Feature Interview

Creating a New EP Lab: Experience at McLeod Regional Medical Center

Interview by Jodie Elrod

Interview by Jodie Elrod

In this article, we speak with Dr. Rajesh Malik, Medical Director, about the creation of a second EP laboratory at McLeod Regional Medical Center in Florence, South Carolina. 

When was the EP program started at your institution? 

Electrophysiology (EP) is an exciting field of cardiology that many patients in our service area of Northeastern South Carolina and Southeastern North Carolina have benefited from since 1993. The McLeod Heart and Vascular Institute serves 15 counties with a population of more than one million. In 1995, McLeod Regional Medical Center opened a dedicated electrophysiology laboratory, and we recently opened a second EP laboratory this year. 

What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week?

Our EP program averages 1,400 cases a year. Annual volumes for the current EP lab include: 167 atrial fibrillation (AF) ablations, 156 other ablations, 38 basic EP studies, 192 ICD implants, 153 biventricular implants, 390 pacemakers, 103 implantable loop recorder implants, and 25 WATCHMAN device implantations (Boston Scientific). Other services offered at McLeod Regional Medical Center include internal loop recorder implants, leadless pacemaker implants, ablations with 3D mapping for PVCs, ischemic VT with Impella (Abiomed) support, and management of arrhythmias such as supraventricular tachycardia and atrial tachycardia. 

In addition, our medical center achieved Atrial Fibrillation Certification in 2013 after a comprehensive review by an accreditation review specialist from the Society of Cardiovascular Patient Care (now the ACC Accreditation Services). The goal for McLeod in achieving this certification was to more effectively manage the atrial fibrillation patient and improve patient outcomes. The EP team at McLeod plays a big role in maintaining this goal. In 2016, McLeod Regional Medical Center cared for more than 5200 patients with atrial fibrillation.

Why did your EP program decide to expand?

Currently, Dr. Rajesh Malik, Medical Director, and Dr. Prabal Guha are the two electrophysiologists at McLeod Regional Medical Center. (A third electrophysiologist is being actively recruited to join this dynamic team.) With the work of our two electrophysiologists, our EP volume has seen a 32 percent increase over the last five years. With higher volume demands and case complexity, an additional EP lab was warranted. 

Tell us about the design and completion of the second lab.

The new lab has been designed to accommodate more space for anesthesia, including upgraded imaging equipment, biplane x-ray technology, increased storage space, a cohesive monitoring room, and additional square footage that allows for ease of access. 

Design of the new EP lab incorporated a specialized team of architects, x-ray vendors, mapping system engineers, information technologists, computer programmers, and construction. Also, departments and personnel within McLeod that contributed to planning and design were Biomedical, Information Systems, Procurement Services, Infection Control, Anesthesia, Administration, Cath Lab Director, EP physicians, and the EP lab staff.

From concept to completion, this project was three years in the making. The construction timeline took eight months. During this time, the specialized team continued to meet and discuss room obstacles and challenges as needed. It required a great amount of collaboration between all parties involved to bring functionality, adaptability, and efficiency to the room workflow. The goal was to make sure all equipment fit into place, worked well in its location, and functioned systematically with each other to create the picture-perfect EP lab. The second dedicated EP laboratory opened in July 2017.

What measures were incorporated into the new lab to protect against radiation exposure? 

Radiation exposure is always a concern in electrophysiology. Excellent image quality and the lowest possible radiation dose are both requirements for patient and staff. The new system at McLeod is a truly integrated solution for enhanced patient care. It is equipped with a standard comprehensive portfolio of applications for dose savings and image quality enhancements to help deliver better patient care at the lowest possible dose. The x-ray system computer helps the user avoid fluoroscopy during repositioning and reduces dose by adapting the frame rate. It also has a feature to allow monitoring of radiation during procedures and easily compiles structured dose reports.

To further reduce radiation exposure, our physicians are able to apply new and innovative techniques to current procedures, reducing the use of x-ray. Combining the source of 3D mapping and intravascular ultrasound technology in a specific and systematic approach, physicians can build an anatomical map of the cardiac system and heart without the need for x-ray. Once the maps are created, the physicians can complete a diagnostic EP study and even perform an ablation with limited to no x-ray. This greatly reduces radiation to the patient, physician, and staff. Eliminating x-ray frees the physicians and staff from consistently having to wear heavy x-ray protection equipment. 

When the lead protection system is needed, an additional radiation protection system has been installed that reduces the weight of traditional protection equipment. It is a suspended radiation safeguard system that increases the level of radiation protection, as well as eliminates the weight burden for the operator due to its suspension. The new radiation protection system utilizes a 1.0 mm lead body shield that engages magnetically to a vest worn by the operator, which then allows the system to move in sync with the operator. The system is then easily stored away when not in use. It also features a 0.5 mm lead equivalent acrylic face shield that protects the head, eyes, and throat of the operator. Additionally, clinicians who often work with fluoroscopy are at risk of orthopedic strain from the weight of their personal protective apparel. The radiation protection system removes the weight off the shoulders of the operator so orthopedic strain no longer limits productivity.

What other technologies were added to the new EP lab?

The new EP lab also features 3D biplane technology that enables three-dimensional views of the patient’s heart from any direction during the procedure. The new system includes two advanced x-ray detectors that provide high-resolution images and also helps visualization of interventional devices, from almost any angle. The biplane technology allows for improved efficiency and accuracy as well as reduced procedure time, since there is less movement of the c-arm to capture images.

In addition, a customized monitoring system has been incorporated to combine various technologies. A 56-inch display monitor provides more than 200 layout configurations, and up to 12 different screen combinations with input from up to 24 image sources that can be directly selected at table side. The image of clinical focus can be zoomed up to twice the size of a standard display. In addition, the new monitor customizes the physician’s preferences and offers touchscreen technology for quick access to meet the physician’s needs. Installation of the monitor was also placed at eye level to avoid neck strain.

What additional EP techniques are being utilized in the new lab?

A new procedure being performed in the EP lab for the care of chronic AF patients is the leadless pacemaker. This pacemaker is 93 percent smaller than modern-day pacemakers, and completely self-contained within the heart with no leads required. The implant procedure involves a 105-cm catheter system with a handle that controls deflection and deployment. Because of its size and implantation method, there is no chest scar, no bump, and limited post-implant activity restrictions. There is specialized training required for implanters and only select heart programs are able to offer this device. At this time, McLeod is the only program in our region of North and South Carolina with the leadless pacemaker.

Is there anything else you’d like to add?

The EP lab at McLeod Regional Medical Center is a truly integrated innovation for enhanced patient care. The EP lab features everything from new safety mechanisms, reduced x-ray exposure times, integrated 3D echo technology, navigational 3D mapping systems, and integrated monitoring systems. Enhancing and expanding for the future of electrophysiology is necessary to provide exceptional service for the cardiac patients in our region.

Disclosures: Dr. Malik has no conflicts of interest to report regarding the content herein. 

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