Cardiovascular Medicine

Our heart, the central organ and at the same time emotionally charged - both positively and negatively... especially when something is close to our heart. It pumps our blood through the large arteries to all organs, to the smallest periphery. It warms us, and we turn red or pale depending on the circulatory situation.

After the organism has been supplied, the "used" blood returns to the right ventricle and is enriched with oxygen again in the pulmonary circulation. From there, it goes into the left ventricle and is pumped back into the body circulation. Sixty to seventy times a minute, or even faster if we exert ourselves. Around the clock, every day.

It is all the more important that this system remains intact and in rhythm. Especially since cardiovascular diseases are the most common cause of death in Germany - according to the RKI, they are responsible for about 40 percent of all deaths. Many of them could be prevented as some of the crucial external risk factors are influenceable - e.g. high blood pressure, Diabetes, lipid metabolism disorders and obesity –, but also the behaviors that can lead to them, such as smoking, unhealthy diet and lack of exercise. Here, behavioral changes towards a healthier life and medical therapies can have a proven positive effect. Prevention therefore plays a decisive role in cardiovascular health.

High blood pressure (hypertension) is one of the most common "underlying diseases." In the long term, it leads to damage to the heart, blood vessels, kidneys, and other organs. Unfortunately, elevated blood pressure is rarely noticed; it often remains symptom-free for a long time and is only diagnosed by chance.

Preventive examinations for the heart

Preventive examinations are officially recommended from the age of 50, but they can also be worthwhile earlier - for example, if there is a corresponding family history. The start of such a check-up is a detailed history taking. This includes the collection and assessment of lifestyle, medical history, or indeed family predispositions. Lifestyleof existing diseases. In addition, laboratory tests with recording of the lipid status (cholesterol levels), a heart ultrasound as well as an ultrasound of the carotid artery are recommended. This way, risk factors can be identified or treated early and the course for a healthy life - not only in old age - can be set.

Such a check-up is carried out by an internist or cardiologist. Additional examinations include, for example, an exercise ECG, a stress echocardiography or more detailed imaging such as a cardio-CT, an MRI, or a scintigraphy.

“Heart Teams”

In addition to diagnostics, the cardiologist is also responsible for the therapy or intervention of various heart diseases. More complex procedures are then carried out by the cardiac surgeon or together in a "Heart Team." Because the areas often overlap, especially in interventional and minimally invasive areas, clinics are increasingly having such "Heart Teams" consisting of specialists from the fields of cardiology, cardiac surgery, as well as anesthesiology, and possibly radiology, internal medicine, vascular surgery, etc. Together, they decide on the best approach in an interdisciplinary manner.

Many procedures can be performed on the beating heart - i.e. without the use of the heart-lung machine or even without opening the chest. This also shortens the stays in the intensive care unit and in the hospital, and the recovery is faster.

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Indications for cardiac surgery

The most common diseases include:

Arteriosclerosis and coronary heart disease

It is the most common cause of death in industrialized countries – in Germany alone, almost 5 million people are affected. The trend is slightly declining, which is partly due to a change in lifestyle, but also due to improved medical treatment of risk factors. However, this is no reason to give the all-clear. increasing age increases the risk of arterial calcification, in which genetic predisposition also plays a role.

What happens? The inner layer of the vessels, called the endothelium, is increasingly damaged by high blood pressure, high blood sugar, and high LDL cholesterol levels; microscopic injuries occur. There is also much to suggest inflammatory processes that seem to be partly responsible for the formation of deposits of cholesterol and calcium. These "plaques" grow and increasingly obstruct the blood flow, causing the vessel to become calcified and the heart muscle to be inadequately supplied. If the deposits rupture, a blood clot can form and block the vessel – a heart attack threatens as a consequence.

Typical symptoms include a feeling of tightness in the chest (angina pectoris), shortness of breath, or burning during exertion. It is important to note that women may also experience atypical symptoms in the upper abdomen or jaw and these are often misinterpreted or go unnoticed.

Calcified and narrowed coronary arteries can be opened or bypassed through various surgeries. On one hand, such narrowings can be interventionally dilated and supported via a heart catheter. If multiple coronary arteries or the so-called main trunk of the coronary system are affected, a Bypass surgery may often be the more sustainable option. Under certain conditions and in specialized clinics, this can even be done without the use of the heart-lung machine, i.e., "off-pump".

Diseases of the heart valves

The heart can only function well if blood flows in the right direction. This requires valves that open to allow enough blood to flow into the circulation but also close tightly to prevent backflow – the heart valves. In total, there are four heart valves: The aortic valve separates the left ventricle from the aorta and, like a valve, ensures that oxygen-rich blood only flows towards the aorta. That is, it regulates the blood flow from the heart into the large main artery.

A valve defect affects the heart's performance. A drop in performance or exertion-related shortness of breath can also be due to the mitral valve. This separates the left atrium from the left ventricle and ensures that the blood coming from the pulmonary circulation flows only from the atrium into the ventricle and not back.

Aortic valve stenosis

This disease pattern is the most common heart valve defect. It occurs due to degeneration and calcification, leading to a narrowing or stenosis of the heart valve. This means the heart has to exert more force, which leads to fatigue and consequently reduced pumping performance. Typical symptoms can include shortness of breath, dizziness, sudden unconsciousness, and a feeling of pressure in the chest.

After a thorough diagnosis using ultrasound (transesophageal echocardiography, also known as TEE) as well as computed tomography (CT) or, if necessary, magnetic resonance imaging (MRI), appropriate treatment is chosen. In the advanced stage, surgical intervention may be necessary. There are various procedures: on the one hand, surgical treatment with aortic valve reconstruction or replacement using a heart-lung machine and (minimally invasive) opening of the chest; on the other hand, there is the alternative possibility of transcatheter aortic valve implantation (TAVI), which is performed minimally invasively on the beating heart. This method particularly benefits patients who are over 75 years old and/or not suitable for major surgical intervention.

Mitral valve insufficiency

The leakage or insufficiency of the mitral valve is the second most common heart valve disease. It occurs when degenerative processes on the leaflets of the mitral valve itself or indirectly due to a heart muscle disease prevent the valve from closing properly, causing blood from the ventricle to partially flow back into the left atrium, possibly leading to a backlog of blood in the pulmonary circulation. Initially, it is often asymptomatic. With greater severity, it can cause shortness of breath (initially only with exertion) and a dry cough. Other symptoms include heart rhythm disturbances (palpitations, irregular heartbeat), reduced physical performance, and nocturnal urination.

Heart rhythm disturbances – arrhythmias

A heart rhythm disturbance occurs when the heart beats too slowly, too quickly, or irregularly. This happens due to disorders in the formation or conduction of impulses in the heart. Symptoms range from palpitations to dizziness, fainting, and even sudden cardiac death. The causes can be both cardiac diseases and extracardiac, meaning disorders outside the heart.

Atrial fibrillation is the most common heart rhythm disturbance – instead of a normal rate of 60 to 80 beats per minute, there are suddenly frequencies of more than 100 beats or more per minute. This can lead to sudden reduced performance or shortness of breath, but it does not necessarily have to cause symptoms. An important aspect is the increased risk of stroke due to clot formation in the heart.

Aortic aneurysm

This is an enlargement of the blood vessel walls of the aorta; it may be genetically predisposed (tissue weakness) or as a result of arteriosclerosis, but can also arise due to chronically high blood pressure. If the aneurysm remains undetected, there is a risk of rupture. This represents an acute emergency that must be operated on immediately. If detected in time – usually during routine examinations – the prognosis is better due to various treatment options. The therapy depends on the size and extent. Here, there is a collaboration between heart surgery and vascular surgery.

If the aneurysm is too large or if there is also aortic valve disease, an aortic operation should be considered promptly. With each increase in an aneurysm, the risk of the vessel tearing increases. In the ascending part of the aorta, the operation is performed surgically, in the descending part, the vessel can usually be treated interventionally with stent implantation.

Myocarditis

Inflammation of the heart muscle (myocarditis) can occur after common viral infections, such as the flu. As a result, symptoms such as arrhythmias or tachycardia, weakness, shortness of breath, or chest pain occur. Affected are heart muscle cells or even the pericardium (pericardium). Because the ECG is often inconspicuous here, an MRI provides more reliable results. Early detection is useful because neglected myocarditis can lead to heart failure and sudden cardiac death.

Modern heart diagnostics

Modern heart diagnostics offer a variety of methods to detect and assess cardiovascular diseases. Here is a brief overview of the most important procedures:

Ultrasound (echocardiography)

It is a central method in heart diagnostics. Transthoracic echocardiography (TTE) is the standard procedure for assessing heart function, valves, and heart structure. If more detailed imaging is required, transesophageal echocardiography (TEE), performed under mild sedation, is used. This allows for more precise images of heart valves or, for example, thrombi in the atrial appendage.

Advantages: non-invasive, no radiation exposure, widely available

ECG and stress ECG

The ECG records the electrical excitation and conduction in the heart. The stress ECG records heart function during physical exertion (e.g., on a treadmill or bicycle ergometer). It is primarily used to diagnose circulatory disorders (ischemia) and exercise-induced arrhythmias.

Indications: Suspicion of coronary heart disease (CHD), assessment of exercise capacity after heart attack or in heart failure.

Advantages: inexpensive, widespread

Stress echocardiography

This method combines echocardiography with stress (physical or pharmacological). It is used to assess cardiac muscle movement and blood flow under stress conditions and detects changes in reduced blood flow.

Advantages: higher sensitivity than stress ECG

Cardiac catheter examination with ischemia diagnostics

The cardiac catheter examination is the gold standard for visualizing the coronary arteries and diagnosing ischemia.

Procedure: A catheter is advanced through the arm or groin artery to the coronary vessels. Contrast agents and X-rays show the vessels.

Additional options: pressure wire measurement (FFR/iFR) or intravascular ultrasound (IVUS) for the assessment of stenoses.

Advantages: direct visualization and, if necessary, therapy (e.g., stent implantation)

CT with coronary imaging (Coronary CT)

Computed tomography offers a non-invasive alternative for the visualization of coronary vessels and has gained more importance in recent years. It is used to exclude coronary heart disease (CHD) and requires the administration of contrast agents; modern devices provide high-resolution 3D images.

Advantages: non-invasive, high negative predictive value

Magnetic Resonance Imaging (MRI) – function and ischemia diagnostics

Cardiac MRI utilizes magnetic fields and radio waves to create detailed images of the heart. It provides comprehensive information on the structure, function, and blood flow of the heart, is used for depicting ischemia under stress, and can serve to identify scar tissue.

Advantages: no radiation exposure, excellent image quality

Scintigraphy

Myocardial scintigraphy uses radioactive tracers to assess blood flow and heart muscle function and is used to identify ischemias and viable myocardium.

Advantages: high sensitivity

Conclusion

The choice of the appropriate diagnostics depends on the clinical question, the availability of the methods, and individual patient factors. In many cases, the procedures are combined to ensure precise diagnosis and optimal therapy planning.