Electrophysiology in India: Inside the Institute of Cardiovascular Diseases, Madras Medical Mission

In this article, the authors describe their electrophysiology program at Madras Medical Mission in India. Madras Medical Mission (MMM) is an organization inspired by the missionary zeal of Bishop Zachariah Mar Dionysius, Metropolitan of the Madras Diocese of the Orthodox Church of India. Strengthened by the devotion and commitment of the members of this community at Chennai (erstwhile Madras city of Tamil Nadu) who promoted the registered charitable society in 1982, it strives to participate in the healing ministry by seeking to foster an environment of caring, compassion and love that enables it to respond to patient needs in enviable ways. From modest beginnings two decades ago, the synergy of proficient practitioners, prudential management and providential guidance has metamorphosed this ISO 9001:2000 certified Madras Medical Mission into an organization of excellence that promotes some of the finest super-speciality tertiary care medical institutions in India, with superlative infrastructure, leading-edge technology and accomplished professionals. The Madras Medical Mission complex with 250 beds (including 80 intensive care beds) is set amidst landscaped gardens that provide a serene and tranquil environment. At MMM, the Interventional Cardiology Department has performed more than 50,000 percutaneous interventional cases to date through its two state-of-the-art cineless catheterization laboratories. The adult and pediatric cardiac surgical departments have performed more than 30,000 operations, a rare distinction of few hospitals in the world. The independent adult and pediatric intensive care units, with its modern facilities of pendant systems, cardiac output monitoring and hemodialysis, are comparable to the best in the world. The operating rooms and intensive care units are also equipped with the most modern infection control measures in all areas inclusive of air supply quality by using HEPA filters and laminar flows. The excellent facilities and clean, spacious interiors and one-to-one nursing care makes convalescence for the patient a pleasant experience. Electrophysiology Services at Madras Medical Mission In June 1998, the Institute of Cardiovascular Diseases at Madras Medical Mission introduced the cardiac electrophysiology program in the state of Tamil Nadu. The electrophysiology lab at MMM is a component of the cardiac catheterization lab, and has sterile environments for patient preparation, holding and recovery, and support areas such as scrub facilities, the control room, electrical equipment room, viewing room, report room and other incidental support services. The EP lab consists of a 575 square foot procedure room and a 200 square foot viewing room, which is partitioned by lead glass measuring 180 x 120 cm, minimizing radiation exposure and providing unobstructed views between the procedure room and the viewing room. The lab is spacious enough for movement of the patients, room for the physician to do the procedure, and accommodation of the EP machine, ablator, stimulator and the sleeve monitor with adjustable lighting system. Our electrophysiology lab is equipped with a Duo 32-channel computerized recording system (Bard), a Stockert EP Shuttle radiofrequency (RF) generator with power and temperature control modes (Biosense Webster Inc., a Johnson & Johnson company), a PC-based stimulator (Micropace), and the COROSCOP TOP (Siemens) fluoroscopy machine. We offer comprehensive cardiac electrophysiology services for infants, children and adults. A variety of diagnostic, mapping and ablation catheters are used to perform radiofrequency ablation in children and adults. The physicians on our cardiac electrophysiology team are comprised of: Dr. Ulhas M. Pandurangi, MD, DM, Director, (Electrophysiology), who has also received speciality cardiac electrophysiology training in the U.S., Dr. Ramkumar, MD, DNB (Cardiology), Dr. Jaishanker, MD, DM (Cardiology), and Dr. Ameya Udayavar, MD, DM (Cardiology), who completed a cardiac electrophysiology fellowship in Taiwan and is currently undergoing further training in device implantation in Australia. Our team takes pride in having performed the highest number of EP procedures, including radiofrequency ablations and implantations of permanent pacemakers, defibrillators and heart failure devices (CRT-P and CRT-D), in this part of the country. Our electrophysiology team also has two qualified and dedicated technologists, Mr. Ravikumar and Mr. Benjamin, who have more than two decades of experience, and a dedicated nursing staff: Mrs. Theressama, Ms. Bincy, Ms. Sheela, Ms. Anmol and Ms. Sharon. The photo at top shows the Electrophysiology Team: Ms. Anitha (Physician Assistant), Mr. Vinoth (Staff Nurse), Mr. Benjamin Solomon (Technologist), Mr. Ravikumar (Technologist), Dr. Ulhas M. Pandurangi (Director, Cardiac Electrophysiology), Dr. Ramkumar (Consultant Cardiologist), Ms. Sharanya Nakka (Physician Assistant), Ms. Anmol (Staff Nurse), Mrs. Theressama (Sister In-Charge), and Mr. Babu (Technologist). The cardiac electrophysiology lab has aided the Institute of Cardiovascular Diseases to become one of the few centers in India with expertise to manage end-stage heart failure by means of the latest electrophysiological techniques. Our electrophysiology lab is one of the busiest cardiac electrophysiology centers in this part of India. We are proactive in recommending radiofrequency ablations as the preferred mode of therapy for most supraventricular and ventricular tachycardias. We have successfully performed many RF ablations for complex arrhythmias in all age groups of patients ranging from 6-month-old infants to 90-year-old adults. Non-Invasive EP Studies In addition to invasive electrophysiological procedures, non-invasive procedures such as Holter monitoring (Spacelabs Healthcare), exercise stress testing (GE’s MAC 5000, GE/Marquette CENTRA), and signal-averaged ECG (GE’s MAC 5000) are routinely performed. Pioneering Achievements at MMM We are proud of our institution’s many firsts in EP achievement. We were the first center to start a cardiac electrophysiology program in this part of our country. We were the first center to provide device therapy (AICDs, CRT-Ps, and CRT-Ds) for sudden cardiac death and heart failure in the state of Tamil Nadu. We were also the first to perform radiofrequency ablation and defibrillator implantation in pediatric patients in this part of India. In addition, we were the first center in the state of Tamil Nadu to acquire a three-dimensional electroanatomic mapping system (EnSite, St. Jude Medical) with provisions for registration techniques using 64-slice computed tomography (Siemens). Education and Training Programs A basic cardiac electrophysiology course is regularly held at our institute. This course helps postgraduates in medicine and cardiology to analyze surface electrocardiograms with the aid of intracardiac electrograms, understand mechanisms of arrhythmias, and know the non-pharmacological therapies for arrhythmias and heart failure. Every year, approximately 8-10 cardiologists who are interested in device implantation as well as performing electrophysiology procedures come for in-house training. We have hosted EP workshops in conjunction with international faculty, and encourage the exchange of academic dialogue with various international centers. For more information, please visit: www.mmm.org.in