Spotlight Interview: Pranayam Lung and Heart Institute

The Pranayam Lung and Heart Institute opened in September 2012 with the mission to give the people of Gujarat an institute dedicated to all treatment of pulmonary disease. In April 2016, we began offering treatment of all cardiac disease, including arrhythmias and heart failure. In March 2019, a shared EP and cath lab was created by Dr. Vihang C. Shah. Electrophysiology is a relatively new concept at our hospital and in Vadodara. As the first EP lab in Vadodara, we are pleased to offer advanced treatment of complex arrhythmias such as ventricular tachycardia and atrial fibrillation as well as comprehensive management of heart failure. We enjoy seeing the smiling faces of our patients.

Who manages your lab?

It is managed by Dr. Vihang Shah (cardiac electrophysiologist) and Rutvik Valand (EP technician).

What growing pains or learning curves did your lab experience the first year?

Our lab recently celebrated its first anniversary. While we have seen consistent growth in the number of procedures, we have also wanted to educate people about arrhythmias and how EP procedures can change their lives. However, this has been challenging due to a lack of awareness about arrhythmias in our society. We are doing our best to minimize the gap and create awareness. For example, we regularly spread atrial fibrillation awareness through public media or through our website.

What is the size of your lab? Where is the EP lab in relation to the catheterization department?

We have a common EP and catheterization lab. This lab is a single room approximately 400 square feet in size. All cardiac procedures – cath, coronary, pediatric, and electrophysiology procedures — are performed in a single lab.

What is the number of staff members? 

We have 2 cath lab technicians, 2 cath lab nurses, 1 EP technician, and 1 electrophysiologist. 

What types of procedures are performed at your facility? 

We perform all types of supraventricular tachycardia ablation, including AVNRT, AVRT, and Mahaim tachycardia. We perform ablation of atrial fibrillation, atrial tachycardias, PVCs, and ventricular tachycardia (both idiopathic and scar VT). We also perform device and CRT implantation, as well as His bundle / left bundle branch pacing.

What types of EP equipment are most commonly used in the lab? 

For EP cases, we are using the EP-TRACER (Schwarzer Cardiotek) as an EP stimulator and SMARTABLATE (Biosense Webster, Inc., a Johnson & Johnson company) as an ablation machine. We have CARTO 3 (Biosense Webster, Inc.) available with the CARTO VISITAG Module, Ripple mapping, and the CONFIDENSE module. For complex cases, we use the PENTARAY for mapping and SMARTTOUCH catheter for ablation (Biosense Webster, Inc.). Approximately 40% of our device implants are MR conditional pacemaker/ICDs.

How have these technologies changed the way procedures are performed?

We recently performed scar-related VT ablation with substrate modification. We used the PENTARAY catheter (Biosense Webster, Inc.) for 3D mapping, and it helped us decrease the time needed for mapping and fluoroscopic imaging. We find that it gives us a better electroanatomic map and better ablation efficacy.

What would you consider to be the most frequent procedures performed?

AVNRT ablation is the most common procedure performed in our lab.

Approximately how many catheter ablations (for all arrhythmias) are performed each week?

Approximately 2-3 ablations are done every week.

Tell us about your device clinic.

The device clinic is still in its early stages. The pacemaker clinic takes place every Friday. Patients receive regular device checkups every 6 months. 

Are there plans to expand in size?

In our first year of service, we saw drastic and steady growth. If this continues, we plan to expand with a separate EP lab in the near future.

Tell us what a typical day might be like in your EP lab.

Cases usually begin at 7 am and go until noon. Device checks and EP cases are also managed during the day. Our 3D mapping cases often take a long time and last until evening, so we often begin these earlier in the morning (5 am). 

What type of quality control/assurance measures are practiced in your EP lab?

We keep a record of fluoroscopic radiation for all of our EP procedures, and try to attain the lowest possible fluoroscopic timing and radiation. We were awarded by the National Accreditation Board of Hospitals (NABH) and the Ministry of Health and Family Welfare for cleanliness and quality control. A uniform QA mechanism is maintained in the EP lab and throughout the hospital.

What are the best features of your EP lab’s layout or design? What would you include on a “wish” list? 

The best feature of our EP lab is our CARTO 3 system, which gives us an edge in treating complex arrhythmias. Our wish list would include intracardiac echocardiography.

How are new employees oriented and trained at your facility?

We have regular training sessions for interns. After becoming an employee in the lab, they are trained in a stepwise manner. They start by managing the medicines/consumables, then move on to catheters and guidewires, and finally train on the EP systems.

What types of continuing education opportunities are provided to staff? 

Our lab technicians regularly attend EP courses held in India whenever possible. They are also taught EGMs during regular procedures.

How is staff competency evaluated? Does staff receive a bonus based on performance?

Staff are regularly evaluated every year based on their performance according to NABH guidelines. They are also given incentives based on their performance.

Describe a particularly memorable case from your EP lab and how it was addressed.

Our most memorable case was our first atrial fibrillation ablation. The patient was an elderly gentleman who was developing recurrent atrial fibrillation with a fast ventricular rate associated with hypotension. He underwent recurrent DC cardioversion despite being on an amiodarone drip. The patient was referred to Pranayam Hospital for AF ablation. Successful wide area circumferential ablation (WACA) was performed, and the patient was in sinus rhythm post ablation. At 10-month follow-up, he is maintaining sinus rhythm with no antiarrhythmic drugs.

Does your lab perform His bundle pacing? In what percentage of cases? Describe your approach. 

Yes, we do His bundle pacing in patients requiring CRT implantation. We use a decapolar mapping catheter to map the distal and proximal His bundle. The interventricular septum (IVS) is localized in RAO 30 and LAO 30. A C315HIS sheath (Medtronic) is placed adjacent to the IVS. A SelectSecure MRI SureScan Model 3830 is then used. The His signal is mapped using unipolar signals from the distal lead pole, and once good His signals are achieved, it is screwed into the His bundle to get narrow QRS post pacing. We try to achieve a ventricular activation time (VAT) of <90 msec and QRS <120 msec.

What are your thoughts on the use of NOACs in patients with non-valvular AF? 

We regularly use NOACs for non-valvular AF if affordability is not an issue. They provide better control, and their interactions with different drugs and food is minimal. Moreover, patients also do not have to get frequent PT/INR testing done.

Discuss your methods for lifestyle modification as therapy for your patients with atrial fibrillation.

Lifestyle modification is our first approach in treating atrial fibrillation. We suggest that patients try to decrease their weight, especially morbidly obese patients and patients with obstructive sleep apnea (OSA). Control of hypertension is another important parameter to focus on before AF ablation; therefore, we recommend a salt restriction diet and regular exercise. We also suggest yoga and meditation in all patients.

We have a dedicated AF clinic every Tuesday during which patients with atrial fibrillation are updated on their regular medications, receive information about lifestyle modification, and are educated about possible complications associated with atrial fibrillation. In our AF clinic, we have a pulmonologist for patients with OSA, a physiotherapist for weight reduction and exercise, and a yoga trainer for AF patients. Moreover, patients are also referred to an endocrinologist for thyroid-associated atrial fibrillation.

Are pediatric cases performed in your lab? 

We do SVT ablations in pediatric cases, but complex arrhythmias in pediatric cases are not  yet done. 

What approaches has your lab taken to reduce fluoroscopy time? What types of radiation protective shielding and technology are used? 

Ablation of complex arrhythmias is usually done under 3D electroanatomical mapping. Minimal fluoroscopy using a low dose and low frame rate is utilized. Lead aprons, thyroid shields, and caps are also used — these are regularly tested and approved. We also use lead glass below the patient to prevent exposure to reflected radiation.

What are your methods for device infection prophylaxis?

We are very stringent with infection prevention during device implantation. Simple antibiotics are usually used, as well as antiseptic precautions such as a preoperative chlorhexidine bath and post-operative dressing for up to 10 days. 

Do you utilize digital tools or wearable technologies in your treatment strategies for patients?

Yes, we suggest devices such as the Apple Watch in our patients with atrial fibrillation. 

Is your EP lab involved in clinical research studies? 

We are not involved in any EP-related clinical research studies as of now.

How do you see social media changing the field of healthcare? 

Electrophysiology is still very new in India. Many patients are scared of being treated due to incomplete knowledge about procedures. Social media can help bridge this gap between patients and physicians.

Describe your city or general regional area. How is it unique from the rest of the U.S.? 

Vadodara is a Tier-2 city in India that consists of a large working-class population. Since the field of EP is still in its infancy in India, many people are not aware that abnormalities other than coronary artery blockages exist and are treatable to a large extent. There is also limited awareness of atrial fibrillation and sudden cardiac death. So there is a challenge in creating awareness between patients and physicians. However, Vadodara is very unique in the way its people are connected — positive feedback from one good case can bring in 10 more patients! Therefore, word-of-mouth publicity is still the most powerful medium here for healthcare.

In addition, SVT ablation and device implants are available free of cost to appropriate patients through the government. 

What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”? 

Pranayam Hospital is the first in our city to have dedicated EP services. It’s also the first and only private hospital in the state of Gujarat to have a 3D system.

Please tell our readers what you consider special about your EP lab and staff.

We are a team of young doctors and EP technicians at Pranayam Hospital. Our zest and excitement for our EP cases is unmatched. We wish to offer comprehensive treatment for all aspects of the heart — coronary or electrical. We find that many EP conditions are often undertreated, which leads to more comorbidities for patients. However, with EP treatment now available in Vadodara, we hope to shift the paradigm to preventive healthcare through awareness and expansion to other cities. 

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