Electrophysiology Study in India and UAE | Complete Patient Guide

• ELIGIBLE PATIENTS:

• Patients with documented or suspected supraventricular tachycardia (SVT), including AVNRT, AVRT, and atrial flutter, that is symptomatic or refractory to at least one antiarrhythmic drug

• Patients with Wolff-Parkinson-White (WPW) syndrome, especially those with pre-excitation and syncope, to risk-stratify and ablate accessory pathways

• Patients with unexplained syncope or pre-syncope where non-invasive testing (Holter, tilt-table test, event monitor) has been inconclusive

• Patients with sustained or non-sustained ventricular tachycardia (VT) for substrate mapping and ablation planning

• Patients with known structural heart disease (prior myocardial infarction, dilated cardiomyopathy, ARVC) being evaluated for ICD implantation or VT ablation

• Patients with high-degree AV block or suspected sinus node dysfunction requiring precise localization (AH and HV interval measurement)

• Survivors of sudden cardiac arrest without a clear reversible cause

• Patients with Brugada syndrome or Long QT syndrome requiring risk stratification

• Pre-ablation mapping prior to planned surgical maze procedure

• REQUIRED PRE-PROCEDURE DIAGNOSTICS:

• 12-lead resting ECG and 24–72-hour ambulatory Holter monitoring

• Transthoracic Echocardiogram (TTE/ECHO) to assess structural heart disease, ejection fraction, and valvular pathology

• Cardiac MRI (CMR) with late gadolinium enhancement (LGE) for scar mapping in structural VT patients

• Exercise stress testing or pharmacological provocation (ajmaline/flecainide challenge for Brugada, epinephrine for LQTS)

• Complete blood count, coagulation profile (PT/INR/aPTT), renal function panel, and electrolytes

• Thyroid function tests (TSH, FT4) in patients with atrial fibrillation

• Chest X-ray and baseline CT angiography if pulmonary vein isolation (PVI) is anticipated

• CONTRAINDICATIONS:

• Active systemic infection or bacteremia (risk of seeding intracardiac catheter)

• Uncontrolled heart failure with hemodynamic instability

• Recent acute myocardial infarction (within 4 weeks, unless emergent)

• Uncorrected coagulopathy or therapeutic anticoagulation that cannot be safely bridged

• Severe peripheral arterial disease precluding femoral access

• Known intracardiac thrombus (particularly left atrial appendage thrombus on pre-procedure TEE or CT) — requires thrombus resolution before left-sided procedures

• Severe, uncorrected electrolyte disturbances

• Allergy to contrast media or heparin (requires individualized protocol modification)

DIAGNOSTIC EPS (STANDARD):

The foundational EPS protocol involves placement of 3–4 multipolar electrode catheters under fluoroscopy in the high right atrium, His bundle position, right ventricular apex, and coronary sinus. Baseline intervals are measured — PA interval (intra-atrial conduction), AH interval (AV nodal conduction, normal 55–130 ms), and HV interval (His-Purkinje conduction, normal 35–55 ms). Programmed electrical stimulation (PES) with single and double extrastimuli at multiple drive cycle lengths is used to assess sinus node recovery time (SNRT), AV node Wenckebach cycle length, and to induce arrhythmia. Pharmacological provocation with isoproterenol, adenosine, or procainamide is employed to unmask latent pathways or conduction disease.

3D ELECTROANATOMICAL MAPPING (ADVANCED):

Modern EPS integrates real-time 3D electroanatomical mapping (EAM) using CARTO 3 (Biosense Webster), EnSite X NavX (Abbott), or Rhythmia HDx (Boston Scientific). These platforms construct point-by-point or ultra-high-density contact maps of the cardiac chamber, coloring activation sequences (activation mapping), voltage amplitude (voltage mapping to identify scar), and pace-mapping fidelity. Ultra-high-density mapping catheters — such as the PentaRay (64 electrodes), Advisor HD Grid (16 electrodes with omnipolar technology), or Orion basket catheter (64 electrodes) — acquire thousands of electrograms in minutes, dramatically improving the accuracy of substrate identification and ablation target localization.

CATHETER ABLATION (THERAPEUTIC — SAME SESSION OR STAGED):

• Radiofrequency Ablation (RFA): Delivery of 350–750 kHz alternating current via a 4 mm tip or irrigated-tip (3.5 mm) ablation catheter creates resistive heating and a discrete lesion (5–7 mm diameter, 3–5 mm depth). Irrigated-tip catheters (ThermoCool SmartTouch with contact-force sensing) allow deeper lesions with reduced char formation. Used for AVNRT, accessory pathways, atrial flutter (cavotricuspid isthmus), and VT.

• Cryoablation: The Arctic Front Advance (Medtronic) balloon catheter delivers cryoenergy (–60°C to –75°C) for pulmonary vein isolation in atrial fibrillation. Preferred in patients with anatomically favorable pulmonary vein ostia; associated with lower risk of atrioesophageal fistula compared to point-by-point RF.

• Pulsed-Field Ablation (PFA): The newest paradigm — the Farapulse (Boston Scientific) and Volt system — delivers ultrashort, high-voltage electric field pulses that cause irreversible electroporation selectively in cardiomyocytes, sparing the esophagus, phrenic nerve, and pulmonary veins. PFA dramatically shortens procedure time and is being rapidly adopted at leading Indian and UAE centers.

• Remote Magnetic Navigation (Niobe Genesis, Stereotaxis): A robotic catheter guidance system allowing precise, force-controlled catheter movements in complex anatomies (congenital heart disease, epicardial VT). Available at select tier-1 Indian centers.

IMPLANTABLE DEVICE IMPLANTATION (POST-EPS):

When EPS reveals significant sinus node dysfunction, high-degree AV block, or inducible sustained VT/VF in high-risk patients, same-admission device implantation may follow: permanent pacemaker (PPM), implantable cardioverter-defibrillator (ICD — single/dual-chamber or CRT-D for heart failure patients), or subcutaneous ICD (S-ICD, Boston Scientific) if venous access is unsuitable. Leadless pacemakers (Micra AV/VR, Medtronic) are increasingly used for AV block when venous implant is contraindicated.

STEP 1 — PRE-TRAVEL CONSULTATION (2–4 weeks before travel): GAF Healthcare coordinates a secure telemedicine consultation between the patient and the designated cardiac electrophysiologist. All prior records — ECGs, Holter reports, echocardiogram, cardiac MRI, and medication lists — are reviewed. The EP team determines whether the planned procedure will be diagnostic-only EPS or integrated EPS + ablation. Anticoagulation bridging protocol is communicated (e.g., holding warfarin 3–5 days pre-procedure; NOAC-hold strategy for 24–48 hours depending on agent and renal function).

STEP 2 — ARRIVAL & PRE-PROCEDURE WORKUP (Day 0–1): The patient arrives and is admitted. A dedicated GAF Healthcare coordinator escorts the patient from the airport. Same-day or next-morning pre-procedure bloodwork, 12-lead ECG, ECHO, and anesthesiology assessment are completed. Transesophageal echocardiogram (TEE) or cardiac CT angiography is performed if pulmonary vein isolation or left-sided ablation is planned, to exclude left atrial thrombus. NPO (nothing by mouth) begins 6–8 hours before the procedure.

STEP 3 — THE PROCEDURE (Day 1–2, Duration: 1–5 hours): The patient is brought to the electrophysiology (EP) lab. Conscious sedation (midazolam + fentanyl) or general anesthesia (preferred for complex VT ablation, AF ablation, or pediatric cases) is administered. Venous sheaths (6F–9F) are placed in the right femoral vein under ultrasound guidance. For left-sided procedures, transseptal puncture (Brockenbrough technique, confirmed by intracardiac echo or fluoroscopy) allows access to the left atrium. Systemic anticoagulation with unfractionated heparin is titrated to achieve ACT >300 seconds. Catheter mapping, arrhythmia induction, and ablation proceed per the mapped strategy. Hemostasis is achieved post-sheath removal with manual compression or a vascular closure device (Angio-Seal, Perclose ProGlide).

STEP 4 — IMMEDIATE POST-PROCEDURE MONITORING (Day 1–2): The patient is transferred to the cardiac step-down unit or cardiac ICU for continuous telemetry monitoring. Bed rest for 4–6 hours (femoral access) with limb immobilization is maintained. Post-procedure 12-lead ECG, chest X-ray (to exclude pneumothorax or pericardial effusion), and groin site inspection are performed. Heparin bridging or reinitiation of oral anticoagulation follows the EP team's protocol. Oral antiarrhythmics (if any) are reassessed.

STEP 5 — HOSPITAL DISCHARGE (Day 2–4): For uncomplicated diagnostic EPS, discharge typically occurs within 24 hours. Following successful ablation (AVNRT, AFL, WPW), discharge within 24–48 hours is standard. Complex VT ablation or AF ablation with PFA/cryo requires 2–4 days of observation. A comprehensive discharge summary, procedure report with 3D map images, and the electrophysiologist's follow-up plan are provided in English for continuity of care at the patient's home institution.

STEP 6 — POST-DISCHARGE & FIT-TO-FLY PERIOD (Days 3–14): Patients are seen in outpatient follow-up 2–5 days post-discharge for wound check and arrhythmia assessment (ECG, brief monitor). For diagnostic-only EPS, patients are typically cleared to fly within 3–5 days. Following ablation, a 7–10 day in-country recovery is recommended before long-haul flight, with compression stockings and adequate hydration advised. GAF Healthcare arranges serviced apartment accommodation near the hospital for this period.

STEP 7 — LONG-TERM RECOVERY (1–3 months): A blanking period of 3 months is observed after AF ablation, during which recurrent arrhythmias do not necessarily indicate procedural failure — antiarrhythmic drugs are commonly continued for 3 months post-ablation. Remote cardiac monitoring (implantable loop recorder or wearable patch monitor) may be prescribed. A 3-month telemedicine follow-up with the operating electrophysiologist is coordinated by GAF Healthcare.