Spotlight Interview

Spotlight Interview: William P. Clements Jr. University Hospital

Mark S. Link, MD, Director of Cardiac Electrophysiology, University of Texas Southwestern Medical Center, Dallas, Texas

Mark S. Link, MD, Director of Cardiac Electrophysiology, University of Texas Southwestern Medical Center, Dallas, Texas

The University of Texas Southwestern Medical Center (UTSW) is relatively new; inaugurated in 1943, it was born of the desire to bring a medical school to Dallas. However, despite its short history, UT Southwestern has expanded into a world-class institution in research, education, and clinical care. In fact, 6 Nobel laureates have called UTSW their home. The medical school’s class size has grown to 200 per year, with the number of residency graduates at 1000 per year. UT Southwestern is one of the few medical centers to offer all specialty and subspecialty training. 

UT Southwestern faculty cover patient care at the William P. Clements Jr. University Hospital, Parkland Health & Hospital System, and the Dallas VA Medical Center, with EP labs located at all three. This article will focus on the EP laboratory at the William P. Clements Jr. University Hospital.

Clements University Hospital opened in December 2014, and has 2 fully equipped EP labs.

The mission of Clements University Hospital is threefold: to heal, innovate, and educate. The new hospital, with its design focused on patient care, offers the latest in hospital function centered around patient care.

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

There are 2 dedicated EP labs and 4 cath labs at Clements University Hospital. In addition, there is a hybrid room for lead extractions, and a room for cardioversions and tilt table tests. 

Our EP fellowship program began in 1992; we have 2 EP fellows each year.

What is the number of staff members? What is the mix of credentials at your lab?

The dedicated EP lab staff consists of 4 full-time nurses and 1 technician. In addition, staff are shared with the cath lab, which includes 5 additional nurses and 6 technicians. The hybrid OR is staffed by the OR staff, and the CV/tilt room is staffed by the PACU staff. Anesthesia staff cover nearly all cases in the EP laboratory.

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? 

Clements University Hospital performs all EP procedures, from the simplest cases (e.g., CV and voltage-guided cardiac biopsies) to complex ablations and left atrial occlusion devices. Other procedures offered at Clements University Hospital include implantations of pacemakers, transvenous ICDs, implantable loop recorders, CRT-ICDs, subcutaneous ICDs, and leadless pacemakers (~150 PPM and 250 ICDs). We also treat SVTs and complex SVTs, perform endocardial and epicardial VT ablations (~300 SVT/AF ablations and 75 VT ablations), surgical ablation, and lead explantations (~200/year). Our atrial fibrillation (AF) ablation program is extremely active, and includes cryoablation and radiofrequency ablation with all mapping strategies. Our ventricular tachycardia (VT) ablation program benefits from our active heart failure and transplant program. Both our AF and VT ablation programs draw patients from across the region.

Because of UTSW’s expertise in heart failure, LVADs, cardiac transplant, pulmonary hypertension, and lung transplant, we see a broad variety of SVTs and VT, including those following organ transplantation and LVADs. Our busy pulmonary hypertension and lung transplant program generates many atypical SVTs every month. These range from focal atrial tachycardias to atypical flutters that are not generally observed in other patients. In addition, our LVAD/pre-cardiac transplant patients present with a wide variety of ventricular tachycardias. 

Clements University Hospital also has a very busy lead explantation program, led by Dr. Michael Jessen, a cardiovascular surgeon. Over 200 explants a year are performed by him and his team, with referrals from the entire region.

Who manages your EP lab?

Carolyn Carlson is the head nurse in the EP lab. Others involved in administration are Eldon Setterlund, James Goodson, Homer Capiral, and Carolyn Swann.

Are employees cross trained?

Yes, employees are cross trained. The EP lab staff is trained to assist in left heart caths, right heart caths, and biopsies. The cath lab staff is cross trained to assist in EP procedures limited to implantation of devices. 

What type of hospital is your EP program a part of? 

Clements University Hospital is an academic hospital in the UT Southwestern Health System. The EP lab at Parkland Health & Hospital System is in a separate facility and is staffed by its own dedicated nurses and techs. Similarly, the Dallas VA Medical Center has its own EP lab and dedicated staff.

Our EP program benefits from these other excellent programs in the UTSW system. Our heart failure/transplant program is known for its excellent outcomes in patient care. Our pulmonary hypertension/lung transplant program is one of the busiest in the country, accounting for many arrhythmias and referrals to EP. The Hypertrophic Cardiomyopathy program at UT Southwestern was recently designated a HCM Center of Excellence by the Hypertrophic Cardiomyopathy Foundation of America; this center offers subspecialty excellence in the care of HCM patients, including arrhythmia management through ablation, device implant, surgical myectomy, and alcohol septal ablation. Patients from across the region are drawn to this center for its strength in HCM knowledge and care.

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

Given the fellowship training mission of Clements University Hospital, the lab carries a wide assortment of products. We utilize catheters from Abbott, Boston Scientific, Bard, and Medtronic. We use implantable devices from those companies as well, including BIOTRONIK. Our stimulators are the EP-4 Cardiac Stimulator (Abbott) and Micropace Cardiac Stimulator (GE Healthcare). We currently use the NavX and EnSite Precision Cardiac Mapping System (Abbott) as well as CARTO (Biosense Webster, Inc., a Johnson & Johnson company) for our mapping systems. We are dedicated to training our fellows on a broad assortment of products so that they are facile in any lab in which they are recruited.

How is shift coverage managed? What are typical hours (not including call time)?

Our first cases are scheduled to begin (i.e., stick) at 8:30 am. Thus, our patients arrive at 6:30 am to begin the preparatory process, which includes IVs, labs, and consent. These preparatory procedures are performed in a dedicated pre-op area, with each patient assigned to a single room. Our EP lab staff begins working with patients at 7:30 am. We aim to finish by 6 pm each night, although that is not always possible. 

Tell us what a typical day might be like in your EP lab.

Perhaps this is best ascertained by the patient experience. Outpatients arrive at 6:30 am, to be checked in at the outpatient admitting desk on the third floor. They are then escorted to a private room in the pre-operative area located immediately behind admitting. There, they change into their hospital gown, have IVs placed, ECGs performed, blood work drawn (if needed), and meet the nurses, fellows, and anesthetists who will be involved in their care. Consent is discussed and signed. Their personal physician reviews the procedure and the expectations of the day. Around 8 am, the patient is brought into the EP lab, adjacent to the pre-op area. Anesthesia begins, whether MAC or general, and prepping and draping commences for an 8:30 incision or venous access time.

Patients scheduled throughout the day follow the same sequence, but with a different start time. Inpatients follow the same pattern, except for those in the ICU; these patients are brought directly to the EP lab without stopping in the pre-op area.

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

Clements University Hospital’s EP lab employs state-of-the-art technology. The fluoroscopy and mapping equipment are all newly acquired. The latest updates to the NavX, EnSite Precision Cardiac Mapping System, and CARTO are all in place. We also implant the WATCHMAN device (Boston Scientific) and Micra Transcatheter Pacing System (Medtronic). In addition, we implant MR-conditional pacemakers and ICDs from all companies.

Has your EP lab expanded in patient volume? 

Our volume for both device implants and ablations has dramatically increased in the last 2 years. For example, volume is 20-30% higher than it was each previous year. 

Prior to the move to Clements University Hospital, a single EP lab was housed at St. Paul Hospital. Adding 2 labs to Clements has definitely helped our growth. In addition, the growth in our cardiac and pulmonary transplant volume has generated many more VT and SVT cases.

Have you developed a referral base?

Clements University Hospital is a large academic quaternary referral hospital in a metropolitan area of 7.5 million individuals. We have recently allied with Texas Health Resources to become part of one of the largest healthcare systems in Dallas.

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

We have had such a large number of memorable cases, that it is difficult to name just one. However, the cases that stand out are typically the younger individuals. Last week, we ablated a patient who was admitted with an SVT 7 months after his lung transplant. During the ablation, his clinical SVT was a focal tachycardia at the insertion of the transplanted left superior pulmonary vein into his native left atrium. After this was successfully ablated, we induced another SVT, which turned out to be another focal tachycardia from the insertion of his right superior pulmonary vein into his native left atrium. This one was also successfully ablated.

Another memorable case was an adult congenital heart disease (TGA post inferior myocardial infarction) patient admitted for incessant VT storm and cardiogenic shock. Our EP staff worked as a team with our adult congenital, interventional, transplant, and cardiac surgery services to place the patient on ECMO and then successfully perform emergent VT ablation on a weekend. The patient was eventually discharged home with an ICD.

Our Hypertrophic Cardiomyopathy program also sees many interesting cases, including patients with AF and those at risk for sudden cardiac death. One memorable patient is a 25-year-old with HCM who had a fractured Sprint Fidelis lead. He had the lead explanted in the hybrid room, followed by implantation of a subcutaneous ICD. His mother, who has an ICD and is also followed here, had a VF episode terminated by her ICD a couple of months later. Almost exactly 24 hours after that, the 25-year-old had a VF episode, which was terminated by his S-ICD. This was the first ventricular episode for both of them.

Does your lab use a third party for reprocessing or catheter recycling? 

We do not recycle catheters.

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

For first-time AF ablations, cryoablation is utilized in approximately 90%. For second procedures, SVT ablations, or VT ablations, radiofrequency is utilized.

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

We are generally big fans of NOACs and DOACs for AF in patients without mechanical valves or mitral stenosis.

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

We utilize voltage-guided biopsies for diagnosis of heart disease in our cardiomyopathy patients. 

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

UT Southwestern has a separate pediatric hospital with 2 pediatric EP physicians. Thus, we rarely perform pediatric procedures. 

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

The Clements University Hospital lab has state-of-the-art fluoroscopy with all the resultant built-in decreases in radiation exposure for both patients and staff. In addition, we extensively utilize intracardiac echo during our AF and VT ablations. 

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

The increase in AF ablation efficacy and safety has dominated the EP landscape over the last 5 years. I see this as continuing in the future.

How is outpatient cardiac monitoring managed?

We have a dedicated outpatient monitoring station.

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

We utilize products by AliveCor.

Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic?

Yes, UTSW has an active genetic clinic, with some of the best geneticists in the world.

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

Social media has exploded in the general public, and is now beginning to penetrate medicine. 

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

Dallas-Ft. Worth is a booming metropolis. It is one of the most rapidly growing metropolitan areas in the world. Major corporations and individuals are attracted to this area for many reasons. The arts scene includes traditional art museums such as the Dallas Museum of Art, impressionist museums such as the Kimbell Art Museum in Ft.Worth, and modern art museums in both cities. World-class symphonies can also be found in both cities, as well as ballet companies, theater, and opera. Outdoor activities are available year round. Our airport hub offers nonstop flights to most cities in the U.S. as well as around the world. 

Please tell our readers what you consider special about your EP lab and staff.

Clements University Hospital is a thriving place. We have excellent experienced staff, great support from our administration, and wonderful patients. Our quaternary care environment ensures a wide variety of electrophysiologic cases. The staff love taking care of patients; they also enjoy their jobs and get along with fellow staff: it is truly a wonderful place to work. ν

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