We have two new questions this month on catheter selection and catheter placement. If you would like to respond, please email us at eplabdigest@hotmail.com or go to www.eplabdigest.com and click on the email discussion group link. Remember, when posting or responding to the discussion group, please let me know if you would like your name, location, and/or email address listed as well — that way you will get more instant results! This month, we are also premiering a new feature in which a guest moderator answers one of the questions under discussion every month. See the inset for more information. In this issue, Dr. L. Bing Liem provides his expertise on a case of right ventricular outflow tract tachycardia. Keep posted for more guest moderators! We hope to hear from you soon!

New Questions:

Catheter Selection
We are a newly established EP lab and are finding it extremely frustrating not to understand some of the basics about catheter selection (i.e., what catheter for what region of the heart and why). I know that there are some excellent spiral bound books for heart catheterizations and interventions; is there something out there for the EP lab?
— name withheld
(Readers, to reply to this question, please type “Catheter Selection” in your subject line.)

You probably know that there is not one catheter type that goes to a certain position inside the heart. What I can share with you is that I have eight EP doctors in our lab, and one of them wants Bard woven (pin ends) because it retains its shape. Some doctors like to use Daig supreme catheters (5 Fr) for RVA (softer) for HIS and RA — they liked it with 6 Fr Daig as well.
— name withheld

Catheter selection is usually a physician preference, just like the sutures they use to close incisions, and usually reflects what they used in training. Most texts will either give general guidelines or will be specific to the people who wrote the book or article. 
Generally, a Josephson catheter is used in the right atrium or right ventricle. Some doctors will use it in the His position as well. 
A Cournand catheter or a steerable (deflectable) quad is often used in the His position to take advantage of the broader curve to cross the tricuspid valve and achieve a more stable catheter position.
A steerable quad catheter may also be used in the right ventricular outflow tract (RVOT) because it is more maneuverable.
A deflectable quadripolar, octipolar, or decapolar catheter is usually used to enter the coronary sinus (CS) from the femoral approach, while either a deflectable catheter or a fixed curve decapolar CS catheter is used to enter the CS from above. CS catheters introduced from above may be placed from the left subclavian or right internal jugular veins. CS catheters were originally introduced from the antecubital veins as well (through a sheath), and some physicians may still use this technique because there is no risk of pneumothorax or of sticking a major artery. It is a little less comfortable for the patient, though.
There is also a Damato catheter that has a very broad curve. It can be used in the His position, to enter the CS (especially from above), and in the RA or RV.
— name withheld

Catheter Placement by Non-Physician Staff
Need the help of the EP community: for the last four years, technologists have been placing catheters for basic EP tests for the physicians. We have come to find out that there is no policy for the staff protection. Thanks to JCAHO and the lawyers of the world, this has to be evidence-based. Do any labs out there allow catheters to be placed by non-physician staff? Looking for policies or a lab that allows this practice.
— Mitch Hammond, BSHSc, EP-CVT, NREMT-P
(Readers, to reply to this question, please type “Catheter Placement” in your subject line.)

Our facility is a teaching hospital. According to our Risk Management department, an Attending Physician must be present during the critical parts of any procedure. In the Cardiac Cath and EP labs, this means placing catheters in the heart, whereas venous and arterial access may be obtained without the Attending present. On occasion, it becomes necessary to remind the fellows that this is the policy of the facility. We are all patient advocates, and patient safety should be high on our list of priorities.
— name withheld

Regarding catheter placement, even vein access, our techs are very well trusted by our doctors to place catheters inside the heart (with them around); we even put long sheaths (SR0, SL’s or SR’s). We also do the baseline measurements. As far as policy is concerned, we don't have any, but you do have to gain the trust and confidence of your MDs for them to give you the blessing to push the catheter in. Besides, they are just outside the room, so if ever we get stuck, they are right there.
— name withheld

Many hospitals allow non-physician staff to insert introducers and some of them allow catheter insertion as well. You definitely need policies in place to protect the staff. Because these people will be working outside of their scope of practice, their malpractice insurance may not cover them. You'll want to be sure the hospital covers them in case of litigation as well.
The best developed program I know of is at Lancaster General Hospital in Lancaster, Pennsylvania. Their staff are trained in both sheath and catheter insertion/manipulation. They have a training program and should have policies in place as well. Remember that you will probably be working in a different jurisdiction, so be certain that any policies you develop do not contradict state regulations. These regulations are usually published or available online and should be reviewed. When researching this once before, we found out that it wasn't specifically forbidden, but the hospital would bear the responsibility and the staff would be held to the same standard of service as "the person usually responsible" for performing the procedure (the doctor) if it went to court. Knowing exactly what you are getting into and that the hospital is willing to support it by policy is essential for the protection of you and your staff.
— Howard Mattingly, RN, Team Leader, EP Lab, Methodist Hospital, Indianapolis, Indiana

New! Discussion Group Guest Moderator

- SVT in the RVOT What can anyone tell me about SVT thought to be originating in the RVOT? I am a technologist who will be mapping such a case with Navex and/or an array balloon system. — anonymous I believe you meant VT originating in the RVOT. The RVOT is a common site for the so-called "idiopathic VT", which is a term to indicate that the VT is not from ischemic scar, so it carries a less malignant prognosis. It is believed to be either automatic or trigger-activity in mechanism, thus, the standard PES is not at all useful in inducing the VT. Isuprel (without PES) also has mixed results and is only effective when the RVOT tachycardia appears to be exercise-induced. About 50% of RVOT tachycardia occurs in the absence of heightened sympathetic tone.  The most common modality to "map" RVOT tachycardia is by mapping the PVCs, which are usually of the same origin and morphology. Pace-mapping is the easiest method. Single PVC mapping with a 3-D system is also useful. Finally, it should be noted that some RVOT tachycardia comes from the LVOT. Due to the varying presence and inducibility of RVOT (or any idiopathic VT), the endpoint is vague. Thus, the success rate of RVOT VT ablation is quite variable. If only PVCs are present at baseline, the recurrence rate is rather high, approximately at 20–30%. — L. Bing Liem, DO, New Mexico Heart Institute, Albuquerque, New Mexico, and Section Editor, EP Lab Digest

Under Discussion:

Paper Recording to New Recording System
We are moving from paper reporting of our implants to our new Witt recording system. We are interested in what is the minimum reporting requirements for the body of the implant, example wordage after the Access and before Closing Incision. If you have any information you could share, we would appreciate your assistance. Thank you!
— Joyce Miller, RN, CCRN
(Readers, to reply to this question, please type “New Recording System” in your subject line.)

I am also interested in this response. Our hospital will be implementing the same and uses from Witt.
—anonymous

We document sheath size, any angiography (through IV or sheath or CS), placement of leads (ventricular and atrial), thresholds obtained, leads sutured, attached to device, antibiotic to pocket...pretty much the flow of the implant. We do not document the serial numbers into Witt; however, with the new CME guidelines and the registry we are keeping, we do enter the patient into the registry. But this does not impact our charting in Witt.
—name withheld

Nurse Practitioners
How does your EP practice utilize nurse practitioners?
— anonymous
(Readers, to reply to this question, please type “Nurse Practitioners” in your subject line.)

EP Training Program/Accredited for Techs and RNs
Besides the EP/Pacer HRS exam and vendor-supported education, are there any programs getting ready to start EP/pacer training from the basic through complex mapping and ablations? If so, how long is the training, and what is the name of the school/institution?
— Jerry Leblanc, RCIS, Central Washington Hospital, Wenatchee, WA
(Readers, to reply to this question, please type “EP Training Program 2006” in your subject line.)