Heart Failure

Introduction:

Heart Failure (HF) continues to be a major heart problem and an important cause of hospitalization in India. The number of patients with HF has been gradually increasing due to improving life span of patients and improved survival after heart attacks in the last few years. More patients are being saved from heart attacks due to better availability of drugs and immediate revascularization of the blocked vessels. Though this is heartening news, the number of patients with poor heart function has been increasing all over the country.

What is Heart Failure?

Heart Failure does not mean that heart has stopped working or is about to stop working. HF is a condition in which the heart becomes so weak that it has trouble pumping a normal amount of blood carrying enough oxygen and nutrients to meet the body’s needs.

 

What causes HF?

HF develops either as a result of (1) damage to the heart muscle (which could be caused by coronary artery disease,  infection or toxic exposure to chemicals such as alcohol and drugs) or (2) when too much strain is placed on the heart because of years of untreated high blood pressure or an abnormal heart valve.

 

What is the commonest cause of Heart Failure/ heart muscle damage?

The commonest cause of HF is coronary artery disease where in the blockages of the coronary arteries cause damage to the heart muscle thereby reducing the pumping of the heart. The loss of pumping function of the heart is directly related to how fast the patient seeks treatment for a heart attack. Patients who receive treatment within one hour of onset of chest pain due to a heart attack do well as the heart muscle is salvaged from further damage due to early intervention in the form of drug treatment or angioplasty. Damage to the heart muscle due to drugs, alcohol or infections is the second common cause of HF.

 

What do the patients complain of?

The commonest symptom is shortness of breath, also called dyspnea, which is caused by accumulation of fluid in the lungs due to failure of the left side of the heart.

Swelling of feet, ankles, legs and abdomen due to accumulation of fluid is caused by failure of the right side of the heart.

Chronic cough, loss of appetite and fatigue are some of the symptoms which patients experience.

Some of the patients may complain of palpitations which may be caused by irregular heart beats.

 

Diagnosis of HF:

Patients are mostly diagnosed by their physicians due to their typical symptoms and then advised to undergo tests like Electrocardiogram, Echocardiography and Coronary angiography.

  1. The Electrocardiogram (ECG) give information about the rhythm of the heart, any electrical disturbance of the heart and also if the blood supply is less.
  2. The Echocardiography is the sonography of the heart wherein its imaged and the pumping of the heart is studied. It’s the most important test to diagnose heart failure. It gives the physician information on heart pumping, the function of the valves and leaks across the valves. The pumping of the heart can be quantified as Ejection Fraction (EF) which is normally in the range of 55-65%. Any decrease in EF below the normal range suggests some weakness of the heart muscle and needs to be investigated further. Patients with EF lower that 35% entail more risk of sudden death and heart failure hospitalizations and need more specialized treatment.
  3. Coronary angiography: is necessary to diagnose blockages in the coronary arteries which would need subsequent correction by either angioplasty or bypass surgery.

 

Risks of Heart Failure:

Patients with HF are at high risk of Sudden Cardiac Death and recurrent hospitalizations due to heart failure episodes. The patients at most risk are the ones with an EF of less than or equal of 35%. HF patients keep getting admitted in hospitals due to recurrent dyspnea which need to be treated with intravenous medications.

 

Devices in Heart Failure:

There are 2 devices which can be used in HF treatments (1) Cardiac Resynchronization Therapy and (2) Implantable Cardiac Defibrillator

 

 

Summary:

Patients with heart failure are at risk of dying from progressive heart failure and sudden cardiac arrest. This can be now corrected and treated effectively by implanting devices (namely CRT and ICD respectively). However, these patients need to be carefully evaluated and selected by the cardiologist before undergoing these procedures so as to ensure maximum benefit.

 

 

Bradycardia (slow heart rates)

 

Do you experience slow heart rates (Bradycardias)?

This is the condition when the heart rate slows down thereby compromising the circulation. These can be caused either by problems of electrical current generation or conduction.

 

What do the patients complain of?

The patients tend to complain of giddiness, lightheadedness, fatigue, breathlessness or episodes of fainting.

 

How is this condition diagnosed?

The condition can be diagnosed by a electrocardiogram (ECG) which reveals the slow heart rate. Some patients may need to undergo EP study to diagnose this condition.

 

How is this condition treated?

Once the diagnosis is confirmed, these patients need to be treated by Artificial Pacemakers.

 

What are pacemakers?

Artificial pacemakers are small coin shaped devices (1-2 inches in diameter) which generates electrical current. They are placed just below one’s collar bone and the current is transmitted to the heart with the help of one or two wires (leads) positioned in the right side of the heart. They carry out the normal electrical function of the heart and thus cure the patient of his symptoms.

Tachycardia (fast heart rates)

Do you experience Fast heart rates (Tachycardias)?

 

What do the patients complain of?

 

The patients tend to complain of episodes of palpitations due to fast heart rates. Some patients may feel giddy or have  episodes of fainting if the heart rates are too fast.

 

How is this condition diagnosed?

The condition can be diagnosed by a electrocardiogram (ECG) which reveals the fast heart rate. Some patients may need to undergo EP study to diagnose this condition.

What are the causes of Fast heart rates?

These can be due to various causes, however, the common one seen are SVT (supra-ventricular tachycardia), AF (atrial fibrillation) and VT/VF (ventricular tachycardia/ fibrillation).

  • SVT (Supra-Ventricular Tachycardia):  These are caused by the presence of an extra electrical connection between the upper and lower chambers. These patients experience intermittent fast heart rates associated with palpitations and lightheadness. The episodes can be highly distressing and limit one’s activities. They can be easily controlled with medications. However, with the advent of new technology, it has become easier to get rid of them and cure the patient of the fast heart rates. The procedure is called EP (electrophysiology) study and is carried out by inserting small catheters via one’s groin upto the heart. The heart is then stimulated to start the fast heart rate and the location of the extra connection is studied. The pathway can be burnt (ablated) by radiofrequency energy in a controlled manner with the help of catheters. These procedures have a good success rate (> 90%) and take around 2-3 hours. The patient can be mobilized after few hours and discharged the next day.

 

  • Atrial fibrillation: This is a disease of the elderly in which the upper chambers (atria) beat at extremely fast rates (400-750 beats/minute). Thus there is no effective pumping of the upper chamber, causing blood to stagnate and form clots which can cause strokes in high risk individuals. These patients need to be treated with drugs called blood thinners to reduce the risk of stroke. In addition, drug therapy is required to prevent the lower chambers from going fast which can be very distressing to the patient or life threatening. Ablation therapy can be offered in some patients in the early form of the disease. The procedure lasts 4-6 hours and are done through the groin. The chances of recurrence are high (around 30%)

 

  • VT (ventricular tachycardia): These are life threatening and are responsible for sudden cardiac deaths. Most of the patients who suffer from these either have blocks in their blood supply to the heart (have suffered heart attacks before) or have low pumping function of the heart. These patients can be controlled by oral medications. However, devices called Defibrillators are implanted to treat future episodes and to reduce the death rate in patients with heart attacks and poor heart function.  These are implanted just like pacemakers except that they have the additional function to detect and shock these dangerous rhythms. In patients with poor heart functions, an extra wire (lead) is placed on the left side of the heart to improve the heart function.

About me!

Hi!

My name is Dr. Ameya Udyavar, I am a Cardiologist who specializes in Heart Beat/ Rhythm Disorders!

When your heart goes Dhak! Dhak! due to the smile of your sweetheart, that’s normal. But that should not happen when you are just relaxing or doing your daily chores. People with heart beat problems suffer from palpitations, giddiness and also fainting spells. That’s when my speciality kicks in! Its a nice branch of cardiology which is growing by leaps and bounds. There is so much to learn and keep myself updated. That’s equally true for all branches of medicine, particularly in Cardiology.

The field of Cardiology boasts of maximum trials and innovations being conducted. Yet, inspite of all these advances, heart disease remain the no. 1 killer all over the world and also in India. The people suffering from heart illnesses is increasing day by day. My intention of writing this bog is provide people at  large  health related information in particular to preventing and treating heart disease. I hope my endeavour bears fruits in the form of informed choices being made by our patients.

So, enjoy going through my blog. Interact if you have queries and suggestions.

I grew up in the lovely city of Mumbai and did my medical education from Mumbai University. I specialized in Cardiac Electrophysiology from Taipei and Australia. I  am currently practicing in P.D. Hinduja Hospital in Mumbai.

I have a beautiful wife who is also a Physician and 2 lovely kids. When I am not working in the hospital, I like to spend time with my family.

I love jogging and cycling. Travelling and playing the guitar is what I do in my past time.

so, READ, INTERACT, SUGGEST and GET HEALTHY!

Chao!

Ameya

Tests we perform

 

Cardiac Electrophysiology is a subspeciality of Cardiology and deals with the diagnosis and management of arrhythmias. It is estimated that approximately 1 million patients in India suffer from abnormal tachycardias which can be cured by a procedure called Ablation.

 

Hinduja hospital has recently acquired the state of the art St. Jude Medical EP Workmate which is the recording and mapping system used for treatment of arrhythmias. Also, it’s the first hospital to acquire the 3D-Mapping system called Ensite Velocity from St. Jude Medical in the whole of Western India. Also with the joining of Full time Cardiac Electrophysiologists, the hospital provides the full range of diagnostic and therapeutic services necessary for cardiac electrophysiology.

 

These services can be categorized into the following:

  1. Diagnostic services for patients with Syncope
  2. Diagnostic/ Therapeutic services for patients with Tachycardias (Fast heart rates)
  3. Diagnostic Services for evaluating the risk for Sudden Cardiac Arrest
  4. Diagnostic/ Therapeutic services for patients with Bradycardias (slow heart rates)
  5. Device therapy for patients with Heart Failure

 

 

A. Diagnostic services for patients with Syncope:

Syncope is a common symptom presenting in the emergency department or as an outpatient problem. These patients need careful evaluation of their history in order to differentiate them from seizure and also to risk stratify them. The following tests have been provided in this hospital for them

  1. ECG (Electrocardiogram): needed to rule out cardiac disorders like ischemic heart disease, arrhythmias and genetic disorders like long QT syndrome.
  2. Holter recording: ECG is recorded for 24 hours to detect and rule out arrhythmic causes of syncope.
  3. Tilt-table testing: Herein, the patient is made to lie on the tilt bed and then the bed tilted 70 degrees with monitoring of heart rate and blood pressure. Subsequently a provocative phase is carried out by giving drugs. This is an extremely useful test for patients with vasovagal syncope.
  4. External Event recorder: This is a device like a Holter which is rented to the patients on a long term basis (weekly) to as to record the ECG during syncopal episodes. It records the ECG 30 seconds before the syncope episode thereby pinpointing any cardiac arrhythmias.
  5. Internal Event recorder: This is small device implanted in the chest to record syncope which are infrequent, and can be kept in the patient for 2-3 years.

 

B. Diagnostic/ Therapeutic services for patients with Tachycardias (Fast heart rates)

1. Electrophysiology (EP) Study:  An electrophysiology (EP) study is a specialized procedure conducted by the Electrophysiologist who has gained special expertise in these procedures. These are carried out in patients with arrhythmias and patients with bypass tracts. Three thin flexible wires/ catheters are inserted and placed in different locations within the heart to record the electrical activity. With the help of the catheter, the electrical system of your heart is studied and problems diagnosed.

2. Ablation: The sources of abnormal heart beats or abnormal connections are then burnt off/ blocked by delivering radiofrequency (RF) energy with the help of a fine catheter. This is called Ablation. This gives complete relief to the patient by curing him permanently of the arrhythmia.

3. 3D-Mapping study: Here in a state of the art 3D-mapping system (Ensite velocity) is used to map the electrical activity of the heart. This is the first and the only hospital in Western India to acquire this technology. This is used in specialized procedures for patients with complex arrhythmias like atrial fibrillation, ventricular fibrillation, atrial tachycardias and flutters.

 

C.  Diagnostic Services for evaluating the risk for Sudden Cardiac Arrest (SCA):  

SCA kills approximately 4-5 million Indians every year (2 per1000 persons). SCA stops the heart thereby leading to death within minutes. Patients with prior heart attacks and reduced heart function (ejection fraction less than 35%) face the highest risk of SCA. These tests evaluate the risk of developing SCA by non-invasive electrocardiology tests. Hinduja hospital is the only hospital in the country to provide all the below mentioned electrocardiography tests under one roof.

  1. Signal averaged ECG with Late Potentials: This is a specialized ECG test where the electrodes are connected on your chest and limbs and a high definition ECG is recorded with a special machine. This machine amplifies your ECG and gives a value for the Late Potentials. Presence of late potential warns of higher risk of sudden cardiac arrest
  2. T wave Alternans: In this test, the patient is made to walk on a treadmill. At the end of the test, the software calculates  a value for T-Wave Alternans which is a very sensitive marker for sudden cardiac arrest
  3. Heart Rate Variability: The Heart Rate Variability value is derived from the 24 hour Holter recording with the help of a special software. Decrease heart rate variability may be an indicator of increased risk of sudden cardiac arrest.

 

D.  Diagnostic/ Therapeutic services for patients with Bradycardias (slow heart rates)

  1. Electrophysiology (EP) Study: These are carried out to study the function of the sinus node and the AV node.

2.  Pacemaker implantation: Artificial pacemakers are small coin shaped devices (1-2 inches in diameter) which generates electrical current. They are placed just below one’s collar bone and the current is transmitted to the heart with the help of one or two wires (leads) positioned in the right side of the heart. They carry out the normal electrical function of the heart and thus cure the patient of his symptoms due to bradycardia. Pacemaker outpatients clinics are held every Friday from 2 to 5 pm where in patients with pacemakers are followed up and their devices checked.

 

E. Device therapy for patients with Heart Failure (Ejection fraction < 35%)

Heart Failure (HF) continues to be a major heart problem and an important cause of hospitalization in India. In 2006, the prevalence of heart failure patients was estimated to be around 18.8 million (which is 1.7% of the population) with the annual incidence of 1.57 million per year.

There are 2 devices which can be used in HF treatments (1) Cardiac Resynchronization Therapy and (2) Implantable Cardiac Defibrillator

1.  Cardiac Resynchronization Therapy:

The  synchronized contraction (Synchrony) is lost between the various chambers of the heart in patients with heart failure.
CRT is designed to correct this dys-synchrony between chambers of the heart and thereby improve the heart function. In this procedure, a pacemaker  is implanted in the upper chest region and 3 wires (leads) are inserted into the heart to deliver electrical therapy. This results in a more coordinated and effective heart beat improving the heart function.

2.  Implantable Cardiac Defibrillators (ICD)

ICD is a device designed to shock the heart out of a dangerous life threatening rhythm. It is implanted below the skin in the upper chest and is then connected to a wire (lead) which monitors the heart rhythm 24 hours. Whenever it detects a dangerous heart rhythm, it delivers an internal shock to the heart and Patients most at risk from sudden cardiac arrest benefit from these devices

 

Hinduja hospital has for the first time in the country provided the entire gamut of diagnostic and therapeutic services in the field of cardiac electrophysiology. We hope to provide relief and specialized care to the patients suffering from arrhythmias as these disorders can be very difficult to detect and treat.

Life’s Simple 7

Start your new life resolution today! 

The American Heart Association’s My Life Check empowers you to take a big step toward a healthier life. In just a few minutes, you can get your personal heart score and a custom plan with the 7 simple steps you need to start living your best life. 

 http://bit.ly/9Ff50m

Courtesy: American Heart Association

7 small steps to BIG changes:

1. Get Active

2. Eat Better

3. Loose Weight

4. Stop Smoking

5. Manage Blood Pressure

6. Reduce Blood Sugar

7. Control Cholesterol

Cholesterol, fats, lipids! what are they and what should be their levels?

What are the types of Fats in our body?

The human body contains different types of fats or lipids. Lipids are important chemicals present in the body and needed for various cellular functions. The fats in our body are of different types. They can simply be divided in Bad and Good fats.

Which are the Bad fats/ lipids? How do they harm us?

The Bad fats get deposited in our arteries thereby causing blocks. These blocks decrease the blood supply of the organs causing various serious illnesses like heart attacks (decrease blood supply to the brain), paralytic strokes (decrease blood supply to the brain), or gangrene of the limbs (decrease blood supply to the limbs). Thus it is important to keep our Bad cholesterol below the normal range.  There are 2 types of Bad Cholesterol in our body: LDL Cholesterol and Triglycerides. Higher levels of Bad Cholesterol can be harmful in the long run.

Which are the Good fats/ lipids? Do they harm us?

The Good Cholesterol is protective and higher levels are better. The Good Cholesterol in our body is HDL Cholesterol.

How do we know our fat/lipid level?

One needs to do a Complete lipid profile (blood test) after 12 hours of fasting.

What should be your LDL (Bad) Cholesterol level?

If one suffers from any of the below mentioned illnesses, then the LDL Cholesterol needs to be below 100 mg/dl. These disorders are

  1. Diabetes
  2. Heart attacks
  3. Blocks in your coronary artery causing angina (chest pain)
  4. Undergone angioplasty or bypass surgery
  5. Renal failure
  6. Blocks in any of your arteries: carotid artery or peripheral arteries
  7. dilatation of your aorta.

Does diet and exercise help to reduce Bad Cholesterol?

Yes, they do. Brisk walking every day for 30-45 minutes can help reduce your bad cholesterol and increase your good cholesterol. Avoiding foods rich in fats like fried food, cakes, sweets can also help reduce the bad cholesterol.

Are there medicines which reduce Bad Cholesterol and prevent heart attacks?

Statins are called the wonder drugs which reduce LDL cholesterol. These drugs are extremely safe and also decrease triglyceride levels and increase the good cholesterol! They have been proven to prevent heart attacks and in some cases reduce the blocks! These drugs need to be taken on a daily basis and need to be continued lifelong.

Devices for Heart Failure

Devices for Heart Failure:

 

There are 2 devices which can be used in HF treatments (1) Cardiac Resynchronization Therapy and (2) Implantable Cardiac Defibrillator

 

(I) Cardiac Resynchronization Therapy:

The heart is made of 2 upper chambers called atria and 2 lower chambers called ventricles. An electrical system controls the synchronized pumping action of these chambers. The atria contract first followed by the 2 ventricles. The 2 ventricles contracts simultaneously to as to ensure optimal pumping of blood to the body and lungs. However this synchronized contraction (Synchrony) is lost between the atria and the ventricles and also between the 2 ventricles. This dys-synchrony leads to further less effective contraction of the heart thereby reducing thereby aggravating the heart failure. This Dys-synchrony can be easily diagnosed by the Physician with the help of the electrocardiogram and the echocardiogram.
CRT is designed to correct this dys-synchrony between the upper and lower chambers of the heart and also between the 2 lower chambers. This ensures simultaneous contraction of the 2 lower chambers thereby improving the contractions. In this procedure, a pacemaker (the size of a pager) is implanted just below the skin in the upper chest region and 3 wires (leads) are inserted into the heart to deliver electrical therapy. The 3 leads are positioned in the right upper, right lower chambers and the left lower chambers. The CRT device simultaneously stimulates the left and right ventricles and restores a coordinated, or “synchronous,” squeezing pattern. This reduces the electrical delay and results in a more coordinated and effective heart beat.

Who needs the CRT?
According to the Heart Rhythm Society, the ideal candidate for a CRT device is someone with:

  1. Moderate to severe heart failure symptoms, despite lifestyle changes and medication
  2. A weakened and enlarged heart muscle
  3. A significant electrical delay in the lower pumping chambers.

How effective is CRT?

There have been around 8-9 clinical trials involving around 5000 patients. Clinical studies demonstrate modest improvements in exercise tolerance, heart failure severity, and quality of life in most patients. Almost two-third of the patients implanted with the device benefit in their symptomatic status and also have decrease in the number of hospitalizations over the next few years. Improvement may happen quickly, but sometimes it can take several months.

(II). Implantable Cardiac Defibrillators (ICD)

ICD is a device designed to shock the heart out of a dangerous life threatening rhythm. The device is similar to the pacemaker and is the size of a pager. It is implanted below the skin in the upper chest and is then connected to a wire (lead) which monitors the heart rhythm 24 hours. Whenever it detects a dangerous heart rhythm, it delivers an internal shock to the heart and restores the normal rhythm.

Who needs ICD? Who is at risk of developing dangerous heart rhythm?

Dangerous heart rhythms can cause Sudden Cardiac Arrest which can cause instant death. Patients most at risk are those with compromised heart function (Ejection fraction < 35%). These patients if symptomatic need to undergo an ICD implantation so as to reduce their risk of dying from sudden cardiac arrests.

How effective is ICD?

There have been around 6 clinical trials involving around 3000 patients. Clinical studies demonstrate modest reduction in the death rates due to sudden cardiac arrest and have been life-saving in the majority of the patients.

Summary:

Patients with heart failure are at risk of dying from progressive heart failure and sudden cardiac arrest. This can be now corrected and treated effectively by implanting devices (namely CRT and ICD respectively). However, these patients need to be carefully evaluated and selected by the cardiologist before undergoing these procedures so as to ensure maximum benefit.

Pacemaker Implantation (PPM)

Pacemaker implantation is a procedure to put a small, battery-operated device called a pacemaker under the skin of your chest, just below your collarbone (clavicle), to help your heart beat regularly. Usually this is a minor surgical procedure performed under a local anaesthetic. Occasionally, the pacemaker may be implanted under general anaesthetic.

About a Pacemaker

The pacemaker is a small metal box weighing 20-40g, which contains a pulse generator (usually a lithium battery) attached to one or more wires/ leads that run to your heart. The pacemaker also contains a computer circuit that converts energy from the batteries into electrical impulses, which flow down the wires and stimulate your heart to contract.

Why do I need a pacemaker?

When you’re resting, your heart normally beats (or contracts) 50 to 80 times a minute. If you exert yourself or feel anxious or stressed your heart can beat at two or three times this rate to pump blood faster around your body. This beating of the heart is a result of generation of electrical current in the SA node which is situated in the right upper chamber of the heart. This current then get transmitted through a special tissue called AV node and His-Purkinje system to the lower chambers. Once the current reaches the lower chambers, they pump blood to the whole body. Any problem with either the generation or conduction of electrical impulses of the heart gives rise to Slow Heart Rates (Bradycardia). This can give rise to giddiness, lightheadedness, fatigue, breathlessness or episodes of fainting. The pacemaker is implanted to correct this problem.

What will be done once I get admitted?

You will be told to get admitted one day prior or early morning on the day of the procedure. Once you finish the admission procedure on the ground floor of the Main Hospital building, you will be allotted a bed on one of the floor or in the ICU in the Main Hospital building. You will be examined by one of the nurses and the doctors to see if you have any problems and your medications and reports checked. We are here to make you comfortable and relaxed before the procedure. If you have any doubts or queries do feel free to ask your nurse or doctor. You have nothing to lose by asking queries.

What preparation do I need before the pacemaker implantation?

Your doctor will tell you about the procedure in advance. He will explain to you the procedure in detail before getting admitted and after getting admitted. Your doctor will tell you ahead of time whether to stop taking any of your medications.

Few things necessary before the procedure:

  1. An informed written consent will be taken from you explaining the procedure, its details and its risks if any.
  2. You will be told not to eat or drink at least 6 hours before the start of the procedure
  1. The left or right side of your chest will be cleaned and shaved.
  1. An intravenous IV cannula will be inserted in one of you hands/arms before the start of the procedure to give you fluids and medications.
  2. An intravenous antibiotic will be given intravenously before the start of the procedure
  3. Please let the doctor know if you have any allergies or reactions to any drugs.

Where are these procedures performed?

The procedure is performed on the second floor in the Cath lab situated in the Main Building. The Cath lab laboratory has a moveable procedure table on which the patient lies down and an X-ray machine that is suspended over the table. This X-ray machine guides the doctor in placing the wires or leads within your heart. In addition, there are monitors which will monitor your heart rate and blood pressure.

Before the Start of the procedure:

  • You will lie flat on the procedure table. The electrocardiogram (ECG) leads will be connected on your body to record your ECG during the procedure. The nurses will thoroughly cleanse the chest and neck region with special soap. The procedure is done under local anesthesia with intravenous sedation. You will be given intravenous drugs to make you feel sleepy and relaxed. This will relieve
  • Sterile drapes will be used to cover you from your neck to your feet.
  • A support will be placed below your waist and arms to prevent your hands from coming in contact with the sterile area.

What kind of anaesthetic will I have?
The procedure is done under local anaesthetic with intravenous sedation. A medication will be given through your IV line to relax you and make you feel drowsy, but you won’t be asleep during the procedure.

Pacemaker Implantation
After you have been adequately sedated and relaxed, the doctor will inject local anesthesia at the site of pacemaker implantation (upper part of chest just below your collar bone. Once the effect of the anesthesia has taken place, the cardiologist makes a small incision of 5-6 cm (2-3 inches) below the collarbone and makes a small ‘pocket’ to insert your pacemaker. He then inserts the pacing lead into a vein. He then guides this into the correct chamber of your heart using X-ray guidance. The pacing lead is connected to the pacemaker and the pacemaker is fitted into a small ‘pocket’ under the skin of your upper chest. The cardiologist then tests how much electrical energy is needed to stimulate your heartbeat and adjusts the pacemaker accordingly. Some patients may need 2 leads to be implanted which will be told to you before the procedure. The procedure usually takes between 60 and 120 minutes or longer if you’re having a bi-ventricular pacemaker or other heart surgery at the same time. You’ll usually need an overnight stay in hospital and a day’s rest after the procedure. After the pacemaker has been implanted, the doctor uses an external device (programmer) to program the final settings based on your response to the procedure.

Will I feel anything?
You’ll feel an initial burning or pricking sensation when the cardiologist injects the local anaesthetic. You’ll soon become numb, but you may feel a pulling sensation as the cardiologist makes the pocket in the tissue under your skin for the pacemaker. When the leads are being tested, you may feel your heart rate increase or your heart beat faster. Please tell the team what symptoms you’re feeling. You should not feel pain. If you do, it’s important to tell the team immediately.

Risks of pacemaker implantation

  • Infection: There is a small risk of infection (about 1%) at the site of the implant. If it spreads, there’s a risk the pacemaker may need to be replaced.
  • Loosening of pacing leads: There’s a small risk that one of the leads might move out of position (about 1%) which is why you’re advised to avoid vigorous exercise for a few weeks.
  • Air trapped in the chest (pneumothorax): There’s a small risk of air leaking from the lungs to the chest during the procedure. The doctor will check this on your chest X-rays before you leave hospital.
  • Death: This is very rare with pacemaker implantation
  • The operation can’t be performed: For about one in 100 people the operation is too difficult and the doctor has to stop without fitting the pacemaker on the first occasion.

Post procedure care

After the procedure the patient will be shifted to the ICU for monitoring of the heart rhythm. You should avoid vigorous movement of the arm where the pacemaker is implanted. An X-ray of your chest and ECG will be done on the same day after the procedure. After some rest, the patient can begin moving about, and generally is ready to go home the next day after the pacemaker has been checked.

Will I feel pain after the procedure? 
You may feel some pain or discomfort during the first 48 hours and will be given pain relieving medication

Before Discharge

Before you go home the cardiologist will come to see you and discuss the results of the procedure and answer any questions you have.  After your pacemaker has been fitted, you’ll be given a pacemaker registration card which contains details of the make and model of your pacemaker. You should always carry this with you in case of an emergency. You may also be given extra information produced by the pacemaker manufacturer.

Wound care 
You should avoid getting the wound wet for 7 days after the procedure. Please keep the wound dry and clean. If you notice any serious swelling, pain or redness, please consult your doctor. Nowadays, the cardiologist uses absorbable sutures, so there is no need to get the sutures removed after 7 days. Your first follow up visit to the hospital will be after 7 days.

How soon can I drive? 
If you are driving your personal vehicle, you can start driving again after a week (provided you don’t have any symptoms, such as dizziness or fainting, which would affect your driving). If you are driving a large or passenger-carrying vehicle (public), you’ll have to wait for six weeks after your pacemaker is fitted.

When can I do exercise or play sports again? 
You should avoid strenuous activities for around three or four weeks after having your pacemaker fitted, after which you should be able to do most activities and sports. If you play contact sports, however, such as football or rugby, it’s important to avoid collisions. You may want to wear a protective pad. You should also avoid extreme activities, e.g. squash/ tennis, although swimming should be ok.

EP study and Ablation

Cardiac electrophysiology is a medical speciality devoted to the diagnosis and treatment of abnormal heart rhythms.

Electrophysiologists are fully trained cardiologists who have undertaken additional fellowship training in clinical cardiac electrophysiology. Cardiac electrophysiologists have expertise in the invasive diagnosis and treatment of cardiac arrhythmias (abnormal heart rhythms). They perform invasive procedures including diagnostic electrophysiology testing, radiofrequency catheter ablation, and implantation of antiarrhythmic devices such as pacemakers and defibrillators.

What is an EP study?

An electrophysiology (EP) study is a specialized procedure conducted by a highly trained Cardiologist who has gained special expertise in these procedures. In this procedure, 3 thin flexible wires/ catheters are inserted into your veins or arteries from the groin. These catheters are placed in different chambers and locations within your heart to record the electrical activity. With the help of the catheter, the electrical system of your heart is studied and problems diagnosed. These problems may be caused either due to an abnormal extra connection/circuit or abnormal focus. The conduction of the electrical impulses traveling in your heart is studied and extra abnormal ciruits detected and located.

The sources of abnormal extra heart beats or abnormal connections are then burnt off/ blocked by delivering radiofrequency (RF) energy with the help of a fine catheter. This is called Ablation. The procedures usually last 2-3 hours and have been performed safely for many years. Complications are very rare.

What will be done once I get admitted?

You will be told to get admitted one day prior or early morning on the day of the procedure. Once you finish the admission procedure on the ground floor of the Main Hospital building, you will be allotted a bed on one of the floor in the Main Hospital building. You will be examined by one of the nurses and the doctors to see if you have any problems and your medications and reports checked. We are here to make you comfortable and relaxed before the procedure. If you have any doubts or queries do feel free to ask your nurse or doctor. You have nothing to lose by asking queries.

What preparation do I need before the EP procedure?

Your doctor will tell you about the procedure in advance. He will explain to you the procedure in detail before getting admitted and after getting admitted. Your doctor will tell you ahead of time whether to stop taking any of your medications.

Few things necessary before the procedure:

  1. An informed written consent will be taken from you explaining the procedure, its details and its risks if any.
  2. You will be told not to eat or drink at least 6 hours before the start of the procedure
  3. The catheters are positioned from the groin and sometimes from the neck. These areas will be cleaned and shaved.
  4. An intravenous IV cannula will be inserted in one of you hands/arms before the start of the procedure.
  5. Please let the doctor know if you have any allergies or reactions to any drugs.

Where are these procedures performed?

Electrophysiology (EP) studies are performed on the first floor in the DSA lab situated in the Main Building. The EP laboratory has a moveable procedure table on which the patient lies down and an X-ray machine that is suspended over the table. This X-ray machine guides the doctor in placing the catheters within your heart. In addition, there is a large number of special electronic and computer equipment in the laboratory that is used during the electrophysiology (EP) study. These are EP equipment which transmits electrical signals from the heart onto the monitor, so that the doctor can analyze them.

Patient safety is the first and most important job in the EP laboratory.

Before the Start of the EP procedure:

You will lie flat on the procedure table. The electrocardiogram (ECG) leads will be connected on your chest to record your ECG during the procedure. The nurses will thoroughly cleanse the groin region and/or right neck region with special soap. The procedure is done under local anesthesia with intravenous sedation. You will be given intravenous drugs to make you feel sleepy and relaxed. This will relieve you of your anxiety before the procedure and let your drift to sleep.

Following this, the doctor will inject local anesthesia into your groin at the site where the catheters will be inserted. After the local anesthesia has taken effect, the doctor will introduce 3-4 small tubes (2-2.5 mm wide) into your groin. In some patients, he may opt to put a small tube in the neck on the right side. At all times during your time in the EP laboratory your heart rate, blood pressure, respiration, blood oxygen level, and ECG will be continuously monitored by the nurses and doctors in the room.

The EP procedure:

During an EP procedure, 2-4 temporary electrode catheters/ wires are inserted into multiple heart chambers. The catheters or wires are inserted through the small tubes and positioned in the heart. One does not feel the movement of the catheters when they are moved up to your heart. The catheters are about 50 inches long and 2 mm wide and the electrodes are located near the tip. For some cases, a wire may also be inserted in a vein in the right neck region. The wires are positioned in different locations in the heart by advancing them through the veins under X-ray guidance. Most of them are placed in the upper chamber (atria), the lower chamber (ventricle) and an area called the His bundle and into the coronary sinus vein (which lies behind the heart). The wires permit electrical stimulation of the heart and recording of electrical activity.  The patterns of the electrical conduction through the heart are displayed on a computer monitor. After the completion of the procedure all the catheters are removed.

After insertion of the wires, the diagnostic portion of the electrophysiology study will begin. This involves electrical stimulation of the heart and recording of electrical signals. This may cause the patient to feel their heart beating fast. The physicians analyze these electrical signals to determine the type of tachycardia (fast heart rate), the patient has and the location of the abnormal circuit. The patient should not feel alarmed if they feel their heart beating fast or irregularly during the procedure because this is a normal part of the study.

Radiofrequency (RF) Ablation

Ablation is the burning of the abnormal circuit or focus by delivering a very controlled burn with the radiofrequency energy. Ablation is performed to eliminate the tachycardia/ arrhythmia by getting rid of the abnormal circuit or focus. Not all tachycardias can be ablated. The cure rate for some tachycardias ranges from 90 to 98% while for some other types of tachycardias, it may be lower.

Procedure Time

The entire procedure (diagnostic and therapeutic portions) generally takes 1-3 hours; however, in very rare cases when the abnormal circuit/focus is difficult to find or reach with the ablation catheter, it may take longer, sometimes 5 hours. During the procedure the patient remains sedated and critical vital signs are continuously monitored. At the end of the procedure all the catheters and monitoring equipment are removed and the patient is taken to a regular hospital room where monitoring of vital signs and heart rhythm is continued.

What care should I take after the procedure?

After an ablation procedure the patient must lay in bed for 4-6 hours with the right leg remaining straight to avoid any bleeding from the groin. After that time, the patient can begin moving about, and generally is ready to go home that same day assuming no complications. When an ablation procedure is completed late in the day, the patient is kept overnight and discharged home the following morning.

What are the Benefits and Risks of Electrophysiology Procedures?

Patients need to weigh the small risks of the procedure against the potential benefits with the guidance of their doctor. The risks of the ablation procedure are very small, although it is not a risk-free procedure. The most serious reported complications in the medical literature include death, stroke, heart attack, cardiac perforation requiring emergency surgery, heart valve damage, artery damage, blood clots, bleeding, or infection are rare. Some patients have a risk of complete heart block (electrical block) requiring implantation of a permanent pacemaker although in our experience the risk is still very low. Lot of care is taken during the procedure and these procedures are now extremely safe if carried out by experienced personnel.