Building a Successful Ablation Program: Interview with Adam E. Berman, MD
How did you get into the field of cardiac electrophysiology (EP)?
I always enjoyed reading electrocardiograms as a medical student. Then, while a resident at Georgetown University Medical Center, I had the opportunity to work with Drs. Al Solomon and Cyndi Tracy, who intensified my interest in electrophysiology. This made my decision to pursue EP as a career much clearer.
Once I became a cardiology fellow, the decision was fairly easy to subspecialize in EP. My EP training at Duke was outstanding. We were very fortunate to routinely gain exposure to complex ablation and device work. I also had the privilege to work with a number of superb electrophysiologists. Ultimately, the research experience there was a great foundation for my decision to continue in academic medicine.
The opportunity at MCG was a good fit for me: it is a program that really wanted to build an ablation program from the ground up, which has certainly proved very challenging.
Tell us about your role as Director of Cardiac Arrhythmia Ablation Services at the Medical College of Georgia. What is a typical work day like for you?
Two and a half days a week are spent in the EP lab. I have three half-day clinics a week as well: one is dedicated to device follow ups, and the others are for new and follow up EP patients. Lab days are typically very busy. I also round on the consultative EP service every other week.
We have striven to build a robust ablation program, as our region is tremendously underserved, so I have been heavily focusing on educating our EP lab staff. We ve done this by doing didactic sessions, as well as simply taking the extra time during EP studies and ablations to explain to our nurses and techs what I am doing and what it means. I joke with them that they are my EP fellows! The investment has paid off, too in a year they have accomplished a tremendous amount. We now routinely perform complex ablations, including ischemic ventricular tachycardia (VT) and atrial fibrillation (AF). In addition, I recently started a Web site (www.epmcg.net) designed to help educate our patients, their families and referring doctors about what we have to offer. Web programming can be very challenging!
What are some of the daily challenges you encounter in the lab?
We are primarily limited by space. We have only 1 EP lab, and are in the preliminary stages of planning a second. So, when it is busy, turnover times are an issue.
What do you consider unique about your ablation program?
Our region is the Central Savannah River Area, of which Augusta serves as the hub. We are the only biplane EP lab and the only regional lab with both ESI and Carto as well as Siemens ICE. In addition, we are the only lab with cryoablation, of which we perform 3-4 procedures a week. Thus, we are very unique in our region. We are also equipped to perform any type of ablation, as well as perform ablation in the adolescent population.
Recently, in collaboration with our cardiac surgeons, we began successfully performing hybridized EP surgeries, such as complex epicardial left ventricular (LV) mapping and ablation via a mini-thoracotomy approach, in our lab. This allows unprecedented catheter mobility in the epicardial space in patients with prior sternotomies who are not ideal candidates for a sub-xyphoid approach. We are the only center in the region performing procedures such as this.
What ablation patient case was most challenging or memorable for you?
We recently had a patient who was experiencing ischemic VT and ICD shocks that recurred despite therapy with amiodarone and mexilitine. He is a bilateral above-knee amputee, with an AAA and bilateral common femoral artery aneurysms. We performed an ischemic LV ventricular tachycardia ablation via a purely transseptal route. He has had no further VT in the four months on amiodarone monotherapy. The patient feels great of course, this was a very rewarding case for our whole team as well.
How often is cryo utilized at MCG? What has been your success rate with cryo?
Cryoablation has become my first-line therapy for AVNRT ablation. Also, since we use ablation in pediatric cases, we use cryoablation in these instances as well. For example, we recently ablated a 14-year-old with multiple left-sided accessory pathways with cryo. When ablating during orthodromic tachycardia, cryo adds catheter stability that is maintained upon loss of AP conduction and subsequent tachycardia termination. He s done great in follow up.
Our acute success rate with cryo is well above 90%, approximately 95-97%. Cryoablation is particularly attractive for a young ablation program, given its excellent safety profile and widespread applicability. Our success rates with cryo have been comparable to those with radiofrequency (RF). There is a learning curve associated with a new energy delivery system, but once you develop your own technique, results are reproducible. We also routinely perform cryoablation during AF ablation within the left atrium (LA), utilizing a hybridized RF and cryo approach. I have recently started using CryoCath s 6 mm and 8 mm tip catheters in the left atrium on the posterior wall and for touch-up within the vein orifices. The stability of the 8 mm tip catheter is excellent; I also use the steerable Bard sheath with the 8 mm cryo catheter. In addition, we use the irrigated tip RF catheter for other locations within the LA. The emerging data regarding the cryo balloon is exciting as well.
What advice can you give for those just starting out in the field of EP?
My biggest piece of advice is to pick cases wisely and don t be afraid to say No. For example, I ve found that referring physicians unfamiliar with our procedures may occasionally refer patients who are poor candidates for complex ablations given their comorbidities. In these situations, I do my best to offer an alternative strategy palatable to both the patient and referring physician. Remember, patient safety is number one. I am a big advocate of minimizing patient risk.
Also, don t be shy about asking for a second opinion; two brains are always better than one!
What research or clinical goals to you hope to achieve at MCG? Are you currently Involved in any research projects?
We are currently enrolling in several prospective clinical trials here, including the small pilot study BiV-NavX, which is investigating coronary sinus mapping during BiV implant. We are about to launch an ischemic VT ablation protocol, and we are also involved in arrhythmia genomics work. In addition, we are finishing enrollment in DEVISE-CRT at Duke, which is investigating BiV optimization in patients receiving BiV-ICDs. Our goal is to become vigorously involved in clinical and basic science EP research while continuing to deliver advanced arrhythmia care.
What advances do you hope to see in cardiac electrophysiology in the next few years?
The advent of balloon-based pulmonary vein isolation techniques is very encouraging. The burden of AF that we see is overwhelming, so faster techniques of AF ablation are very attractive. Echocardiographic assessment of ventricular dyssynchrony is also an area of rapid growth that I think will change conventional criteria for BiV candidacy.
Is there anything else you d like to add?
I d like to commend the EP team here at MCG; they have done a fantastic job of growing and learning. The result is top-notch comprehensive patient care.