The Heart Center sees patients who are either referred by other physicians or who call in for appointment. Dr. Andres also attends to patients in all the area hospitals. The following services are offered:

Electrocardiogram (EKG,ECG) Holter Monitor Event Monitor Pacemaker insertion Pacemaker Clinic Echocardiogram (ECHO) with Doppler Trans-esophageal ECHO (TEE) Carotid Duplex Scan Exercise Testing Nuclear Imaging Chest Pain Clinic Abdominal Aortic Aneurysm What is in the future?

Cardiopulmonary Stress Testing Pulmonary Function Testing Segmental Pressure Measurement Cardiac Catheterization Peripheral Angiography Percuaneous Coronary Interventions (PCI) Balloon Angioplasty Directional Coronary Atherectomy (DCA) Rotational Atherectomy (PTCRA) Coronary Stenting Peripheral Angioplasty

Electrocardiogram (EKG,ECG) - A recording of the electrical activity of the heart. It may give a clue to the presence of previous heart attack, circulation problem, or rhythm abnormality.

Holter Monitor - Continuous tape recording of the electrocardiogram, usually for twenty-four (24) hours, to look for intermittent rhythm abnormality.

Event Monitor - Digital recording of the electrocardiogram that can be worn several days at a time to pick up less frequent episodes of rhythm abnormality.

Pacemaker insertion - Minor surgical procedure where a small battery operated computer with wires (electrodes) that lead to the chambers of the heart is inserted under local anesthesia, usually under the collar bone. Pacemakers stimulate the heart when the rate is too slow. They are capable of adjusting the heart rate during various phases of activity.

Pacemaker Clinic - This is a pacemaker surveillance that checks on implanted pacemakers. It is usually done through the scheduled interrogation by using a telephone transmitter and magnet. Occasionally, there is a need for a more detailed interrogation at the Heart Center with the use of a more sophisticated computer programmer.

Echocardiogram (ECHO) with Doppler Color Flow - An ultrasound study of the heart including the walls, valves and chambers, and the blood flow pattern inside the heart. It provides information about the size of the chambers, thickness and contractility of the walls, and abnormality in the valve function, either leaky or tight, that can result in turbulent flow. It can also show abnormal communications or even abnormal masses or growth in the heart and its adjacent structures.

Trans-esophageal ECHO (TEE) - An ultrasound study of the heart like the ECHO but done with a flexible scope that is inserted through the esophagus and positioned behind the heart, similar in technique to the upper gastrointestinal endoscopy for looking for ulcers in the stomach. It provides better detail of the heart structures and flow pattern by avoiding the interference caused by the chest wall, ribs, and lungs. It is done under light intravenous sedation and using local numbing medication on the throat to minimize gagging and irritation.

Carotid Duplex Scan - This is an ultrasound imaging of the arteries of the neck to show the blood flow pattern and any cholesterol plaque that may be obstructing the flow of blood to the brain that can lead to stroke.

Exercise Testing - Usually done with a treadmill, the subject exercises following a set standard protocol while the electrocardiogram and blood pressure are monitored. This can provide valuable assessment of the subject's physical capacity, as well as determine the presence or absence of circulation problems. This is usually combined with either the echocardiogram or with the heart scanner to enhance its accuracy.

Nuclear Imaging - A radioisotope is injected into a vein either at rest and/or during exercise which is then picked up by the heart. The small amount of radiation (less than a Chest X-Ray) is detected by the heart scanner. The scanner can detect uneven distribution of the radioisotope that may be caused by circulation problem. It is the most accurate non-invasive way of determining the contractility of the heart muscle (ejection fraction).

Cardiopulmonary Stress Testing - This measures the breath by breath changes in the amount of oxygen inhaled and carbon dioxide exhaled during exercise. This can then be used in determining at which point during exercise the body becomes inefficient (anaerobic threshold). This is very useful in differentiating whether the limitation during exercise is caused by the heart, or by the lung, or merely by poor physical conditioning. This also provides information that is very valuable during cardiac rehabilitation.

Pulmonary Function Testing - this measures the volume of air that is inhaled and exhaled, and at what rate it is forcefully exhaled. It can also give information about the ease of absorption of oxygen from the lungs. It is important in testing for the severity of emphysema and bronchial asthma.

Segmental Pressure Measurement and Pulse Wave Doppler Study of the Legs - This is a good way for screening for circulation problems in the legs (peripheral circulation). The blood pressures of the legs are normally slightly higher than the pressures of the arms. When the blood pressure of the leg is divided by the arm pressure, a number greater than one (1) should be derived [ankle-brachial index (ABI) ratio]. Any ratio below one is therefore abnormal and is suggestive of obstructed leg arteries. In addition the pulse wave form is also dampened.

Cardiac Catheterization - This is an X-ray guided procedure where an Iodine-based contrast agent (dye) is injected into the arteries and chambers of the heart. This is currently the most definitive way of demonstrating the percentage of narrowing in the arteries of the heart. The pressures in the heart and adjacent structures are also recorded and the heart output (the amount of blood that the heart pumps out) can also be measured. This is usually the basis for making decisions about the need for angioplasty or heart surgery.

Peripheral Angiography - This is an X-ray procedure where an Iodine-based contrast agent (dye) is injected into the arteries of the body outside the heart. Special digital X-ray technique is then applied to record any obstruction in the arteries of the neck and brain, the aorta and its major branches including the kidneys and the arteries of the legs from the groins down to the feet.

Percutaneous Coronary Interventions (PCI) - These are procedures that are done to open the clogged arteries caused by build up of cholesterol plaque. It is accomplished by inserting a catheter, usually in the groin, through which various devices can be introduced in side the coronary arteries. These devices are often times used in combination to achieve the best result.

Balloon Angioplasty - First introduced for use in human hearts by Dr. Andreas Gruntzig, a Swiss cardiologist, in 1977, this opened up a new horizon in the treatment of coronary heart diseases. It works by compressing the plaque against the wall thereby immediately opening the clogged artery. The debris that is created is then cleared up by scavenger cells (white blood cells). A favorable healing results in a new lining inside the artery that may stay open for several years. Depending on the complexity of the narrowing, there is a recurrence rate of 30-50% in six to twelve months.

Directional Coronary Atherectomy (DCA) - This is a circular saw that is contained within a metallic capsule which has an open window on one side and a balloon on the other side. The balloon is inflated to push the window against the plaque. A battery-operated motor drive unit then rotates the circular saw that is pushed forward inside the capsule shaving off the plaque. These pieces that look like "bacon strips" when stretched, are deposited in the nosecone and come out with the whole device at the end of the procedure.

Rotational Atherectomy (PTCRA) - This is a diamond-tipped burr that is rotated at a very fast speed by a gas turbine thereby abrading the plaque into very tiny pieces (even smaller than the red blood cells). These debris are then taken up by scavenger cells (white blood cells) and are also filtered by the lymph nodes, liver and spleen. This procedure is the closest in appearance to a "roto-rooter". It is most useful in working on long narrowings especially if they are also hardened by scar tissue and calcium deposits. It is best combined with balloon angioplasty and/or stenting.

Coronary Stenting - This is the latest comer among the group but it is the most extensively used. This is made of a metallic "wire-mesh" that is mounted over a balloon. Once delivered in the area of the narrowing, the balloon is inflated, pushing and embedding the stent against the wall. The balloon is then deflated and pulled out leaving the stent propping the artery open acting as a scaffolding to prevent it from collapsing and reclosing. This procedure leaves the biggest opening of the artery. The recurrence rate of the narrowing (restenosis) is reduced to 10-20% in six to twelve months. Some stents (Drug-Eluting Stents) contain medicine that can reduce restenosis to <10% in 6-12 months in appropriate patients.

Peripheral Angioplasty - All the above percutaneous coronary intervention techniques are also applicable in the peripheral circulation. Dr. Andres is doing balloon angioplasty and stenting on renal (kidney) arteries, iliac, and femoral (groin and thigh) arteries, and on the smaller arteries of the legs (tibial arteries).

Chest Pain Clinic - For those patients who continue to have chest pain despite increasing medications, percutaneous interventions and/or bypass surgery, a new mode of improving circulation is now available. EECP (Enhanced External Counter Pulsation) works by squeezing blood from the leg veins and arteries thereby improving the blood flow to the arteries and veins of the body. If done daily over a period of time (1 hour daily sessions for 35 days), it somehow restores the function of the inner lining of the arteries (endothelial function) making it produce the important substances that keep the smaller arteries open over a longer period of time, even beyond the days of actual treatment (>2-3 years). This is specially important for those who are no longer candidates for angioplasty or surgery. This can also be helpful in some patients who have heart failure and are on significant amount of medications just to keep them stabilized.

Endovascular Intervention for Abdominal Aortic Aneurysm - Aneurysm is a weakening of the walls of the artery of the body usually related to a build up of cholesterol. It is most commonly encountered in the abdominal aorta below the kidney arteries. This can progressively get bigger and can balloon out to eventually rupture if left unattended. The most common way of managing this is by surgical repair where the ballooned out segment of the aorta is replaced with a fabric material. This entails a major operation with its attendant risk of heart attack, heart failure, stroke, kidney failure, leg circulation problems, among other potential complications. It usually requires 1-2 weeks of hospitalization and 1-2 months of recovery.

There is now a new technique of repairing some abdominal aortic aneurysm called endovascular stent grafting. This entails the insertion of a fabric-covered stent through needle holes or small incisions in the groins under X -ray guidance. It requires an overnight stay with even a potential for outpatient procedure in the appropriate circumstances. There is less stress to the heart, brain, kidneys and peripheral circulation so that the risks are considerably lessened. Recovery is not much different from that of a heart angioplasty. The first two procedures of this kind were done by Dr. Primo Andres on October 18, 2001 using Medtronic AneuRx stent grafts with excellent results thus far.

What is in the future?

Drug-eluting stents (DES) has finally arrived and we have seen the benefits as well as the controversies about its use. Applied in the right patient and environment, this new device is a good addition to the armamentarium that we have against early renarrowing of arteries following any intervention. Only one company, Cordis (Johnson & Johnson) has been approved to market this particular stent which has limited its use due to limited availability and exorbitant cost. In the near future, Boston Scientific will be releasing their DES at a more competitive price and with a wider selection of sizes so that this new technology can be offered less selective to our needy patients.

In the realm of endovascular stent-grafting of abdominal aortic aneurysm, Gore (maker of Goretex and Teflon) has entered into the arena with a local Indiana company, Cook based in Bloomington, in addition to Medtronic and Guidant in providing alternative devices for the management of this otherwise morbid condition. Being smaller in profile, The Gore “Excluder” device opens up the potential of doing this procedure under local anesthesia and without surgical incisions in the groin in the appropriate patients.