Cardiology in Cambridge - Dr Leonard M. Shapiro BSc MD FRCP FACC

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Procedures

Dr. Shapiro has widespread clinical and research interests, and has undertaken a very large number of cardiac procedures in each of these clinical areas whilst in Cambridge. Dr Shapiro undertakes interventional cardiology at Papworth Hospital.

What will happen

Just before the procedure you will be prepared. What will happen is explained in detail. You will be asked to sign a consent form which gives us permission to do the tests and acknowledges that you have understood the risks (see below). The nurses will shave a small amount of hair from the groin area so it does not interfere with the equipment. Often you will be able to walk to the theatre. Dr. Shapiro performs this procedures in a modified operating theatre, called a cardiac catheterisation laboratory (usually known as a cath lab). This is a sterile area where the patient is draped in sterile green or blue paper sheets, and staff are clothed in sterile gowns. Caps and masks are not usually worn. The difference from a normal operating theatre is the presence of a large X-ray machine. This is a very high resolution machine allowing real time video images of the passage of devices into the circulation and the heart, and the taking a detailed images. The images are usually made with an injection down the catheter (long plastic tube). The dose of radiation is surprisingly small. To see the outline of the arteries, a contrast medium or dye is used. This occasionally may induce a warm flush or rarely chest pain. In the past, the dye often made the patient rather sick, and allergic reactions were common, but the newer and much more expensive products are much better.

Most of the procedures Dr Shapiro performs are carried out via the femoral vessels (these are an artery and vein at the crease at the top of the leg in the groin). These vessels are entered by needle puncture after the placement of copious amounts of local anaesthetic. This is usually almost completely painless. The passage of catheters (long specially designed plastic tubes) can take place through the blood vessels themselves. Fortunately, human beings have no pain sensation inside blood vessels - so other than a curious sensation of pressure, normally nothing is felt. Many patients feel anxious before and during these procedures, which is not surprising but many are relieved by the absence of pain and reassurance from experienced staff. We give some patients a gentle sedation to calm their fears. The passage of the catheters, which are specially shaped for this particular purpose , is viewed on the X-ray screens and are directed to wherever required both by rotation and forward and backward motions. The movements of the catheters on the X-ray screens as well as the images taken (similar to above) can be seen by the patients (although some people definitely don't want to look!). Many comment how extraordinarily strange it is to see things moving inside you without any sensation of it happening. The tubes placed in the arteries have valves attached to prevent bleeding.

At the end of the procedures, the tubes need to be removed. As they are placed in blood vessels, there is a risk of bleeding. To prevent this, simple pressure with the fingers may be sufficient - plus there are a number of gadgets to help the process. There are also some clever devices which introduce a plug (of collagen) or a stitch into the artery to seal the hole. Most patients need a few hours of bed rest. For simple or painless procedures such as a coronary angiography, PCI and defect closure, many go home the same day. Although the area in the groin may be a little sore for a few days there should be no other significant pain.

For procedures such as a hole in the heart (PFO and ASD) closure (see below for description) an extra form of imaging is used, namely ultrasound. This is done in one of two ways. The first option involves the use of a TOE probe. This is placed in the gullet, which fortunately lies just behind the heart and produces excellent images particularly of the back portion where the holes in the heart are found. This probe is passed under a general anaesthetic which is used for ASD closure. An alternative ultrasound probe is available which is much smaller and is passed through the veins to the heart (known as intracardiac echo or ICE). This can readily be performed under local anaesthetic and is painless.

This is an echo picture taken in the cath lab showing a coloured jet passing across a small hole in the heart from the left atrium above to the right atrium below.

Coronary angiography:

What does the test show: This is a diagnostic test ( usually the first one performed) , called a Coronary Angiogram or arteriogram which produces moving images of the outlines the arteries of the heart which with considerable reliability shows if there are any narrowings or blockages. The movie above shows a narrowing in the right coronary artery which supplies blood to the muscle of the underside of the heart. The tight narrowing was the cause of a heart attack. Dr Shapiro has performed at least 20,000 cases since 1980

Video image of the right coronary artery showing the catheter , the artery and a severe narrowing that had led to a heart attack.

See aslo:

www.nlm.nihi.gov

Coronary angioplasty or percutaneous coronary intervention PCI: This is a procedure that uses balloons and stents to open partly or completely blocked coronary arteries that cause heart attack and angina. The procedure starts the same as a coronary angiogram with the painless passage of tubes from the artery in the groin to the heart. Then a very thin guide wire is steered through the artery and the narrowings (see figure). Over this wire, balloons and stents are pushed through the catheter and across the narrowings . The balloons and stents stretch up the narrowing and restore normal flow down the artery. This is a very successful procedure which was first performed by performed by Andreas Grunzig in Switzerland in 1978. Dr Shapiro first undertook this procedure in 1983 .

Dr Shapiro undertakes between 300 and 600 cases per year in Cambridge with career total of approximately 8000 to 10000 cases since 1983. For Dr Shapiro, the PCI audit data reveals more than a 98% success rate with no deaths in stable patients. For stable patients , the generally accepted risk is of death in less than 1 in 500, with a lower need for emergency surgery. The longer term risk of a reoccurrence of chest pain is between 2 and 8%. The introduction in the past few years of stents with a drug coating to prevent narrowing has reduced this further.

There may be a little chest pain during and after the narrowing is opened up . Usually there usually no further pain but occasionally there is some residual dull aching and stabbings in the chest over the next few days.

This figure is the same patient as the above and shows the narrowed part of the artery fully open with fine metal stent in place. The guide wire is seen.

See also:

www.nlm.nih.gov

Atrial septal defect closure: Dr Shapiro has performed approximately 400 cases since 1992 The audit data shows no deaths or serious complications includes device displacement. Such holes are usually not apparent on examination and an echocardiogram is usually needed to make a diagnosis. (see figure below).. Symptoms include breathlessness and palpitations ( awareness of abnormal heart beats.). The risk of stroke is also higher than normal and there is potentially an association with migraine ( see below).

The device used is like a large pad of extremely expensive wire wool which has the special property to return to its manufactured shape and size after it has been pulled out into a narrow shape in the delivery catheter. The procedure is usually performed under general anaesthetic but many patients are treated as a day case. The device is placed from the vein in the groin and there is little in the way of post-operative pain and there is a prompt return to normal activities. Often a six month course of aspirin is prescribed.

Patent foramen ovale or PFO Closure: Patent foramen ovale (PFO) closure (potential hole in heart ) that can allow passage of clot or chemicals from the right to the left side of the heart which can cause stroke and other neurological conditions and decompression symptoms when SCUBA diving): Dr Shapiro has performed approximately 200 cases since 1992. The audit data shows no deaths or serious complications includes device displacement . This is often performed under local anaesthetic with an ICE ultrasound probe as described above. Patients are usually treated as a day case and return promptly to normal activity. Often a six month course of aspirin is prescribed.

See aslo:

www.bcis.org.uk

Migraine and PFO: Migraine is a common cause of headache in about 5 to 10% of the total population. There is some evidence which suggests that echocardiography ( ultrasound scan of the heart) shows a PFO (see above) in a much higher proportion of migraine sufferers than expected. It is suggested but not yet proven that closure of the PFO may improve the headaches. Currently Dr Shapiro is co-ordinating in this country based at Papworth Hospital in Cambridge a large study of the affect of patent foramen ovale closure in migraine

Mitral balloon valvuloplasty: Dr Shapiro has performed approximately 600 cases since 1985.. Using a balloon to open up a narrowed valve. This uses a uniquely designed large balloon which is introduced via a vein in the groin and advanced into the heart through a special approach facilitated by a transeptal puncture. This uses a long needle to make a tiny hole in the atrial septum to allow passage of the balloon. This is all carried out without sedation painlessly and often as a day case.

Percutaneous valve replacement: This new technology uses a catheter based valve replacement which can be inserted via a femoral artery in the groin or by a small incision over the heart. Unlike standard valve surgery this does not require open heart surgery and cardiopulmonary bypass ( heart lung machine) and can be performed in patients who are too ill for a normal operation. I have been involved in established a programme at Papworth Hospital .

Dr Shapiro performs a variety of other valvular and non-coronary intervention including VSD closure, septal ablation in hypertrophic cardiomyopathy, patent ductus arteriosus closure and aortic Coarctation stenting

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