Hospital Pró-Cardíaco is a community hospital located in the south zone of the city of Rio de Janeiro, Brazil. It is an academic affiliated hospital that positions itself through the provision of quaternary cardiovascular care through technology, processes, and specialized people. The hospital is comprised of 141 beds distributed within the traditional vertical structure of intensive care units (53 bed spaces), stepdown units, regular nursing floors, and five operating rooms (including one hybrid room, a catheterization laboratory, and a state-of-the-art imaging diagnostic park) beside an emergency department. Hospital Pró-Cardíaco is accredited by the International Joint Commission, and several of its clinical programs are also certified by international agencies.
Hospital Pró-Cardíaco is part of a network of hospitals in Brazil called Americas Medical Services, which belongs to the UnitedHealth Group (UHG), a North American multinational with more than 260,000 employees, headquartered in Minnesota.
When was the EP program started at your institution? By whom?
The EP program began in October 2003 with the arrival of Dr. Eduardo Saad, after his fellowship training with Dr. Andrea Natale at the Cleveland Clinic. Dr. Andre d’Avila later joined Dr. Saad after a period in Boston (Figure 1); Dr. d’Avila stayed until December 2005, when he left to join Massachusetts General Hospital in Boston.
What growing pains or learning curves did you experience your first few years?
For the first few years, we had to share the interventional lab with cardiologists, since at the time the only alternative was a manual C-arm in the OR on a standard surgical table that would not move. Therefore, for longer cases (eg, AF ablations), we would start the case at 5 AM in order to not occupy the lab during their busy schedule. It was also not unusual to delay procedures when a patient presented to the ER with acute coronary syndrome.
After the acquisition of a higher quality automatic C-arm and moving table, we moved the EP procedures to the OR. At the same time, volume was significantly rising and a separate dedicated EP lab was needed to be able to grow.
What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization department?
EP procedures are performed in the hybrid room at the surgical center (Figure 2), and are responsible for most of the activity in this suite. The space is 63 m2 (678 sq ft) in size. A Zero-Gravity suspended radiation protection system (BIOTRONIK) is available for the main operator. Simpler procedures such as AV node ablations or pacemaker implantations are frequently performed simultaneously in a conventional operating room. The cath lab is located away from the surgical center, on a different floor, near the emergency room.
What is the number of staff members? What is the mix of credentials at your lab? Describe your lab staffing and structure.
The team is composed of five board-certified (by the Brazilian Society of Cardiac Arrhythmias, or SOBRAC) electrophysiologists (Eduardo Saad, Luiz Eduardo Camanho, Charles Slater, Luiz Inácio Oliveira Jr., and Lucas Dias Carvalho), three EP nurses (Carla Peixoto, Natalia Quirino, and Margarida Vicente), and one EP fellow (Gustavo Vignoli dos Santos) (Figure 3). We also have a dedicated anesthesiologist (Paulo Maldonado) that works exclusively with our EP team. Two physicians have a PhD and FESC titles (ES and LEC), and two hold a FHRS title (ES and CS).
Two electroanatomical mapping systems (CARTO, Biosense Webster, Inc., a Johnson & Johnson company, and EnSite NavX system, Abbott) as well as ICE equipment are available and consistently used in almost all ablation procedures, especially after the launch of our zero fluoro program in June 2019. In fact, our lab was the first in the country in 2003 to use ICE. Since then, all AF ablation cases have been performed under ICE guidance.
What types of procedures are performed at your facility? What types of complex ablations are performed?
Most EP procedures are performed in our lab. Catheter ablation for atrial fibrillation (AF) and ventricular tachycardia (VT) as well as epicardial ablations are routinely performed. Device implantations (CRTs, His, and left bundle pacing) and lead extractions are also performed routinely. LAA occlusion procedures occur less often.
What would you consider to be the most frequent procedures performed or the most common arrhythmias seen?
AF ablation is the most common procedure performed; flutter, SVT, and VT/PVC ablations come next. Pacemaker and ICD implantations are also common.
Since June 2019, we have performed all ablations with zero or near-zero fluoroscopy, guided by 3D mapping and ICE (Figure 4).
Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week?
An average of 15 ablation cases are performed weekly, along with 10 device implants. Lead extraction and occlusion of the left atrial appendage are performed less frequently.
What percentage of implants use subcutaneous or leadless devices?
Less than 10% of ICD cases are with subcutaneous devices. We have not yet performed leadless pacemaker implantation — these devices have not yet been released for commercial use in Brazil by the manufacturers.
What type of hospital is your EP program a part of?
It is a quaternary private hospital, focused on complex cardiovascular procedures. The hospital has an official cardiology fellowship program as well as fellow positions for intensive care, imaging, and nuclear cardiology. An internship program for medical students is also available.
What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?
Since 2003, the EP-TRACER system (Schwarzer Cardiotek GmbH) has routinely been used. It is a convenient EP system since it can be installed in either a regular desktop or laptop, and the image can be transferred to a large monitor.
All main catheters and devices from the major manufacturers are available in Brazil and are regularly used. Contact force sensing catheters and multipolar high-density mapping catheters from Biosense Webster, Inc. and Abbott are used. The same is true for devices from the largest four companies (BIOTRONIK, Abbott, Boston Scientific, and Medtronic).
What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
The most recent change we made to the lab was the routine adoption of zero fluoroscopy procedures for all types of ablation (Figure 5). This was possible with a relatively short learning curve due to the accumulated experience of several years of ICE use. We started to progressively reduce fluoroscopy use to guide the transseptal punctures and manipulation of the catheters until it became dispensable.
We also embraced the physiologic pacing strategy with stimulation of His and left bundles, with excellent results.
How is shift coverage managed? How does your lab handle call?
We have a 24/7 coverage for hospital calls. During weekends and holidays, there is always one EP staff member on call for emergency calls. It is not infrequent to have procedures performed on weekends.
Tell us what a typical day might be like in your EP lab.
The staff team is usually divided between EP procedures (which may be performed concomitantly in different rooms), hospital consults, clinic, and patient discharge. A typical day starts at 7 AM and ends at about 7 PM.
Who handles procedural scheduling?
The programming of procedures is done individually by each staff member and their secretary, after contact with the nursing staff to check room availability. We use an online calendar manager that is shared with all members.
How is inventory managed at your EP lab? Who handles the purchasing of equipment/supplies?
The hospital is in charge of handling equipment and supplies. Usually, no materials are stocked in the hospital; instead, the hospital requests the companies to bring the required materials on a case-by-case basis, guided by physicians’ request and payer’s acceptance.
What are the best features of your EP lab’s layout or design? What would you include on a “wish” list?
Working in a large hybrid room with an easily modifiable configuration is indeed very convenient and comfortable. Any wish list items would be focused on faster acquisition of new technology.
What changes have you made to improve lab efficiency and workflow as well?
Lab efficiency has been largely improved by the very early start by our nurses and anesthesia team. Some procedural adaptations, such as figure of eight sutures, have also helped in that regard. Proper communication with the floor nurses and cleaning team have helped with turnover times as well.
What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year? How is travel and out of office time to conferences determined and managed?
There is a vast opportunity for continued education (Figure 6). All staff members frequently attend national and international major events, as long as there is adequate coverage for the service by at least one EP physician. Out of office time is generally managed on a first come, first served basis but also prioritizes the directors of the service.
How is patient education managed?
Patient education is taken very seriously and is carried out individually by the physician who is responsible for scheduling the procedure. Time is taken to properly address all questions and concerns as well as give detailed information to make patients absolutely aware of all aspects of the procedures.
Does your lab use a third party for reprocessing or catheter recycling? How has it impacted your lab?
Our lab does not reprocess electrophysiology catheters. Everything is single use, based on local regulatory guidelines.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency? Why?
Radiofrequency is the main energy used, accounting for more than 99% of procedures performed. Cryo is reserved for specific circumstances, such as ablation near the AV node. The reason is personal physician preference, since we usually follow an ablation technique that involves a lot of extra PV ablation. Cryo availability is also significantly limited in Brazil compared to RF.
Describe your approach to His bundle pacing.
We have been performing His bundle (and subsequently, left bundle pacing) since 2017, initially with a low volume. However, volume is quickly growing, especially for avoiding pacing-induced dyssynchrony or coronary sinus lead implant failure. We no longer guide His lead placement with an EP catheter, since with experience and specially designed cables we have great EGM recordings using the leads and EP system.
Do you have a primary approach for LAA occlusion?
Yes, LAA occlusion was first performed here in 2011. The Amplatzer Cardiac Plug (ACP; Abbott) has been mostly used since it was the first device to be approved. Currently, 3 devices are approved in Brazil: the ACP / Amplatzer Amulet (Abbott), WATCHMAN (Boston Scientific), and LAmbre LAA Closure System (LifeTech Scientific Corporation).
Describe your approach to epicardial ablation of atrial fibrillation.
Epicardial access is routinely performed in our lab for epicardial mapping along with endocardial instrumentation. When needed, subxiphoid surgical access is obtained with the collaboration of our surgical colleagues.
Does your program have a dedicated atrial fibrillation clinic?
Yes, we have a Center for Atrial Fibrillation where all patients with AF are included in a database after consent. They are evaluated by our EP team to discuss the best management strategy for each individual case. An institutional protocol was developed to improve the care of patients with AF, involving the initial definition of rhythm versus rate control, medication adjustment, ablation indications, and appropriate prescription of anticoagulants.
Do you offer multidisciplinary care for AF?
We do not offer it directly in our center; however, we collaborate closely with our nutritional team as well as sleep physician specialists and the cardiac rehabilitation team.
What other innovative EP techniques are being utilized in your lab?
Besides zero fluoro cases, ultrasound-based vascular access has routinely been used for several years for femoral, jugular, and axillary vein-guided access (Figure 7). All device implants start with ultrasound-guided access and end with an ultrasound check of the pleural space to rule out pneumothorax.
Are pediatric cases performed in your lab? Does your institution also have an associated cardiovascular genetics research clinic?
Pediatric cases are performed in our institution by all EP physicians. We use an affiliated lab for our genetic evaluations.
Tell us more about your approach to reduce fluoroscopy time.
Several years of experience with the use of intracardiac echocardiography has allowed us to progressively reduce the need for fluoroscopy during procedures. For example, in early 2019, a typical AF ablation was associated with a very low fluoro dose exposure (1-5 mGy). We then transitioned to zero fluoroscopy for all procedures. Our experience has been presented at the LAHRS annual sessions as well as at the Brazilian EP Congress (SOBRAC), having received an award for best scientific work at both meetings.
When fluoro is used, our laboratory uses the Zero-Gravity system for radioprotection. We are also very strict with use of ALARA principles and very low doses of pulsatile fluoro (usually 3 frames per second).
What are your methods for device infection prophylaxis?
We routinely use a single dose of prophylactic antibiotics during anesthesia induction with a second-generation cephalosporin. Vancomycin is used in higher risk patients.
What are some of the dominant trends you see emerging in the practice of electrophysiology? What specific trends have you seen in your procedures and/or patient population?
There are three clear trends in contemporary EP: fluoroscopy reduction, physiologic pacing, and non-PV AF ablation.
In our procedures and patient population, there is a clear trend toward performing EP procedures in the elderly. Both the AF “epidemic” as well as the increased survival of HF patients are contributors to this trend.
Do you utilize remote monitoring of CIEDs?
We do for very selected cases, mostly on patients from remote regions.
Do you utilize digital tools or wearable technologies in your treatment strategies for patients?
Yes, it is quite common to receive ECGs performed with smart bands and watches from our private patients.
How do you see digital technologies changing the field of EP?
Social media has already changed the way physicians interact. Cardio Twitter is a great example of innovation sharing and discussions. The hashtag #EPeeps has had great success. We recently created the hashtag #IceEyes to expand information on ICE technology and reinforce that ICE acts as our “eyes” during zero fluoro procedures.
What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?
Pró-Cardíaco has been a dedicated cardiological institution for 60 years in the heart of the beautiful city of Rio de Janeiro. It started as the first cardiology emergency hospital in Rio de Janeiro, and has pioneered several landmark evolutions over time: it was the first to have a chest pain unit, perform primary angioplasty 24 hours a day, conduct research on stem cell therapy for heart failure, perform LVAD implants (including ECMO) and heart transplants, and perform LAA occlusion, TAVI, and percutaneous as well as minimally invasive mitral valve procedures.
Please tell our readers what you consider special about your EP lab and staff.
Our team delivers high-quality care that is individualized to our patients. We work as tailors, dedicating time and having an open relationship with our patients. All patients have our personal cell phone numbers and can call or text us anytime. We treat patients as we would like to be treated. Our patients are our partners.