Development of Pacing,
Electrophysiology and Defibrillation in India
Mohan Nair, MD., DM.*, Johnson Francis, MD, DM.**, K. Venugopal, MD.,
DM.***
*Director, Metro Golden Heart Institute, New Delhi, India.
**Associate Professor *** Professor and Head,
Department of Cardiology, Medical College Calicut, Kerala, India.
Address
for correspondence: Mohan
Nair, MD, DM, Director, Metro Golden Heart Institute, New Delhi, India.
Email: mnair@bol.net.in
Cardiac Pacing
History
of cardiac pacing in India dates back to late 1960s. Kar1 reported that cardiac pacing was introduced in
India in 1966. Basu2 while discussing on
cardiac
pacemaking in Calcutta, mentions that the first pacing was performed in
April 1967 at the Institute of Post Graduate Medical Education and
Research (IPGME&R). Bhatia et al3
started pacemaker
implantation at AIIMS, New Delhi in 1968. Their first patient was a
doctor
from Assam and the pulse generator was supplied by Medtronic Inc. The
pulse
generator was powered by a mercury-iodide battery which lasted for
about
2 ½ years, after which the patient underwent pulse generator
replacement.
Unfortunately he succumbed to miliary tuberculosis about a year after
that.
Currently around 8000 pacemakers are being implanted annually in India,
in various centers around the country.
The IPGME&R is the centre which implants maximum number of
pacemakers in the country1. Various
hypotheses has been put forward to explain the high incidence of
conduction system disorders in the Eastern part of the country. Mustard
oil is the usual cooking medium in the Eastern part of the country.
Erucic acid content of Mustard oil is around 48%. Studies conducted by
the Indian Council of Medical Research4 has
shown erucic acid content in all the 50 heart samples obtained from
Calcutta (Eastern part of India) while none of the samples from
Trivandrum or Madras (South India) showed any trace of erucic acid. The
cooking medium in the latter regions is coconut oil, with no erucic
acid content. Erucic acid has been shown to produce myocardial fibrosis
and lipidosis5,6,7.
High incidence of heart block has also been reported from Sweden8 , where the cooking medium is rape-seed oil
which also has a high erucic acid content. More studies are needed to
conclusively prove whether Mustard oil is the etiological factor in the
high incidence of heart block in the Eastern regions of India.
The first temporary pacemaker manufactured in India was the
Khalilullah-Mendez pacemaker, which was marketed in 1970. It was a
single chamber fixed rate pacemaker with facility for adjustment of
pacing rate and pacing current. The device was jointly developed by
Prof. M. Khalilullah at G.B. Pant Hospital, New Delhi and Mendez, an
engineer-entrepreneur. Khalilullah-Mendez team also manufactured an
indigenous monitor-defibrillator which was known as KM
monitor-defibrillator.
The first permanent pacemaker manufactured in India was from Shree
Pacetronix Ltd. The pulse generator was called Ventralith-I and it was
a non-programmable VVI pacemaker. First implant was on September 9th,
1994 at Kastruba Hospital, Bhopal. Subsequently Shree Pacetronix has
started manufacturing multiprogrammable pacemakers as well. The first
multiprogrammable pacemaker was implanted on June 6th, 1995
at Ramakrishna Mission Seva Pratishthan, Calcutta. At present single
lead VDD pacemakers, multiprogrammable DDD pacemakers and single
chamber pacing system analyzers are also being manufactured by Shree
Pacetronix and they continue to be the only pacemaker manufacturer in
India.
Fig 1:
Ventralith-I : VVI Non Programmable Pacemaker
Fig 2:
Pinnacle: VVI, multiprogrammable pacemaker
Fig 3: Charak:
DDD, multiprogrammable pacemaker
Invasive Cardiac Electrophysiology
G.B. Pant Hospital New Delhi has been the
pioneering center in the field of Invasive Cardiac Electrophysiology in
the country. Bhatia M.L et al9 and
Khalilullah M et al 10,11,12,13 were the pioneers in
His bundle electrography in the country. Prof. K.K. Sethi was the first to perform
catheter ablation in the country. Direct Current ablation was started
in 1988 followed by Radio Frequency (RF) ablation later on. The number
of centres having electrophysiology setup in the country has increased
from about 10 in 1997 to around 30 in 2001 (Fig 4). The number of RF ablations being performed in
the country has gone up from 800 to 2000 during the same period (Fig.
5). At least 3
government aided centers are offering subsidized diagnostic and
therapeutic facilities. Average cost in private hospitals is around
$200 for diagnostic procedures and $ 600 for ablation. Cost containment
is mainly by frequent reuse of catheters. The national board has
initiated post doctoral fellowship in electrophysiology. Three national
and three regional electrophysiology workshops are being conducted
every year in the country. Currently there are about
50 electrophysiologists under training.
Fig 4.
Number of EP Centres in India
Fig 5. Number of RF Ablations in
India
Research Activities in Electrophysiology
Newer insights in the field of atrial fibrillation in rheumatic heart
disease have been obtained by electrophysiological studies from the
country. Atrial disease due to rheumatic carditis is an important
parameter, in addition to valvular involvement in the genesis of atrial
fibrillation. Multiple substrates for atrial fibrillation are present
in these cases, namely: stretch, fibrosis, raised pressures, increased
atrial size and increased anisotropy. Atrial fibrillation in rheumatic
heart disease is generally
of long duration and affects a younger population. Control of Rate versus
Rhythm in Rheumatic Atrial Fibrillation Trial -‘CRRAFT’ conducted at
Mumbai has documented the effectiveness of amiodarone in the treatment
of rheumatic atrial fibrillation.14 Mapping and successful RF
ablation of flutter circuits seen at initiation after cardioversion of
rheumatic atrial fibrillation has been achieved.15
Surgical RF
Pulmonary Vein Isolation for Rheumatic Atrial Fibrillation
Surgical RF pulmonary vein isolation using Thermaline
Multi-Electrode Catheter [EP Technologies] has been done in 27 patients
with rheumatic atrial fibrillation of more than one year duration.
Lesions were as follows: bilateral pulmonary vein isolation, isolation
of the left atrial appendage and connection lesion between left atrial
appendage and pulmonary veins. The mean left atrial diameter was 7.2
cm. 18 patients regained sinus rhythm immediately while 6 patients
achieved sinus rhythm after one week. Two patients continued to be in
atrial fibrillation while one went into atrial flutter. Atrial
fibrillation recurred in three of the successful cases. (Fig. 6)
Fig.6: Surgical
Pulmonary Vein Isolation: Indian Experience (Results)
Implantable
Cardioverter
Prof.
K.K. Talwar, AIIMS, New Delhi and Dr. T.S.
Kler, Escorts
Heart Institute & Research Centre, New Delhi were the first
to implant Implantable Cardioverter Defibrillators (ICD) in India. Current annual ICD implantation rates stand at
60 per year.
Acknowledgement
We gratefully acknowledge the help of C. Ashokan Nambiar,
MD, DM, and K. Sugathan, MD, DM, Former
Professors of Cardiology, Medical College Calicut for providing the
preliminary details of the first patient who has undergone permanent
pacemaker implantation at AIIMS. Prof. C.C. Kar, Prof. M.L. Bhatia,
Prof. M. Khalilullah and Prof. K.K. Sethi were very kind enough to
respond to telephone calls and give the details of their pioneering
work. Dr. Ashish Dubey,
Marketing Manager, Shree Pacetronix Ltd. provided the pictures and
Ramkumar, Regional
representative of Medtronics Inc. has
provided the details of ICD implantation and pacemaker implantation
statistics. Dr. Sudipto Roy, Hony. Editor,
Journal of Indian Medical Association(JIMA) deserves special
thanks for providing reprints of previous articles published in
JIMA.
References
1.
Basu A.K.
Cardiac pacing in India. J Indian Med Assoc. 1980 Nov 16;75(10):205
2.
Kar. C.C.
Problem of cardiac pacing in India. J
Indian Med Assoc. 1980 Nov 16;75(10):204, 203
3.
Bhatia
ML - Personal communication
4.
Indian Council of Medical Research
(ICMR) Annual Report, 1977, p. 109
5. Roy S,
Sengupta K.P. & Chatterjee G.C. Effect of mustard oil, rapeseed oil
& groundnut oil feeding on development of myocardial lipidosis
&
fibrosis in rats. Indian J. Exp. Biol 1979; 7:918
Medline
6.
Kramer JK, Farnworth ER, Johnston KM, Wolynetz
MS, Modler HW, Sauer FD. Myocardial changes in newborn piglets fed sow
milk or milk replacer diets containing different levels of erucic acid.
Lipids 1990 Nov;25(11):729-37
7.
Kramer JK, Farnworth ER, Thompson BK, Corner AH.
Testing
a short-term feeding trial to assess compositional and
histopathological changes in hearts of rats fed vegetable oils. Lipids
1988 Mar;23(3):199-206
8.
Borg K.
Acta Med. Scand. (Suppl) 1975; 585:5
9.
Bhatia ML, Ashokan Nambiar C, Shrivastava S, Roy SB. Effect of
acute digitalization on His bundle intervals and corrected sinus
recovery time in normal young adults. Indian Heart J 1977
Mar-Apr;29(2):78-84.
10. Khalilullah M,
Venkitachalam CG, Mahapatra NK, Pais P, Padmavati S. His bundle
electrogram in the disorders of conduction and impulse formation.
Indian Heart J 1978 Jan-Feb;30(1):29-38
11.
Khalilullah M, Ahuja U, Padmavati S. Complete heart block with
narrow QRS complexes with site of block below the His bundle. Indian
Heart J 1979 Mar-Apr;31(2):120-3
12.
Sunghal NK, Khalilullah M. His bundle electrography--an analysis
of first 100 consecutive studies. J Assoc Physicians India 1979
Jun;27(6):519-24
13.
Khalilullah M, Jaishankar S, Sethi KK, Singhal NK. Paroxysmal
supraventricular tachycardia. Role of His bundle electrography and
electrical pacing. Indian Heart J 1980 Sep-Oct;32(5):271-8
14. Control
of Rate versus Rhythm in Rheumatic Atrial Fibrillation Trial -‘CRRAFT’
Presented at the Annual Conference of the Cardiological Society of
India, 2001.
15.
Nair M,
Shah P,
Batra R,
Kumar M,
Mohan J,
Kaul U,
Arora R..
Chronic Atrial Fibrillation in Patients With Rheumatic Heart Disease:
Mapping and Radiofrequency Ablation of Flutter Circuits Seen at
Initiation After Cardioversion.
Circulation. 2001;104:802
