Arrhythmias in India and UAE | Complete Patient Guide

• Documented supraventricular tachycardia (SVT) including AVNRT, AVRT/WPW syndrome, atrial flutter, or atrial tachycardia not controlled by or refractory to medical therapy

• Genetically confirmed or clinically diagnosed channelopathies: Long QT syndrome (QTc >500 ms or symptomatic), Short QT syndrome, Brugada syndrome, CPVT — especially with breakthrough events on therapy

• Symptomatic complete or high-degree AV block (congenital or post-surgical) requiring permanent pacemaker implantation

• Junctional ectopic tachycardia (JET) or incessant SVT causing tachycardia-induced cardiomyopathy (EF <45%)

• High-risk WPW: shortest pre-excited RR interval ≤250 ms on ambulatory monitoring, or syncope/cardiac arrest history

• Post-operative congenital heart disease patients with incisional atrial tachycardia or VT refractory to antiarrhythmics

• Paediatric patients with ICD-indicated conditions (aborted sudden cardiac death, LQTS with recurrent events, hypertrophic cardiomyopathy with ≥2 major risk factors)

Required Pre-procedural Diagnostics:

• 12-lead ECG and 24–72-hour Holter or event monitor

• Transthoracic echocardiogram (TTE) with congenital anatomy protocol

• Cardiac MRI with late gadolinium enhancement (LGE) where structural or myopathic substrate is suspected

• Genetic arrhythmia panel (NGS-based, covering SCN5A, KCNQ1, KCNH2, RYR2, CACNA1C and ≥40 additional genes) for suspected channelopathy

• Exercise stress test (paediatric Bruce protocol) for CPVT, LQTS type 1, or exertional syncope evaluation

• Electrophysiology study (EPS) with programmed stimulation for accessory pathway characterisation, VT inducibility, and AV node function

• Complete blood count, renal and hepatic function panel, coagulation profile, thyroid function (pre-amiodarone)

• Anti-Ro/La antibodies (for neonatal complete heart block evaluation)

Contraindications and Cautions:

• Active systemic infection or bacteraemia (device implantation must be deferred)

• Uncorrected haemodynamically significant structural congenital heart defect requiring prior surgical repair before arrhythmia ablation

• Severe pulmonary hypertension (PAH) with Eisenmenger physiology precluding safe catheterisation

• Allergy to contrast agents or heparin without established alternative anticoagulation protocol

• Weight <15 kg for standard transvenous catheter ablation (epicardial or modified approach may be required in smaller infants)

• Known bleeding diathesis or inability to receive anticoagulation perioperatively

Pharmacological Management (First-Line and Bridge Therapy):

Beta-adrenergic blockade with nadolol (preferred for LQTS due to sustained plasma levels) or propranolol forms the pharmacological cornerstone for LQTS types 1 and 2 and CPVT. Class IC agents (flecainide) are utilised as adjunct therapy for CPVT and selected SVT subtypes. Amiodarone — a Class III multi-channel blocker — is reserved for haemodynamically significant or post-operative arrhythmias due to its paediatric toxicity profile, with careful monitoring of thyroid, pulmonary, and hepatic function. Mexiletine (Class IB) serves as add-on therapy for LQTS type 3 (SCN5A gain-of-function mutations), and ivabradine is emerging for inappropriate sinus tachycardia in selected paediatric patients.

Catheter-Based Electrophysiology Study (EPS) and Ablation:

This is the definitive curative intervention for most re-entrant SVTs and accessory pathway-mediated tachycardias. The procedure is performed under general anaesthesia in paediatric patients. Vascular access is achieved via femoral vein (standard) or internal jugular/subclavian approaches. Multi-electrode mapping catheters (Lasso, PentaRay, HD Grid) are deployed with 3D electroanatomic mapping systems (CARTO 3 — Biosense Webster; EnSite Precision — Abbott) to reconstruct chamber anatomy and identify the arrhythmia substrate with precision.

• Radiofrequency Catheter Ablation (RFCA): Delivers resistive heating (target temperature 50–60°C, power 20–35 W) to create a discrete ablation lesion at the tachycardia substrate — AV nodal slow pathway (AVNRT), accessory pathway insertion sites (WPW), or ectopic focus. Success rates: AVNRT 95–98%, accessory pathway ablation 92–97%.

• Cryoablation: Preferred for para-Hisian or septal pathways where radiofrequency energy risks AV block. Cryomapping at −30°C allows reversible lesion testing before permanent ablation at −70°C, providing a critical safety margin in children.

• Zero-Fluoroscopy or Low-Fluoroscopy Ablation: State-of-the-art paediatric electrophysiology centres employ intracardiac echocardiography (ICE) and 3D mapping to perform ablation with near-zero radiation exposure — essential for long-term radioprotection in children.

• Epicardial Ablation: Reserved for accessory pathways, VT substrates, or post-operative scars inaccessible via endocardial approach; performed via subxiphoid pericardial puncture.

Cardiac Implantable Electronic Devices (CIEDs):

• Permanent Pacemaker (PPM): Dual-chamber rate-responsive pacing for complete AV block or sinus node dysfunction. Leadless pacemaker technology (Micra AV — Medtronic) is increasingly applied where appropriate. Epicardial lead systems are preferred in children <20 kg or those with intracardiac shunts to avoid paradoxical embolism risk.

• Implantable Cardioverter-Defibrillator (ICD): Transvenous ICD (TV-ICD) with antitachycardia pacing (ATP) capability for high-risk channelopathy patients meeting Class I/IIa indications. Subcutaneous ICD (S-ICD — Boston Scientific Emblem) is preferred for children without pacing indications, avoiding intravascular leads and preserving venous access for future procedures.

• Cardiac Resynchronisation Therapy (CRT): Biventricular pacing for pacing-induced or tachycardia-induced cardiomyopathy with LBBB morphology and reduced EF.

Surgical Arrhythmia Correction:

• Surgical Ablation (Cox-Maze IV Procedure): Employed in patients with complex structural congenital heart disease undergoing concurrent cardiac surgery, where catheter ablation is infeasible. Uses bipolar radiofrequency or cryothermy to create conduction block lines in atrial tissue.

• Left Cardiac Sympathetic Denervation (LCSD): A thoracoscopic (VATS) procedure involving resection of the lower half of the left stellate ganglion and T2–T4 thoracic sympathetic ganglia. Reduces ventricular arrhythmia burden by 70–80% in refractory LQTS and CPVT — recommended for patients with breakthrough events despite maximal pharmacotherapy and ICD shocks.

• Surgical AV Node Modification: Historical, largely superseded by catheter techniques; still relevant in complex post-operative cases.

Advanced and Emerging Technologies:

• Pulse Field Ablation (PFA): Non-thermal, electroporation-based ablation technology offering tissue-selective myocardial injury with preserved collateral structure safety — currently in paediatric investigational use.

• Remote Magnetic Navigation (Stereotaxis Niobe): Enables catheter manipulation via external magnetic fields, reducing operator radiation and improving catheter stability in small cardiac chambers.

• AI-Assisted Electroanatomic Mapping: Machine-learning algorithms integrated into mapping platforms for automatic annotation, activation propagation analysis, and substrate identification, reducing procedure time and improving ablation accuracy.

Step 1 — Pre-Travel Medical Review (2–4 weeks before departure): GAF Healthcare's clinical team performs a structured remote assessment: review of all prior ECGs, Holter reports, echocardiograms, genetic results, and operative notes (for post-surgical cases). A paediatric cardiac electrophysiologist at the receiving centre provides a written medical opinion confirming candidacy and proposed procedure. The family receives a pre-travel checklist: medications to continue/withhold (e.g., antiarrhythmic hold protocol), fasting instructions for the child, and emergency contact protocols during transit.

Step 2 — Arrival and Pre-Procedural Workup (Day 1–2): Upon arrival, the child undergoes a structured outpatient pre-procedural assessment: consultant review, repeat 12-lead ECG, TTE, blood panel (CBC, coagulation, renal/hepatic function, electrolytes), and anaesthesiology paediatric assessment. Baseline arrhythmia documentation is completed. Consent is obtained from guardians with interpreter support if required. Admission occurs the evening before the procedure; NPO (nil per os) protocol is initiated as per age-appropriate paediatric anaesthesia guidelines (clear fluids up to 2 hours, breast milk up to 4 hours, formula/solids up to 6 hours prior).

Step 3 — The Procedure (Day 2–3): Catheter ablation is typically 2–5 hours under general anaesthesia; device implantation (pacemaker/ICD) is 2–3 hours. The child is continuously monitored with pulse oximetry, invasive arterial pressure, surface ECG, and intracardiac electrograms. Post-procedure, the child is transferred to the Paediatric Cardiac ICU (PCICU) or High Dependency Unit (HDU) for 4–12 hours of cardiac monitoring. A post-procedure ECG and chest X-ray are performed immediately.

Step 4 — In-Hospital Recovery (Day 2–5 for ablation; Day 3–7 for device implantation): For catheter ablation: femoral access sites are monitored for haematoma; the child is mobilised within 6–8 hours; oral fluids and diet are resumed post-anaesthesia recovery. Repeat ECG at 24 and 48 hours confirms arrhythmia resolution and absence of AV block. Antiarrhythmic medications may be weaned or discontinued based on electrophysiologist review. For device implantation: wound site is inspected daily; device programming is optimised via remote telemetry interrogation; activity restrictions (arm immobilisation for pacemaker/ICD lead stability) are initiated. Prior to discharge, a formal device check, patient/family education session on device care, ICD shock protocol, and emergency response is completed.

Step 5 — Post-Discharge Observation Period (Week 1–3 in-country): The child attends an outpatient follow-up visit at Days 5–7 and Day 10–14 post-procedure. Assessment includes: wound inspection, repeat ECG, Holter monitor (24-hour) to confirm sustained arrhythmia suppression, and device interrogation (for CIED patients). Families are accommodated in partnered serviced apartments arranged by GAF Healthcare, with 24/7 medical liaison access. Physical activity is restricted to light ambulation; return to school and sports is guided by the electrophysiologist.

Step 6 — Fit-to-Fly Clearance and Discharge Planning: Fit-to-fly clearance is issued by the paediatric cardiologist based on: stable cardiac rhythm, healed vascular access site or device wound, completed device programming optimisation, and haemodynamic stability. For uncomplicated ablation: clearance at 7–10 days. For device implantation: clearance at 14–21 days. A comprehensive discharge summary, device identification card (for airport security and international follow-up), medication reconciliation, and a 3-month remote monitoring plan via GAF Healthcare's telecardiology link is provided to the family.

Step 7 — Long-Term Follow-Up: GAF Healthcare facilitates remote follow-up at 1, 3, 6, and 12 months via teleconsultation with the treating electrophysiologist. CIED patients are enrolled in remote monitoring platforms (Medtronic CareLink, Abbott MerlinNET, Boston Scientific Latitude) enabling automated transmission of device data to the treating team internationally.