Spotlight Interview

Spotlight: Maimonides Medical Center

Yisachar Greenberg, MD, FACC, FHRS and Felix Yang, MD, FACC, FHRS, CCDS, Brooklyn, New York

Yisachar Greenberg, MD, FACC, FHRS and Felix Yang, MD, FACC, FHRS, CCDS, Brooklyn, New York

Maimonides Medical Center is a 711-bed, non-profit academic teaching hospital located in Borough Park, in the New York City borough of Brooklyn. The primary objective of our EP program is to deliver comprehensive arrhythmia care to a very diverse patient population. The Division of Electrophysiology is equipped with the most advanced technologies to diagnose and treat arrhythmias. 

When was the EP lab started at your institution? Who manages your EP lab?

Our EP lab was established by Dr. Yisachar J. Greenberg in 1997. Dr. Greenberg serves as Director of the Division of Electrophysiology and Director of the Atrial Fibrillation Program. Dr. Yang is the Associate Director of Electrophysiology and Director of the Lead Extraction Service. 

We also have a nurse manager, nurse team leader, and PA team leader who oversee the day-to-day operations in the lab. 

What is the size of your EP lab facility? 

Our service includes two electrophysiology laboratories as well as two new multispecialty hybrid operating rooms that are used for complex EP procedures. There is a pre- and post-procedural care area adjacent to the electrophysiology suites.

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

The lab is staffed by two physicians, four physician assistants, six nurses, and a patient care technician. There are also three administrative assistants who facilitate the outpatient care of the arrhythmia patients.

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? How many cases do you do a year? 

We performed 1600 procedures in the past year; this included more than 350 ablation procedures as well as greater than 1000 cardiac device implants and extractions.

We are a full-service electrophysiology laboratory. We perform all types of device implants and a full range of ablations, from simple SVTs to complex VT and atrial fibrillation (AF). We work closely with our surgical colleagues to perform hybrid AF ablations. We also perform laser lead extractions and LAA closure, and have a large outpatient consultative practice and device clinic.

Are employees cross-trained between the cath and EP labs?

Yes, some of our nursing staff work in both laboratories.

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

Maimonides Medical Center is a non-profit, non-sectarian hospital. Maimonides is both a treatment facility and academic medical center, with more than 70 primary care and subspecialty programs.

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

We utilize equipment from Philips, GE Healthcare, St. Jude Medical, Boston Scientific, Medtronic, BIOTRONIK, Spectranetics, and nContact, Inc.

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

Our nurses arrive around 7 AM to prep the room and patients. Back-to-back cases take place in both of our dedicated EP labs throughout the day until 7 PM. EP consultations are evaluated in between procedures.

What new equipment, devices and/or products have been introduced at your lab lately? How has this changed the way you perform those procedures? 

We are currently one of only two EP labs in New York to utilize the latest Biosense Webster Carto 3 System Version 4, with the ConfiDENSE and CartoReplay Modules. Using this system, we have been able to quickly acquire detailed electroanatomical maps of the cardiac chambers to guide our ablation therapies. 

In addition, for the past year we have been using force-sensing ablation catheters, which have greatly improved our ability to deliver effective ablation lesions. This technology is an important advancement for patient outcomes.

We also utilize the Abiomed Impella circulatory support system in our VT ablation cases. This system has allowed us to maintain optimal hemodynamics while mapping endocardially and epicardially during VT.

What imaging technology do you utilize?

We use CartoSound (Biosense Webster, Inc., a Johnson & Johnson company) as well as rotational angiography by Philips.

What has been your experience with MR conditional cardiac devices? 

For the past few years we have been using MR conditional pacemakers, to the satisfaction of our patients.

Who handles your procedure scheduling? 

The charge PA and nurse team leader coordinate the daily schedule in the laboratory.

Who handles the purchasing of equipment and supplies? 

We have a business manager dedicated to the purchasing of equipment in the EP and cath labs.

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

Yes, our brand-new lab includes two procedure suites as well as tilt and recovery areas. We are also expanding our procedure capacity to perform certain complex procedures in the hybrid operating room.

Does your lab utilize any alternative therapies for patients in the EP lab? 

Our labs are equipped with stereo speakers that are linked to satellite radio and Pandora. As many of our procedures are performed with conscious sedation, the patients can request whatever genre of music they desire to help relax them during the procedure. Our nurses have been known to provide scalp massages, and Dr. Greenberg has a talent for live song entertainment. One of our team members also performs Reiki.

What measures has your lab taken to reduce fluoroscopy time and minimize radiation exposure to physicians and staff? 

In addition to using lead drapes that hang off the sides of our fluoroscopy table as well as a moveable radiation barrier, we utilize the X-Drape (AADCO Medical), radiation gloves, and radiation-shielded caps. For extended cases, we utilize the CATHPAX radiation protection cabin (Anthem Medical). Fluoroscopy is usually utilized in the lowest 3.75 frames per second setting in order to reduce radiation exposure to patients and staff.

What are your methods for infection prevention?

We are very diligent in our infection prevention techniques. We are meticulous with proper scrub techniques. All device implant patients receive perioperative IV antibiotics, and antibiotic flushes are used to clean the device pocket prior to closure. We frequently utilize the Medtronic TYRX Antibacterial Envelope in patients at higher risk for infection.

Who participates in the follow-up of pacemakers and ICDs?

Our physician assistants are an integral part of the perioperative management of our patients in the device clinic. They participate in wound checks and device interrogation.

What innovative EP techniques are being utilized in your lab? 

We currently perform the Convergent Procedure for AF utilizing nContact’s EPi-Sense Guided Coagulation System with VisiTrax. Our collaboration with cardiothoracic surgeons has allowed us to offer this multidisciplinary approach for treating AF. We have had remarkable results in restoring normal sinus rhythm in patients who have been in longstanding AF. We were the first to perform the procedure in the NY/NJ region, and have found it to be our procedure of choice in treating AF patients with difficult substrate.

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

We are currently actively involved in a number of trials: the RAID study, investigating the use of Ranolazine in patients with ICDs; the NAVIGATE X4 study, investigating Boston Scientific’s ACUITY X4 LV pacing lead and the RELIANCE 4-Front ICD lead; and the Boston Scientific S-ICD Post Approval Study. We will be involved in the Boston Scientific Praetorian trial, which is a randomized trial comparing the S-ICD versus transvenous ICDs, as well as the St. Jude Medical Cardiac Lead Assessment Study.

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

Brooklyn is the most populous of the 5 NYC boroughs, with a census of over 2.6 million people. If it were an independent city, Brooklyn would be the fourth most populous city in the U.S., behind only the other boroughs of NYC combined, Los Angeles, and Chicago. Brooklyn is home to a culturally diverse population.

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

The FDA approval of Boston Scientific’s WATCHMAN Left Atrial Appendage Closure Device provides AF patients with an important option in reducing embolic events. We are pleased to have been selected as one of the first 50 sites in the U.S. to implant the WATCHMAN devices. This aspect of arrhythmia management is likely to grow dramatically in the next few years.

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

What makes us unique is the relationship we have with each other and our patients. Many of our EP staff employees have worked together as a group for many years, and have created a warm environment that caters to not only the medical but emotional needs of the patients. We have close relationships with our local communities that the hospital serves. The greatest privilege is the referral by our patients of a close friend or family member. This friendly environment inspires both confidence and comfort when patients are going through a challenging time in their lives.

We strongly believe in a team approach to healthcare. Our EP staff works closely with our colleagues in cardiothoracic surgery and interventional cardiology. We merge into a team of highly skilled professionals offering the high-quality care in an environment that is dedicated to patient safety. Our program is multidisciplinary and is fully integrated with the other cardiovascular services, creating a rather unique electrophysiology experience.