In this feature interview, EP Lab Digest speaks with Dr. Daniel Friedman, an electrophysiologist with Manatee Memorial Hospital in Bradenton, Florida.
Tell us about your medical background. How long have you been practicing? Where have you practiced?
I am a cardiac electrophysiologist at Bradenton Cardiology Center. I have been in private practice for 8 years in southwest Florida. Prior to moving to Florida, I was an assistant professor of medicine at St. Louis University in St. Louis, Missouri for 2 years after completing my electrophysiology fellowship (St. Louis University). My practice is concentrated almost exclusively on electrophysiology. I spend the majority of my time performing procedures such as catheter ablations and cardiac device implantations.
Tell us about your EP program.
Our EP program is based at Manatee Memorial Hospital and consists of 1 dedicated electrophysiology laboratory, 1 hybrid catheterization lab, and 2 additional catheterization laboratories. There are 2 nurses and 2 technicians that work in the EP lab. Per week, I routinely perform 4-7 atrial fibrillation (AF) ablations, 2-4 other ablations, 1-3 WATCHMAN left atrial appendage device implantations, and an average of 5 pacemaker, ICD, or loop recorder implantations. Manatee Memorial Hospital’s EP lab continues to invest in technology for the EP program to enhance patient outcomes.
Manatee Memorial Hospital’s EP lab was the first in Florida to use the TactiCath contact force ablation catheter (St. Jude Medical), which has been shown in a randomized clinical trial to improve AF ablation outcomes. We will soon be the first in the region to use high-frequency jet ventilation to improve AF ablation outcomes as well as reduce procedure and ablation times. We were the first in the region to use FIRM ablation of persistent AF with the Topera (Abbott) system. The lab has also invested in cryoballoon technology, the Zero-Gravity Radiation Protection System (CFI Medical), the radiofrequency NRG Transseptal Needle (Baylis Medical), and the SafeSept Needle Free Transseptal Guidewire (Pressure Products). Safety is our number-one goal, and we have less than 1 tamponade complication per year from AF ablation.
Where do you currently use steerable sheaths? What is the biggest clinical benefit you see in steerable vs fixed curve use?
I use steerable sheaths in all of my AF ablations. I use radiofrequency ablation with contact force sensing and a 3D electroanatomic mapping system. A steerable sheath provides better control at the ablator tip resulting in better manipulation and contact, helping to create a more transmural lesion set.
What steerable sheath(s) did you normally use? What, if any, limitations did you face with your current sheath technology?
Prior to the Vado sheath, I routinely used the Agilis steerable sheath (St. Jude Medical). The Agilis sheath has pull wires. Small and precise movements are challenging with the Agilis sheath. I would have to use the ablation catheter for the small and precise movements to ablate point to point. I would then use the Agilis sheath for the larger movements after finishing a segment with the ablation catheter deflection mechanism. The shaft of the Agilis bends in the inferior vena cava (IVC) and right atrium. This can make it difficult to navigate to certain areas in the left atrium, such as the inferior portion of the right inferior pulmonary vein. Stability during ablation is sometimes difficult to achieve with the Agilis sheath, especially along the ridge between the left atrial appendage and left superior pulmonary vein.
How many procedures have you completed with the Vado? What have you used it for so far (e.g., FIRM ablation, PVI, flutter line)?
Vado is a new product. I switched sheaths to the Vado sheath after my first few experiences using it. I now use it for all of my AF ablation procedures, which often include atrial flutter ablation and FIRM-guided ablation as well as pulmonary vein isolation. I have completed 30 cases thus far with the Vado sheath.
How would you describe the Vado’s performance relative to other sheaths you’ve used? Is there an area in particular where the Vado has helped you do something you weren’t able to do before?
The Vado sheath has several advantages over my previous sheath. Using a single transseptal puncture technique, I use the ablation catheter as a guidewire within the Vado sheath to cross the septum next to a guidewire that has been placed into the left atrium (via an initial fixed curve transseptal sheath and puncture). This technique saves time and avoids multiple transseptal punctures and needle passes. The taper of the Vado sheath at its distal end along with its stiffness allows seamless insertion into the left atrium using the single transseptal technique. The previous sheath would routinely buckle at the level of the atrial septum using the ablation catheter as the guidewire because of the sheath’s bulky transition at its distal end.
Vado uses a patented technology called TruVector™*, which is the basis of the shaft design. How do you think TruVector technology has helped improve stability and performance?
TruVector has allowed me to obtain consistent movement of the catheter to achieve precise navigation and avoid skip lesions during pulmonary vein isolation. The shaft is completely straight through the IVC. The sheath predictably deflects at its distal end and allows the operator to essentially dial-in the amount of desired contact force. The first lesion is always the best lesion prior to the development of tissue edema. It is important to have catheter stability and contact force from the beginning to improve outcomes. The contact force measurements are more consistent and controllable with the Vado sheath than with the Agilis sheath throughout the cardiac and respiratory cycle. This translates into more efficient ablation lesions that are more effective, require less radiofrequency ablation time, less procedure time, and less repeat procedures.
What did you find most compelling about the Vado sheath? Why did you decide to switch from your current sheath to the Vado?
The most compelling aspects of the Vado sheath are the predictable deflection motion that allows fine movements, and more consistent stability and contact force. For these reasons, I decided to switch from my current sheath to Vado.
Is there a specific case you would like to highlight where the Vado helped clinically?
The redo pulmonary vein isolation ablation cases usually involve repeat ablation in areas that are difficult to maintain good catheter stability and contact force. The Vado sheath has provided increased maneuverability, stability, and contact force delivery.
Go to Abbottep.com for more information.
* Note: TruVector is the name for the design consisting of an inner and outer shaft bonded at the tip, where deflection is achieved by pulling on the inner shaft when the knob is deflected. This enables the Vado to operate without the use of pull wires.
Disclosure: Dr. Friedman has no conflicts of interest to report regarding the content herein.