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.

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.