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DEVELOPMENT OF ARRHYTHMOLOGY IN ARMENIA
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Smbat Jamalyan, MD Hrair Garabedian, MD May 2005
ACG ADM 31.1.01
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Any good story have its beginning ..
ACG ADM 31.1.01
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CARDIOLOGY CARDIAC SURGERY in Armenia
Thanks to joined efforts of

• Dr. Hrair Hovaguimian
• Medical Outreach for Armenians
• UAF
• Dr. Hrair Garabedian
• USA Embassy in Armenia
• Armenian government
• Whole medical staff of NMMC
• anyone in this room who helped us

THANKS
In 1993 NMMC was established . a Major Cardiac
Center of the CIS countries ...performing about
1000 open heart surgeries a year
ACG ADM 31.1.01
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CARDIOLOGY CARDIAC SURGERY in Armenia
In 2000 at NMMC we determine lack of an important
subspecialty Arrhythmology ... I was selected
to be trained in the USA, Spokane, WA
THANKS

• Medical Outreach for Armenians
• Mr. Arthur Halvajian
• Dr. Hrair Garabedian
• Dr. Tim Lessmeier Dr. Kenneth Zahka
• Medical staff of Sacred Heart MC
• anyone in this room who helped me

ACG ADM 31.1.01
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THE HARDEST PART
One year intensive training at SHMC, Spokane
14-18 hours of hard work missing my family
back to Armenia no equipment, no devices, no
team nothing . Start training nurses and
technicians 2 years step by step building the
service
THANKS

• an EP lab was donated to NMMC by SHMC
• catheters and other devices
• Dr. Tim Lessmeier came over in 2002
• in 6 days we did 17 ablations

ACG ADM 31.1.01
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Step 1 CREATING a TEAM
We have started with one doc one nurse and
created professional group and professional
team

• 3 Invasive Cardiologists
• 3 Non-invasive Cardiologists
• 1 Fellow Cardiologist
• 1 Rotating Fellow from NMMC
• 3 Non-invasive technicians
• 9 Nurses
• 5 invasive technicians
• 5 Administrative personal

30 members
ACG ADM 31.1.01
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Step 2 CLINICAL ACTIVITIES
During the last 3.5 yeas more than 5000 new
patients were examined and treated there
were over 19000 visits to the clinic
Data acquired by May 1st, 2005
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Details Outpatient activities

• HOLTER and EVENT MONITORINGS 4745
• ECG 9567
• DRUG TESTS and EXERCISE TESTS 2005
• PM Follow-up TESTS, 2211
• CONSULTATIONS 9302
• ECHO 7732

36562
Data acquired by May 1st, 2005
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Details In-Patient Activities

• EP STUDES OF THE HEART ILR IMPLANTATIONS 226
• - PACEMAKER IMPLANTATIONS 337
• ICD IMPLANTATIONS 46
• RF ABLATIONS of arrhythmia 218
• CARDIOVERSIONS 190
• CARDIAC RESYNCRONIZATION THERAPY for HF
  21

1038
Data acquired by May 1st, 2005
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WHAT DOSE THIS MEANS?
Percentage of affected population receiving
therapy

• meticulous, consecutive work with the companies
• balanced price and charge policy
• recognition of our charity programs.
• Bring this high-tech medicine to a more or less
  accessible level for Armenia
• Did one thousand interventions
• .. but how are the results?

ICD implants
PM implants
Ablations
CRT
ACG ADM 31.1.01
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Complications - Implants
Out of 404 implants Overall complication rate
was 3.1 and major complications was in 0.5 with
0 mortality

• of PTs
• Major..
• wound infections that required extraction of
  device and Leads 2 - 0.5 - Bleeding
  required reoperation, mortality related to
  intervention 0 - 0
• Minor.
• RV electrode placed in the cardinal CV 1 -
  0.2
• Failed to cannulate CS 2 - 0.5
• - Electrode dislodgment required repositioning
  4 - 1.0
• High pacing thresholds (not required lead
  repositioning) 3 - 0.7
• Device Migration (required intervention) 1
  - 0.2

ACG ADM 31.1.01
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Learning Curve - Implants
Success Rate
of implants/year
123
98.6
91.8
33
ACG ADM 31.1.01
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Ablations

• Site.. Success rate (LT)
  Major Compl-tions
• RV/LV VT 21 100 NO
• HIS 22 100 NO
• AVNRT 88 100 NO
• AVRT LEFT 45 96 NO
• AVRT RIGHT 29 93 1 heart
  perforation
• FLUTTER 9 89 NO
• Right Maze 4 75 NO

2 months child, 3.9 kg _at_ Incessant SVT 230BPM
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Details In-Patient Activities
The percentage of the patients from Abroad is
increasing Currently about 35 of our patients
are from CIS
South Russia
Georgia
All others

ACG ADM 31.1.01
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Step 3 FIRST TIME IN ARMENIA AND IN THE REGION
First EP study of the heart performed in Dec 25/01
1
First Ablation Jan 30/02
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First DR pacemaker Implant Feb 23/02
3
First ICD Implant - Mar 21/02
4
First CRT - Aug 9 / 02
5
6
First CRT ICD Implant - May 26/04
ACG ADM 31.1.01
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Step 4 INFORMATION MANAGEMENT
Computer based registry for heart rhythm
disorders was created
Currently this database contains data of 5019
patients
Demographic
EP studies
follow-up visits
PT
Implantations
labs
Cardioversion
ECG
Ax
ID tracking
DS registry
ECHO
Tx F-up plan
HOLTER
DVD archive
Exercise tests
ACG ADM 31.1.01
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Step 5 EDUCATION
no charge for any of the event
8 EP technicians was trained for 8 months
each. 4 EP nurses was trained for 12 months
each. ..all are joined to the group. 36
Workshops on up-to-date cardiology problems were
conducted . ..bringing some 1900
participants from all over Armenia, Georgia and
South Russia. 6 ACC and ESC Guidelines were
translated to Armenian and Russian and published
1000s of each 12 Brochures for Patient
education and self assessment were published
matherials are available in the internet
www.acg.am
ACG ADM 31.1.01
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Step 5 EDUCATION
www.acg.am

• three-lingual site AM RU EN
• 950 MB information
• Patient education 35
• Physician education 35

Visits
Downloads
Hits
ACG ADM 31.1.01
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Step 6 CHARITY In-Patients Activity
Out of 1038 interventions

• NO CHARGE FOR CHILDRENS UNDER 7 56
• 30 CHARGE FOR NEEDY PEOPLE 209
• 70 CHARGE FOR PTs between 7 and 17 89
• MISCELLANEOUS DISCOUNTS 351
• FULL CHARGE 333

ACG ADM 31.1.01
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Step 6 CHARITY Out-Patients Activity
Out of last 12000 visits

• NO CHARGE FOR CHILDRENS UNDER 7 1560
• 30 CHARGE FOR PTs between 7 and 17 1923
• Miscellaneous discounts 3369
• FULL CHARGE 5148

ACG ADM 31.1.01
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Future Plans Targets
?

• - upgrading the EP lab for most advanced
  technology
• apply an ISO 2000 9001 standards
• Quality Management tool
• building new in-patient service for 10 beads
• training one or two Electrophysiologists
• continue to enjoy our educational work
• - In Fall 2005 FOUR more workshops will be held
• - 1 Guideline and 2 patient educational
  brochures will be
• published by the end of 2005.
• - continue education by our WEB site
• continue to do as much charity
• 
  as we can

?
?
?
?
ACG ADM 31.1.01
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Conclusion
FIRST CLASS PRACTICE CAN BE ESTABLISED IN
ARMENIA AS FAR AS WE CAN FOCUS ON ONE THING
THANKS
5 years ago I would not believe to this and
I would like you to believe it now.
ACG ADM 31.1.01