CTC services and support

Your heart and how it works

The heart is a muscular pump. The right side of the heart receives blood from the body and pumps it to the lungs, where the blood picks up oxygen that you have breathed in. The left side of the heart receives this oxygen-rich blood from the lungs and pumps it to all parts of the body. This is a continuous process.

Reasons for needing heart surgery

Coronary artery disease

The heart muscle (myocardium) receives its blood supply from the coronary arteries. Sometimes these arteries can become narrowed where fatty deposits are gradually laid down inside them. This is known as coronary artery disease or atherosclerosis.

As the coronary artery becomes narrowed, the blood supply to the myocardium is decreased. When demand for oxygen-rich blood is greater than the supply, angina pain arises from the muscle.

If the coronary artery becomes completely blocked, usually by a blood clot where the artery is narrowed, a heart attack (myocardial infarction) occurs.

The narrowing of your artery will be identified by a coronary angiogram investigation, performed by a Cardiologist.

A Coronary Artery Bypass Graft (CABG) operation can be carried out to relieve angina and reduce your risk of having future heart attacks.

During the CABG operation extra blood vessels are sewn to your narrowed arteries to ‘bypass’ the narrowed area and bring blood to your heart muscle. There are ‘spare’ arteries inside the chest wall and the forearm, and spare veins in the legs which can safely be removed. All these can be used to construct excellent bypass grafts.

Bypass surgery for coronary artery disease is very effective. Most patients find that their angina goes away completely following surgery, and some patients experience improved function of the heart muscle.

Heart valve disease

The heart pumps blood continuously around the body. Within the heart are four valves that ensure that the blood flows the right way. Sometimes one or more valves can become damaged or diseased. They may not open properly and obstruct the blood flow (valve stenosis) or they may not close properly allowing blood to leak back (regurgitation or incompetence).

These problems place an increased strain on the heart. They are often recognised by tiredness and/or breathlessness when you exercise, although sometimes there are no symptoms, but a heart murmur may be heard by the doctor. Without treatment the heart muscle can become permanently damaged.

The most common valves to be affected are the aortic and mitral valves. The affected valves are either replaced or repaired.

If you are having an operation on your heart valve it is very important that your teeth and gums are healthy. This is because infected teeth and gums can cause the new heart valve to become infected. Please ensure that you see a dentist regularly – we will have already asked your dentist for information about your dental treatment. Your operation may be delayed if you need dental treatment as this will need to be carried out before your operation.

Some patients need both valve and coronary artery bypass graft surgery at the same time.

How long will I need to stay following heart surgery?

The average stay in hospital following heart surgery is 5 – 10 days. However this stay may be a short as 4 – 5 days depending on your recovery.

Thoracic surgery is for the prevention, early diagnosis and treatment of (non-cardiac) diseases of the chest.

We provide a broad range of thoracic services:

Airway surgery

We offer several surgical procedures of the airway, including tracheal resections and the treatment of trachea-oesophageal fistula. There is a comprehensive endobronchial airway service and we are able to offer cryotherapy, endobronchial resection, flexible and rigid bronchoscopy, and stenting.

Bronchoscopy

This is an investigation of the airways, using a bronchoscope (a small flexible telescope). The bronchoscope is passed through your mouth and into your windpipe, so that the surgeon can examine your airways, and take a small sample of tissue (biopsy), to find out what is causing your symptoms. A bronchoscopy is usually carried out under general anaesthetic.

Chest wall surgery

Chest wall surgery includes cancer resections for lung cancer, primary chest wall tumours and secondary tumours to the chest wall. We offer chest wall stabilisation and reconstruction after surgery.

Complex lung resections

Including sleeve resections, other lung-sparing surgery, chest wall resections and resections involving the heart or great vessels.

Investigation and management of pleural diseases

We offer an 'easy-access pleural service', and aim to achieve a diagnosis and to alleviate the problem in as few as steps as possible.

We have expertise in the management of pneumothorax, pleural effusions, empyema and pleural tumors such as mesothelioma.

Lung cancer

Patients are referred to the CTC with early lung cancer, locally advanced lung cancer (T3/T4) or when there is limited spread (N2) and in highly selected patients metastatic disease (M1).

All such cases are discussed in a multi-disciplinary group, and if appropriate we may be able to offer surgery supported by additional treatments such as chemotherapy and radiotherapy.

We receive requests for second opinions and also consider patients for surgery when other options may have been unsuccessful.

Lung volume reduction surgery

This established treatment can help some people by removing poorly functioning parts of the lung which allows the rest of the lung to work better and also reduces the effort needed to breathe.

Mediastinoscopy

This is an examination of the lymph nodes, using a short endoscope (a small flexible telescope). The endoscope is passed through a small incision made at the base of the neck under the chin. A mediastinoscopy is carried out under general anaesthetic.

Metastasectomy

Some people with mestastases to the chest may benefit from resection of these tumors. Each case is very carefully assessed to allow the best decision to be made for the patient.

Minimal access surgery

Where possible and appropriate, keyhole surgery is used. This is performed with the help of small operating telescopes which often give an excellent view and is known as 'video-assisted' or 'VAT' surgery.

Open lung biopsy

During an open lung biopsy, a small incision is made in the chest so that samples of tissue (biopsies) can be taken, to find out what is causing your symptoms. This procedure is carried out under a general anaesthetic. A chest drain may need to be inserted following the procedure, to drain fluid or air.

Pectus surgery

We offer pectus operations and sometimes operate with plastic surgery colleagues to produce the best results.

Surgery for patients with reduced lung function

Each person is assessed on their own merits. Some patients may have been advised that they are inoperable due to poor lung function. Our approach is try to improve their breathing and other illnesses to see if they can tolerate an operation. If surgery is performed we may advise a lung-sparing approach, and such patients benefit from our experienced specialist intensive and nursing care.

Surgery for the mediastinum

We offer a range of operations for tumors and in the mediastinum.

Thoracic sarcoma

Sarcomas are a form of tumour. We work with oncologists who also have a special interest in this area, with the aim of getting the best results.

Thoracoscopy

This is an investigation of the inside of the chest area, using an endoscope (a small flexible telescope). The endoscope is inserted through the chest wall, so that the surgeon can examine the area, and take a small sample of tissue (biopsy). A thoracoscopy is carried out under general anaesthetic. A chest drain may need to be inserted following this procedure, to drain fluid or air.

Thoracotomy

A thoracotomy is an operation which involves making an incision into the chest wall (thorax). This allows the surgeon to operate on your lung. Some of the procedures the surgeon may carry out include:

Lobectomy - the removal of a part (a lobe) of the lung.

Pneumonectomy - the removal of an entire lung.

Pleurectomy – the removal of the lining of the chest wall (called the pleura), to allow the lung to 'stick' to the chest wall. This procedure is carried out for persistent collapse of the lung (pneumothorax).

Decortication - the removal of any pus or debris from the lining of the lung. This procedure is carried out under general anaesthetic.

Interventional cardiology involves treating heart disease without using open surgery (large cuts or incisions to the body). Most of the procedures are called minimally invasive, because they involve small cuts to gain access to the inside of the body and often use catheters (thin, hollow, flexible tubes).

Cardiac Angiogram

A cardiac angiogram is a type of x-ray using a special dye, which shows if an artery is narrowed or blocked. The artery can be viewed or recorded on film / video.

What happens during an angiogram?

A nurse will check your blood pressure, pulse, temperature and oxygen levels. A small sample of blood may be taken to make sure it is not too thin.

A small tube (cannula) will be inserted into a vein in your arm, so that you can be given sedation and other drugs intravenously.

You will be asked to remove any dentures just before the procedure. Please tell us if you have any capped or loose teeth. You will be taken to the cardiac catheter lab for your procedure.

You will be given a local anaesthetic in either your groin or forearm, depending on where your doctor would like to insert the dye. You may be given a mild sedative. You will be awake throughout the procedure.

A thin flexible tube called a catheter is passed into the artery. The catheter will be moved, under x-ray guidance, until it reaches the correct position in your heart. Dye is then injected into the catheter. This can be seen on the screen. X-rays are taken as the dye passes through your arteries, outlining the blood supply to your heart. Some people experience a hot flushing sensation from the dye, which will last for a few seconds only. You will be told when this will happen.

Angioplasty

A coronary angioplasty is a procedure used to widen blocked or narrowed coronary arteries. The term angioplasty means using a balloon to stretch open a narrowed or blocked artery. However, most modern angioplasty procedures also involve inserting a short wire-mesh tube, called a stent, into the artery during the procedure. The stent is left in place permanently to allow blood to flow more freely.

Coronary angioplasty is sometimes known as percutaneous transluminal coronary angioplasty (PTCA). The combination of coronary angioplasty with stenting is usually referred to as percutaneous coronary intervention (PCI)

If, during your cardiac angiogram, an artery is found to be narrowed or blocked, an angioplasty may be carried out, to relieve the narrowing or blockage. Both procedures are performed under local anaesthetic and mild sedation. You will need to stay in hospital overnight.

Cardiac electrophysiology is an area of cardiology that deals with the diagnosis and treatment of heart rhythm disorders.

Electrophysiological Study

An Electrophysiological Study (EP Study) is a procedure to test your heart's electrical system. It is the electrical system of the heart that generates the heartbeat.

The results of the study may help the Electrophysiologist (a specialist in electrical activity in the heart) to determine your further treatment. This could include inserting a pacemaker or defibrillator, or performing Radiofrequency Ablation.

What happens during the Electrophysiological Study?

A nurse will check your blood pressure, pulse, temperature and oxygen levels. A small sample of blood may be taken to make sure it is not too thin.

A small tube (cannula) will be inserted into a vein in your arm, so that you can be given sedation and other drugs intravenously.

You will be asked to remove any dentures just before the procedure. Please tell us if you have any capped or loose teeth.

You will be taken to the cardiac catheter lab for your procedure.

You will be awake throughout the procedure, so you will be given a local anaesthetic and possibly a mild sedative. You will need to lay flat during the procedure and you will be asked to lie as still and relaxed as possible.

A small plastic catheter (tube) will be inserted through a vein in your arm or leg and advanced until it reaches your heart. Using special x-rays called fluoroscopy to guide the catheter, it will be positioned in the correct area of the heart. Fine wires are then positioned within the heart.

From these wires, electrical activity from specific areas of your heart is able to be recorded. Extra beats are given via a pacemaker, which may bring on your palpitations. You may feel uncomfortable during this part of the procedure. The rhythm can be restored again quite quickly by giving more extra beats.

Pacemaker

A pacemaker is an implanted device that monitors your heartbeat and prevents your heart from beating too slowly.

It consists of a box (pulse generator) attached to one or two wires (leads). The pulse generator is usually placed underneath the skin or muscle beneath your collarbone. The lead or leads pass inside the large veins of your chest from the generator to your heart. The leads transmit information about your heartbeat to the generator.

If your heart beats too slowly the pacemaker sends out a tiny electrical impulse to 'pace' the heart, i.e. to make it beat at an appropriate speed. If your heart then speeds up again, this is detected by the pacemaker, which then stops pacing your heart.

Cardiac Resynchronisation Therapy (CRT)

Most cases of heart failure occur because the main pumping chamber of the heart (the left ventricle) is not contracting well enough. Normally all parts of the ventricle contract simultaneously. In some patients with heart failure contraction of part of the ventricle is delayed relative to the rest. This is referred to as dys-synchronous contraction. Dys-synchronous contraction makes the heart less effective as a pump.

The aim of cardiac resynchronisation therapy (CRT) is to stimulate the ventricle to contract simultaneously, improving its function.

Radiofrequency Ablation

Radiofrequency Ablation is a procedure to treat some types of rapid heart beating. It is most often used to treat rapid, uncoordinated heartbeats (also known as tachy arrhythmias).

The procedures are performed under local anaesthetic. You may be able to go home the same day or you may need to stay overnight. You will be informed of this at your pre-admission assessment.

What happens during Radiofrequency Ablation?

During radiofrequency ablation a form of energy will be delivered down a wire to target the area in the heart that has been causing your palpitations. Most commonly the energy used is a heat source, called radiofrequency energy, but other types may be used such as cryo therapy, which freezes the area.

You may stay overnight or you may be discharged the same day. This will depend on the complexity of your procedure.

Implantable Cardioverter Defibrillator (ICD)

An Implantable Cardioverter Defibrillator (ICD) acts as a constant heart monitor. An ICD box is implanted under your skin, usually near the collarbone. Leads from the box are attached to your heart. These leads detect the heart's rhythm, and feed this information back to the box.

The ICD is set to detect heart rates above a certain level. This level will be different from person to person. The ICD will continuously monitor the speed of your heart. If your heart starts beating too fast, then the ICD will switch to 'alert'. Then:

If your heart rhythm returns to normal on its own, then the ICD will switch back to 'monitor'.

If your heart continues to beat too fast, then the ICD will start to deliver treatment.

The treatment may be pacing therapy, or shock therapy. It will continue to treat until either the heart rhythm goes back to normal or until all treatments have been delivered.

Trans Oesophageal Echocardiogram (TOE)

A TOE is a procedure to take detailed ultrasound images of your heart from the gullet (also known as the oesophagus or food pipe) which lies directly behind your heart.

To do this, a long flexible probe will be passed into your mouth and down the gullet. This provides an excellent view of your heart chambers and valves, and allows us to examine how efficiently they are working. This procedure provides the most accurate information in diagnosing problems with the heart valves such as:

Infection of the heart valves (endocarditis).

The need to repair or replace the valve, or whether the valve needs stretching (valvuloplasty).

A blood clot (thrombus) in the heart chambers.

The procedure is performed as a day case, under sedation. You will be able to go home two to three hours after the procedure.

What is an arrhythmia?

Arrhythmia is a term used to describe a number of conditions where the muscle contraction of the heart is too slow, too fast or irregular because of a disturbance with the heart's normal electrical activity

What are the different types of arrhythmia?

Ectopic beats are early beats that frequently cause palpitations and are described as missed or extra beats. Ectopic beats are not normally dangerous and don't damage the heart.

Atrial fibrillation (AF)

Atrial fibrillation (AF) is the most common, sustained, abnormal heart rhythm involving rapid and irregular activity in the heart. It involves very rapid, irregular activity in the atria (the top chambers of the heart). The ventricles (the bottom, main pumping chambers of the heart) try to keep up and are therefore often fast and irregular too. AF can start and stop on its own after seconds, minutes or even hours. This is known as paroxysmal AF. Persistent AF is AF that does not stop on its own but will stop if a doctor treats it; the doctor may use medicines or a small electric shock (cardioversion). Permanent AF is AF which remains even after cardioversion.

Atrial flutter

Atrial flutter involves the top chambers of the heart (the atria) beating very rapidly, as electricity circulates around them. It arises from the upper chamber on the right side of the heart, the right atrium. Electricity circulates around this chamber at a rapid rate and drives the main pumping chambers (ventricles) at a fast rate, often 100 to 150 beats per minute.

Atrial tachycardia

Atrial tachycardia is an uncommon arrhythmia that may result in rapid palpitations. It is often seen in patients with a diseased heart, although it may occur in patients with an otherwise normal heart. Atrial tachycardia arises from a small area (focus) of tissue in the atria of the heart. This focus starts to fire and drive the heart, more rapidly than the heart's natural pacemaker. Usually, the focus fires only intermittently (this is sometimes known as paroxysmal atrial tachycardia) but occasionally it can continue for days or even persist for months at a time.

Ventricular tachycardia (VT)

Ventricular tachycardia (VT) is a fast rhythm that starts in the bottom chambers of the heart (the ventricles) and leads to the heart beating inefficiently. Symptoms including palpitations, breathlessness, chest pain and dizziness are often present. Rapid ventricular tachycardia may lead to loss of consciousness and degenerate into ventricular fibrillation, causing cardiac arrest.

Common causes of VT include coronary disease and cardiomyopathy, but it may also occur in patients with a structurally normal heart. In these patients VT may be associated with a genetic condition such as long QT syndrome or Brugada syndrome. It is commonly seen in patients who have suffered a previous heart attack and in this setting may be life-threatening.

Sudden Cardiac Death

The majority of patients who die suddenly and unexpectedly have coronary artery disease. Often this was previously unknown. In younger patients - typically age less than 35 years, one of a number of less common, although often inherited heart conditions may be the cause. These include hypertrophic cardiomyopathy, long QT syndrome and the recently recognised Brugada syndrome.

Heart Failure

This is a condition based on a deterioration in the ability of the heart to pump blood around the body. It is a progressive disorder affecting many organs and systems in the body. People with heart failure may experience a limitation in exercise capacity with symptoms of breathlessness and fatigue.

Special Echo Department, Level B, The Essex Cardiothoracic Centre
Basildon University Hospital site, Nethermayne, Basildon, Essex, SS16 5NL

Contact
Telephone: 01268 394155

Transthoracic echo

A transthoracic echo is an easy and safe test which provides information on heart muscle function and valve function. It is particularly useful before and after cardiac surgery and for patients following a heart attack. The physiologist moves a small, hand-held probe across the patient's chest to obtain a variety of ultrasound images.

The test takes approximately 30 minutes and can be performed as an inpatient, outpatient or part of a clinic appointment.

We perform a number of advance transthoracic studies. These can be for:

• Heart failure
• Contrast studies to assess for heart function, thrombus and small holes in the heart.
• 3D, strain and speckle studies
• Congenital heart disease
• Dys-synchrony studies for patients with suspected uncoordinated heart function that may need highly specialised pacemakers (CRT devices)

Trans Oesophageal Echocardiogram (TOE)

A TOE is a procedure to take detailed ultrasound images of your heart from the gullet (also known as the oesophagus or food pipe) which lies directly behind your heart. To do this, a long flexible probe will be passed into your mouth and down the gullet. This provides an excellent view of your heart chambers and valves, and allows us to examine how efficiently they are working. This procedure provides the most accurate information in diagnosing problems with the heart valves such as:

• Infection of the heart valves (endocarditis).
• The need to repair or replace the valve, or whether the valve needs stretching (valvuloplasty).
• A blood clot (thrombus) in the heart chambers.
• The procedure is performed as a day case, under sedation. You will be able to go home two to three hours after the procedure.

Dobutamine Stress Echo (DSE)

The Dobutamine Stress Echo (DSE) aims to make the patient's heart beat faster and harder using the drug Dobutamine and occasionally atropine. Abnormalities not seen at rest can then be detected (ischemia) and areas of muscle which are thought not to be working can be assessed to see if they have the ability to recover (viability).

The test is performed by a team including a consultant, a physiologist and a nurse. Patients are admitted to Thames Ward as a day patient, and the procedure and is usually performed under a light sedation.

Myocardial Perfusion Contrast Scan

This test is performed by a consultant or Cardiac Nurse Specialist and a physiologist and is used to determine whether the muscle may be permanently or partially damaged after a heart attack and can help plan patient future treatment.

A bubble contrast agent is given through a cannula in the arm to visualise areas of heart muscle filled by the coronary circulation. The bubbles in the contrast are burst and the time taken for the coronary arteries to refill the muscle with blood is measured.

Exercise Stress Echo

Patients are asked to cycle on the specially designed exercise bike which can tip the patient into a position allowing the physiologist to take images of their hearts while still cycling. This enables the consultant to see and measure dynamic changes to the patient's heart while they are exercising without having to use medication of any type.

Unexplained shortness of breath, valve disease and heart muscle diseases can all be diagnosed using this procedure.

The role of clinical perfusion is providing artificial heart and lung support.

The ability to remove blood before it enters the heart and lungs and return it to the body after the heart is key to facilitating nearly all cardiac surgery. If blood is not passing through the heart and lungs the function that these organs provide needs to be replaced. This is done artificially. Blood is filtered, pumped, oxygen is added, carbon dioxide is removed and the temperature is controlled.

Blood is important to fighting infection and promoting healing. The CTC uses state-of-the-art perfusion technology to make the artificial heart and lung support as similar to normal bodily function as possible. We aim to provide artificial heart and lung support during surgery without the blood or body knowing it has happened.

None of the patient’s blood is lost, which increases the chances of leaving hospital earlier, and reduces the risk of receiving donor blood.

Cardiac Rehabilitation Team, Level A, The Essex Cardiothoracic Centre
Basildon University Hospital site, Nethermayne, Basildon, Essex, SS16 5NL

Contact
Telephone: 01268 524900 ext 4076

Cardiac rehabilitation is an integral part of recovery following heart surgery, and involves continuing support and guidance for patients and their family. The rehabilitation process starts in hospital and continues to provide support for many weeks after.

Anyone who has had a heart attack, certain types of heart surgery or insertion of a stent will have cardiac rehabilitation.

There are three phases of the rehabilitation process which The Essex Cardiothoracic Centre facilitates.

Phase 1 - While you are in hospital

A member of the Cardiac Rehabilitation team will visit you on the ward prior to transfer to your local hospital or discharge home. They will discuss with you and your family, your event, recovery, lifestyle modification and answer any questions, queries or worries that you might have.

You will be given literature to take home and read and details of the local cardiac support group. You will also be given contact details for cardiac rehabilitation for you to call if you have any queries or worries.

Phase 2 – When you are at home

If you live in the area normally served by Basildon Hospital you will receive a phone call from the cardiac rehabilitation team to enquire how you are progressing. We will also try and answer any of your questions and if necessary ask you to attend a nurse led clinic appointment.

If your local hospital is not Basildon we will forward your details to your local cardiac rehabilitation service as soon as you are discharged. You will be contacted by them for further support and follow up.

Phase 3 – Exercise and education programme

If you live locally you will be invited to attend a structured exercise and education programme either at the purpose built air conditioned gym at The Essex Cardiothoracic Centre or if preferred a home based programme called the Heart Manual. These programmes can last 4 – 8 weeks and attendance can be once or twice a week depending on your individual needs.

Patients out of our area will be offered very similar programmes depending on what their local service provides.

Who will I meet?

As well as our specialist nurses, we have two senior physiotherapists and many other professionals including dieticians, a pharmacist and a counsellor. You will also have the opportunity to meet others who have had similar experiences.

We also have a cardiac support group called Hearts and Minds, run by previous patients. They have an informative website that includes patient stories of their experiences, a question and answer section and much more: www.basildonheart.org.uk