FAQ

Heart controls should be started in mother’s womb. After the 3rd month, it is needed to look the ventricles of babies with ultrasonography and make a diagnosis regarding their health. ECHO should be made when they are 5, and blood sugar, blood fats and blood pressure controls should be done at least a couple of times before 20.

Between the ages of 20 and 30 is the period when the life is so fast. University, leaving the family, marriage, having a kid and smoking exhausts the heart. When we were born, our heart is 0 years old. When we are 20, it is frequently more than 20. The important thing is handling the heart age and the normal age in a balance.

Heart is an organ which works 24 hours a day without a break and needs more oxygen than a normal muscle. If a vein is blocked and enough oxygen does not reach to the heart, heart attack occurs. Heat attack may start with pains while walking and then it may reveal itself while resting. The patient without a pain is unlucky.

If pain in chest, neck, arm, left wrist or finger, feeling of pressure, numbness or tingling exists, a doctor should be immediately consulted.

Pain is a mechanism which protects the body. The patients with disturbed pain mechanism are the ones with diabetes and the overweight individuals. The first step to be protected against pain should be abstaining from smoking. Then the weight, blood pressure and sugar should be taken under control.

The individuals whose family has an early heart disease, diabetes, high blood pressure history and overweight persons are in the high risk group. The persons in the risk group should have a blood test, blood pressure control and effort test once a year after the age of 30, and the ones who have no risk should have the tests once a year after the age of 40. I especially suggest the ones who work in high risk jobs, and executives with high adrenaline to have computerized coronary angiography after the age of 40. Nowadays the young persons are working in the jobs which exceed their age and occupational experience, they are taking the responsibilities which they cannot bear because of their age, and consuming themselves to prove their personality, and this situation increases the risk of coronary heart diseases. Thanks to this wonderful technology, it is possible to have info about the situation of cardiovascular diseases for the next ten years.

We have two hormones which are produced by us in our body: adrenalin and endorphin. Adrenalin is a hormone which carries us through. It increases our blood pressure and pulse. But it also causes a

bounding pulse, spasm and high blood pressure. Endorphin, on the other hand, enlarges the veins. Both of these give happiness and cause addiction. While listening to a good music, or after a decent walk, our endorphin level rises in blood. It is good for heart when the endorphin is as high and adrenaline is as low as possible.

The death cases experienced in children because of cardiac reasons are not heart attack. In order to have a heart attack, the veins which nourish the heart should have a blood clot inside and this clot should block the veins. The cases in children are frequently caused by the congenital events. This may be a valve narrowness (mostly the aorta valve), congenital rhythm disorder or thickening of the area between the two walls of heart. Most of the death cases in children occur because of the rhythm disorders caused by congenital anomalies. If there are some problems like empurpling while sucking, this is a messenger of a congenital heart anomaly.

The cases or heart attack and vascular diseases increase during winter. Coldness is a factor of spasm. When the cold is directly taken via chest or breathe, it causes a spasm. Especially in cold weather, it is important to wear warm clothes and have a scarf. Some medicines for flu which are increasingly taken during winter may cause rhythm disorder but it has not been seen that they cause a fatal effect yet. If there is an effect of the medication there should also be a side effect. But if any bounding pulse happens, the medication should be given up and a doctor should be consulted.

The most beneficial exercise for the heart is a quick walk. The exercises should be done without exhausting oneself so much. If the body is used to it, it is good to have a 45 minute walk daily. But if the exercise is to be done for the first time, exhausting the body will not be a true policy. The second important sport for heart health is swimming.

Differing from the other imaging methods, namely echocardiography and coronary tomography, the most distinctive feature of this method is its giving detailed information on tissue level. There is no other method which makes such an evaluation regarding the tissue of cardiac muscle. For example, when echocardiography is applied to a patient with cardiac insufficiency, only the existence and level of the coronary insufficiency is detected. On the other hand, having Cardiac MR gives significant info on the reason of cardiac insufficiency. The cardiac MR is the best method the answer the questions whether a coronary artery disease, congenital cardiac insufficiency or inflammation caused the cardiac insufficiently. Thanks to this, the diagnosis and treatment process of the patients are accelerated and this makes a tremendous contribution to the course of the disease.

While ensuring all these, another significant feature of this method is its’ not causing any radiation exposure.

The follow-up of the patients is also important besides the diagnosis and treatment of patients after starting the treatment process. For example, if the pre-bypass evaluation is made with cardiac Mr,

the amount of tissue which will potentially recover can be predicted. Cardiac Mr can be used to make detailed measurements and evaluation on tissue level.

In chemotherapy patients, some medications can cause a toxic effect on cardiac tissue Especially in the patient groups with low echocardiographic imaging quality, the heart functions can be tacked with MR. It is also important for the cancer patients because there is no radiation.

It can be investigated whether a permanent damage has remained after the treatment of myocarditis or cardiac attack with cardiac MR.

Besides, the cardiac muscle can also be affected as a result of some rheumatologic diseases. If there is any uptake and it is considered the cardiac insufficiency is caused by these diseases, the treatment can be altered completely. For this reason, cardiac MR provides a guidance regarding if there is any uptake in the heart in case of rheumatologic diseases.

The imaging quality of cardiac MR is far better than echocardiography. The volume, contraction strength and all the anatomy of the heart can be analysed in details. Especially the right ventricle has a tough shape like a funnel and while the detailed evaluation of the right ventricle is hard with echocardiography, the detailed volume and functional evaluation can be made easily with cardiac MR. Cardiac MR is one of the diagnosis methods which are written on the handbooks regarding the cardiac disease which is hand in hand with rhythm disorders that may threaten life, called as arithmogenic right ventricular dysplasia (ARVD).

Because it gives the advance level info of an alteration of ligament in cardiac muscle and a possible rhythm disorder, in some genetic diseases like hypertrophic cardiomyopathy which develops with the thickening of cardiac muscle, it is needed to be taken in these patients in any case. Besides, because this disease has a genetic transition named as “autosomal dominant”, if there is any ambiguous situation or a suspicion of an early stage disease as a result of the electrocardiography of the family members, also taking the cardiac MR of the family members can be thought for a detailed and tissue-level evaluation. During the intra cardiac mass evaluation, it provides detailed info on the type and spread of the mass.

Cardiac MR is frequently used because it provides info on the anatomic, volume and hemodynamic of the congenital cardiac diseases. It is also preferred in the decision of the type of operation and the routine controls because it is radiation free, there is an opportunity for hemodynamic evaluation and it provides detailed imaging.

It takes approximately 50-60 minutes.

f the kidney functions of the patients are disordered, the process of dehydration (giving serum from the veins) is made or some precautions are taken for this situation. People with kidney problems should inform the physician before the cardiac MR. As a rule, the levels of creatinine are controlled before cardiac MR. If the patient has any creatinine result in the recent period, then it is not requested again, but if not, the creatinine in blood should be controlled.

As mentioned above, cardiac Mr does not have any side effects other than the possibility of allergy to the contrast substance which is to be given during the process and advancement of the kidney disease if no precaution is taken in some kidney patients.

If there is no indication in the patient, there is no need to have it regularly. On the other hand if the patient has a disease like cardiac insufficiency, valve disease, congenital cardiac disease or aortic widening which necessitate follow-up, there patients may be recommended to have cardiac MR follow up and evaluation. Especially in the patients with aortic widening and the ones who need to have an annual or semi-annual follow up, doing the follow up with cardiac MR instead of computed tomography will eliminate the exposure to radiation.

Contrast substance is given in cardiac MR. There are some cases named as late or early gadolinium uptake. In case of the early uptake, it is controlled whether there is a blood clot or microvascular obstruction in heart. In case of the late gadolinium phase, it is needed to give contrast to see if there is any ligament alteration in the muscle tissue of heart, named as myocardia. If no contrast substance is given, it is not possible to see the alteration of ligaments in cardiac muscles, localization or amount of the dead heart cells.

When a successful imaging is executed with coronary ct angiography, a high level imaging can be obtained nearly like in case of angiography. Besides, while it is only possible to see the inner part of the veins via angio, also the vein wall of the patient can be seen in coronary ct angiography. In this way, the structure of plaques in the veins can be analysed. Plaque ingredients analysis is important because the prevalence and character of the plaques gives insight about the risk group of the patient. The treatment is planned according to all these evaluations. Sometimes the effort test result can be normal even if the patients are in a high risk group. So if the physician evaluates the patient in high risk group, coronary ct angiography is recommended and sometimes critical narrowness cases can be uncovered in this method. In the patients whose vein narrowness does not indicate any critical condition with intermediate or light plaques, the medication therapy is started or the existing medication therapy is regulated. Besides, coronary ct angio is applied on the patients with an existing cardiac disease to see the course of the disease and whether there are any additional problems. Coronary ct angiography is not recommended in the patients with the micro stents, but if the sizes of stents are suitable, the intra stent narrowness can be checked via coronary ct angiography.

Coronary ct angiography is also used to measure the calcium amount in the completely blocked veins, plan the road of the wires which will be used during the application and determine the treatment strategy. It also bears importance as a guide during the hard applications. It only takes

5-6 minutes and the total process is 40 minutes with the processes like informing the patient, opening the vascular access, giving the necessary medication and executing the application.

The advantages of coronary CT angiography are:

1. The imaging quality is quite enhanced.
2. It is preferred frequently because it gives the image with high resolution. It gives advanced level info regarding the complicated and simple congenital heart diseases, anatomic and vascular connections.
3. It does not cause any disturbances in patients because 5-7 minutes is enough for imaging and there is no noise problem unlike MR.
4. No pain is felt during and after the process.
5. It can be safely applied on the persons with previous bypass operations or the ones with unknown coronary artery diseases previously. Also the detailed info on the coronary anatomy and levels of narrowness can be learned via this application.

On which patients should the coronary tomography/coronary BT angiography not be applied?

Because contrast substance is used during the process, the application should be decided after a pre-evaluation by the doctor of the patients and the department of Nephrology. Coronary CT will not give optimum results on the patients with minimal stents. If tomography is needed for the patients who should not take radiation, the imaging is executed while takin precautions for the minimum radiation dose. Apart from this, the process can be applied on all the patients.

For the patients with kidney problems, liquid intake may be needed before and after the process. The patients with no detected cardiac insufficiency are urged to take 2-2.5 litres of water in any case. This enables the discharge of the contrast substance from body easily. The patients must not stand up suddenly after the process. They are requested to sit a while and then the pulse and blood pressure is controlled. The patients are kept under control for immediate intervention in the cases of dizziness, low blood pressure etc. Then the reporting process may take 1-2 days.

Because coronary tomography does not contain any radioactive substance unlike nuclear medicine, there is no need to watch anything after the process.

No, no pain is felt.

Because allergy can develop as a result of the contrast substance given during the process, the allergic history of the patient is taken in details beforehand. If there is an allergic situation, the process is executed after giving the protective medicine and the patients are taken into surveillance for a longer time. In case of the patients with more serious allergic history like anaphylaxis, the Allergy Department is consulted and the precautions are discussed.

If there is a serious narrowness or insufficiency in mitral valve, the repair or replacement of valve with minimal invasive method can be applied nearly in all patients. Minimal invasive (small cut) methods provide tremendous benefits especially in the situations like diabetes, chronic lung disease or obesity which create high risk during the open surgical metyhods.

For the repair and replacement of mitral valve with minimal invasive method, it is sufficient to make an approximately 3 cm small cut from the 4th gap of the right chest wall. The main pathological areas in the wall are detected via a camera system which is placed to evaluate the valve. If any repair is to be done, the pathology in the area is repaired with various repair methods and the function loss in the valve is eliminated. If it is not suitable for repair, the valve is taken out after making the necessary measurements and the suitable metal or biological mitral valve is stitched onto this area.

Not only in mitral valve diseases, minimal invasive can also be applied in case of other hearth operations like coronary bypass. Except the cosmetic advantages brought by the small cut, the most significant advantages are the minimum wound infection and bleeding complication, the more rapid recovery of lung functions and shorter inpatient stay in comparison with the open surgery. The recovery period of the cut bone is 8-12 weeks approximately in a patient who had open surgery and a serious movement restriction should be applied during this period. On the other hand, the patient can return the professional life and pre-operation living quality just in approximately 2-3 weeks in case of minimal invasive heart surgery.

In the da Vinci robot, there is a console, a 3-d screen in the console and joysticks, just like in computer games. There are also 3 or 4 sticks. The operation is performed by managing the sticks via the joysticks. The actions can be taken via minimal cuts or no cut as in case of coronary artery bypass operations. In case of valve operations, a 2-3 cm cut is opened and the operation is performed from

there. Robotic surgery is a team work. There should be another surgeon to manage the console besides the performing surgeon, and also the nurse should be knowledgeable about the robotic surgery process.

In case of minimal invasive, that is, the robotic operations performed by the cuts which are smaller than the small cut method, the chest wall integrity is protected because the bone in the frontal wall of the chest has not been cut. This ensures the decrease of respiratory system problems which is frequently encountered after operations. The bleeding amount is so low during and after the operation, the patients are discharged mostly without needing the process of blood transfusion. With the accelerated recovery process, the duration of stay at intensive care unit decreases to 1 day, and the duration of stay at the service decreases to 3-4 days. On the other hand, the bone union takes approximately 2 months in case of open surgical methods. The patients are needed not to turn the other side in the bed, not to lift their arms higher than their head level and not to carry any load. On the other hand, the patients can lie down however they want after their drains are pulled, they can execute any activity they did previously like driving a car, swimming or lifting a load. The conventional surgical methods in which the chest bone is opened also cause cosmetic problems. Especially the young patients experience cosmetic and psychologic problems and this causes a longer recovery period. With the minimal invasive method, the chest gap is opened 6-7 cm, but with the robot this amount decreases 3-4 cm in the operations. As long as the arms are not upheld, no surgical mark can be seen.

Everybody can be a candidate for cardiac robotic assisted surgery operations. Many operations like Coronary artery bypass surgery, congenital heart operations, arrhythmia operations, cardiac valve operations, septal defect operations, taking out the tumours in heart can be performed via robotic technology.

Robotic technology cannot be applied on the children below a certain age and weight, just like in the small cut operations. The minimum limit is accepted as 20-25 kg and 8-10 years because some of the equipments used in robotic technology may not be suitable for children. The tubules, named cannula, which are inserted in the veins to tie the heart to the lung machine, cannot be used in small children or infants. Besides this, robotic surgery cannot also be performed on the person s who had the lung diseases like pneumonia an tuberculosis or lung operations and then whose pleura has stuck on the chest wall. It is not possible to get rid of that stickiness and reach the heart. Moreover, small cut or robotic surgery is not preferred in case of the valve operations of the patients with seriously damaged heart functions, serious leakages in the aortic valve during the mitral interventions and in case of the necessity of another operation in the patients who had a previous valve operation with robotic surgery.

The preparations to be done during the per operation process are also applicable for robotic surgery. The patients give up eating-drinking 1 day before the operation due to anaesthesia. Also the necessary blood tests are performed before operation. The functions of kidney, liver, respiration and carotid artery narrowness are investigated. If there is a problem regarding these, the patient is taken into treatment and then the operation starts.

The healing process after operation in robotic surgery is quite easy in comparison with the open surgery. Many limitations to be watched after open surgery are not applicable for robotic surgery. For example, the patients shouldn’t turn to left or right while laid down in bed for a month, and carry load above 5 kg. On the other hand, there are no such limitations in robotic surgery, so returning to the daily life happens earlier. There can be some situations to be noted before the operation which is to be performed via da Vinci robotic surgery, e.g. bypass or valve operation. The information regarding these is given before the discharge.

The element which can be regarded as disadvantage is the cost. Because special robots are used during the process, the cost increases in comparison with the small incision method. On the other hand, it can be said that the recovery period and returning to social life is shorter in comparison with the conventional open surgery, even with the small incision method, so this diminishes this disadvantage. In the minimal invasive method, the moves more than the surgeon can do are ensured with 360 degree 3d images. Surgeons use special lenses, namely, loop, to have a better image, but the 3d image in robotic surgery does not necessitate the usage of this equipment. So the process is executed more clearly. For example, the bypass operations are extremely delicate operations which are performed with extremely thin robes, like a strand. Thanks to the decent imaging in robotic surgery, the vein stitches can be made more clearly. The imaging is better than the imaging which can be seen by human eye.

Although there is no pain like in case of the cut of thoracic bone, named as sternum, there can be some pain which can be alleviated via simple painkillers.

Robotic surgery is a method which takes some time to learn, just like small incision method. So the surgeon should take the training of robotic surgery to use it, besides, experience, surgical maturity and skilfulness are important. Even if the surgeon is familiar with the conventional operations, a special training is necessary to perform robotic surgery. So this method is safe if performed in safe hands and equipped centres

Although there is no certain age limit, the additional risk factors which are brought by the advanced ages, like kidney or respiratory problems should be examined. If there is not such a problem, there is

no age limit. Regarding the minimum age limit, it is not suitable for small children and infants until reaching the below limit. Children above 20-25 kg and 8-10 years are accepted as the minimum limit.

The standard risks of conventional surgery are also applicable for the robotic method. On the other hand, all the necessary blood tests are performed before operation. The functions of kidney, liver, respiration and carotid artery narrowness are investigated beforehand. If there is a problem regarding these issues, the patient is taken into treatment and then the operation is performed.