PROCEDURES

Inpatient / Outpatient

INPATIENT PROCEDURES

Dr. Fayaz Shawl has devoted his career to the very latest in cardiovascular innovations, advancements and patient procedures. The following inpatient procedures are all performed in exceptional well-equipped facilities along with a highly qualified team of nurse/nurse practitioners, technicians and a medical support staff specifically trained in cardiovascular care. Please contact our team with any questions and we will be happy to assist you with any inquiries. The highlighted inpatient procedures are the most common and follow graphical illustration and/or a summary of the procedure. If you would like more information on a specific procedure that is not highlighted, contact our offices directly.

Coronary
Balloon Angioplasty
Coronary Stenting
Directional Atherectomy
Rotoblation
Rotational Atherectomy
Brachytherapy
High Risk/Inoperable CPS supported angioplasty
Hybrid (MID CAB - LIMA/RIMA + angioplasty)
Excimer Laser
Front Runner cutter for CTO
Percutaneous Cardiopulmonary Bypass Support - PCPS (High Risk / Waiting for transplant / In Cardiac Arrest)
Renal (Kidney) Artery Stenting

Valvuloplasty
Mitral
Aortic
Pulmonary

Investigational
Cartoid Stenting
Endoluminal Grafting
Percutaneous Aortic Valve Replacement
Cell Regeneration
PTMR
Pericardial Window
Intracranial Angioplasty
Cell Regeneration for CHF
Percutaneous - bypass (vein-arterial conduit)
Distal protection
Acute stroke intervention
VSD - closure
Alcohol Septal Ablation HOCM

Peripheral
Subclavian
Renal
Lliac
Superficial femerol artery
Infrapopliteal
Aortic Stenting
AAA Endovascular repair
Cell-embolization for aneurysms and fistula
PFO Closure
ASD Closure

Balloon Angioplasty - (PTCA or Percutaneous Transluminal Coronary Angioplasty) is a procedure in which a small balloon-tipped catheter is placed into the artery where there is a narrowing. The balloon is inflated at the blockage to push the plaque and fatty deposits against the artery wall. The balloon is then deflated and removed, allowing blood to flow without difficulty.

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Coronary Stenting - In about 70-90% of all balloon angioplasty procedures a stent is also used. A stent is a tiny metal mesh tube that is inserted into a narrowed artery by a balloon- tipped catheter. When the balloon is inflated the stent opens out to the size of the artery. The balloon is then deflated and removed while the stent remains in place. This provides support for the arterial wall, keeping the artery open. Some stents are self-expanding and do not require a balloon to open them.

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Directional Atherectomy - A procedure in which fat deposits and plaque are removed by shaving them from the walls of the artery using a small "cutting" device. This procedure is usually followed by a balloon angioplasty to squeeze the remaining plaque against the wall of the artery and smooth out the edges. A stent may also be used to help keep the artery open.

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Rotoblation - A procedure in which a catheter with a rough diamond-coated tip is inserted into the narrowed artery. This tip spins at high speeds grinding the hardened plaque creating an opening. This procedure may be followed by balloon angioplasty and sometimes a stent, to smooth the edges and keep the artery open.

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Hybrid (MID CAB - LIMA/RIMA + angioplasty) - This is an "integrated minimally invasive approach" or "hybrid procedure". The only advantage of conventional bypass surgery is excellent outcome with arterial conduits like LIMA, RIMA, radial or gastroepiploic vessels. We can use these conduits by minimally invasive (MIDCAB) surgery. In patients with multiple vessel disease, instead of conventional CABG, we use combined MIDCAB and percutaneous intervention.

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Excimer Laser - This procedure removes blockages (plaque) from the artery with laser energy. The laser energy is sent through a metal tipped catheter and the blockage is vaporized and cleared from the artery.

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Percutaneous Cardiopulmonary Bypass Support - PCPS (High Risk / Waiting for transplant / In Cardiac Arrest) (PCPS) is a highly specialized procedure developed by Dr. Shawl especially for the "high-risk" patient. PCPS provides assistance to the heart during cardiac arrest and, in a controlled setting, during high-risk coronary intervention. Click here to access videos about this procedure.

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Renal (Kidney) Artery Stenting - Renal artery blockages result from a build up of plaque, which narrows the artery. This may lead to high blood pressure and total blockages can lead to kidney failure. The renal arteries can be treated the same as other peripheral arteries. The stent is placed with a balloon-tipped catheter. This is introduced into the patient by a needle puncture into the groin site (femoral artery). The balloon is removed leaving the stent in place to keep the artery open.

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Valvuloplasty - A non-surgical treatment for heart valve stenosis (a narrowing of the heart valve). During this procedure the narrowed valve is stretched open by a balloon-tipped catheter. The balloon is inflated until the valve is expanded; then the balloon is deflated and removed.

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Cartoid Stenting - The carotid arteries are located on each side of the neck and supply blood to the brain. Carotid artery stenting is done to prevent future strokes in people with a blockage in the carotid artery. This is a non-surgical procedure in which a metal mesh cylinder is inserted into the carotid artery by a balloon-tipped catheter. The balloon is inflated which expands the stent to the artery wall thus opening the blood vessel. The balloon is deflated and removed and the stent remains in place to keep the artery open.

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Endoluminal Grafting - This procedure is done to treat aortic aneurysms. Aortic aneurysms are a weakening of the arterial wall in the aorta, which is located in the abdomen. This arterial wall becomes dilated (like a balloon) and may rupture. Endoluminal grafting is a non-surgical procedure in which a graft is placed inside the aneurysm through a tube in the groin (femoral artery). This graft is attached to the wall of the artery above and below the aneurysm. Blood will then flow through the graft away from the weakened arterial wall allowing the aneurysm to shrink.

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PTMR Percutaneous Transluminal Myocardial Revascularization - There are many patients who because of small size vessels or diffuse disease are not good candidates for percutaneous interventions or bypass surgery. These patients become severely limited because of incapacitating angina. PTMR can provide these patients with symptomatic relief of angina. In some animals, like crocodiles and alligators, the blood flow to the heart muscle is directly from the LV chamber via small channels. Based on this knowledge, Dr. Mirhoseini created channels in human hearts using laser energy. Over the last few years other surgeons have created similar laser channels directly into the heart muscle with objectively evident beneficial effects. However the surgical method is more invasive and is associated with 10-19% mortality. Now, using catheter-based technology, we are able to create channels from inside the chamber of the heart into the LV muscles. Dr. Fayaz Shawl performed the first PTMR in the human heart in India without any complications. Today, Dr. Shawl performs PTMR in the U.S. with FDA IDE approval and has done a number of cases with great success and promising results.

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Alcohol Septal Ablation HOCM - A technique in which ethanol is injected directly to the heart in order to treat thickening heart muscle cells in patients diagnosed with Hypertrophic Obstructive Cardiomyopathy. The alcohol septal ablation procedure begins with physicians inserting a small catheter into an artery in the groin, and then threading it to the heart. The treatment decreases the thickened muscle that divides the heart's two chambers so that it can retract, restoring normal function. After treatment, patients will notice significant improvement almost immediately.

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PFO Closure - A Patent Foramen Ovale means a "hole" between the right and left atrium. A patient who has PFO has an increased chance of stroke. Drugs, such as Coumadin (Warfarin), thin out the blood and assist in the reduction of a clot returning to the right atrium from the venous circulation in some patients. Coumadin may lead to complications including internal bleeding, cerebral bleeding, ulcers, hematuria, and hemorrhoidal bleeding. It is recommended that PFO's be closed in such patients particularly those with mini-strokes(transient ischemic attacks or TIAs). And, although traditional methods of closing PFO would involve open-heart surgery, modern medicine and technological advancements now make it possible to use special cardio devises and new treatments in which recovery is quick and the patient is discharged from the hospital in less than 24 hours without the need to open the chest.

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ASD Closure - Atrial septal defects (ASD) are congenital irregularities. When the opening between the wall and the two atria or septum does not close at birth as it is supposed to, the blood to bypass the lungs does not occur correctly. The size of the ASD can be very small or more than an inch in diameter. The higher blood pressure in the left atrium pushes blood into the right atrium, adding additional supply of blood to the heart. This added volume increases both the workload of the right ventricle and the flow of blood in the lungs. Larger defects may cause symptoms including shortness of breath, sweating a lot with activity, increased breathing rate, or decreased growth. Congestive failure may develop, with cough and swelling of the legs and ankles. Occasionally, the added strain on the heart results in irregular heart beats. Patients who are found to have an ASD should have it closed. In the past ASD closure required surgery, now ASD closure is a "knifeless" procedure. This procedure is very safe, and prevents the patient from suffering blood clot and heart rhythm and pumping disturbances.

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OUTPATIENT PROCEDURES

Diagnostic outpatient procedures, such as the one listed below can detect medical conditions early to prevent cardiovascular complications in the future, thus placing greater emphasis on proper cardiac care. Early detection of coronary, carotid, renal and peripheral artery blocklages are extremely important in cardiovascular disease prevention.

The following outpatient procedures are all performed in exceptional well-equipped facilities along with a highly qualified team of nurse/nurse practioners, technicians and a medical support staff specifically trained in cardiovascular care. Please contact our team (link) directly with any questions and we will be happy to assist you with any inquiries. Further information regarding the following procedures, including descriptions and pre and post procedural information can be found on our site under Patient Information (link) The highlighted outpatient procedures are the most common and follow a text summary of the procedure. If you would like more information on a specific procedure that is not highlighted, contact our offices directly.


Outpatient services include: (anchors)

Blood tests (Lipids, C-Reactive Protein, Homocysteine)
Nuclear Stress Testing
Carotid Duplex Ultrasound
Vascular Duplex Ultrasound
Echocardiogram

Blood tests (Lipids, C-Reactive Protein, Homocysteine)

Lipoprotein(a): Lipoprotein(a) or Lp(a) is an established risk predictor for heart attack. It not only has a cholesterol component, like LDL (bad lipid), but a pro-thrombotic (blood clotting) component. Lp(a) levels are genetically determined and remain relatively constant over an individual's lifetime. Unfortunately, they are not affected by lifestyle changes or by most drug therapy. High Lp(a) levels increase the risk for developing coronary artery disease as well as cerebral vascular disease. Elevated levels of Lp(a) are thought to work independently, to add to any underlying heart or vascular disease processes.

High Lp(a) levels can occur in individuals with normal cholesterol levels; if so, they do not carry the same cardiovascular risks as high Lp(a) levels in individuals with high LDL levels. According to one review, the relative risk of cardiovascular disease events attributable to elevated Lp(a) is modest (2-fold increase) in subjects with normal LDL cholesterol levels. However, subjects with high LDL levels, such as those with familial hypercholesterolemia who typically present with LDL levels in the 300 mg/dL range, have a 12-fold increase in the risk of heart attack attributable to concomitantly high levels of Lp(a).

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C-Reactive Protein: The C-reactive protein (CRP) test is a blood test that measures the level of CRP in the blood. CRP is an inflammatory marker - a substance that the body releases in response to inflammation. High levels of CRP in the blood mean that there is inflammation somewhere in the body. Other tests are needed to determine the cause and location of the inflammation. A test called "High Sensitivity CRP" (HS-CRP) is done to distinguish between arthritis inflammation and inflammation possibly related to cardiovascular disease. Studies indicate that men with high levels of CRP have triple the risk of heart attack and double the risk of stroke compared to men with lower CRP levels. In women, studies have shown that elevated levels of CRP may increase the risk of a heart attack by as much as seven times.

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Homocysteine: Homocysteine is an amino acid produced as a normal byproduct of the breakdown of methionine (from proteins), which is an essential amino acid acquired mostly from eating meat. Studies have shown that too much homocysteine in the blood is related to a higher risk of coronary heart disease, stroke and peripheral vascular disease. There's plenty of evidence that homocysteine can be kept at moderate, healthy levels if the body has adequate levels of three important B-vitamins: vitamin B-6, vitamin B-12 and folic acid (the synthetic and more easily absorbed version of folate). These B-vitamins convert homocysteine into a harmless substance. However, a lack of any of these three vitamins can increase homocysteine levels, which could prove to be dangerous. Consult your physician before taking these vitamins because they could hide a B-vitamin deficiency, which could lead to nerve damage. Some physicians routinely screen for this deficiency before adding B-vitamins.

The basic determination is that homocysteine is most likely an independent risk factor for cardiovascular disease but it's contribution is less then the major risk factors. The major risk factors are smoking, diabetes, high cholesterol and high blood pressure.

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Nuclear Stress Testing: Also known as "thallium or sestimibi stress testing," this procedure is almost identical to exercise stress testing. After the patient is attached to an electrocardiogram (EKG) and a blood pressure machine, exercise is started on a treadmill, a stationary bicycle, or a stair machine. Nuclear stress testing is performed to evaluate the condition of the heart and the arteries that supply it. During exercise, the heart has a greater need for blood and the oxygen and other nutrients within it. If the coronary arteries are partially or totally blocked, they will not be able to meet that demand, creating a condition called cardiac ischemia - inadequate blood supply to the heart muscle. Monitoring the thallium blood flow in the heart, and the amount of time that it remains there, reveals abnormalities in the heart and coronary arteries.

With the nuclear test, a radioactive isotope, thallium or sestimibi, is injected in an arm vein and the thallium is absorbed into the heart muscle for several hours. Scans are performed immediately after exercise and several hours later to detect a lack of blood supply to the heart. EKG electrodes are attached to the chest and a blood pressure cuff is placed around the upper arm. Depending on the patient's response to stress, the test could last from one to 15 minutes. When the doctor decides that the exercise stress has been sufficient, the exercise machine is stopped, and an intravenous injection of the radioactive material is given.

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Carotid Duplex Ultrasound: Carotid duplex is the use of ultrasound -- high frequency sound waves -- to evaluate blood flow in the carotid artery in the neck. It generates a two-dimensional, black and white picture that shows whether there are any blockages, such as atherosclerotic narrowing or blood clots, in the carotid artery. The carotid artery supplies blood to the brain. A carotid duplex is performed to detect narrowings or obstructions (such as clots) in the artery, which increases the likelihood of stroke.

The patient reclines on an examining table while the sonographer moves the transducer wand slowly along the sides of the neck. Images from the sound waves will appear on a video screen that the sonographer views during the process. Total time is between 15 and 30 minutesThe sonographer applies a cool, colorless gel to the neck and to the tip of the sonography wand (transducer). The wand is gently rubbed across the patient's neck. Sounds from the movement of blood and images of the blood flow in the artery are generated. The test is non-invasive and painless.

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Vascular Duplex Ultrasound: Vascular Doppler is performed to detect obstructions in the leg arteries. These obstructions may be causing symptoms, such as leg pain when walking or doing other forms of exercise.

Vascular Doppler, also known as an arterial ultrasound, uses two techniques to evaluate the blood pressure and blood flow in the arteries in your legs. These techniques are blood pressure measurement using cuffs similar to those used for arm measurements of pressure, and ultrasound (high frequency sound waves). Essentially, a sonography wand replaces the stethoscope normally used when blood pressure is taken. The process generates pressure measurements and images that show whether there are any blockages in the leg arteries. Blood pressure measured in the legs should be similar to that taken in the arms; if it is lower, it may signal the development of atherosclerotic plaque in your arteries that is interfering with the circulation.

The sonographer wraps a blood pressure cuff around the patient's leg at four or five locations. Then a cool, colorless gel is applied to the top of the foot and to the tip of the sonography wand (transducer). The wand detects blood pulses as the blood pressure cuffs inflate and deflate. Total time for the test is between 45 minutes and an hour. The test is totally non-invasive. There is no post-procedural care and the patient may leave immediately after the test. In cases when leg pressures need to be checked both before and after exercise, the patient is asked to walk on a treadmill for a short time before the pressure measurements are repeated.

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Echocardiogram: Also known as: echo, 2D echo, cardiac ultrasound, cardiac sonogram. An echocardiogram is an imaging procedure that uses high frequency sound waves to provide a picture of the heart's movement, valves, and chambers. It may be combined with a Doppler ultrasound and color Doppler to evaluate blood flow through the heart's valves. An echo reveals the size and shape of the heart, and its chambers. It can provide information about disease of the muscle and valves, and can help identify tumors and congenital heart disease. It also assesses the pumping function of the heart, yielding a number called the ejection fraction. (A normal EF is 55 to 80%; lower numbers reveal some level of impaired pumping.)

A cool, colorless gel is applied to the chest and to the tip of the wand held by the cardiac sonographer. (The wand looks like a small microphone.) The wand is gently rubbed across your chest. A gentle pressure is felt from the wand, but there is no pain. During a Doppler procedure, dull thumping sounds may be heard. These sounds are normal and are produced by the movement of blood through various vessels.

- The patient is asked to remove all clothing and jewelry, from the waist to the neck, and given a hospital gown.
- The sonographer places three electrodes on the chest, using small sticky patches. These electrodes are attached by wires to an electrocardiograph monitor to generate an electrocardiogram (ECG) - a record of the heart's electrical activity.
- The patient lies on his left side on an exam table.
- The sonographer applies a small amount of cool gel to the chest and to the sound-wave transducer at the tip of the wand. The gel helps assure good contact and clearer pictures.
- The sonographer moves the wand slowly around the chest.
- The patient is asked to change position, from the back to the side, to provide different visual angles. The patient will also be asked to hold his breath briefly during some parts of the procedure.
- The sonographer watches the images on a screen during the procedure, and a permanent record of the images also is made.
- Depending on the extent of the procedure, it may take anywhere from 30 to 60 minutes.

There is no post-procedural care and no risks to the procedure. After the procedure, the sonographer wipes the gel from the chest and the patient may dress and leave.

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