Spotlight Interview: Paras HMRI Hospital

Paras HMRI Hospital is the first corporate hospital of Bihar and Jharkhand. The 350-bed multispecialty tertiary care institute, with over 25 medical and surgical disciplines, is a state-of-the-art facility with the latest high-tech infrastructure and equipment, offering clinical services in the fields of oncology, cardiac sciences, neurosciences, orthopedics and joint replacement, nephrology, and emergency care, to name a few.

The doctors and nurses at Paras HMRI aim to deliver excellence to the more than 600,000 people of Patna as well as to the adjoining areas of Uttar Pradesh, Jharkhand, Nepal, and Bangladesh. 

What is the size of your EP lab facility? When was the EP program started at your institution? 

Our facility consists of 1 EP lab. The EP program was started 3 years ago by Dr. Pramod Kumar. 

What is the number of staff members? What is the mix of credentials at your lab?

Dr. Narendra Kumar is a full-time, board-certified cardiac electrophysiologist. He obtained his doctorate in cardiology from Maastricht University, and has more than 50 publications in EP-related topics and >200 citations to his credit. The EP team also includes several trained invasive cardiologists: Dr. Anand Gopal, Dr. Dinanath Kumar, Dr. Shaheen Ahmad, and Dr. Ajay Kumar Sinha. The cardiac technicians include Lakshmikant Mishra, Raushan Kumar Singh, Belal Hussain, Kamlesh Yadav, Rajneesh Kumar, Aneesh M. Jacob, Tabasssum Khatoon, Shyam Sharma, Anoop Philip, Anju Kujur, and Annu Kumari.

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week? 

The EP lab at Paras HMRI provides comprehensive cardiac care. Device implantation of pacemakers, ICDs, biventricular defibrillators, CRT-Ds, and CRT-Ps is done on a regular basis. We perform diagnosis and management of cardiac arrhythmias, including treatment for patients with syncope, nodal conduction studies, diagnostic EP studies, and ablation for supraventricular tachycardia, AV nodal reentrant tachycardia, Wolff-Parkinson-White syndrome, atrial fibrillation (AF), etc. We are planning to acquire an electroanatomical mapping system so that we can start ablating complex arrhythmias on a regular basis. Our EP program is the only center with full-time EP faculty in this region of northeast India, covering the states of Bihar, Nepal, Purvanchal, and Bhutan. 

Who manages your EP lab?

Our leadership team includes Dr. Ajay Kumar Sinha, Director of Cardiology, and Mr. Syed Hasan, Manager of the Cardiovascular Invasive Labs at Paras HMRI Hospital. 

Do you have cross training inside the EP lab? 

All staff members are cross trained for each of the different roles in the EP lab. Each cardiologist has their own dedicated niche (i.e., peripheral intervention, cardiac cath, EP, and pediatric cases) that they specialize in. 

What type of hospital is your EP program a part of? 

We are a tertiary care hospital under the private management of Paras Healthcare, which has several locations in India (including Darbhanga, Patna, Gurgaon, Panchkula, etc.).

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

We use products by Abbott and Biosense Webster in the EP lab. 

How is shift coverage managed? What are typical hours (not including call time)?

Typical shift hours are from 10 AM until 6 PM. We have round-the-clock coverage, with a different set of staff taking care of the night shift.

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

We initially schedule the cardiac cath procedures in the lab; after that, device cases are done, and after that, EP cases are performed. 

Do you implant MR-conditional pacemakers or ICDs? 

Most of the implants at our center are done with MRI-compatible pacemakers and ICDs.

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

Since this hospital is among the first in the state to be certified by the National Accreditation Board for Hospitals and Healthcare Providers (NABH), we strictly follow their standard guidelines.

What types of continuing education opportunities are provided to staff members?

Since the arrival of our full-time cardiac electrophysiologist, our EP program has grown immensely, so more educational programs related to EP are being conducted for hospital staff and local area physicians.

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

While attempting ablation of a left lateral accessory pathway, the delta wave was not disappearing, despite having a good (fused atrial and ventricular) signal. Unfortunately, the ablation infusion pump for the irrigated-tip radiofrequency catheter was not working that day due to technical reasons. After a quick brainstorming session, we decided to use an injector (normally used for injection of contrast during interventional procedures). Immediately in the next radiofrequency ablation, after 1.9 seconds, the pre-excitation on the surface ECG disappeared. 

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

Although Dr. Narendra Kumar was trained at a center with very high usage of cryo, because of the unavailability of cryo in the region, this center does 100% of ablations with radiofrequency. 

What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular AF? 

They are excellent drugs with a good safety profile, especially compared to warfarin. We counsel patients when NOACs are started.

Do you perform only adult EP procedures or do you also do pediatric cases? 

Only adult EP procedures are done at Paras HMRI Hospital. 

Is your EP lab currently involved in clinical research studies? 

Yes, we are continuously monitoring data for clinical research studies in the EP lab, giving more insight about arrhythmias more prevalent in the Asian population, such as rheumatic heart disease, AF, etc. 

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

I firmly believe that in the coming days, tools for imaging and ablation of atrial fibrillation will evolve into an almost 90-95% success rate. The number of EP centers will grow beyond the metropolitan cities in south Asia. The number of Asian EP equipment manufacturers will also rise. We expect hybrid ablations (collaboration between the cardiologist and cardiac surgeon), especially for AF, to become more popular.