Dr. Andrew Brenyo, an electrophysiologist with the Greenville Health System in Greenville, South Carolina, discusses his decision to pursue radiation reduction and lead removal.
Why was pursuing workflows with reduced radiation and decreased time in lead important to you?
The increased risk of radiation-induced malignancy is well described within the literature. A lot of my reasoning had to do with seeing more senior EPs attribute their orthopedic injuries to wearing lead for long periods of time. Seeing these otherwise healthy colleagues needing back/neck surgery or even developing cancer motivated me to maintain my quality of life and think of radiation as a “necessary evil” and not necessarily relied upon on a day-to-day basis, considering the current technology we have at hand.
Were there any early objections from your staff or partners in moving forward?
I didn’t really ask for permission — I began this process piece by piece, and the staff never objected. In fact, as we began to rely even less on lead use and fluoroscopy in our procedures, all of a sudden it made me relatively popular! My partners then began to adopt similar steps to minimize their fluoroscopy exposure and time in lead.
What initial procedural workflow steps did you take, and what tools did you use?
When we were getting started, our first goal was to target cases for which we knew what our ablation strategy would be. For example, when ablating atrial flutter, we would utilize a long sheath for the ablation catheter and a short sheath for the coronary sinus (CS) catheter. In the beginning, I wasn’t 100% confident in terms of feel, so I would place the wire into the vein and advance it slowly, until I felt resistance. I would then measure just above the patient’s bellybutton with the sheath, and I would advance the sheath until I got to that point within the venous vasculature. Next I would advance the ablation catheter into the RA until I saw atrial electrograms. I’d make my 3D map and bring my sheath up into the RA. Once I had the map made, I’d put in the CS catheter and perform the ablation along the cavotricuspid isthmus. Most of the time when you’re advancing catheters slowly from the femoral vein superiorly toward the cardiac structure, they’re going to find the RA without fail the majority of the time. I once had a patient with an IVC filter that I didn’t know about; I kept encountering resistance early, and wound up having to use fluoroscopy. However, once we’re in the range and have our catheters in place, we can begin the EP study and ablation strategy of our choice.
What tools were most impactful in your radiation reduction workflows?
When we first started, becoming oriented with the ablation catheter and which side of the catheter bent to which color of the catheter, helped me learn how to manipulate the catheter based upon just looking at it. The evolution of contact force and utilizing the THERMOCOOL SMARTTOUCH® Catheter in our ablation workflow was important. Use of the PENTARAY® Catheter was also a big addition, and through its design and catheter behavior, has allowed me to see if I am touching a wall. Therefore, I can very quickly generate an accurate map of the chamber I am working in, primarily for LA procedures, and get a CT quality image with minimal effort in little time. With the addition of contact force and appropriate VISITAG™ Module settings, we have developed a much more efficient workflow, while at the same time, reducing our lead burden and x-ray exposure.
The CARTOSOUND® Module allows me to see everything that is going on within the chamber in question, and has pushed me to get better with intracardiac echo (ICE) so I can see what is occurring during transseptal puncture and LV or LA ablation. In addition, the CARTOSOUND® Module allows for appropriate delineation of anatomy and a good representation of intracardiac structures such as the papillary muscles as well as the LAA and upper vein ridge. We use the CARTOSOUND® Module heavily and oftentimes will watch our ablation procedures from the CS with the CARTOSOUND® Module, or conversely, we’ll see the formation of rings around the PVs from inside the LA or PVs. So it truly does augment the procedure — once you’re good with ICE and in particular the CARTOSOUND® Module, it makes the reduced fluoro procedure that much more comfortable.
How many cases did it take to get comfortable with the new workflows?
I took the process relatively slowly. With appropriate guidance, that process can be much faster. It only took my colleague about 10 cases to get comfortable with the new workflow.
Can you elaborate on tools for reducing radiation during transseptal?
It has to do with first increasing the footprint of the CARTOSOUND® Module in your ablation procedures — you need to be very comfortable with intracardiac echo to understand how to position the ICE catheter for good imaging of the interatrial septum and to allow for sheath exchange through the interatrial septum while performing your transseptal. There are tools available from transseptal needle manufacturers that allow you to visualize the needle as you cross the interatrial septum. We’ve adopted the use of this, and I think it’s been very beneficial to see the relationship between the 3D anatomy acquired in the RA prior to transseptal puncture and the location of the eventual needle that goes through the interatrial septum. It’s a reassuring element that can provide you with where you’re going through the interatrial septum and make sure that your transseptal is not only safe but exactly where you want it on the septum. I think I initially underappreciated the utility of the CARTOSOUND® Module, not only for my transseptal but for my entire procedure. Once I began to adopt it more, it made the transseptal that much easier for me. The use of technology that is commercially available to visualize the transseptal needle was also a big step in finding out where it was on my 3D map. Depending on the procedure, I may vary where I want that needle to go through the septum.
How low is “low enough” with fluoroscopy?
For me, the critical step is whether you are confident enough with your anatomic map to remove your lead for longer procedures. If you’re using a minute of fluoro and not removing your lead, it’s as if you stepped on fluoro the entire time. The obvious difference is the x-ray exposure, but your time in lead is unchanged. Once you get to a point where your time in lead is being affected by your comfort with the mapping system and tools, that is low enough for me. Keep in mind that approximately 10 minutes of fluoro can be equivalent to hundreds of chest x-rays — that is something that I began to explain to my patients after looking at the actual exposure data. So how low is appropriate? It’s an individual decision, but the important element is when you begin to change how much time you’re standing in lead and whether or not your patients see it as a differentiator for you as a physician and for their procedure. That was the sweet spot for me.
What tools were critical for giving you enough confidence in your 3D map to reduce your time in lead?
The critical tools included not only the CARTOSOUND® Module, but the PENTARAY® Catheter for quick and accurate delineation of anatomic structures to allow effective ablation, and the THERMOCOOL SMARTTOUCH® Catheter to make sure you are contacting the wall in a way that is appropriate to deliver RF energy. In addition, we use Biosense Webster, Inc.’s ESOPHASTAR® Catheter to position the esophageal temperature probe to minimize the risk of esophageal injury. Lastly, the VISITAG™ Module is used to improve procedural efficiency. All of these tools have been added to my current workflow to make it more effective.
What does an optimized mapping and ablation experience involve for you?
It involves the appropriate understanding of your hardware, software, and mapping system, as well as support from your lab staff and clinical support staff from Biosense Webster, Inc. However, I believe the most important aspect is the dramatically reduced amount of time I have to wear lead during the procedure — it gives me the freedom to work as hard as I want in the EP lab, and not have achy joints or fatigue that evening or the next day.
How has a workflow with reduced radiation and decreased orthopedic burden of lead use optimized your procedural experience? Why did you make this change now?
It has enhanced my understanding of this technology, and allowed me to use it more efficiently and appropriately. My dad used to tell me that any job is a struggle if you don’t have the right tools. However, if you have the right tools but don’t know how to use them, that job is still going to be a struggle. So understanding the appropriate use of the CARTOSOUND® Module, the THERMOCOOL SMARTTOUCH® Catheter and PENTARAY® Catheter, and mapping features such as the CONFIDENSE™ Module and VISITAG™ Module, helped make the procedure efficient and successful. In particular, if you’re doing multiple procedures per day, wearing lead for a shorter time is a huge differentiator. I can now perform 8-9 hours of cases a day, and not go home and feel as if I’ve been hit by a truck. That has made advanced EP a lot more fun for me. I don’t fatigue anymore during procedures — after a complicated 8-hour VT ablation, I can perform two additional procedures and still go home to play with my kids. This helped me want to make ablation therapy a central portion of my practice. I’m also not worried anymore about having to get my knee replaced when I’m 45. Having an efficient CARTO SMARTTOUCH™ Catheter Technology experience helps me with what’s important to me after I leave work.
What key pieces of advice would you give to other EPs who are interested in limiting radiation exposure and the orthopedic burden of lead?
Give it a chance! Find someone in your region who has done this already and can act as a helpful sounding board. Consider visiting a center that is doing it, or inviting someone in as a proctor. In particular, if the CARTO SMARTTOUCH™ Catheter Technology is already in your lab, it’s just a question of how they’re going to be used. It is not as difficult as you think — it is achievable for every electrophysiologist.
What were the most significant milestones in this journey for you?
Being able to use all the tools that I already had in my lab was a milestone moment for me, particularly in the cost-constrained environment of EP. This process is a different way of doing it, but can still provide added value to your patients, your staff, and yourself.
It involves the appropriate understanding of your hardware, software, and mapping system, as well as support from your lab staff and clinical support staff from Biosense Webster, Inc. However, I believe the most important aspect is the removal of my lead during the procedure — it gives me the freedom to work as hard as I want in the EP lab, and not have achy joints or fatigue that evening or the next day.
What effects did your radiation reduction workflow have on your staff, practice, and hospital brand?
We have really enjoyed this transition. As other doctors in the practice adopt this and become successful at it, they find that it is not a complicated process and is very reproducible. Our regional hospital brand has also been quite successful in terms of making patients aware of this ablation strategy. Although it’s hard to know definitively if this has grown our market share, we have continued to grow year over year in our ablation volume. My ablation volume with this process has truly overtaken my device volume, which I did not anticipate. The radiation reports are also much more favorable than they used to be.
Would you ever consider using an ablation modality in which you would have to revert to consistently wearing lead for long hours again?
Which has been more impactful for you: the reduced radiation, or the freedom from prolonged time lead?
It is difficult to separate the two aspects for me. The orthopedic burden of lead and the risk of ionizing radiation were the two main factors that drove me to make this change. You definitely notice the orthopedic burden of lead on a day-to-day basis.
Besides the CARTO SMARTTOUCH™ Catheter Technology, can you factor how the THERMOCOOL SMARTTOUCH® Catheter and the CONFIDENSE™ Module with the PENTARAY® Catheter have also helped with workflows?
It’s important when utilizing contact force to gauge not only how much of the wall you are touching, but how you are touching it. That is one of the elements of the PENTARAY® Catheter that I’ve enjoyed — it tells you how it’s touching the wall through the activity of the spline. So utilizing the force vector allows me to see if I’m touching the left upper side of the appendage ridge. For example, is the left upper portion of the ridge between the PV and the appendage? Am I touching the ridge directly on, or am I touching it on the appendage side? I then can more effectively guide my ablation in terms of its location. It’s also important to utilize the CONFIDENSE™ Module — one of the things I’ve begun doing is voltage mapping at the onset of our AF ablations to target areas that either would require additional ablation, or also areas within the PVs where the PENTARAY® Catheter will fit nicely on voltage so that I can watch my signal as I go around the PVs. In addition, once we’ve completed our PV isolation, we again utilize CONFIDENSE™ Module voltage mapping to show durable bidirectional block within the PVs; if you have leaks from your initial ablation, you can easily target those utilizing the CONFIDENSE™ Module mapping within the PV. Therefore, these technologies are very important. The vector tells you how you’re touching the tissue and can guide where you’re ablating with specific discussions surrounding the ridge or other intracardiac structures like a papillary muscle. CONFIDENSE™ Module mapping has sped up the verification process as well as the process of touching up the PVs if there is either edema or incomplete entrance block.
Some physicians might say that in order to try these workflows, it could take quite a bit more time. What are your thoughts on this?
I would pretty confidently say that if you were going to adopt this workflow, that it would significantly reduce your procedural time. The first few cases will likely take longer, but once beyond that short learning curve, procedures become more efficient. For instance, to do an anatomical map within the right atrium utilizing the PENTARAY® Catheter prior to transseptal, it takes an average of three minutes. I have found that a map of the left atrium with a PENTARAY® Catheter without fluoro takes an average of four and a half minutes. To isolate the PVs on the left side takes us an average of 10-12 minutes, and the right side takes 19-20 minutes (for complete isolation on each side). So this is not something that has slowed us down at all. We have data to indicate that it has reduced the amount of total ablation time for typical atrial flutter, SVT, and AF ablations. It has also reduced our in-room and in-procedure times. So in my experience, with the appropriate use of tools already in your lab, this technology will reduce your procedural time, improve your procedural experience, and minimize your risk of orthopedic injuries and ionizing radiation.
Disclosure: This interview is sponsored by Biosense Webster, Inc. Dr. Brenyo has no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Brenyo reports personal fees for consulting and educational honoraria from Biosense Webster, Inc.