Cardiac catheterization lab.

I spent yesterday in the cardiac cath lab and got to see a lot of interesting cases and procedures.

The first procedure of the day was a pacemaker installation. The doctor had difficulty accessing the left subclavian vein due to obstruction and scar tissue from the patient's previous bypass surgery. The patient was pretty adamant that the pacemaker be implanted on the left side, so a cardiothoracic surgeon was called in to access the vein. Once that was done, the wires were implanted in the heart and tested to make sure they could pace the heart properly. Then the actual pacemaker was implanted (I got to unwrap the outer casing and hand it to the nurse). The procedure took 1.5 hours, which was a little ridiculous for so simple an operation.

The second case was a carotid artery stent placement. This was particularly neat because once the doctor had access to the artery, he could inject dye into the line and you could watch the dye spreading up into the patient's brain, the vessels lighting up in real time and the dye becoming more diffuse and it entered smaller and smaller vessels. I thought that was pretty cool.

The third case was a trans-esophogeal echocardiogram, the same technique they use in the OR to make sure repaired/replaced heart valves are working properly. The patient was an obese middle-aged woman who had experienced an episode of blindness/possibly a mini-stroke a few weeks ago. The TEE was supposed to rule out cardiac defects which may have contributed to the episode. To the patient's surprise, the cardiologist found a 10-14 mm hole in the septum which separates the left atrium from the right. This defect is actually fairly common; it affects about 1 person out of 5, though most people are asymptomatic and never know they have it. In this patient's case, the hole was large enough that blood was flowing from the left atrium to the right, which never happens in a normal heart. This extra blood in the right side of the heart caused the right atrium and ventricle walls to enlarge slightly. The cardiologist recommended that because of its side, the patient should have the hole closed up, and that doing so might solve her mini-stroke problem.

The next case was an actual cardiac catheterization; the doctor was looking for possible mitral valve stenosis and measuring the pressures inside the heart chambers. Everything was going smoothly until the doctor advanced the wire down through the aorta and into the left atrium. At that point, the patient's heart rate and blood pressure dropped so abruptly that the next thing I knew, the doctor was shouting, "Atropine! ATROPINE!!!" and the nurses were scrambling to inject the drugs and increase the woman's fluid intake. After waiting about fifteen minutes for the patient to stabilize and stop feeling so nauseous from the sudden drug dose, the procedure continued without interruption. It was quite exciting, and totally woke me up from my after-lunch stupor.

The final case was an emergency coronary artery catheterization and stent placement. This case lasted over an hour and there were several intense moments when it appeared the patient was going to have to undergo emergency bypass surgery, because the doctor couldn't advance the wires far enough into the artery; the vessels were too blocked. The doctor was forced to used a diamond-tipped drill to blast away some of the calcification inside the artery so he could fit his stent and balloon in there. That was pretty intense; we were all holding our collective breath when the drill roared to life and everyone's eyes were glued the the EKG monitor, waiting to see how the patient would respond. Ultimately the procedure was successful and two stents were placed, but the doctor turned to me just before he left and said, "That was a close one."

Anyway, it was a very interesting and informative day, though after wearing a heavy lead apron for nearly 9 hours my shoulders and back were aching and I pretty much collapsed when I got back to my room. The nurses told me to come back anytime, and I may take them up on the offer, since aside from the discomfort of the apron, I had a really enjoyable time.