Dr. Dickfeld interviewed Dr. Rishi Anand, who is currently working as an electrophysiologist in private practice at Holy Cross Hospital in Fort Lauderdale, Florida, regarding the opportunities and challenges regarding ventricular tachyarrhythmia (VT) ablations in a community hospital setting.

What is the case mix of ventricular tachyarrhythmias in your current practice? What are the differences to university settings?

VT ablations represent a small share of ablation procedures that we perform. VT ablations represent, on the high end, no more than 10 percent of our ablation case load. We have a relative mix of ischemic and nonischemic mediated VT favoring ischemic VT. If I had to guess, about 60–70% of our VTs are ischemic. We do not perform epicardial VT ablations.

What are the differences in setting up and performing ventricular tachyarrhythmia cases in regards to a community hospital setting?

Holy Cross Hospital is a community hospital with an electrophysiology lab adept and proficient in setting up for complex ablations. Our EP lab team performs well in room turnover and patient logistics. We typically do not have lab time issues, as we employ “block time” scheduling. This way an electrophysiologist is guaranteed protected lab time.

What might be some hurdles to performing more VT ablations in private practice?

The biggest hurdles revolve around two major points. One is the physician's skill set and familiarity with performing VT ablations. The second is regarding having a proficient lab with enough expertise in performing complex ablations and being able to perform basic pacing maneuvers to assist the physician with arrhythmia interrogation.

Can/should all VTs be ablated in private practice?

There is a big range of complexity in ventricular tachyarrhythmias. Monomorphic endocardial ischemic mediated VT is relatively straightforward to map and ablate. However, there are numerous VTs that can become complicated, especially when the arrhythmia circuit becomes epicardial in origin. These VTs require specialized expertise typically found in university-based settings with access to special techniques such as epicardial access.
With the work and research being performed in the university setting regarding ventricular arrhythmias and the continuing education of community-based electrophysiologists, it is very possible to safely and effectively perform VT ablations or scar modification in the community hospital setting for the appropriately selected patient. It is also incumbent on physicians to realize when these should be referred to a university-based setting. As a general rule for my personal practice, any patient with a suspicion of an epicardial origin VT would be referred to a university setting proficient in VT ablations.

Timm Dickfeld, MD, PhD is the Chief of Electrophysiology at the VA Baltimore, Associate Professor of Medicine at the University of Maryland, and Founder of the Maryland Arrhythmia and Cardiology Imaging Group (MACIG).