In EP Lab Digest’s second edition of the new “How To” section, author Craig Swygman reviews a few of the clinical scenarios that may be encountered during implantable cardioverter defibrillator (ICD) troubleshooting.

Results of clinical trials conducted in the past several years have led to a dramatic increase in the number of ICDs implanted in the United States and around the world. ICDs have been shown to be superior to anti-arrhythmic medications for primary and secondary prevention of sudden death. Additionally, ICDs with the capability of providing cardiac resynchronization therapy have been shown to provide benefit in patients with congestive heart failure who are also at risk of lethal tachyarrhythmias. ICD technology has progressed rapidly with sophisticated features available both for the treatment of bradycardia and tachycardia.

Dr. Marrouche is the Director of the Cardiac Electrophysiology Laboratories and the Atrial Fibrillation Program at the University of Utah School of Medicine, which for more than 20 years has been a leader in developing innovative MRI applications. In this article, Dr. Marrouche describes his innovative ablation technique using MRI.

More than 3.5 million Americans have atrial fibrillation (AF), and its prevalence increases markedly with age in older adults, from less than 1 percent for those younger than age 60 to roughly 1 in every 10 persons aged 80 years or older.1 People with AF are up to seven times more likely to suffer a stroke than the general population. The Centers for Disease Control estimates that AF is a contributing cause for more than 66,000 deaths and is responsible for more than 1.7 million hospitalizations among persons in the Medicare population.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

We operate 5-6 EP labs per day, and have a separate non-invasive room for tilt table studies and any ICD follow-up examinations that require DFT testing. Along with our lab facilities, we operate the Heart Rhythm Center, which includes our Implantable Device Clinic, Arrhythmia Clinic, Atrial Fibrillation Clinic, Long QT/Inherited Arrhythmia Clinic, Pediatric and Adolescent Arrhythmia Clinic, and Syncope Clinic.

When was the EP lab started at your institution?

Our laboratory was started in 1972; the first case was for arrhythmia mapping during open-heart surgery.

What types of procedures are performed at your facility?

With year-to-date volumes available through September 2008, we are projecting to perform over 850 ablations, which includes over 400 PVI and 95 ventricular tachycardia ablations. We are estimating 500 ICD implants and 750 pacemaker implants.

Background

In September 2006 I realized I was out of shape. I weighed between 230 and 235 lbs, my cholesterol was in the 300 range and I had hypertension. My primary care physician told me I was also at risk of heart disease, and suggested exercise and medication.

I started slowly, walking every day for 20 minutes. Along with a regimented diet, I started losing weight. Encouraged, I also added weight training and jogging, and three times a week I would work on strengthening different body parts.

I continued losing body fat and added muscle mass, but then stopped improving. At 195 lbs I needed help. In addition, my blood pressure still had to be controlled and my cholesterol was unimproved. So in August 2007 I joined a gym in Tampa and hired a great trainer, Dennis Ruppert. I became obsessed with fitness, and even thought about becoming a body builder, though this was a long shot at 53 years old.

In the Hospital

In this feature interview, we speak with Dr. Thomas Neumann from the Kerckhoff Heart Center in Bad Nauheim, Germany about a recent three-center trial to study the effectiveness and safety of the Arctic Front.

How long have you been using the Arctic Front catheter and why do you use it for pulmonary vein isolation?

We’ve been using CryoCath’s Arctic Front since 2004 at our clinic. We were one of the first two centers in the world to use the original cryoballoon prototypes in a clinical trial. We wanted to see if a cryoballoon could simplify pulmonary vein isolation, which is now widely accepted as the foundation for catheter ablation of atrial fibrillation.

In this installment of EP Lab Digest’s “5 Ways” section, author Peggy McElgunn lists the acronyms of five crucial EP organizations.

Being a professional in the healthcare arena can be both a complex and confusing place to work. One of the challenges faced daily is the use of acronyms as a way of shortening our communication and presumably saving time. However, this theory works only if you understand the acronym. Otherwise, the time and effort it takes to understand one piece of communication may be excessive.

In an effort to assist, we have included below the five acronyms that any EP professional should know.

IBHRE: International Board of Heart Rhythm Examiners

The Bethesda Heart Institute opened on February 4, 2008, adding an entire cardiovascular service line to Bethesda Memorial Hospital. This article from Cath Lab Digest features an interview with Barbara J. Dale, Executive Director, and Tracy Justice, Assistant Nurse Manager of the Cath/EP lab at Bethesda Heart Institute in Boynton Beach, Florida.

Barbara, in addition to your position as executive director of Bethesda Heart Institute (BHI), what other management is in place?

Barbara: Right now BHI has an assistant nurse manager for the admission/recovery area (ARU), and Tracy Justice is the assistant nurse manager for the cath lab and electrophysiology procedures (EP) area. Prior to the opening of the Heart Institute, the hospital did not have open-heart services or an interventional laboratory. Bethesda Memorial Hospital originally had a 300-procedure diagnostic catheterization laboratory (cath lab).

In the first installment of this multi-part series for the EP 101 section, the authors discuss evaluation and proper diagnosis of a wide complex tachycardia in the setting of coronary artery disease.

Case Presentation

A 53-year-old man with hypertension, hyperlipidemia and coronary artery disease (s/p stent placement in 2001) presented to the emergency room with chest pain radiating to the jaw associated with tachycardia, dyspnea and diaphoresis. An electrocardiogram indicated the presence of a wide complex tachycardia (WCT) at 190 bpm with a left bundle branch block (LBBB) morphology and normal QRS axis (Figure 1). Blood pressure was 139/60 mmHg.

Ventricular tachycardia (VT) was presumed and lidocaine 100 mg IV was given, which terminated the tachycardia and symptoms. A subsequent ECG showed sinus rhythm with a narrow QRS, normal intervals and inferior Q-waves (Figure 2).

In 2004, a huge unmet need existed — nurses lacked a professional network to address their need for ongoing education, support, and collaboration in the care of patients with heart failure. Thus was born the American Association of Heart Failure Nurses (AAHFN), an organization dedicated to uniting professionals, patients, and families in the support and advancement of heart failure practice, education, and research. We currently have 1,700 members and are growing quickly!

Approximately five million people in the U.S. are currently living with heart failure, with estimates of that number growing to 10 million by the year 2040. This number will continue to grow as the population ages, even though treatment increasingly improves short-term outcomes for patients with acute coronary events.

Typical right atrial flutter (AFL) commonly occurs in patients who have been previously treated with biventricular pacemakers and defibrillators. Such patients may benefit substantially from catheter ablation, but may not be approached due to concerns over coronary sinus (CS) lead dislodgement. Three cases of radiofrequency (RF) ablation of atrial flutter in the presence of CS pacing leads are presented along with an approach that allows for confirmation of bidirectional isthmus block. Our method, which utilizes a 10-mm, high-output ablation catheter, minimizes the number of diagnostic catheters required and restricts their location to areas that are less likely to result in CS lead dislodgement.