodes are placed on different parts of the body. Different tracings of the heart's electrical activity can be made and permanently recorded on paper or in a computer. Three major waves of electric signals appear on the ECG. Each one shows a different part of the heartbeat. The P wave records the electrical activity of the atria. The QRS wave records the electrical activity of the ventricles, and the T wave records the heart's return to the resting state. Doctors study the shape and size of the waves, the time between waves and the rate and regularity of beating. This tells a lot about the heart and its rhythm.

o Exercise Stress Testing

A stress test, sometimes called a treadmill test or exercise test, helps a doctor find out how well your heart handles work. As your body works harder during the test, it requires more oxygen, so the heart must pump more blood. The test can show if the blood supply is reduced in the arteries that supply the heart. It also helps doctors know the kind and level of exercise appropriate for a patient.

A person taking the test

is hooked up to equipment to monitor the heart.
walks slowly in place on a treadmill. Then the speed is increased for a faster pace and the treadmill is tilted to produce the effect of going up a small hill.
may be asked to breathe into a tube for a couple of minutes.
can stop the test at any time if needed.
afterwards will sit or lie down to have their heart and blood pressure checked.

Heart rate, breathing, blood pressure, electrocardiogram (e-lek"tro-KAR'de-o-gram) (ECG or EKG), and how tired you feel are monitored during the test.

Healthy people who take the test are at very little risk. It's about the same as if they walk fast or jog up a big hill. Medical professionals should be present in case something unusual happens during the test.

A physician may recommend an exercise stress test for various reasons:

To diagnose coronary artery disease
To diagnose a possible heart-related cause of symptoms such as chest pain, shortness of breath or lightheadedness
To determine a safe level of exercise
To check the effectiveness of procedures done to improve coronary artery circulation in patients with coronary artery disease
To predict risk of dangerous heart-related conditions such as a heart attack.

Depending on the results of the exercise stress test, the physician may recommend more tests such as a nuclear stress test or cardiac catheterization.

o Holter Monitoring

What are Holter, Event and Transtelephonic Monitors?

	Figure 1.

Holter Monitors
The Holter monitor, invented by Dr. Norman Holter, is a device that records the heart rhythm continuously for 24 hours. This means that it records each and every heart beat over that time. Sticky patches (electrodes) on the chest are connected to wires from the Holter monitor. The monitor is carried with the patient for the recording period. The heart rhythm is recorded onto a cassette tape or flash card technology and then processed at a heart center. From this recording, a wide variety of information can be obtained including heart rates during day and night, abnormal heart beats, and recording of rhythm during any symptoms during the recording. A diary comes with the Holter for the patient or caregiver to write down the time and type of symptoms so the rhythm can be reviewed.

Figure 1. Holter monitor with four leads and solid state recording. Other monitors may have up to seven leads and run on cassette tapes.


Figure 2.

Event Monitors
Event monitors are small devices that are used by patients over a longer period (weeks to months, typically one month). Two sticky patches (electrodes) on the chest connect two wires to the event recorder. The monitor is always on but will only store the patient’s rhythm when the patient or caregiver pushes the button. Most monitors will save the rhythm for several seconds of rhythm before the button is even pushed. The rhythm is also saved for a period after the button is pushed. A few specialized monitors are used only after the patient has symptoms. The intent is for most event monitors to be worn as much as possible every day to increase the chances of recording the patient’s rhythm when he/she has symptoms.

Once a recording (sometimes more than one) has been made, it can be transmitted over the phone back to your child’s heart center.

Figure 2. Event monitor with leads. Some devices will store more that one event.

	Figure 3.

Transtelephonic monitors
These small devices transmit the patient’s rhythm live over the phone. An example is shown in Figure 3. These devices do not save a recording of rhythm for later playback like an event monitor. The transtelephonic devices are commonly used by pacemaker/ICD patients for routine scheduled checks over the phone. (An ICD is an implantable cardioverter-defibrillator or shock device used for treating life-threatening rhythm problems.)

Figure 3. Transtelephonic monitor used with pacemaker patients. Each wristband is a lead that is worn by the patient during transmission of the rhythm. The white round magnet is used by some pacemaker patients to transmit specific data about the pacemaker.

Implantable Loop Recorders (ILRs)
Some patients have serious but very infrequent symptoms that can't be recorded by regular event recorders because they occur so rarely. In these cases, it may become necessary to implant a special event recorder called an ILR under the patient’s skin. An ILR is the size of an adult’s little finger. It is implanted under the skin by a one-inch incision on the chest. The battery lasts 14 months. It is always watching the patient’s rhythm. It will make a recording of the patient’s rhythm when either the patient places an activator over the ILR and pushes a button when they are having a symptom or when the patient’s rate goes above or below the limits set in the ILR. The recordings cannot be sent over the phone. Instead, a programmer machine reads the information with radio waves. The ILR will store up to 14 events between each reading.

Do they hurt or are they harmful?
The Holter monitor, event monitor and transtelephonic monitors do not hurt. They do not cause any harm because they're recording devices. They do not send out electricity.

The ILR requires a small surgical incision that causes minimal discomfort for a few days. After that, there is no pain.

Is there anything else to know about these devices?
The Holter, event and transtelephonic monitors cannot get wet or they will become damaged. The ILR is protected by the skin so bathing and swimming with an ILR is fine after the wound has healed. The ILR will need to be removed when it is no longer needed. This is usually when the reason for the infrequent symptoms has been determined.

Echocardiography (or Echocardiogram) — A diagnostic method in which a hand-held device is placed on the chest and high-frequency sound waves (ultrasound) are used to produce images of the heart’s size, structure and motion. An “echo” provides valuable information about the health of the heart and helps gather information about abnormal rhythms (arrhythmias).

o EP Studies/Catheter Ablation

An electrophysiologic, or EP, study provides information that is key to diagnosing and treating arrhythimias. The test produces data that makes it possible to:

Diagnose the source of arrhythmia symptoms
Evaluate the effectiveness of certain medications in controlling the heart rhythm disorder
Predict the risk of a future cardiac event, such as Sudden Cardiac Death
Assess the need for an implantable device (a pacemaker or ICD) or treatment procedure (radiofrequency catheter ablation) www.HRSpatients.org

o Internal Cardiac Defibrillators

Defibrillation — The use of an electrical device (defibrillator) to give an electric shock to the heart to help restore a normal heartbeat. It is used for dangerous arrhythmias, such as ventricular tachycardia or ventricular fibrillation, and in cardiac arrest.

Defibrillator — A device that delivers “pacing” or an electric shock to the heart when an abnormal rhythm (arrhythmia) is detected. A defibrillator may be external or internal. External defibrillators use pads that are placed on the chest to deliver the electric shock. Internal defibrillators (implantable cardioverter defibrillators or ICDs) look similar to a pacemaker, but they continuously monitor the heart rhythm to detect overly rapid arrhythmias such as ventricular tachycardia or ventricular fibrillation. The ICD corrects the heart rhythm by delivering precisely calibrated and timed electrical shocks to restore a normal heartbeat when one of these dangerous arrhythmias has occurred.

o Pacemakers

What is a natural pacemaker?

The heart's "natural" pacemaker is called the sinoatrial (SA) node or sinus node. It's a small mass of specialized cells in the top of the heart's right atrium (upper chamber). It makes the electrical impulses that cause your heart to beat.

A chamber of the heart contracts when an electrical impulse moves across it. For the heart to beat properly, the signal must travel down a specific path to reach the ventricles, the heart's lower (pumping) chambers.

The natural pacemaker may be defective, causing the heartbeat to be too fast, too slow or irregular. The heart's electrical pathways also may be blocked.

What's an artificial pacemaker?

An "artificial pacemaker" is a small, battery-operated device that helps the heart beat in a regular rhythm. Some are permanent (internal) and some are temporary (external). They can replace a defective natural pacemaker or blocked pathway.

A pacemaker uses batteries to send electrical impulses to the heart to help it pump properly. An electrode is placed next to the heart wall and small electrical charges travel through the wire to the heart.

Most pacemakers are demand pacemakers. They have a sensing device. It turns the signal off when the heartbeat is above a certain level. It turns the signal back on when the heartbeat is too slow.

AHA Recommendation

If you have an artificial pacemaker, be aware of your surroundings and the devices that may interfere with pulse generators:

Home appliances

CB radios, electric drills, electric blankets, electric shavers, ham radios, heating pads, metal detectors, microwave ovens, TV transmitters and remote control TV changers, in general, have not been shown to damage pacemaker pulse generators, change pacing rates or totally inhibit pacemaker output.

Several of these devices have a remote potential to cause interference by occasionally inhibiting a single beat. However, most people can continue to use these devices without significant worry about damage or interference with their pacemakers.

Power-generating equipment, arc welding equipment and powerful magnets (as in medical devices, heavy equipment or motors) can inhibit pulse generators. Patients who work with or near such equipment should know that their pacemakers may not work properly in those conditions.

Cell Phones

Cell phones available in the United States (less than 3 watts) don't seem to damage pulse generators or affect how the pacemaker works.

Technology is rapidly changing as the Federal Communications Commission (FCC) is making new frequencies available. Newer cell phones using these new frequencies might make pacemakers less reliable. A group of cell phone companies is studying that possibility.

Medical equipment

Carry a wallet I.D. card with you. Equipment used by doctors and dentists can affect your pacemaker, so tell them you have one.

Magnetic resonance imaging (MRI) uses a powerful magnet to produce images of internal organs and functions. Metal objects are attracted to the magnet and are normally not allowed near MRI machines. The magnet can interrupt the pacing and inhibit the output of pacemakers. If MRI must be done, the pacemaker output in some models can be reprogrammed. Discuss with your doctor the possible risks and benefits before you undergo MRI scanning.

Extracorporeal shock-wave lithotripsy (ESWL) is a noninvasive treatment that uses hydraulic shocks to dissolve kidney stones. This procedure is safe for most pacemaker patients, with some reprogramming of the pacing. You'll need careful follow-up after the procedure and for several months to be sure your unit is working properly. Patients with certain kinds of pacemakers implanted in the abdomen should avoid ESWL. Discuss your specific case with your doctor before and after the treatment.

Radiofrequency (RF) ablation uses radio waves to manage a wide variety of arrhythmias. Recent studies of patients with implanted pacing systems measured the units before, during and after RF catheter ablation. They showed that most permanent pacemakers aren't adversely affected by radio frequencies during catheter ablation. A variety of changes in your pacemaker can occur during and after the treatment. Your doctor should carefully evaluate your pacing system after the procedure.

Transcutaneous electrical nerve stimulation (TENS) is used to relieve acute or chronic pain. Several electrodes are placed on the skin and connected to a pulse generator. Most studies have shown that TENS rarely inhibits bipolar pacing. It may sometimes briefly inhibit unipolar pacing. This can be treated by reprogramming the pulse generator.

Diagnostic radiation (such as screening X-ray) appears to have no effect on pacemaker pulse generators. However, therapeutic radiation (such as for treating cancerous tumors) may damage the pacemaker's circuits. The degree of damage is unpredictable and may vary with different systems. But the risk is significant and builds up as the radiation dose increases. The American Heart Association recommends that the pacemaker be shielded as much as possible, and moved if it lies directly in the radiation field. If you depend on your pacemaker for normal heart pacing, the electrocardiogram (ECG) should be monitored during the treatment, and your pulse generator should be tested often after and between radiation sessions.

Dental equipment doesn't appear to affect pacemakers adversely. Some patients may feel an increase in pacing rates during dental drilling.

Electroconvulsive therapy (such as for certain mental disorders) appears to be safely used in patients with pacemakers.

Short-wave or microwave diathermy uses high-frequency, high-intensity signals. These may bypass your pacemaker's noise protection and interfere with or permanently damage the pulse generator.

o Angioplasty

Angioplasty is a medical procedure to open narrowed or blocked blood vessels of the heart. These blood vessels are called the coronary arteries. Angioplasty is not considered to be a type of surgery. It is called a percutaneous coronary intervention (PCI).

Alternative names: Balloon angioplasty; Coronary angioplasty; PTCA; Percutaneous transluminal coronary angioplasty

o Balloon Angioplasty

During a coronary angioplasty, doctors insert a long, slender tube called a catheter through an incision in the groin and guide it into the heart. With a balloon angioplasty, a small balloon at the tip of the catheter is inflated to stretch the artery open.

o Endovascular Treatment of Peripheral Vascular Disease

An estimated 10 million people in the United States have peripheral vascular disease (PVD) with symptoms; 20 to 30 million have PVD without any symptoms. As people grow older, the symptoms from PVD will increasingly limit daily activity. Several years ago, vascular surgical procedures were the only alternative to medical therapy in patients with PVD. Today, advances in minimally invasive percutaneous interventions have made endovascular procedures the primary treatment option for revascularization in most patients. Endovascular interventions offer comparable, or in some cases, superior success rates with very low rates for morbidity and mortality. Also, most of these endovascular interventions are performed on an out-patient basis.

o Stent Implantation

What is a stent and how is one used?
A stent is a wire metal mesh tube used to prop open an artery during angioplasty. The stent is collapsed to a small diameter and put over a balloon catheter. It's then moved into the area of the blockage. When the balloon is inflated, the stent expands, locks in place and forms a scaffold. This holds the artery open. The stent stays in the artery permanently, holds it open, improves blood flow to the heart muscle and relieves symptoms (usually chest pain). Within a few weeks of the time the stent was placed, the inside lining of the artery (the endothelium) grows over the metal surface of the stent.

When are stents used?
Stents are used depending on certain features of the artery blockage. This includes the size of the artery and where the blockage is. Stenting is a fairly common procedure; in fact, over 70 percent of coronary angioplasty procedures also include stenting.

What are the advantages of using a stent?
In certain patients, stents reduce the re-narrowing that occurs after balloon angioplasty or other procedures that use catheters. Stents also help restore normal blood flow and keep an artery open if it's been torn or injured by the balloon catheter.

Coronary artery disease is the leading cause of death in the United States. Exercise testing and nuclear scanning are common tools that are used to diagnose the presence of obstructions in the coronary vessels and to evaluate their severity.

“Nuclear cardiology helps your cardiologist get detailed information about your heart through the use of safe, radioactive drugs, usually thallium. During a nuclear test, your heart is "exercised" either on a treadmill or with medications. Then, a small amount of thallium is injected into the bloodstream and its movement is traced by a special nuclear imaging camera. (See photo below) Thallium flows freely through normal arteries and less so through narrowed arteries.”

Nuclear Camera

o Myocardial Perfusion Imaging

The most common nuclear test of the heart is known as a myocardial perfusion scan. Myocardial perfusion images are obtained while the patient is lying down under a special camera or scanner (See above photo) that generates a picture of the radioactivity coming from the heart.

Myocardial perfusion scans can localize the obstructed coronary vessel(s), demonstrate the extent of the heart muscle area with reduced blood flow, provide information about the heart's pumping function, and identify areas of the heart muscle that are scarred from a heart attack.

“Peripheral arterial disease (PAD) is narrowing of arteries that results in poor blood flow to your arms and legs. When you walk or exercise, your leg muscles do not get enough blood and you can get painful cramps. Peripheral arterial disease is also called peripheral vascular disease.

The most common cause is the buildup of plaque on the inside of arteries. Plaque is made of extra cholesterol, calcium, and other material in your blood. Over time, plaque builds up along the inner walls of the arteries, including those that supply blood to your legs. If plaque builds up in your arteries, there is less room for blood to flow. Every part of your body needs blood that is rich in oxygen. But plaque buildup prevents that blood from flowing freely and starves the muscles and other tissues in the lower body. This process of plaque buildup usually happens at the same time throughout the body. It is called atherosclerosis or hardening of the arteries.

If you have this problem in your legs, you most likely will have it in the arteries that supply blood to your heart and brain. This increases your chance of having a heart attack or stroke. Plaque builds up bit by bit over a lifetime, but symptoms often do not start until after age 65. High cholesterol, high blood pressure, and smoking make you more likely to get atherosclerosis and peripheral arterial disease.”

A noninvasive vascular laboratory is provided in our office and has equipment and clinically skilled technologists to diagnose problems of the vascular system (blood vessels). The tests that are performed in our vascular laboratory are safe, pain-free and quite accurate.

The tests are performed by certified technologists who have completed courses and passed examinations focusing on heart and vascular disease. We have technologists who are RVT (Registered Vascular Technologist) credentialed by the American Registry of Diagnostic Medical Sonographers (ARDMS).

We perform various tests in our vascular laboratory including examination of: the carotid arteries for stroke risk; the abdominal aorta for aneurysm; the kidneys for possible causes of high blood pressure. We also perform arterial imaging of the legs for pseudo-aneurysm.

All definitions from The American Heart Association at http://www.americanheart.org