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.
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:
- Diagnostic services for patients with Syncope
- Diagnostic/ Therapeutic services for patients with Tachycardias (Fast heart rates)
- Diagnostic Services for evaluating the risk for Sudden Cardiac Arrest
- Diagnostic/ Therapeutic services for patients with Bradycardias (slow heart rates)
- 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
- ECG (Electrocardiogram): needed to rule out cardiac disorders like ischemic heart disease, arrhythmias and genetic disorders like long QT syndrome.
- Holter recording: ECG is recorded for 24 hours to detect and rule out arrhythmic causes of syncope.
- 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.
- 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.
- 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.
- 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
- 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
- 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)
- 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.
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:
- An informed written consent will be taken from you explaining the procedure, its details and its risks if any.
- You will be told not to eat or drink at least 6 hours before the start of the procedure
- The catheters are positioned from the groin and sometimes from the neck. These areas will be cleaned and shaved.
- An intravenous IV cannula will be inserted in one of you hands/arms before the start of the procedure.
- 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.
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.