EP Labs From the Caribbean

Spotlight Interview: Health City Cayman Islands

Ravi Kishore Amancharla, MD, FACC

Health City Cayman Islands

Grand Cayman, Cayman Islands

Ravi Kishore Amancharla, MD, FACC

Health City Cayman Islands

Grand Cayman, Cayman Islands

What is the size of your EP lab facility? When was the EP program started at your institution? 

Health City Cayman Islands (HCCI) has one EP lab housed in a hybrid cardiac catheterization lab. The EP program started in April 2014. The EP lab is not separate from the cath lab, as the total volume does not justify two separate labs. There is a designated facility for a discrete EP lab once there is adequate volume. 

What types of procedures are performed at your facility? Approximately how many catheter ablations and device implants are performed each week? 

The HCCI EP lab currently offers a full range of services, including the implantation of pacemakers, defibrillators, pacemakers, loop recorders, and implantation of Cardiac Contractility Modulation (CCM) devices (Impulse Dynamics). 

We also perform lead extractions using manual sheaths, as well as ablations (including epicardial) for all types of SVTs and ventricular tachycardia. We have been performing cryo-based PV isolation for atrial fibrillation and left atrial appendage closures using the WATCHMAN device (Boston Scientific). We perform roughly 3-4 procedures each week.

What is the number of staff members? 

We currently have 1 CVT, 1 RT, and 2 RNs.

Who manages your EP lab?

Srinath Polasani, CVT manages our EP lab.

Are employees cross-trained?

Yes, employees are cross-trained to assist all electrophysiology and coronary interventional procedures.

How is shift coverage managed? How does your lab handle call time for staff members? 

Our typical hours are from 8 am to 5 pm. We are all on call 24/7. However, we do not schedule non-emergent cases on weekends or public holidays.

What types of EP equipment are most commonly used in the lab? 

For 3D mapping, we use the EnSite Velocity System (Abbott); we are planning to upgrade to the EnSite NavX Cardiac Mapping System (Abbott). Our EP recording system is the EP-WorkMate (Abbott). We use the EPIQ 7 ultrasound (Philips) for transesophageal echo (TEE) and the ViewFlex Xtra ICE Catheter (Abbott) for intracardiac echocardiography (ICE). Our radiology equipment is the Allura Xper FD20 x-ray system (Philips). We primarily use implantable devices from Medtronic and Abbott, and catheters from Biosense Webster and Abbott. 

What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures?

We recently acquired cryotherapy and ICE. Cryoballoon ablation is safe and effective for treating paroxysmal atrial fibrillation. ICE helps achieve more precise anatomical delineation as well as reduces our use of fluoroscopy. 

What type of quality control and assurance measures are practiced in your EP lab?

All equipment is serviced annually as per the norms, and we also have a quality control team who audits certain procedures (e.g., hematoma after device implant).

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

Inventory is managed by our CVT in consultation with the electrophysiologist. The supply chain team handles the purchasing of equipment and supplies.

Has your EP lab recently expanded in size and patient volume? 

Yes, our patient volume has increased by more than 100% compared to last year.

In what ways have you helped to cut/contain costs and improve efficiencies in the lab?

We are trying to cut procedure times by migrating from TEE-based procedures (e.g., atrial fibrillation) to ICE-guided procedures. This will also reduce the need for general anesthesia and for full-time anesthesiology support.

How do you ensure timely case starts and patient turnover?

We have implemented a set of regulations that help to ensure that the first case starts on time. Turnover is affected by a number of variables, including anesthesia, groin holding, patient characteristics, etc. We are seeing that there is still a scope in improvement of patient turnover time.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

We are the only center providing EP on the entire island. Across the Caribbean, HCCI is one of the few fully equipped EP service providers in the region. We are in the process of forging an alliance with a cardiology group in the Bahamas.

How are new employees oriented and trained at your facility?

New employees complete a general hospital orientation program. We have not yet recruited new employees to the EP lab.

How is staff competency evaluated?

Staff competency is evaluated half yearly, and is based on performance parameters.

What types of continuing education opportunities are provided to staff members?

The hospital offers funding to attend EP conferences such as the annual Heart Rhythm Scientific Sessions and other local offerings. In addition, we have frequent interaction with company techs who update us on their products, either through specific meetings or observerships in U.S.-based EP labs.

How do you handle vendor visits to your department? 

Vendor visits on the island are uncommon, unless they are coming in to support a recently acquired technology or product. We do have contracts in place with Medtronic and Abbott; these are handled by the supply chain and facility directors. 

Describe a particularly memorable case from your EP lab and how it was addressed.

We had a patient with recurrent SVT (AVNRT), failed by radiofrequency ablation due to a narrow Koch’s triangle. The patient was brought back to the lab the next day for focal cryoablation and successfully ablated.     

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

For paroxysmal and persistent AF, we have moved to 100% cryo. We do not offer ablation for permanent AF.

What are your techniques for LAA occlusion? 

We use the WATCHMAN device (Boston Scientific), and implant it using TEE guidance. The indication has to be ratified by a multidisciplinary team comprising of a cardiologist, electrophysiologist, and hematologist/internist. 

What are your thoughts on the use of NOACs in patients with non-valvular AF?

They are here to stay. However, we make a significant effort to carefully select patients and systematically follow up with them to prevent bleeding complications. Expense is a factor limiting the use of NOACs in the Caribbean.

Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?

Yes. We extensively use this approach, along with therapeutic yoga.  

What other innovative EP techniques are being utilized in your lab? 

We perform renal denervation through a locally developed and validated technique using a conventional ablation catheter.

Do you perform only adult EP procedures or do you also do pediatric cases? 

We perform both adult and pediatric EP procedures (>8 kg).

What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?

We follow the ALARA protocol to reduce fluroscopy time. In addition, we use a ceiling-mounted protection screen, tableside protective shielding, lead glasses, lead skirts, and lead vests with a thyroid collar. We are trying to reduce fluoroscopy using 3D mapping and ICE, even in conventional EP procedures.

What are your methods for device infection prophylaxis?

All patients are given IV antibiotics during device procedures. We give an antibiotic approved by the infection control committee one hour before the implant, and two doses after the implant at eight-hour intervals. The device pocket is irrigated with an antibiotic solution. We have not had a device-related infection in many years.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility? 

We do not use them. We are planning to use a different proprietary software for outcome analysis in the near future.

What are your thoughts on EHR systems? Does it improve your quality of care? 

Our hospital uses EMR for documentation. We feel it has certainly improved our efficiency.

What are some of the dominant trends you see emerging in the practice of electrophysiology?

Trends include a simplified approach to AF ablations and remote monitoring.

Do you utilize digital tools and wearable technologies in your treatment strategies for patients? 

We suggest use of apps for patients with paroxysmal arrhythmias (e.g., AliveCor).

Is your EP lab currently involved in clinical research studies? Which ones? 

Yes, we are actively involved in clinical research studies. The CAFE (Cayman Islands Atrial Fibrillation in the Elderly) study is an epidemiological study of atrial fibrillation on the islands. We are also embarking on the CASH (Cayman Athlete Screening for Heart disease) study.

How do you see social media changing the field of healthcare?

It can have a great impact in spreading awareness of the facility/procedures offered as well as patient testimonials. We have found it to be very helpful.

Describe your city or general regional area. How is it unique from the rest of the U.S.?

The Cayman Islands are a beautiful and exclusive destination. It is very close to the U.S., and yet very different.

Please tell our readers what you consider special or unique about your electrophysiology lab and staff.

Although this is a relatively young department, it is led by passionate staff. We are rapidly realizing our goal to be among the best EP facilities in the Caribbean.