Amit Vora

Guidance on reuse of cardio-vascular catheters and devices in India: A consensus document

Reuse of medical device is accepted worldwide. Benefits of reuse include not only cost saving but a favorable impact on environment. However, certain requirements should be met for reuse to be safe and effective. The devices, which can be reused, should be clearly defined, a meticulous process for dis-infection and sterilization followed and its functionality ascertained before use. Further, an appropriate consent should be obtained where necessary and the cost saving entailed should be directly passed on to the patient.

Radiofrequency ablation in an infant with recurrent supraventricular tachycardia and cyanosis

We report an unusual presentation of supraventricular tachycardia, in an infant, with cyanosis. The child had atrial septal defect with hypoplastic right ventricle. Radiofrequency ablation was performed in view of drug resistant SVT

Profiling cardiac arrhythmia and heart failure patients in India: The Pan-arrhythmia and Heart Failure Observational Study

Background The PANARrhythMia and Heart Failure Registry (PANARM HF) characterized demographic, clinical and interventional therapy indication profiles of cardiac arrhythmia (CA) and heart failure (HF) patients in India. Methods Consulting Physicians (CP) who medically manage CA and HF patients enrolled patients with one or more of the following: syncope, pre-syncope, dyspnea, palpitation, fatigue and LV dysfunction. The CPs were trained by interventional cardiologists (IC) to identify CA/HF patients indicated for implantable device/radiofrequency ablation (RFA). 59 CP’s, 16 IC’s & 2205 patients from 12 cities participated. Demographic, clinical, device/RFA indication and referral-consultation profiles were created. IC’s provided device/RFA recommendations based on these profiles. Results The CA/HF distribution of patients was: HF – 58%, bradyarrhythmia – 15%, atrial fibrillation – 15%, other supraventricular tachyarrhythmia – 10% and ventricular tachycardia/fibrillation – 4.5%. 62% of the CA/HF population was male and 45% were below age 60. Coronary artery disease (52%), hypertension (44%), diabetes (30%) & myocardial infarction (20%) were prominent. 1011 (46%) of the CA/HF population were potential device/RFA candidates according to the IC’s. However, only 700 (69%) of these patients were referred to the IC by the CP. Of referred patients, only 177 (25%) consulted the IC and were recommended therapy. Thus, 824 (83%) of patients indicated for interventional therapy were not advised therapy or did not opt for it. Conclusion The India PANARM HF study provides new information and insights into the demographic, clinical, interventional therapy, referral and consultation pattern profiles of CA/HF patients in India.

A survey of cardiac implantable electronic device implantation in India: By Indian Society of Electrocardiology and Indian Heart Rhythm Society

Background There is limited data regarding the demographics and type of cardiac implantable electronic device (CIED) in India. Aim The aim of this survey was to define trends in CIED implants, which included permanent pacemakers (PM), intracardiac defibrillators (ICD), and cardiac resynchronization therapy pacemakers and defibrillators (CRT-P/D) devices in India. Methods The survey was the initiative of the Indian Society of Electrocardiology and the Indian Heart Rhythm Society. The type of CIED used, their indications, demographic characteristics, clinical status and co-morbidities were collected using a survey form over a period of 1 year. Results 2117 forms were analysed from 136 centers. PM for bradyarrhythmic indication constituted 80% of the devices implanted with ICDs and CRT-P/D forming approximately 10% each. The most common indication for PM implantation was complete atrio-ventricular block (76%). Single chamber (VVI) pacemakers formed 54% of implants, majority in males (64%). The indication for ICD implantation was almost equal for primary and secondary prevention. A single chamber ICD was most commonly implanted (65%). Coronary artery disease was the etiology in 58.5% of patients with ICD implants. CRT pacemakers were implanted mostly in patients with NYHA III/IV (82%), left ventricular ejection fraction <0.35 (88%) with CRT-P being most commonly used (57%). Conclusion A large proportion of CIED implants in India are PM for bradyarrhythmic indications, predominantly AV block. ICDs are implanted almost equally for primary and secondary prophylaxis. Most CRT devices are implanted for NYHA Class III. There is a male predominance for implantation of CIED.

The Indian consensus guidance on stroke prevention in atrial fibrillation: An emphasis on practical use of nonvitamin K oral anticoagulants.

The last ten years have seen rapid strides in the evolution of nonvitamin K oral anticoagulants (NOACs) for stroke prevention in patients with atrial fibrillation (AF). For the preparation of this consensus, a comprehensive literature search was performed and data on available trials, subpopulation analyses, and case reports were analyzed. This Indian consensus document intends to provide guidance on selecting the right NOAC for the right patients by formulating expert opinions based on the available trials and Asian/Indian subpopulation analyses of these trials. A section has been dedicated to the current evidence of NOACs in the Asian population. Practical suggestions have been formulated in the following clinical situations: (i) Dose recommendations of the NOACs in different clinical scenarios; (ii) NOACs in patients with rheumatic heart disease (RHD); (iii) Monitoring anticoagulant effect of the NOACs; (iv) Overdose of NOACs; (v) Antidotes to NOACs; (vi) Treatment of hypertrophic cardiomyopathy (HCM) with AF using NOACs; (vii) NOACs dose in elderly, (viii) Switching between NOACs and vitamin K antagonists (VKA); (ix) Cardioversion or ablation in NOAC-treated patients; (x) Planned/emergency surgical interventions in patients currently on NOACs; (xi) Management of bleeding complications of NOACs; (xii) Management of acute coronary syndrome (ACS) in AF with NOACs; (xiii) Management of acute ischemic stroke while on NOACs.

Safety and Feasibility of Same Day Discharge in Patients Undergoing Radiofrequency Catheter Ablation

We retrospectively analyzed outcomes of radiofrequency catheter ablation in patients who were discharged the same day and compared them with patients staying overnight. For most tachyarrhythmias, it is safe and feasible to discharge patients undergoing radiofrequency ablation on the same day.

Cardiovascular risk profile and management of atrial fibrillation in India: Real world data from RealiseAF survey

Background Atrial fibrillation (AF) is the most common sustained arrhythmia with high risk for many cardiovascular (CV) complications. Adherence to recommended management guidelines is important to avoid complications. In India, there is little knowledge on how AF is managed in real world. Methods This is a cross-sectional study of patients in India enrolled in RealiseAF survey between February 2010 and March 2010 with a diagnosis of AF within the last 12 months. Results From 15 centers, 301 patients {mean age 59.9 years (14.4); 52.5% males} were recruited. AF was controlled in 50% of patients with 77 (26.7%) in sinus rhythm and 67 (23.3%) with heart rate <80 beats/min. Hypertension (50.8%), valvular heart disease (40.7%), heart failure (25.9%), and diabetes (20.4%) were the most common underlying CV diseases. Increased risk for stroke (CHADS2 score ≥ 2) was present in 36.6%. Most of the patients (85%) were symptomatic. AF was paroxysmal, persistent, and permanent in 28.7%, 22.7%, and 34.3% respectively. In 14%, AF was diagnosed as first episode. Forty-six percent of patients had rate control, 35.2% rhythm control, 0.3% both strategies, and 18.4% received no therapy for AF before the visit. At the end of the visit, adoption to rate control strategy increased to 52.3% and patients with no therapy decreased to 7%. Conclusion AF in India is not adequately controlled. Concomitant CV risk factors and risk of stroke are high. The study underscores the need for improved adoption of guideline-directed management for optimal control of AF and reducing the risk of stroke.

Pharmacotherapy to reduce arrhythmic mortality

Fatal ventricular arrhythmias and heart failure are the common modes of death in patients with cardiovascular diseases. Intracardiac defibrillator (ICD) implantation reduces arrhythmic mortality to a significant extent in the high risk patient. However, there continues to be a need for effective drug therapy to reduce the arrhythmic and overall mortality in patients with or without an ICD. Although anti-arrhythmic drugs (AAD) appear inferior to ICD, the role of beta-blockers and to an extent amiodarone along with non AAD like angiotensin converting enzyme inhibitors (ACE-I), mineralocorticoid blockers (MRB) and HMG-CoA reductase inhibitors (statins) need to be emphasized. There have been many drug trials and meta-analysis to this effect and we review the role of drugs especially in their ability to reduce arrhythmic mortality and sudden cardiac death (SCD). The focus is on post myocardial infarction (MI) and heart failure patients with a brief overview of role of drugs in channelopathies.

Transition from Narrow to Wide QRS Tachycardia: What is the Mechanism?

March 2001 PACE, Vol. 24 A 26-year-old man presented with a history of repeated episodes of paroxysmal palpitations, terminating spontaneously or with adenosine. Clinical examination and 12-lead electrocardiography (ECG) during sinus rhythm were normal and echocardiogram showed a structurally normal heart. The patient was taken for electrophysiological study with a view to performing radiofrequency ablation. During electrophysiological study, tachycardia was induced and the 12-lead ECG is shown in Figure 1.

Idiopathic left ventricular tachycardia: what is the mechanism?

A 14-year-old boy presented with sustained, symptomatic, broad QRS tachycardia precipitated hy exertion. The surface ECG during tachycardia showed a rigbt bundle branch block morphology with QRS axis of -90° (Fig. 1). The tachycardia was responsive to intravenous verapamil with a clinical diagnosis of idiopatbic left ventricular tachycardia (ILVT). Tbe patient underwent electropbysiological stndy with a view to radiofrequency (RF) ablation. Mapping during tacbycardia revealed a sharp presystolic Purkinje potential 46 ms earlier than the surface QRS from the distal electrodes of the ablation catheter, apically in tbe