Procedures

An angiogram is used to show any narrowing or blockage of your coronary arteries.

Angioplasty and stenting is often used instead of surgery to treat narrowed or blocked coronary arteries.

You may have one or both of the following procedures.

A needle with a tube connected to it will be put in your arm. This is called an intravenous line or IV. After an injection of local anaesthetic, a fine tube (catheter) is put into the artery in your groin or arm. The tube is carefully passed into the coronary arteries.

A series of pictures are taken using x-rays and x-ray dye.

If any narrowing or blockages are found then a tube with a tiny wire is passed down the affected artery so that a sausage shaped balloon can be passed over it and into the part that is narrowed or blocked.

To open up the artery, the balloon is blown up with fluid, which then presses against the plaque, pushing it out of the way.

In some people,

• the coronary artery may be split or damaged; OR
• the artery may become narrowed again as the balloon goes down; OR
• the artery may become blocked again.

Most of the time, one or more stents may be placed in the artery to help keep the artery open. A stent is a metal tube or spring coil. This is passed into the diseased part of your artery using a balloon. The balloon is removed once the stent is in place.

The stent stays in for life. After the procedure, you will be given drugs which reduce your risk of blood clotting and the stent blocking.

While the catheter is in the artery, a number of additional mechanical devices may be used to complete the procedure. These include pressure wires and an intravascular ultrasound (IVUS).

If the heart becomes unstable during the procedure, an additional balloon device to stabilise the heart may be required. This is called an intra-aortic balloon pump.

At the end of the procedure the artery may be closed with a special plug to stop the bleeding.

Medication such as Clopidogrel (Plavix or Iscover) is used for up to four weeks and sometimes longer. A small daily dose of Aspirin may need to be taken for the rest of your life.

This procedure will require an anaesthetic.

See Local Anaesthetic and Sedation for Your Procedure information sheet for information about the anaesthetic and the risks involved. If you have any concerns, discuss these with Dr Gonçalves.

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

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

• Minor bruising at the puncture site.
• The coronary artery can become narrowed or blocked again. Many factors can influence this and your doctor will discuss these with you.
• Loss of pulse in the arm after a radial artery (arm) procedure.
• Major bruising or swelling at the puncture site.

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

• Abnormal heart rhythm that continues for a long time. This may need an electric shock to correct.
• A heart attack
• .Surgical repair of the groin/arm puncture site or blood vessel.

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

• The stent may suddenly close within the first month. This can cause angina or heart attack. It may be treated with another angioplasty or with surgery.
• Emergency heart surgery due to complications with the procedure.
• A reaction to the medications given to prevent blood clotting.
• Minor reaction to the x-ray dye such as hives.
• Loss of kidney function due to the side effects of the x-ray dye.
• A stroke. This can cause long term disability.
• An allergic reaction to the x-ray dye.
• A higher lifetime risk of cancer from x-ray exposure.
• Rupture of a blood vessel requiring surgical repair and blood transfusion.
• Skin injury from radiation, causing reddening of the skin.
• Death as a result of this procedure is rare.

A coronary angioplasty and possible stenting may be offered as a treatment option for patients presenting with a heart attack.

Outcomes after angioplasty and stenting depend upon the following:

• age of the patient
• number of arteries supplying blood to the heart that are diseased
• location of the heart attack
• time taken to present to the hospital following the heart attack
• degree of blood flow in the blocked artery
• clinical status of the patient.

The less of these risk factors you have the better the clinical outcomes. If more than one artery is diseased you may need further procedures after some time.

If you are having angioplasty and stenting as treatment for a heart attack, the risk of a poor outcome may be higher than the risks above and depend on the severity of the heart attack.

• You should not eat or drink anything at least 6 hours before the procedure.
• You should inform Dr Gonçalves about an iodine allergy as specific medication is required prior to the procedure.
• Please bring your usual medication with you from home. Your blood pressure medication and medication for chest pain should be taken with a small sip of water prior to the procedure.
• Please inform the staff of any concerning symptoms after the procedure such as pain at the puncture site, chest pain and shortness of breath.
• You may eat and drink after the procedure, unless specifically told not to do so.
• If the procedure was done through the artery in the groin and no device is used to close the groin, you should remain flat in bed for 6 hours. If the artery is closed with a device you may mobilise after 2 hours.
• If the procedure is done though the arm you can mobilize immediately.
• You may leave only after discharge by Dr Gonçalves and after confirming with the ward staff. You may require discharge medication before leaving.
• If you have any concerns after leaving the hospital please contact the ward staff for advice or alternatively Dr Gonçalves’ rooms. 

A local anaesthetic is used to numb a small part of your body. It is used when nerves can be easily reached by drops, sprays, ointments or injections.

It is used to prevent or relieve pain, but will not put you to sleep.

Local anaesthetic is a less risky alternative (if appropriate) to having a general anaesthetic.
Sometimes a drip or IV will be put into a vein in your hand or forearm.

Common side effects and complications of a local anaesthetic:

• Nerve damage - Nerve damage, if it happens, is usually temporary, and will get better over a period of weeks to months. Damage may cause weakness and/or numbness of the body part that the nerve goes to. Permanent nerve damage rarely happens.
• Bruising (haematoma) - If you take Aspirin, Warfarin, Clopidogrel (Plavix and Iscover) or Dipyridamole (Persantin and Asasantin) you are more likely to get a haematoma as it may affect your blood clotting. Dr Gonçalves will discuss this with you.
• Failure of local anaesthetic - This may require a further injection of anaesthetic or a different method of anaesthesia to be used.

Less common side effects and complications of a local anaesthetic:

• Infection
• Damage to surrounding structures such as blood vessels, nerves and muscles.
• Allergy to the local anaesthetic solution.

Rare Risks and complications of a local anaesthetic:

• Overdose of local anaesthetic
• Seizures
• Cardiac arrest may cause death.

Bring all your prescribed drugs, those drugs you buy over the counter, herbal remedies and supplements and show Dr Gonçalves what you are taking. Tell Dr Gonçalves about any allergies or side effects you may have.
Drink less alcohol as alcohol may alter the effects of anaesthetic drugs. Do not drink any alcohol 24 hours before the procedure.

Stop taking recreational drugs before the procedure as these may affect the anaesthetic. If you have a drug addiction, please tell Dr Gonçalves.
If you take Aspirin, Warfarin, Clopidogrel (Plavix and Iscover) or Dipyridamole (Persantin and Asasantin) or any other drug that is used to thin your blood ask Dr Gonçalves if you should stop taking it before the procedure as it may affect your blood clotting.

You must tell Dr Gonçalves of any:

• Health problems
• Infectious diseases
• Past operations
• Serious illnesses
• Any medical problems needing regular treatment or a stay in hospital including diabetes and high blood pressure
• Allergies/intolerances of any type.

For your own safety ask Dr Gonçalves whether you can:

• drive any type of car, bike or other vehicle.
• operate machinery including cooking implements.
• drink alcohol, take other mind-altering substances, or smoke. They may react with the anaesthetic drugs.

Take care not to injure or bump area that has been numbed with the local anaesthetic as you will not be able to feel it.

The exercise stress test measures the function of the heart, lungs and blood vessels. It is done to help diagnose blocked arteries in the heart (coronary artery disease), assess abnormal heart beats or to check the function of pacemakers.

Before the test starts, an electrocardiogram (ECG) is taken. This is a paper recording of your heart beat.

Next, your heart is exercised or ‘stressed’. If you can walk easily, you can walk on the treadmill. The speed and slope of the treadmill will increase every three minutes. This makes your heart do more work. The test will be stopped if you have severe chest pain, become very tired or very short of breath (puffed). Your pulse, blood pressure and electrocardiogram are monitored during and after the test. If the doctor is worried about this, the test is stopped.

If you feel unwell you should tell staff at once.

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

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

• Mild angina.
• Shortness of breath.
• Musculoskeletal discomfort.

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

• Low blood pressure.

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

• Fainting.
• Abnormal heart rhythm that continues for a long time. This may need an electric shock to correct.
• Build-up of fluid in the lungs. You may need medication to treat this.
• Severe chest pain. This is treated with medications.
• Heart Attack
• Death as a result of this procedure

Your anaesthetist is a specialist doctor who will:

• assess your health and then discuss with you the type of anaesthetic suitable for your surgery.
• discuss the risks of suitable anaesthetic options.
• agree to a plan with you for your anaesthetic and pain control.
• be responsible for giving your anaesthetic and caring for you during your surgery and straight after your surgery.
• Most procedures that I will perform will be under local anesthetic. Only some procedures may require General Anesthetic.

Pre-medication
Pre-medication is a drug that may be given to you before an anaesthetic to help reduce or relieve anxiety. They are not given very often.

You will be having a General anaesthetic, a Local anaesthetic, a Regional anaesthetic or a combination of these.

General anaesthesia
A general anaesthetic is a mixture of drugs to keep you unconscious and pain free during an operation.

Drugs are injected into a vein and/or breathed in as gases into the lungs. A breathing tube will be put into your windpipe to help you breathe while under the anaesthetic. The tube is removed as you wake up after surgery.

Local anaesthesia
A local anaesthetic is used to numb a small part of your body. It is used when nerves can be easily reached by drops, sprays, ointments or injections.

Regional anaesthesia
Regional anaesthesia is where a large part of the body is numbed, for example epidural and spinal anaesthetics. These techniques are used to stop pain during the operation, and/or for stopping pain afterwards.

With local and regional anaesthetics you can stay awake or you can sleep through the surgery (by giving you sedation or a general anaesthetic as well) but whether you are awake or asleep you are free from pain.

Modern anaesthesia is generally very safe. Every anaesthetic has a risk of side effects and complications. Whilst these are usually temporary, some of them may cause long- term problems.

The risk to you will depend on:

• whether you have any other illness
• personal factors, such as whether you smoke or are overweight
• how simple or complex your surgery is
• whether your surgery takes a short or a long time and
• whether your surgery is done in an emergency.

Common side effects and complications of anaesthesia

• Nausea or vomiting
• Headache
• Pain and/or bruising at injection sites
• Sore or dry throat and lips
• Blurred/double vision and dizziness
• Problems in passing urine.

Less common side effects and complications of anaesthesia

• Muscle aches and pains
• Weakness
• Mild allergic reaction - itching or rash
• Temporary nerve damage.

Uncommon side effects and complications from anaesthesia

• Being awake under general anaesthetic
• Damage to teeth and dental work
• Damage to the voice box and cords, which may cause a temporary hoarse voice
• Allergic reactions and/or asthma
• Blood clot in the leg
• Epileptic seizure
• Chest infection (more likely with smokers)
• Permanent nerve damage due to the needle when giving an injection or due to pressure on a nerve during the surgery
• Worsening of an existing medical condition.

Rare risks which may cause death

• Severe allergy or shock
• Very high temperature
• Stroke or heart attack
• Vomit in the lungs (pneumonia)
• Paralysis
• Blood clot in the lungs
• Brain damage.

Increased risks
Risks are increased if;

• you are elderly
• smoke and
• are overweight

and if you have the following:

• A bad cold or flu, asthma or other chest disease
• Diabetes
• Heart disease
• Kidney disease
• High blood pressure
• Other serious medical conditions

Risks of a regional anaesthetic

Rarely, damage to nearby structures (eg blood vessels, lungs).

Nerve damage, due to bleeding, infection or other causes. This may cause weakness and/ or numbness of the body part that the nerve goes to. This is usually mild and only lasts a short time.

Rarely, nerve damage, may be severe and permanent. With an epidural or spinal this may cause paralysis of the lower half of the body (paraplegia) or all of the body (quadriplegia).

Extra specific risks with spinal and epidural anaesthesia are:

• Headache. Usually temporary but may be severe and can last many days.
• Backache. This is usually temporary due to bruising around the injection site. Rarely can it be long-term.
• Difficulty in passing urine. Usually temporary but for a few men it may require a consultation with a urology specialist.

You are at less risk of problems from an anaesthetic if you do the following:

• Increase your fitness before your surgery to improve your blood circulation and lung health.
• If you are overweight, loosing some weight will reduce many of the risks of having anaesthetic.
• Give up smoking at least 6 weeks before your surgery to give your lungs and heart a chance to improve. Smoking cuts down the oxygen in your blood and increases breathing problems during and after an operation.
• Bring with you to hospital all your prescribed drugs, those drugs you buy over the counter, herbal remedies and supplements and show your anaesthetist what you are taking.
• Tell your anaesthetist about any allergies or side effects you may have.
• Drink less alcohol as alcohol may alter the effect of the anaesthetic drugs. Do not drink any alcohol 24 hours before surgery.
• Stop taking recreational drugs before surgery as these may affect the anaesthetic. If you have a drug addiction please tell your anaesthetist.
• If you take Aspirin, Warfarin, Persantin, Clopidogrel (Plavix and Iscover) and Asasantin ask your surgeon and anaesthetist if you should stop taking it before surgery as it may affect your blood clotting. You should not stop these without medical advice.
• If you are on the contraceptive pill let the surgeon and anaesthetist know.

You must tell the hospital doctor and the anaesthetist of any:
− Health problems
− Infectious diseases
− Past operations
− Serious illnesses
− False teeth, caps, loose teeth or other dental problems
− Any medical problems needing regular treatment or a stay in hospital including diabetes, high blood pressure
− Allergies/intolerances of any type

It is very important not to eat, drink, chew gum or lollies before your surgery. You will be told when to have your last meal and drink. If you eat or drink after that time, your operation maybe delayed or cancelled.

This is to make sure your stomach is empty so that if you vomit under the anaesthetic, there will be nothing to go into your lungs.

After the surgery, the nursing staff in the
Recovery Area will watch you closely until you are fully awake.

You will then be returned to the ward or Day Procedure Area where you will rest until you are recovered enough to go home.

Tell the nurse if you have any side effects from the anaesthetic, such as headache, nausea, or vomiting. The nurse will be able to give you some medication to help.

The anaesthetist will arrange pain relief, any other medications and extra fluids by a drip if needed.

Some ways of giving pain relief are:

• Tablets or pills – used for all types of pain. You need to be able to eat and drink and not feel sick for these to work. These take at least half an hour to work.
• Injections – the most common way giving pain relief. Injections are given into a muscle and will take 20 minutes to work. Injections can also be given into a vein, pain relief is within a few minutes.
• Suppositories – these are small pellets that are placed into your back passage (rectum) for pain relief.
• Patient-Controlled Analgesia (PCA) – this is where you control your own pain relief by pressing a delivery button to cause injection (via your drip) of strong pain relief drugs.
• Local/regional anaesthesia - this was explained under the types of anaesthesia heading.
• If you have had a general anaesthetic the surgeon often injects local anaesthetic into the wound while you are asleep; this can give you around 4 – 6 hours of pain relief afterwards before it wears off.

A general anaesthetic will affect your judgment for about 24 hours. For your own safety;

• Do NOT drive any type of car, bike or other vehicle.
• Do NOT operate machinery including cooking implements.
• Do NOT make important decisions or sign a legal document.
• Do NOT drink alcohol, take other mindaltering substances, or smoke. They may react with the anaesthetic drugs.
• Have an adult with you on the first night after your surgery.

• Consume enough until just full (caloric restriction may be ideal).
• Avoid processed foods (The axis of evil – salt, sugar and fat)
• Avoid dairy products – substitute soya
• Avoid animal protein – If you must – dark oily, fresh fish x1 per week
• Avoid nutritional supplements (except perhaps Vit B12)
• Have 3 meals a day.
• Consume fresh, whole plants (ideally raw):
  
  • Grains x 3 portions daily (each portion is one small cup)
  • Vegetables x 10 portions daily (including x 3 legumes – ideally soya,
    plenty green leafy plants, nuts, seeds and sprouts (x1))
  • Fruits x 5 portions daily

Why change?

• Reduced CV death (lower BP, improved lipid profile)
• Reduced cancer rates– Breast, prostate, colorectal etc
• Reduced obesity
• Reduced diabetes mellitus type II
• Reduced autoimmune disease rates
• Reduced osteoporotic fracture rates
• Reduced macular degeneration
• Reduced gout attacks
• Reduced renal stones
• Reduced dementia rates
• Enhanced longevity (10% with caloric restriction alone)

Suggested Reading

• The China Study (by Colin Campbell)
• The Blue Zones

Recipe Books

• Forks over knives
• Easy living food
• Rawlicious

Suggested Films

• Forks over knives
• The end of the line
• Food Inc.

Places To Visit

• The fresh earth food store
• Leafy greens café

A pacemaker will treat a slow heartbeat.

There are three types of Pacemakers.

The doctor will decide which Pacemaker suits your condition.

i. Single Chamber: one lead to the lower chamber of the heart.
ii. Dual Chamber: two leads. One to the upper and one to the lower chamber of the heart.
iii. Biventricular: three leads. One to the upper and two to the lower chambers of the heart.

A Pacemaker is made of two parts, a pulse generator, which gives off impulses and a lead(s), which sends impulses to and from the heart. The pacemaker is ‘programmed’ to your needs by the doctor who puts the device in. An external machine is used to check the pacemaker. The rate of the pacemaker can be set using this machine. As part of the clinic test, the pacing speed of your pacemaker may be temporarily increased and decreased. Then it will be reset to its normal setting.

Pacemakers ‘stand by’ until the heart rate falls below the set rate of the pacemaker. It will then step in and ‘pace’ your heart rate.

You will have the following procedure:

A needle with a tube connected to it will be put in your arm. This is called an intravenous line or IV. Before the procedure, you may be given antibiotics. These are given to prevent an infection from occurring.

You will have an injection of local anaesthetic. The pacemaker is put in below the left or right collarbone, just under the skin. The skin is cut to put the pacing wires (leads) into a vein which leads to the heart. The leads are threaded down the vein, into the heart. The doctors can see the lead using x-ray imaging. Once positioned in the heart, the leads are tested to make sure they are working properly.

Then they are connected to the ‘pulse generator’. The pulse generator is placed under the skin and then the skin is sewn back together.

Pacemaker Device

The battery is checked each time you come to your clinic appointment. The battery lasts between 6 and 8 years and cannot be recharged. When the battery needs changing, it will require a procedure similar to this.

This procedure will require an anaesthetic.

See Local Anaesthetic and Sedation for Your Procedure information sheet for information about the anaesthetic and the risks involved. If you have any concerns, discuss these with your doctor.

If you have not been given an information sheet, please ask for one.

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:

• Bruising at the pacemaker site.

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

• The pacemaker lead can move. The lead will need to be put back into place by repeating this procedure.
• Bad bruising if you are taking blood thinning drugs such as Warfarin, Aspirin, Clopidogrel (Plavix or Iscover) or Dipyridamole (Persantin or Asasantin).
• Unexpected pacemaker failure. There is a risk of battery (generator) or lead failure. This is uncommon but means the battery or lead will need to be removed and a new one put in.
• Infection of the pacemaker site. This will need treatment with antibiotics and/or removal of the pacemaker.

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

• A punctured lung. This may require a tube to be inserted into the chest to reinflate the lung.
• Blood clot in the subclavian vein.
• A hole is accidentally made in the heart or heart valve. This will need surgery to repair.
• Blood clot in the lung.
• Heart attack.
• A stroke. This can cause long term disability.
• Death is possible due to the procedure or other heart problems.

• You should not eat or drink anything at least 6 hours before the procedure.
• You should inform Dr Gonçalves about an iodine allergy as specific medication is required prior to the procedure.
• Please bring your usual medication with you from home. Your blood pressure medication and medication for chest pain should be taken with a small sip of water prior to the procedure.
• Please inform the staff of any concerning symptoms after the procedure such as pain at the puncture site, chest pain and shortness of breath.
• You may eat and drink after the procedure, unless specifically told not to do so.
• The arm will be placed in a sling after the procedure.
• You may leave only after discharge by Dr Gonçalves and after confirming with the ward staff. You may require discharge medication before leaving.
• If you have any concerns after leaving the hospital please contact the ward staff for advice or alternatively Dr Gonçalves’ rooms. 
• You cannot drive for 4 weeks after a pacemaker.
• You must keep your arm in the sling for 4 weeks.