Dr Martin Brown - Sydney Heart Failure

(02) 9812 2900 or 02 94226040

Heart Failure Procedures

Coronary Angiogram

Coronary angiography is the Gold standard test for imaging blocked or aberrant coronary arteries. It is often used to assess for angina, heart attacks or cardiomyopathy due to reduced blood flow to the heart muscle.

It is performed as a day-stay procedure in hospital under local anaesthesia with sedation.

It involves a small tube (catheter) approximately 2mm in diameter being inserted into the artery in the groin or wrist. The catheter is moved through the blood vessels until it reaches the heart. Radiographic contrast dye is then injected and X-ray images are obtained. An angiogram can determine whether coronary stenting or coronary artery bypass surgery might be needed.

You will need to be fasted for 6 hours prior to testing and will be directed which usual medications to take beforehand.

Transthoracic Echo

This is a non-invasive test of the heart using ultrasound which allows real-time visualisation of the heart valves, ventricles, plumbing, pressures and heart function.  It is a painless, non invasive test and does not routinely require any injections or radiation exposure.

Transoesophageal Echo

This is similar to a trans thoracic echocardiogram except a probe is inserted via the throat into the oesophagus and stomach to allow for clearer and more detailed images using ultrasound. It is performed in hospital as a day procedure with a light anaesthetic and carries a 1:1000 risk of a serious complication.

Stress Test

Stress testing is performed with exercise or a chemical that stimulates the heart, to increase the work-load of the heart and assess the blood supply through the coronary arteries to the heart muscle, as well as evaluating valvular function, pressures and electric rhythm. As the demand for blood flow down the arteries will be greater with stress, a normal resting heart may become abnormal when stressed.

The most easily accessible method is the exercise stress test using the treadmill or bicycle. The treadmill will increase in speed or elevation every few minutes depending on the protocol being used. An ECG is used to monitor heart rate and rhythm and blood pressure is also monitored. The stress echocardiogram combines peak exercise ultrasound images of the heart muscle. This test is about 80% sensitive for blocked arteries but can both undercall (false negative) or overcall (false positive) the result.

A chemical stress test is used if mobility is limited (dobutamine stress echo) and nuclear medicine used to assess blood flow (radioactive isotope instead of ultrasound).

Right Heart Catheter

A right heart catheter is placed into the heart from the neck (jugular), arm (basilic) or groin (femoral) vein to assess for fluid status, heart function and lung pressures.

The vein is found with ultrasound. You will be given an injection of local anaesthetic. A fine tube (catheter) is put into the vein and passed inside until it reaches the heart and then goes up into the blood vessels of the lungs. This is usually painless but you may feel palpitations. The doctor uses x-ray imaging to see the catheter.

Pressures in the lungs and the heart are recorded. Blood samples are taken to measure oxygen levels.

At the end of the procedure, the catheter and sheath are removed. The whole procedure usually takes about 1 hour. Usually you can be discharged 1-4 hours after the procedure. You must not drive home yourself.

You do not need to fast for this test.

Take all your usual medications the morning of the test including aspirin or clopidogrel but not frusemide, dapagliflozin or empagliflozin and you will be advised about other blood thinners eg apixaban, rivaroxaban and dabigatran.

The test can be done if you are taking warfarin but your INR must be between 2 and 3.0. You may be required to have this tested the day before the procedure.

Risks of a right heart catheter (internal jugular vein approach)

There are risks and complications with this procedure. They include but are not limited to the following.

Common risks and complications (more than 5%) include:

  1. Minor bleeding and bruising at the puncture site.
  2. Abnormal heartbeat (palpitations) lasting several seconds, which settles by itself.

Uncommon risks and complications (1- 5%) include:

  1. Unable to get the catheter into the vein. The procedure may be changed to a different approach eg an arm or a leg vein.
  2. Abnormal heart rhythm that continues for a long time. This may need medication or an electric shock to correct.

Rare risks and complications (less than 1%) include:

  1. Allergic reaction to the local anaesthetic. This may require medication to treat.
  2. The artery is accidentally punctured. This may require surgery to repair.
  3. Blood clot in the vein. This may need medication to treat.
  4. A blood clot may form and break off from the catheter. This is treated with blood thinning medication.
  5. Air in the lung cavity. A chest tube may need to be put in to the chest to drain the air.
  6. Damage to the vein in the neck causing bleeding. This may need surgery to repair.
  7. Air embolism. Oxygen may be given.
  8. A hole is accidentally made in the heart or the heart valve. This may need surgery to repair.
  9. Unable to position the balloon catheter into the lung vessels or around the heart. The procedure would be cancelled if this occurred. This is more common if there are congenital malformations of the heart.
  10. Damage to the lung blood vessel causing bleeding. This may need surgery to repair.
  11. A stroke. This may cause long term disability.
  12. Heart block requiring a pacemaker
  13. Death as a result of this procedure is extremely rare (1:2000)

Right Heart Catheter Video

Procedures with A/Prof Martin Brown (sydneycardiology.com.au)

Cardiac MRI

Cardiac magnetic resonance (CMR) imaging uses magnets instead of radiation or ultrasound to image the body non invasively.

It can provide information on function, anatomy, inflammation  and scars within the heart.

It requires 60-90 minutes of being inside a loud "banging" tunnel. Approximately 10% people find it claustrophobic.

Heart Biopsy

A Cardiac Biopsy is used to Investigate the cause of cardiomyopathies and to assess rejection in heart transplant recipients.

This can be performed through the neck (jugular) or leg (femoral) vein.

You will be given local anaesthetic and sedation if required. The vein is visualised using a ultrasound and the needle inserted under ultrasound guidance. This is then replaced with a plastic sheath. a longer plastic sheath is then inserted into the right heart. A small 2mm biopsy forcep is then used to take 4-10 samples from inside the heart using echo and xray guidance. This doesn't hurt.

A repeat transthoracic echo is performed after the procedure to exclude complications. After the sheath removal, you are observed in recovery for 60 minutes (Pulse rate, blood pressure, O2 saturations and review puncture site) and can be discharged after 2 hours if neck approach or 4 hours if groin used.

Fasting for 4 hours prior is required and you can take usual morning medications except diuretics, Dapaglifloxin or Empagliflozin.

Let the doctor know if you are taking blood thinners (eg warfarin, Eliquis, Xarelto, Pradaxa).