Cardiology and Cardiac Procedures

At Acıbadem, our Heart Care Center competes at a world-class level to provide the most modern heart care in Turkey. We use state-of-the-art technology and provide the most modern and comprehensive methods for the diagnosis and treatment of cardiovascular disease.

In our Heart Care Center, a team of cardiologists and cardiac surgeons work together for the “heart team approach,” which is the most effective way to deliver truly patient-centered care.

Our center provides non-invasive tests and minimally invasive interventional cardiology diagnosis and treatment, including electrophysiological study, nuclear cardiology, flash computed tomography (CT), positron emission tomography (PET)-CT, cardiac magnetic resonance imaging (MRI), electrocardiogram (ECG) and effort ECG, ECO, and coronary and wrist angiography.

We perform minimally invasive surgeries and complex surgeries, such as coronary angioplasty, stent application, bypass surgery, transcatheter aortic valve implantation (TAVI), and catheter ablation.

Common heart conditions

Coronary artery disease

Coronary artery disease is among the most frequently encountered heart diseases. Blood can travel freely through a healthy coronary artery, supplying the heart with the oxygen-rich blood that it needs.

High levels of cholesterol, high blood pressure, or smoking can damage the interior of the arteries, resulting in a buildup of plaque inside the arterial walls and preventing the flow of blood. This situation signals the beginning of coronary heart disease. The more plaque that builds up in an artery, the narrower it becomes, further reducing the amount of blood flowing into the heart. This starves the heart of oxygen, causing chest pain. A narrowed artery blocked entirely by blood clots will result in a heart attack (myocardial infarction). The lack of oxygen-rich blood leads to permanent damage to the heart muscle.

Heart attack

A heart attack begins when the coronary arteries feeding the heart, or any of their branches, get blocked. This results in irreversible damage to the heart muscle or a fatal heart attack. Heart attacks are the most serious of all coronary heart diseases. Two categories of factors increase the risk of a heart attack: unchangeable risk factors and changeable risk factors. Unchangeable risk factors include genetic factors, age, and being male. Men and people with a family history of early heart attacks are at greater risk. Risk also increases with age.

Changeable risk factors are entirely dependent upon the efforts of the individual. Smoking, high blood pressure (hypertension), diabetes, high levels of blood fats, and obesity are all included in these risk factors. The primary symptom of a heart attack is pain in the chest. Generally, this pain is severe and crushing. Early intervention is extremely important in heart attacks and being aware of the symptoms enables the individual to seek medical assistance immediately.

Cardiac valve diseases

The heart has four valves that open and close continually. The inadequate opening and closing of these valves can result in cardiac valve diseases. Valve diseases can be congenital or developed after rheumatism in childhood or as a result of calcification in old age. Complaints can vary depending on which valve is diseased. Common symptoms include fatigue, tiring quickly, palpitations, shortness of breath, and swollen feet, signaling edema in the body. Prior to the development of symptoms, valve diseases may be diagnosed by chance during routine check-ups when a doctor hears a murmur in the heart. As symptoms progress, a diagnosis can be made using special diagnostic techniques, such as ECG, chest X-ray, echocardiography, and heart catheterization.

Arrhythmia

In arrhythmia, problems arise as a result of the heart rate. Although arrhythmias are generally seen in patients with existing cardiac conditions, they can also develop in people who have no health problems. Some sufferers are unaware of these problems and will only be diagnosed during a routine checkup or following an ECG conducted for a different reason. But a significant number of patients consult their doctors with complaints of palpitations, irregular heartbeat, feeling an irregular sensation in the chest, a feeling of emptiness, dizziness, fainting, a reduction in the capacity for exertion, and shortness of breath.

Endocarditis

Endocarditis is the microbial inflammation of the inner layer of the heart, called the endocardium, which also involves the heart valves. Symptoms vary depending on the part of the heart that is infected and the type of bacteria causing the infection. Patients are given intravenous antibiotics for at least 4–6 weeks. Surgery is an option for heart failure caused by endocarditis or the expulsion of blood clots. Endocarditis must be treated. In particular, patients with other heart conditions need treatment.

Cardiomyopathies (heart muscle diseases)

Defined by the World Health Organization in 1995, cardiomyopathies are diseases of the heart muscle that result in dysfunction of the heart. The four groups of cardiomyopathy are as follows:

1. Dilated cardiomyopathy
2. Hypertrophic cardiomyopathy
3. Restrictive cardiomyopathy
4. Arrhythmogenic right ventricular cardiomyopathy

Many factors cause cardiomyopathy, including coronary artery disease, heart valve disease, hypertension, systemic infection, diseases of the metabolic system, genetics, and various poisons. Surgery can be done when medication or other interventions cannot be implemented.

Major vascular diseases

• Abdominal aortic aneurysms: Damage to the aortic wall causes the largest artery exiting the heart to expand to 1.5 times its original size in the abdominal area. This is most frequently observed in older men. It occurs at a rate of 2–3 cases in 10,000 people. People who smoke; have familial aneurysms; are elderly; are tall; or have blocked arteries, high cholesterol levels, chronic lung disease, or hypertension are at risk of developing abdominal aortic aneurysms. Abdominal aortic aneurysms are generally asymptomatic. The disease is usually identified when the patient consults a doctor for another medical complaint. Approximately 25% of patients suffer continuous or temporary stomach aches.
• Thoracic aortic aneurysm: These aneurysms form in the aorta in the chest area. A localized expansion of approximately 4 cm is called an aneurysm, and 1–1.5% of patients with thoracic aneurysms are aged 65 and over. Thoracic aneurysms can be triggered by aortic dissections, familial aneurysms, connective tissue disease (Marfan syndrome), trauma, and infectious disease. Thoracic aortic aneurysms are generally asymptomatic. Wide aneurysms can cause pain in the chest, back, and abdomen. Symptoms are similar to those experienced during a heart attack. However, other symptoms may include dysphonia, difficulty swallowing, coughing, vomiting, and bleeding. The sudden onset of these symptoms can signal the presence of an emergency, such as the aorta rupturing.
• Dissection: Aortic dissection is a tear in the wall of the aorta. Clinical progress may vary depending on the location of the aortic tear. In most patients, the condition is caused by hypertension. It may also develop as a result of various diseases, such as aortic aneurysm, collagen tissue diseases, aortic stenosis, aortic coarctation, and other medical conditions related to the aorta. Symptoms frequently begin with sudden, severe chest and back pain described as a stabbing sensation. This may be accompanied by complaints, such as perspiring, feeling cold or nauseous, or vomiting.
• Peripheral embolisms: Peripheral vascular disease is a narrowing or constriction of veins other than the coronary veins that supply the heart, which is so advanced that not enough blood is supplied to the organs. Diabetes, long-term hypertension, long-term lipid metabolism disorder, a family history of atherosclerosis (vessel stiffness), gout, insufficient exercise, and nicotine addiction are among the risk factors. The most common symptom is pain. However, the type of pain may vary. People with constriction can experience pain after walking. As the constriction increases, the distance the patient can walk without pain decreases. This pain is usually felt as cramps and disappears after resting for 2–5 minutes.
• Vena Constrictions (venous thrombosis): Vena constriction is caused by a small clot in the vein and may be asymptomatic. However, the tiniest clot can be life-threatening, depending on its location. Surgery is needed for patients who do not respond to medical treatment, are at risk of developing gangrene, or have severe pulmonary embolisms.

Varicose veins

Varicose veins are defined as the expanding, elongating, and twisting of veins in the leg. They are observed in 10–20% of the Western population. The likelihood of varicose veins is proportional to age. As many as 50% of people over 50 suffer from varicose veins.

There are four types of varicose veins:

• Spider web: These veins settle superficially on the skin. They have a diameter of 1 mm or less, cannot be felt to the touch, and are usually red. They are widespread linear forms in the shape of a star or a spider web and may spread to the whole leg.
• Reticular varicose: It is difficult to feel this type of varicose vein that is slightly swollen on the skin, has a diameter of less than 4 mm, and is blue.
• Great vena varicose veins (saphenous varicose veins): These are varicose veins that are easily felt and seen and that form large twists along the large and small saphenous veins. They have a diameter of less than 3 mm. As they run under the skin, they do not usually change the color of the skin, with only the greenish reflection of the vein visible. The swellings become pronounced when standing and disappear when the feet are raised or while lying down.
• Deep great vein varicose: Deep veins are in the deep layer of the leg. Varicose veins cannot be observed on the skin, yet they cause edema and circulation disorders in the leg. Varicose veins are more common in women than men and more common in people with a history of varicose veins in the family than in those without. Varicose veins may occur as a result of obesity, aging, pregnancy, menopause, prolonged standing, and constriction and valve disorders in the deep veins. The exact cause of varicose veins is unknown. The primary cause is the enlargement of the vein due to structural deformation of the vein wall. This leads to a reverse flow of blood due to a malfunctioning valve in the vein. This reverse flow makes it more difficult for blood to return to the heart, gradually increasing the pressure in the vein. The increase in pressure further enlarges the veins, creating a vicious cycle. Varicose veins have fewer common causes. In individuals with a constricted deep in, the superficial vein that carries 10% of the blood in the leg assumes the entire return of the venous blood in the leg. Therefore, the diameter increases, forming varicose veins.

Heart care services in Acıbadem Healthcare Centers includes;

Cardiovascular embolism

• Effort test
• Coronary CT angiography
• Myocardial perfusion scintigraphy
• PET
• Coronary angiography
• Coronary stent and balloon angioplasty
• Coronary bypass
• Robotic coronary bypass
• Small incision coronary bypass

Cardiac valve disease

• ECG
• Angiography and catheterization
• Percutaneous valvuloplasty
• The catheter method and TAVI
• Robotic valve surgery
• Valve surgery with a small incision

Arrhythmia

• Holter monitorization
• Diagnostic electrophysiology study
• Catheter ablation
• Implanting a permanent and temporary pacemaker
• AICD Implantation
• Pacemaker implantation with three chambers

Aorta vascular disease

• Endovascular aneurysm repair
• Thoracic endovascular aneurysm repair
• Hybrid treatment
• Surgical repair
• TAVI

Peripheral embolisms

• Doppler ultrasound
• BT Angiography
• MRI
• Digital subtraction angiography
• Stent application in the carotid aorta
• Endarterectomy in the carotid aorta
• Peripheral surgical bypass
• Peripheral endoluminal bypass

Varicose

• Transdermal laser
• Sclerotherapy
• Varicose surgery
• Endovenous varicose surgery

Cardiomyopathy

• Interventional treatment (ablation)
• Surgical treatment

Congenital heart diseases

• Pediatric cardiology
• Pediatric heart surgery
• Treatment of congenital cardiac diseases with catheterization

Cardiac Rehabilitation

Why should you choose Acıbadem Heart Care Center?

Since 2002, at the Acibadem Healthcare Group, we have been inspecting our medical and administrative performance through performance indicators. With patient safety and satisfaction as our top priority, we view our scores in heart care—and all other branches—as a guide in providing better patient care.

• The EuroSCORE criteria state that the expected mortality rate in open heart surgery is 3.8%, but at Acibadem, our percentage is only 1.6%.
• The EuroSCORE criteria state that the expected mortality rate in coronary bypass surgery is 2.7%, but at Acibadem, our percentage is only 1.0%.
• Operations on seniors, diabetics, or patients with a history of heart attack, heart surgery, contraction and expansion disorders of the heart, or malfunction of the kidneys, liver, or lungs face higher operative risks. Various risk scores exist for the objective evaluation of patients, taking such factors into account. In these scoring systems, weighted risks are calculated. EuroSCORE is the most commonly used scoring system.
• At Acibadem, we provide a high standard of modern diagnostic, treatment, and support services for adult and pediatric cardiovascular diseases.

Robotic and minimally invasive cardiac surgery

Robotic heart surgery, requiring advanced techniques and substructures, is used in only a limited number of centers around the world. The Acibadem Maslak Hospital has been a pioneer in robotic cardiac surgery. World firsts have been realized in Turkey via robotic surgery:

Use of the da Vinci robot in the Acibadem Maslak Hospital:

• Aneurism (ballooning) of the left ventricle of the heart for the first time in the world
• The first complicated mitral valve repair in Turkey
• The first mitral valve replacement

Coronary artery patients without vascular disease are routinely operated on via robotic methods if their anatomical structures are suited to this technique. Furthermore, mitral valve repair, mitral valve replacement, and tricuspid valve intervention can be performed on patients with suitable anatomical structures. The technical rate of success in robotic cardiac surgery is 90%.

Why should you choose robotic and minimally invasive heart surgery?

• Less bleeding
• Decreased need for blood transfusion
• Less pain
• Lower infection risks
• Shorter hospital stay
• Faster recovery
• Better aesthetic results

Advantages of robotic and minimally invasive surgery

The success rate of operations increases thanks to the three-dimensional camera, which allows an easy view of locations that are most difficult to observe. The arms of the robot can turn 540 degrees and move in six directions. Because the devices used are tiny, they can reach locations that a human hand cannot. For example, the success rate of fixing the cardiac valve increases using this method. As the operation is completed with tiny incision, the patients feel less pain when compared with conventional open surgery. Because the procedures are performed from three or four holes of 8 millimeters each, there are no aesthetically unappealing scars left on the skin. Thanks to a small incision and decreased blood loss, patients can be discharged within 1–2 weeks, even after the most complicated surgery. Minimal damage occurs at the surgery sites, so the patient can get out of bed and return to normal activities quickly. Zones of hemorrhage can be clearly seen thanks to the three-dimensional, high-resolution cameras that magnify the operation site, so blood loss is minimized and blood transfusion is not required.

Additionally, because cutting through the breastbone is not necessary, there is no risk of the patient suffering from a displaced or infected breastbone. Maslak Hospital has been a pioneer center in robotic cardiac surgery, with world firsts achieved in Turkey via robotic surgery.

Heart condition diagnosis and treatment

Interventional methods

Coronary angiography: This is the most reliable method to test the anatomical structure of arterial constriction and provide a functional assessment using supplementary techniques. This method is used in patients whose results from other tests suggest coronary constriction, in patients who are scheduled for stent or balloon angioplasty, or in the diagnosis and treatment of heart attacks in emergency conditions. The procedure is performed in the catheter laboratory, making hospitalization necessary. The patient does not feel any pain during the procedure, only a warm sensation spreading across the entire body during the injection of a radio-opaque substance, usually lasting a few seconds. Under normal circumstances the procedure is short, lasting only 5–10 minutes. It has an extremely low mortality rate when conducted by experienced personnel in experienced centers (<0.1%). After the procedure, the patient needs to be monitored for two to six hours in the hospital.

Wrist angiography: Angiography plays a key role in the diagnosis of cardiovascular diseases. With the help of recently developed technologies, it can be done from the wrist instead of the inguinal region. If constriction exists in the veins in the inguinal region, or if the inguinal region is not suitable due to excessive weight, wrist angiography is preferred. It can be used in 99% of patients. Vein complications in the patient are observed only very rarely. Following the procedure, the patient can sit, walk, and eat. The patient can return to his/her daily life on the same day.

Treatment

Coronary angioplasty and stent application: Coronary angioplasty (balloon endarterectomy) is the widening of local constrictions in coronary arteries using non-surgical methods. A guide wire is inserted and pushed from the inguinal aorta into the coronary veins. A deflated balloon is slide through this wire until it reaches the constricted area. When the balloon is inflated from the outside (approximately 3 cm in length and 3–4 cm in width), the constriction in the coronary veins is removed. However, this method is not suitable for every coronary constriction. For some patients, bypass surgery might be necessary, while for others, heart medication can be an effective and safe form of treatment. Such decisions should only be made by specialists.

Bypass surgery: Depending on the degree of arterial constriction, the doctor may recommend coronary artery bypass intervention. This intervention corrects the blood flow that supplies the heart, thus restoring health. Coronary bypass surgery may provide a second chance for the patient’s heart, giving them a chance for a longer life. Coronary artery bypass surgery resupplies blood to the heart through the formation of a new pathway, other than the constricted or narrowed artery. In the event of more than one constricted artery, more than one bypass is required. The artery to be used for the bypass, also known as the graft, is taken from the chest, arm, or leg and attached to the constricted coronary artery. The most used grafts are the internal thoracic arteries, the aorta from the arms, and veins from the legs. Since the areas of origin of these veins have additional veins, their removal does not affect blood circulation.

Small incision surgery: Endoscopic surgery is a minimally invasive method in which open heart surgery is performed using special endoscopic devices through a small incision made in the chest region. During the operation, all surgical instruments are under the control of the surgeon while the endoscopic camera is used to view the surgical area. Coronary bypass using the endoscopic method can be used for valve repair, valve implant, the repair of ventricular septal defects, and ablation for rhythm treatment. When compared with open surgery, mobility is higher and scar healing is much faster, and following surgery, patients can return to work and resume active life much more quickly. However, the structure of the sternum wall and the anatomy of the heart must be suitable for this method.

TAVI: This involves the implantation of an aortic valve in the heart using the catheter method without open surgery. Biological cardiac valves are used in valve implant surgeries globally. In the TAVI method, the biological valve is placed in a stent jacket and, when opened, is firmly placed on the valve implant area. Two different techniques can be used in this method. In the first technique, similar to valve angiography, the valve is pushed from the inguinal area to the heart with the help of a catheter. When in place, the stent mechanism is opened. The second technique is used when there is a constriction in the inguinal region or the abdominal region that will be used to access the heart. Then, a small incision of 4–5 cm is made in the front wall of the sternum to access the endpoint of the heart. The valve is placed with the help of a catheter pushed to the heart. In both methods, there is no need to stop the heart and perform open surgery. The procedure can be completed under local anesthesia.

The patient is taken to their room after the TAVI procedure. They are then given anticoagulants and monitored under normal conditions for 4–5 days before being discharged. Following several days of rest, the patient returns for a follow-up exam and resumes daily life. The TAVI method is primarily recommended for high-risk patients who would otherwise not be able to endure valve implant open surgery. Additionally, it can be used on patients who have other obstacles preventing open surgery. The TAVI method has been proven to be effective on such patients, prolonging their lives and improving their clinical condition. Although TAVI is a recently developed method, technological developments, application experience, and scientific results indicate that it will become much more common in the future.

TAVI at Acibadem: Globally, TAVI valve procedures have been performed in experimental environments since 2002 and on humans since 2004. The operation has been successfully implemented in a number of prominent centers both in the USA and Europe since 2010. It was first used in Turkey in 2009. The Acibadem Cardiology and Cardiovascular Surgery team have at their disposal the necessary equipment to perform this new and successful treatment method and can successfully implement the TAVI procedure. The procedure is organized and completed by a team composed of many specialists from different disciplines, including cardiovascular surgery, cardiology, anesthesiology, reanimation, and radiology.

Diagnosis and treatment options

As with all other diseases, early diagnosis of cardiac disease is vital for successful treatment. Regular check-ups and close monitoring of heart health is the first condition of early diagnosis. At Acibadem Heart Care Centers, we provide diagnostics and treatment using state-of-the-art equipment.

Electrocardiography

An ECG is a device that records the electrical activity of the heart to examine the cardiac muscle and its functioning. It is used for fast assessments, especially in emergencies. The ECG is an important tool in the diagnosis of cardiovascular diseases, structural anomalies, and arrhythmias. ECG monitoring and interpretation can be performed quickly.

The Exercise electrocardiogram

This is an exercise test performed on a treadmill following a systematic, specific protocol. It is based on the interpretation of ECG recordings received via electrodes placed on the chest while exercising. The test usually lasts 5–10 minutes but varies based on the patient’s age and condition. It is a test that monitors the functioning patterns of the heart under effort and is used to identify embolisms that are normally asymptomatic. Interpretation of the effort ECG for diagnostic purposes should be done by experienced doctors to avoid misinterpretations of other diseases with similar findings.

Echocardiography

Echocardiography is a diagnostic and investigative tool that allows for the examination of the structure, pathology, and functioning of the heart using ultrasonic waves. It is possible to examine the movement and cavity of the ventricle wall, the growth of the cardiac muscle, and the cardiac valves using echocardiography. It is also possible to observe the structure and functionality of implanted artificial valves. Virtually all congenital cardiac diseases can be diagnosed using this method. Echocardiography has no harmful side effects on the patient and is easy to use. The patient also feels no pain during the procedure.

Holter monitorization

A Holter monitor is used to monitor the cardiac rhythm or blood pressure of a patient. Separate devices the size of a mobile phone are used for ECG records and blood pressure measurements. The devices are fixed to the body of the patient for 24 hours or more. The devices measure cardiac rhythm and blood pressure continuously. Holter monitorization is usually used to monitor the cardiac rhythm and blood pressure of the patient in their daily life. Physicians use this test when they suspect an abnormal cardiac rhythm or an imbalance in blood pressure.

Trans-telephonic monitor

This is a recording device, similar to the Holter device that is attached to the patient to monitor cardiac functioning. Under normal circumstances, Holter devices can remain on the patient for 2–3 days. However, in patients who only rarely feel discomfort, symptoms may not occur during that time. In such cases, a telemedicine device that operates trans-telephonically can be used.

Stress echocardiography

Echocardiography conducted during periods of rest can determine the width of the cardiac cavity, malfunctions in the movement of the wall, and contraction functions of the heart. It can help indirectly diagnose coronary artery disease. It also helps to identify other conditions such as cardiomyopathy, which complements other valve diseases; cardiac membrane infections; tears in the aorta; and excessive thickening of the heart that could cause chest pains and difficulty in breathing. Stress echocardiography can be used in conjunction with the effort ECG to identify the location of vascular disease.

Myocardial perfusion scintigraphy

Myocardial perfusion scintigraphy is mainly used to identify problems related to blood accumulation in the cardiac muscle. It provides information about the blood build-up in the heart under two different conditions: under stress (for instance, during exercise) and at rest. Myocardial scintigraphy can be used to identify serious coronary artery diseases. Its diagnostic sensitivity and precision in the diagnosis of severe vascular diseases is around 90%. Findings obtained during the test also provide information on the mortality risk, cardiac functioning, and advanced cardiac failure of the patient, and provide vital data to help make decisions about the correct course of treatment.

Flash computed tomography

Flash CT is a radiological method of diagnosis that creates a cross-sectional image of the examined area using X-rays. As a radiological method of diagnosis, Flash CT is able to provide images of all parts of the body, particularly cardiac and pulmonary areas. When compared with single tube and single detector systems, it provides images in half the time. It allows the heart to be scanned in 250 milliseconds, with a 99% accuracy rate (a quarter of the length of a heartbeat). Thus, even in cases where the heart rate of the patient is over 100 beats per minute, there is no need to slow the heart with medication. Flash CT is a scanning tool that emits the lowest level of radiation on the market. Cardiac scanning can be completed with 80% less radiation when compared with several other methods. It can be used in routine procedures as a non-invasive cardiologic diagnostic method.

Cardiac magnetic resonance imaging

The MRI test provides valuable information on congenital cardiac disease and cardiac cavities and enables the detailed assessment of the structure of the main arteries entering and exiting the heart. It supplements the findings from echocardiography without adversely affecting the patient; it provides detailed information in the assessment of cardiovascular constrictions, the extent of the effect of a heart attack on the cardiac muscles, and the condition of the heart in preserving its vitality and functionality. The MRI test has the highest level of diagnostic sensitivity in the assessment of cardiac muscle disease and masses in the heart. In contrast to traditional imaging methods, MRI does not use radiation or ultrasound waves. The accurate images of the organs are displayed using physiological parameters.

Positron emission tomography-computed tomography

The PET-CT is a cardiac examination based on scintigraphy. This method is utilized to observe vitality retention of the heart. It is used mainly to obtain detailed information on the functioning and vitality of cardiac cells, giving accurate results on the vitality of cardiac tissue. It provides guidance in determining whether bypass surgery would be beneficial for a high-risk patient.