Cardiac Catheterization is a test which involves taking photographs and moving images for venticular function, coronary arteries and coronary angiogram and it serves as a guide in interventional elimination of cardiologic disorders. Hacettepe University Cardiology catheter laboratory has given service for about 35 years and approximately 3500 procedures are performed annually. The laboratory is comprised of 2 coronary angiogram rooms and 1 electrophysiological study room. It was revised at February 2002 and equipped with state-of-art devices (Siemens 2000 coroscop). It gives service until evening from 08:00 a.m. on weekdays.

In general, coronary angiogram comes to mind when it is said cardiac catetherisation. Coronary angiogram is generally performed in the event of a strong clinical suspect of coronary heart disease or due to an abnormal non-invasive evaluation. The aim is to identify the spread and the criticality of heart disease and determine the treatment option to be applied (bypass surgery, angioplasty and medical treatment).

Cardiologists can use cardiac catheters in order to expand a narrowed heart valve, coronary artery or a bypass graft. In addition to classic balloons, atherectomy devices, stent or laser angioplasty can also be used in order to open blocked or narrowed vessels. Stents are steel structures which prevent the walls of vessels from sticking to each other and keep the vessel in an open status.

Angioplasty (PTCA) involves opening a narrowed or blocked coronary vessel without performing a surgery or applying general anesthesia. The introduction of coronary stents into use and successfull application of other new techniques and assistive antiplatelet treatment in our day has resulted in increasing types and number of blockages to which angioplasty is applied, yet the need for bypass is reduced down.

Hacettepe Cardiology Catheter Laboratory offers emergency angioplasty opportunity for patients with acute myocardial infarction on a 24-7 basis.

Heart angiogram is a test method which involves entering into the leg artery, or in the event that this vessel is not favorable, into the arm artery in order to identify the structure of heart vessels, contraction strength of heart muscle, the status of norrowness and leakage of heart valves. General anesthesia is not applied to the patient during the procedure; only the entered area is locally anesthetised. It is not a painful procedure and can generally be performed within a short period of time. As primary artery is entered into, patients are given bed rest for a while,so that bleeding does not occur after the procedure. The patient is hospitalized during this period and all of the needs of the patient are fulfilled without moving out from the bed. The patient is discharged after one day of follow-up.

Heart angiogram is not a treatment method. It is only a test and the treatment plan is made in accordance with the result of this test.

Similar to every invasive method, heart angiogram also poses certain risks. Bleeding from the place of procedure, injury of the entered artery, nausea-vomiting during procedure, allergic reaction against medication administered during angiogram, occurance of infection due to failure to keep the place of procedure clean are the most common adverse effects. Besides these, more critical adverse effects which are less common can also occur. These effects can be seen more frequently particularly in the event that the procedure is performed in emergency situation. In order to minimize these undesired effects, you should cooperate with the hospital and inform your physician on the medication you are on, your other diseases and known medication allergies.

Considerations before cardiac catheterisation, coronary angiogram, angioplasty

• Keeping an empty stomach is required for at least 12 hours, starting from the night before.

• Shave of both of the groin areas and take a shower. Shave off the groin area by including all of front, side and rear areas of the leg.

• Bring along the medication you are on.

• Ask your physician if you would need to stop taking any of your medication on the day before your angiogram appointment.

• Particularly, diabetic patients should not use their medication for this disease (insulin or pills) on the morning of the appointment; otherwise your blood glucose can drop down to unfavorable levels.

• You should definitely remember to bring along your Retirement Fund (Emekli Sandigi) / Social Security Organization for Artisans and the Self-Employed (Bag-Kur) health record / all of your documents regarding SSI dispatch, your private life insurance card or institutional dispatch document with you.

• Please confirm the validity and expiry date of official documents such as dispatch report before the appointment day.

• You should bring along your hospital file if it is at your home.

• You should bring along the report of your previous angiogram, if any.

• You should bring the report of your previous heart surgeries, if any.

• You should bring along all of your blood test results, X-rays and, if any, reports about your disease with you.

• You can bring pajamas or sweat suit and slippers while you come to be hospitalized.

• Do not bring any valuable items or jewelry.

• One person can be accepted as an all-day visitor if the patient wishes.

It is a unique technique as it is not an invasive procedure for anatomical and functional evaluation of heart and it is completely safe and risk-free. It involves imaging the reflections of ultrasonic sound waves. It has eco varieties such as 2-dimensional, M mode, Doppler (spectral and color) and types such as transesophageal, stress echocardiography. A routine electrocardiogram evaluation includes 3 stages: 2-dimensional, spectral and color Doppler electrocardiogram. After a gel is applied to the chest of the patient while lying on the bed on the left side or on supine position, tomographic images of the heart are taken from different cross-sections by means of a probe. After electrocardiogram, information is obtained regarding the status of pumping functionality of heart, the structure and functionality of valves and structural abnormalities of heart.

The flows in the heart create red, blue and green color (flowing towards the probe is red, flowing away from the probe is blue and flow jets are green) based on their movements according to the probe in Doppler echocardiogram. It is important for identifying the existence and the criticality of leakage and stenosis of heart valves as well as diagnosing congenital heart defects and heart muscle diseases. Hacettepe University Cardiology Department provides service with a total of 5 echocardiograph instruments, one of which is reserved for use in catheterization laboratory. The echocardiograms of patients who have scheduled appointment from the normal outpatient clinic are performed in Echo unit of outpatient clinic of cardiology from 09:00 to 12:00 while the echocardiograms of patients who received examination in the outpatient clinic of academic staff are performed in Echo unit which is located in Cardiology on floor Z. A usual echo test takes about 20-30 minutes and is performed in a few different ways:

1. Transthoracic echocardiography
It is the method which is applied as the routine. This noninvasive test involves applying gel on the chest of patient who is in lying position and it is performed with a probe.
You do not need to make a special preparation before coming to your appointment.
The result is given directly after the test.

2. Transesophageal echocardiography
This test has been developed in order to obtain a better image of the heart sections that cannot be evaluated by means of a routine echo. Similar to endoscopy, a preliminary preparation which includes topical anesthesia and, sometimes sedative medication is carried out and passing down the probe with a transducer mounted at its tip by means of swallowing and various cross-sectional images of the heart are taken by progressing into the esophagus (gullet) and sometimes into the stomach.

It is particularly preferred in the event of a suspect from structural heart abnormalities (congenital heart defect: ASD, VSD, etc.) or thrombus (blood clog) in heart chambers as well as in case of infective endocarditis. Furthermore, it is extremely valuable in diagnosing aortic dissection and it offers the advantage of applicability in intensive care, by the bed and during an operation. Transesophageal echocardiogram is performed by an experienced team 5 days a week in Hacettepe Cardiology. It takes about 15-20 minutes.

Considerations about transesophageal echocardiography
Transesophageal echocardiography is a test method which provides opportunity for a closer and clearer evaluation of heart chambers thanks to the electrocardiogram method which is inserted into the esophagus by means of swallowing.

As nausea can occur during swallowing the probe during the procedure, you should keep an empty stomach starting from at least 6-8 hours before the procedure, in order to prevent vomiting and gastric contents from leaking into trachea.

Your threat will be locally anesthetized in order to reduce your nausea feeling before starting echocardiogram. As the effect of this medication lasts for 2-3 hours, you should not eat or drink anything for 2-3 hours after the procedure in order to eliminate the risk of failure in swallowing food and aspirating it into the trachea.

If you have removable dental prosthetics, please take these off before the procedure as these can be aspirated into your trachea otherwise.
If you cannot breathe from your nose or you have an esophageal disease, make sure that you definitely inform your physician before the procedure.

Transesophageal echocardiography is a test which is completed in a short period of time. The procedure can easily be performed with your help. It allows your physician to obtain better information about your disease as it offers clearer images compared to echocardiography performed on the chest wall. Dental injury, mild bleeding in the throat, esophageal injury particularly by patients with esophageal diseases, difficulty in breathing by patients who cannot breathe from the nose and aspiration of vomited gastric contents into the trachea in the event of not arriving with empty stomach are the adverse effects that can occur during the procedure. As it has been explained above, the majority of these can be minimized with measures.

You should keep an empty stomach starting from at least 6-8 hours before the procedure.
Make sure that you bring along the contents of your prescription which has been given to you, if any.
Please remember to bring along the report of echocardiogram taken from your chest wall and your file.

3. Stress echocardiography
This echocardiography type is based on identification of abnormal contraction in the ischemic areas
It is generally performed with medication (dobutamin) in Hacettepe Cardiology. The advantages of stress echocardiography over cardiac stress test are: enhanced accuracy, no radiation exposure, reasonable pricing, providing information on cardiac hemodynamic and valvular functions changing with exercise. Furthermore, this method is preferred in the events that ECG cannot be evaluated.

Echocardiography laboratory provides important information for valvular heart diseases, ischemic heart disease, pericardial diseases, cardiac masses, diseases of primary blood vessels, pulmonary diseases and congenital heart defects.

Treadmill test is performed as stress test in Hacettepe Cardiology. A patient, who is attached to an ECG with 12 derivations, is asked to exert on a treadmill which starts with a slow pace and gradually accelerates in scope of predetermined protocols. It is a preferred method as it is noninvasive, cheap and it has comparatively low rate of complications. Treadmill, which is easier for the patients, is tested for patients with a clinical suspect about a coronary heart disease, with the aim of evaluating effort capacity, as a part of rehabilitation program, for revealing stress-related problems and more uncommonly, for monitoring medication treatment. The test is accepted positive in certain circumstances such as depression in the ST segment indicated by ECG, occurrence of typical chest pain or hypotension. Then, coronary heart disease diagnosis is finalized with an advanced test such as cardiac catheterization. 

Considerations about treadmill (stress test)
Treadmill test involves taking your ECG serially and monitoring your blood pressure while you walk on the treadmill in certain paces. In enables abnormal findings, which cannot be detected within your ECG during rest, to be detected after effort. On the condition that you comply with the recommendations described above, it is a safe test which lasts for a short period of time and provides important information about your disease.

Before you come to your treadmill appointment
Do not eat anything for 3 hours before the test.
Bring along your previous ECG.
Male patients need to shave their chests.
It is more suitable for female patients to wear two-piece clothes.

Please stop taking the following medications at least 48 hours before the test if you are using any of these: dideral, prent,tensinor, visken, lopressör, trasicor,beloc,betadol,nortan,artex,concor,diltizem
Patients using Digoksin should stop taking the medication 1 week before.
Please do not stop taking any other medication, particularly the ones you use due to high blood pressure, other than mentioned above (unless otherwise stated by your physician). Otherwise, your blood pressure can increase too much and your test cannot be performed.

Heart can generate electrical stimuli to itself. The specialized cells which generate these are located in the sinus node within the right atrium. These specialized cells generate 50-100 impulses per minute provided that heart functions normally. After each impulse, electrical activity spreads to the rest of the heart with a specialized transmission system.

During the application of electrophysiology, thin catheters are inserted into heart chambers through vessels and records are kept from different points of the heart or impulses are given in order to generate abnormal rhythm. Although this may seem like a dangerous procedure, it is even worse if it occurs outside the hospital and it cause death. In the event that an abnormal rhythm is triggered or an abnormal route other than the normal impulse system of the heart is detected, this abnormal impulse can be eliminated through radiofrequency ablation method. Implantable cardiac defibrillators (ICD) are opted for patients who are detected to have fatal arrhythmia while pacemaker is the method to be preferred for patients with severe slow heartbeat or momentarily stopping heart.

Approximately 150-200 Electrophysiology Studies (EPS) are conducted annually in the electrophysiological study laboratory located within cardiac catheterization laboratory. Furthermore, permanent pacemaker and implantable defibrillator, 3D electrical mapping, intracardiac defibrillation, RF ablation and cyroablation services are also provided in EPS laboratory.

Before you come to your appointment
The rules for coronary angiogram preparation shall apply.
As your physician will instruct you, you will need to stop using certain medication that you use starting from the time to be stated to you.

Heartbeats are recorded by a device worn for 24-48 hours and then these are converted into an ECG tracing with a software. Therefore, abnormal rhythm, extra beats as well as changes which can indicate ischemia in ECG can be determined. It can also be worn in order to monitor the effects of an applied treatment. Everyday, 12 holter monitoring appointments are booked by Hacettepe Cardiology Department for the holter room located in the outpatient clinic of cardiology at the supplementary building of outpatient clinics. The results can be received from the same place 1 day after submitting the device.

Considerations before Holter monitoring
You should bring an AA battery as well as your ID card along. It is very important that you bring back the monitor worn by you in time, as it will be worn by other patients after you.

Male patients need to shave their chests before arriving for Holter monitoring.

It requires a patient to wear a portable device which measures and records the readings of blood pressure once in every 15 or 30 minutes for 24 hours. Also, it is rarely attached to patients who are considered to suffer from white coat syndrome or indicate the symptoms of hypotensive or hypertensive attacks, with the aim of assessing the response to the treatment. 4 ambulatory blood pressure appointments are booked by our department every day and the devices are attached in outpatient clinic of cardiology at the supplementary outpatient clinic building.

It is a portable device which is down by the patient for 15 days and allows detecting any arrhythmia not identified during holder monitoring. Therefore, appointments are booked with intervals of 15 days. 4 event recorders are available in the department. The patient presses the button whenever he/she starts to experience the symptom of interest, and the device starts keeping a record of 2 minutes.
Later on, these records are reviewed on computer.
Please bring one AA battery and 10 electrodes while arriving for your appointment.

It is conducted in case of emergency by opening an intravascular line and monitoring the patient in an environment suitable to any kind of intervention. The patient is instructed to lay down on a table that can move. The table is tilted to 60-80 degrees and the patient is monitored for approximately 45 minutes by checking the blood pressure and pulse rate once in every 5 minutes. It includes two stages: Evaluation of carotid sinus sensitivity and evaluation of the vasovagal reflex of patient on the given inclination of table. It is used for the differential diagnosis of neurocardiogenic syncope, which is one of the most common reasons of fainting. Every Tuesday, 2 patients are given tilt test in the catheter laboratory.

Please do not have breakfast the morning you arrive for your appointment. If you suffer from narrowing or blockage of your neck vessels (carotid artery), you should definitely remind this to your physician.

The lifespan, electrode resistances and conductivities as well as threshold tests of pacemaker of ICD are evaluated with a special device placed on the permanent pacemaker or ICD on the chest wall.

Please remember to bring your pacemaker card and reports of your previous check-ups as well as, if you have it, your file along while coming for your appointment.

As Hacettepe University Department of Cardiology does not have its subordinated nuclear cardiology unit, these services are provided by our Department of Nuclear Medicine.

It is practiced at School of Physical Therapy and Rehabilitation. In addition to the rehabilitative assistance offered to patients recovering from a cardiac disease, it also proves to be protective for those under the risk of cardiac disease. When patients are hospitalized for angina, angioplasty or heart attack, they are registered in this program upon the request and permit of their physicians. Beginning in the hospital, this program can continue for a few months or, in certain circumstances, for a lifetime after being discharged. In addition to medical counselling, it also features as instructional, dietary and physiological counselling. There is also an exercise program practices in this context which gradually increases in order to ensure that the cardiac patient achieves the best and the safest effort capacity.