Cardiac Implant

ELECTROCARDIOGRAM (ECG)

This records the electrical signals in your heart. Electrodes are placed on your chest and a recording is made of your heart rhythm to detect structural abnormalities of the heart and disorders of heart rhythm.

EXERCISE TREADMILL TEST

The exercise treadmill test allows us to assess the response of your heart to exercise and detect significant blockages of the heart arteries and heart rhythm abnormalities. This is done by recording your ECG and monitoring your blood pressure while you walk on a treadmill.

ANKLE BRACHIAL PULSE WAVE VELOCITY/PRESSURE INDEX

The Ankle Brachial Index benchmarks the systolic blood pressure from both brachial (arm) arteries and from both dorsalis pedis and posterior tibial (foot) arteries. The measurement of this pressure is used to detect significant blockages of the leg arteries. Pulse Wave Velocity measures the speed at which the pulse travels through the artery to assess its stiffness and your risk of future stroke and heart attack.

TRANSTHORACIC ECHOCARDIOGRAM (2D ECHO)

This is an ultrasound machine with a probe specially designed to image the heart. Through these images, we can assess the chambers, valves, large blood vessels and the pumping function of your heart.

CAROTID INTIMA MEDIA THICKNESS (CIMT)

Thickening of the arteries is a result of ageing and the presence of risk factors such as high cholesterol, high blood pressure, smoking, obesity, diabetes leading to cholesterol becoming deposited in the artery layers. This can lead to narrowing and even complete artery blockage and also increases the risk of blood clots forming within the blood vessel.

Thickened carotid arteries are a known precursor to future heart attacks and stroke. A thickness greater than 1 mm doubles the risk of you developing a heart attack or stroke in the next six years. Such changes in the carotid artery reflect changes in other arteries found in various organs so this test is an easy and safe way to assess the health of arteries throughout the body.

The CIMT test is an ultrasound scan that measures the thickness of the intima and media layers that line the carotid arteries, which are found just beneath the skin on either side of the neck and supply blood to the brain. During this 20-minute test, your doctor will apply a colourless gel to your neck then run an ultrasound scanner slowly up and down your neck to scan the entire length of each carotid artery. The thickness of the intima-media is measured along with the flow rate of blood passing through the artery.

EXERCISE AND DOBUTAMINE STRESS ECHOCARDIOGRAM

You may experience no or minimal symptoms of a heart artery blockage while at rest but symptoms may be more evident when the heart is stressed by exercise or medications that stimulate the heart. The narrowed arteries can’t enlarge to accommodate the increased blood flow, which compromises blood flow to the heart muscle, starving it of oxygen. Stress echocardiography is capable of diagnosing significant disease in more than 85% of patients with significant narrowing of the heart arteries. It is an outpatient test that takes about 90 minutes. Learn more.

TRANSESOPHAGEAL ECHOCARDIOGRAM (TEE)

This is an essential tool in assessing valvular function and in helping your cardiologist make decisions about your treatment. It uses high-frequency ultrasound waves to produce detailed pictures of your heart and the arteries that lead to and from it. Rather than the transducer that produces the sound waves being placed on your chest as in normal ultrasound scans, it is placed on the end of a tube inserted into your mouth, down your throat and into your oesophagus. Because the oesophagus is close to your heart, clear images can be obtained using this method.

24-HOUR AMBULATORY BP MONITORING

This test monitors your blood pressure (BP) for a continuous 24-hour period as you go about your normal daily life and gives a more accurate reflection of your true BP than a one-time test in our clinic. Your blood pressure is taken by a small digital blood pressure monitor attached to a belt around your waist and connected to a cuff around your upper arm.

TRANSTELEPHONIC ECG

AMBULATORY HEART TELEMETRY MONITOR

This is a wireless, battery-operated portable device that measures and records your heart’s electrical activity (ECG) continuously and remotely. Due to its ease of use, we can continuously record your heart rhythm for up to one week.

SIGNAL AVERAGED ELECTROCARDIOGRAM (SAECG)

This is a special ECG technique in which multiple electrical signals from the heart are averaged to remove interference to reveal subtle abnormalities not visible in a conventional ECG. The presence of these abnormalities predict an increased likelihood of potentially dangerous electrical heart rhythm abnormalities.

CARDIAC RESYNCHRONISATION STUDY

This comprehensive transthoracic echocardiogram (2D Echo) study obtains additional information on the movement of the walls of the heart. It is used to identify whether, as a patient with severe heart failure in spite of optimum medical therapy, you may benefit from Cardiac Resynchronisation Therapy (CRT-D).

TILT TABLE TESTING

You may undergo this test if you have had unexplained black outs or loss of consciousness in a bid to diagnose “vasovagal syncope”, a reflex black out that tends to occur in young people. During the test, you will be strapped to a special table which is then tilted to a vertical position as your heart rate, blood pressure and ECG are continuously monitored. If you black out, the test will be terminated immediately by returning the table to its horizontal position.

CORONARY COMPUTED TOMOGRAPHY (CTA)

A Coronary Calcium Scan measures the amount of plaque or calcium in the walls of your coronary arteries. It provides a calcium score, which your cardiologist will use alongside other health information to determine your future risk of coronary artery disease or heart attack before you develop any symptoms.

Coronary CTA provides pictures of the coronary arteries, which supply blood to the heart muscle, in a non-invasive manner. It enables your cardiologist to look for narrowings, some of which cannot be detected by the more traditional exercise testing, but which cause around three quarters of all heart attacks. Detecting these narrowings early is important as medications can be prescribed to prevent an impending heart attack. Based on the results from the CTA, your surgeon will order further tests to decide on any course of treatment.

We use the latest generation, state-of-the-art Toshiba 64-Slice Coronary CTA scanner, which can simultaneously acquire 64 image slices of the heart in one minute, resulting in highly detailed images of the coronary arteries and the heart

CORONARY CALCIUM SCAN

Coronary artery disease occurs when plaque builds up and narrows the arteries that supply blood to your heart (atherosclerosis) and is the leading cause of heart attacks.

You should consider having a coronary calcium scan if:

you are a man over 45 years of age
you are a woman over 55 years of age
you have at least one of the following risk factors
family history of heart disease
high cholesterol
high blood pressure
diabetes
smoker

The procedure takes about 5 minutes, involves no injections and does not require you to fast beforehand.

CORONARY ANGIOPLASTY

Coronary angioplasty, also called percutaneous coronary intervention, is a procedure used to open clogged heart arteries. Angioplasty involves temporarily inserting and inflating a tiny balloon where your artery is clogged to help widen the artery. It is often combined with the permanent placement of a small wire mesh tube called a stent to help keep the artery open and decrease its chance of narrowing again. Some stents are coated with medication to help keep your artery open (drug-eluting stents), while others are not (bare-metal stents).

Angioplasty can improve symptoms of blocked arteries, such as chest pain and shortness of breath and can also be used during a heart attack to quickly open a blocked artery and reduce the amount of damage to the heart. Learn more.

CORONARY ANGIOGRAM

This is a procedure that uses X-ray imaging to view your heart’s blood vessels to find out if there is a restriction to the blood flow to the heart. During the procedure, a dye that is visible in an X-ray is injected into your artery to allow the vessels in the heart to become visible on X-ray.

LEFT MAIN STENTING

The left main is the main artery that gives rise to two main branches of the heart artery. If the left main is blocked, about 2/3 of the heart muscle will lose its blood supply. The conventional treatment is bypass surgery, although angioplasty is an alternative treatment option if a bypass is not possible.

IVUS

IVUS or intravascular ultrasound is a miniaturized ultrasound probe that can be placed into the heart arteries. This can help your cardiologist determine the severity of narrowing and the amount of cholesterol deposits within the wall of the artery. The results from an IVUS can give very specific information on the diameter and size of the artery, and can also be used to see if a stent is well placed and expanded within the artery. A well-placed and appropriately sized stent reduces the longer-term problems of renarrowing and clots.

ROTABLATION

Some artery narrowings have large deposits of calcium. In such cases, a device known as a rotablator may be required. This miniature “drill” is slowly advanced through the narrowing. Its metal tip coated with small diamond chips rotates at 160,000 rpm and reduces the calcium deposits to powder. Once the calcium is removed, stenting can be successfully carried out.

ACUTE OR EMERGENCY ANGIOPLASTY

Acute angioplasty is performed to reduce damage to the heart muscle following a heart attack caused when a clot chokes up a pre-existing narrowing resulting in no blood flow to the heart muscle. It is the ideal treatment as it is able to restore blood flow in more than 90% of cases and can be done in a timely fashion. Factors such as age and the size of the heart attack can influence the risk during this procedure.

PRESSURE WIRE

This is a wire the thickness of a hair that features a miniature pressure probe at its tip. It can help determine if the narrowing in an artery is compromising blood flow. It is placed before the narrowing in the artery and the pressure at this point is compared to a point in the artery beyond the narrowing to assess the pressure drop caused by the narrowing. If the pressure drop is greater than 20%, your cardiologist will recommend an angioplasty.

SAPHENOUS VEIN GRAFT

In bypass surgery, veins are often taken from the leg to be used as new pipes to supply blood to the heart muscle. These veins can become narrowed or blocked after initial successful surgery and, unlike the heart arteries, they degenerate over time and soft cheese-like material can accumulate in the walls of the veins. If angioplasty were performed, there is a high risk that these soft materials would dislodge into smaller particles and flow downstream to the smaller arteries in the heart muscles, causing a total blockage. Special techniques are needed to prevent this downstream flow of debris and ensure a successful result. These include the use of filters and balloons to catch the debris during angioplasty and to remove them from the body so that they can do no harm.

CHRONIC TOTAL OCCLUSIONS

Chronic total occlusions (CTOs) are narrowings that are totally occluded and have been present for some time. They are different from the total occlusions that occur in the acute setting of a heart attack. The blockages in the CTOs are sometimes very resistant to penetration and dilation, and the success rate of treatment can vary between 50-90%. Predictors of success include the age of the CTO, the amount of calcium deposits in the artery, the length of the total blockage and position of the blockage. A CTO can take many hours to successfully unblock. Occasionally, a special X-ray called a CT angiogram done before angioplasty can help in developing a strategy to successfully overcome a CTO.

HYBRID REVASCULARISATION

Hybrid Revasculerisation allows surgeons to work on the three main arteries of the heart using a combination of bypass and angioplasty (stent) procedures. Using this procedure, there is no need to stop your heart and place you on a heart/lung bypass machine as there would be in a full heart bypass operation in which a bypass procedure would be used for all three arteries.

Instead, your surgeon will only bypass the artery that is easiest to get to at the front of the heart, allowing for a less invasive procedure, and would insert stents or balloons into the other two arteries running at the back of the heart.

WHAT DOES HYBRID REVASCULARISATION INVOLVE?

This surgery is performed while your heart is beating. Your surgeon will graft the left internal mammary artery (LIMA) to the left anterior descending artery (LAD), which lies on the front surface of the heart so is easy to access. Your surgeon will then insert drug-coated stents into the other two arteries to stop narrowing. Clots that form in stents in these arteries are less dangerous than in the LAD artery.

The benefits of this surgery are that scars are much smaller and there is no need to take veins from your legs.

WHY NOT PERFORM ANGIOPLASTY ON ALL THREE ARTERIES?

Grafting the LIMA artery, taken from the breast, onto the LAD artery has been proven over time to provide a longer life span than angioplasty alone. Also, inserting a stent in the LAD artery rather than doing a bypass creates a higher risk of death if the stent clots.

WHY NOT PERFORM A TRADITIONAL HEART BYPASS?

A traditional heart bypass carries extra risk as all three arteries are operated on invasively and surgeons need to stop and move the heart to get to the two arteries that lie underneath the heart. There is also risk in placing you on a heart/lung bypass machine because small showers of debris can cause small strokes that may result in memory loss and forgetfulness. Additionally, veins used to bypass the two arteries under the heart are taken from the leg and these are not as robust as the LIMA artery that is used to bypass the front artery and there is a 20% likelihood of blockage in these weaker veins within a year of the operation.

WHO SHOULD GO FOR HYBRID REVASCULARISATION?

Your cardiologist will only recommend this hybrid procedure if the more traditional heart bypass surgery or angioplasty procedures are considered too risky for you and if it is thought you could benefit from hybrid revascularisation. Discuss the benefits and risks with your cardiologist.

HEART FAILURE MANAGEMENT

ACCURATE DIAGNOSIS OF HEART FAILURE

Patients can be wrongly diagnosed with heart failure, so we combine your clinical history, a physical examination, biochemical markers and cardiac imaging to accurately diagnose your condition.

MEASUREMENT OF N-TERMINAL PRO TYPE B NATRIURETIC PEPTIDE

This service helps us to diagnose and follow up with patients with heart failure. The measurement is taken in our clinic with results available within 15 minutes.

OPTIMAL MEDICAL THERAPY (OMT)

We select appropriate and evidence-based medications to achieve the best results for our heart failure patients.

HOME INOTROPIC THERAPY

We offer this treatment to chronic heart failure patients who are having multiple episodes of recurrent heart failure in order to keep them out of hospital.

CARDIAC RESYNCHRONISATION THERAPY (CRT)

Heart failure patients who have left ventricular dyssynchrony can be offered this special type of pacing therapy

IMPLANTATION OF IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)

This is done for patients with heart failure and severely depressed ventricular function to prevent sudden cardiac death.

LEFT VENTRICULAR ASSIST DEVICE

Heart failure is a chronic disease process that will progressively worse. The definitive answer to advanced heart failure is heart transplantation. However, there is a shortage of donor hearts worldwide and a viable alternative is to implant a left ventricular assist device (LAVD), a so-called artificial heart. This device can take over the function of the failing heart and provide you with a reasonable quality of life.

We use the latest HeartMate II LVAD, which is small enough to be implanted into the abdominal cavity of smaller adults, especially women and Asians. It is very quiet in operation and is ideal for patients who have advanced heart failure and who are dependent on inotropes or have frequent hospitalisations for heart failure.

SIX-MINUTE WALK TEST (6MWT))

This short exercise test helps us to assess the functional capacity of your heart before we decide on the course of treatment.

RIGHT HEART CATHERISATION

We use this to assess the hemodynamic profile of heart failure patients in order to adjust the treatment to tune up the patient.

ARRHYTHMIA MANAGEMENT

ELECTROPHYSIOLOGY STUDY AND CATHETER ABLATION

Electrophysiology studies (EPS) test the electrical activity of your heart to find where an arrhythmia (abnormal heartbeat) is coming from. These results can help you and your doctor decide how your condition will be treated.

An extension of EPS, catheter ablation is a non-surgical technique where a thin electrode catheter (a specially insulated electrical wire) is used to localise the abnormal site in the heart causing the arrhythmia. Radiofrequency energy is then delivered via the catheter to ablate (or destroy) it.

DEVICE IMPLANTATION

PACEMAKER

A pacemaker sends electrical pulses to your heart to keep it beating regularly and not too slowly. Having a pacemaker can significantly improve your quality of life if you have problems with a slow heart rate. It is a common treatment that can be lifesaving for some people.

IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD)

Similar to a pacemaker, this device sends a larger electrical shock to the heart that essentially “reboots” it to get it pumping again. Some devices contain both a pacemaker and an ICD. ICDs are often used as a preventative treatment for people thought to be at risk of cardiac arrest at some point in the future. If the ICD senses the heart is beating at a potentially dangerous abnormal rate, it will deliver an electrical shock to the heart. This often helps return the heart to a normal rhythm. The ICD’s pacing lead may be implanted along a vein or, in newer models, under the skin.

CARDIAC RESYNCHRONISATION THERAPY (CRT-D)

In this procedure, electrodes are inserted in the left and right ventricles of the heart (pumping chambers of the heart), as well as, on occasion, the right atrium (top chamber of the right heart), to treat severe heart failure by coordinating the function of the left and right ventricles via a pacemaker, a small device inserted into the interior chest wall.

HEART SECOND OPINION PROGRAMME

If you have been diagnosed with a heart condition, it is essential to get a second opinion to ensure all possibilities for treatment are considered. A second opinion can ease your mind, possibly prevent an unnecessary procedure and provide you with an alternative option to consider. The following are all legitimate reasons to seek a second opinion:

I’ve had heart surgery but have new symptoms I’m worried about

I’m not sure if my medication regimen is the best for me

I don’t think I’m being taken seriously with my symptoms

I want the latest advancements in surgical and medical treatment

We offer our Heart Second Opinion Programmed to provide you with immediate access to the expert opinion of our talented cardiac team, who specialize in the full range of subspecialty fields within a single centre to diagnose any heart-related problems and to assist patients who have been told that they need a heart-related surgical procedure.

Some of the diagnoses or procedures that we typically provide second opinions for include:

1. Atrial fibrillation

2. Pacemaker

3. Cardiac defibrillator

4. Heart failure

5. Cardiac catheterisation

6. Catheter ablation

7. Mitral or aortic valve repair or replacement

8. Bypass surgery

9. Heart transplant

10. Minimally invasive heart surgery

11. Transmyocardial revascularisation

12. Maze procedure

13. Mechanical/Left Ventricular Assist Device

14. Robotic cardiac surgery

15. Aneurysm

16. Arrhythmia

17. Stents

18. Cardiomyopathy

19. Hypertrophic cardiomyopathy (HCM)

20. Other cardiovascular disease