The Royal Hospital is a large, tertiary-level, acute-care hospital in Muscat, Oman; it is part of the ministry of health hospitals and is an educational facility. Dr. Qasem Al-Salmi is the Director General and CEO of the Royal Hospital. The National Heart Center (NHC) opened in December 2015 and is headed by Dr. Salim Al-Maskari. Arrhythmia services have grown markedly in the last 4 years; in 2019, approximately 1,288 procedures were performed. We are considered one of the busiest centers in the Gulf and Middle East/North Africa.
The Head of the Cardiology Department is Dr. Mohamed Barakat Al-Riyami and was previously Dr. Mohammed Almokhaini, the cornerstone who markedly developed the adult cardiology program and fellowship program at our center. We have had the opportunity to collaborate with many visiting professors, including Drs. Andrea Natale, Paolo Della Bella, and Claudio Tondo. Dr. Michel Haïssaguerre has also been very supportive with consultations for very complex arrhythmogenic syndromes. Cardiac MRI offered by Dr. Faiza Al Kindi and Dr. Rashid Alomeiri allows for advanced care. All these efforts help cover the entire spectrum of healthcare services, irrelevant of complexity or challenge.
When was the EP program started at your institution? By whom?
Dr. Rasheed Majeed Shahrabani began the first device implantations in Oman in 1989. Dr. Said Abdul-Rahman (a device-certified interventional adult cardiologist) performed urgent pacemaker and ICD device implantations from 2006 to 2009. Device implantations began to be regularly performed here in 2009 by Dr. Najib Al Rawahi, who is the first specialized interventional electrophysiologist in Oman and is credited with improving the service. Dr. David Chase later joined him for a few years until 2016. Dr. Ismail Al Abri, who specializes in pediatric electrophysiology, joined in 2015. A dedicated lab for EP procedures was created with the opening of the National Heart Center in December 2015, and is fully equipped with 3D mapping (CARTO [Biosense Webster, Inc., a Johnson & Johnson company) and EnSite [Abbott]). There are a total of four cath labs (one cath lab is used occasionally to perform device implantations, and is shared with adult interventional procedures) and one hybrid cath lab, as well as the old cath lab in the main Royal Hospital building; an additional lab will also be opening soon in a “VIP” center that will be fully equipped with 3D systems. Since 2016, our EP service has experienced extensive and continuous growth in procedural volume and complexity thanks to Dr. Ghaliah Almohani’s great effort and expertise in this field, and who is well known in the region. We expect an increased number of patients over the next few years, after COVID-19. In 2019, another highly qualified electrophysiologist, Dr. Mohamed Al Rawahi, joined the team and is working mainly in the Sultan Qaboos University Hospital, performing calls and procedures in the NHC/Royal Hospital.
What growing pains or learning curves did you experience in the first few years?
Our first complex procedures were atrial fibrillation (AF) and ventricular tachycardia (VT) ablations in September 2016, most of which were performed by Dr. Almohani and the brilliant international visitors that supported us. Since that time, we have experienced continuous growth of the team, with different troubleshooting faced in the beginning. Our EP technicians have become very proficient in their knowledge and use of 3D mapping. Both Abbott and Biosense Webster are greatly supportive of our EP service, and have continuously upgraded their systems and software. We also want to thank the cardiac anesthesia support team headed by Dr. Ranganathan Ananthasubramanian, who understood our role as the only lab for EP procedures in Oman.
What is the size of your lab? Where is it located?
Our dedicated EP/cath lab is 60 square meters. This is one of four labs sharing the same recovery area. The other labs are dedicated to pediatric and adult interventional cardiology. Once a week, we use one of the adult interventional cath labs for device implantation.
What is the number of staff members? What is the mix of credentials at your lab?
Our team is comprised of:
- 2 senior consultants in EP: Dr. Ghaliah Almohani and Dr. Najib Al Rawahi (current coordinator of the EP service).
- 2 consultants: Dr. Ismail Al Abri mainly performs pediatric EP consults, and Dr. Mohammed Najib Al Rawahi, who previously worked with Dr. Francis Marchlinski, is a highly trained consultant who is joining our service from Sultan Qaboos University Hospital.
- 3 specialists: We currently have excellent junior doctors (Dr. Suhail Shahzad, senior specialist and fellow, Dr. Khaled Sharnouby, and Dr. Ahmed Shams), who assist pre- and post-procedurally as well as assist with all inpatient services.
- 4 specialized senior technologists: Walid AlQusaibi, Abdulla Alhebsi, Prakash Sundarajan, and Salim Almeqbali are dedicated to the EP lab rotation in addition to Ahmed Alkharousi (currently heading the Research Department). All are highly qualified professionals who were certified abroad and rotate occasionally in the other labs. They are self-committed to development and continuous education. They are considered to be one of the strongest technologist teams in the region. All of them are experts in device interrogation as well as in EGM analysis and problem-solving.
What types of procedures are performed at your facility? What types of complex ablations are performed?
We treat all kinds of arrhythmias, including SVTs, PVCs, Wolff-Parkinson-White (WPW) syndrome, atrial tachycardias, and atrial fibrillation (using cryoablation or radiofrequency). We utilize different strategies for persistent atrial fibrillation and heart failure. We also treat ventricular tachycardia, ventricular fibrillation, Brugada syndrome, arrhythmogenic right ventricular dysplasia (ARVD), and nonischemic cardiomyopathy, and use an epicardial approach in specific cases.
In the lab, we most frequently see SVTs, atrial fibrillation, ICD shocks due to ventricular arrhythmias, PVCs, and a high percentage of LV summit arrhythmias, with a high success rate (over 90%).
In our series of over 40 patients with heart failure and chronic atrial fibrillation, ejection fraction improved and, in some cases, normalized in more than 85%. These were usually done with Dr. Andrea Natale.
Approximately how many catheter ablations (for all arrhythmias), device implants (ICD, pacemaker, ICM, ILR, etc.), LAA closures, and lead extractions are performed each week?
In 2019, we reached 1288 procedures, one of the highest numbers per center in the region.
We currently perform 20-25 procedures per week (averaging 10 cases per week during the COVID-19 pandemic). Of this total, 40% are device implantations and 60% are ablations. LAA closure is a new procedure for us, so we try to perform 3-5 per month. Lead extraction is not yet performed here, as there are too few cases presented to our center to set up such a service; therefore, the rare cases that are presented to our center are sent abroad.
What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?
For the last 5 years, we have used all MR conditional devices. One subcutaneous ICD and a few leadless devices have also been implanted (due to financial considerations and restriction).
Who manages your EP lab?
Dr. Ghaliah Almohani and Dr. Najib Al Rawahi manage the lab, as well as senior technologists Jamila Alsaeidi and Abdulla Alhebsi. Jamila Alsaeidi is the cath lab’s head technologist.
Tell us about your device clinic, including its staffing model.
The device clinic is covered 2 days per week by our technologists. They can resolve most complex tracing- or clinical-based issues, and consult with our physicians if needed. They also cover all device interrogation emergencies and pre-intervention setup during their cath lab shifts. Total device interrogations may reach 60-80 per week, including post-implant optimization.
Tell us more about the changes in both lab size and patient volume.
Yes, a “VIP” cath lab was recently built and will be used a few days each week for all patients. Another lab will soon be upgraded to accommodate EP procedures as well.
Our patient volume has been continuously increasing, as we are the only arrhythmia service performing EP procedures in the whole country. Emergency-based device implantations are also performed at Salalah Cardiac Center, located south of Oman, by our colleague Dr. Najib Al Rawahi. A new EP system as well as 3D mapping were incorporated there this month. Dr. Amr Nawar also joined Salalah Cardiac Center, which is headed by Dr. Saeed Al-Maashani, to support the development of the service. Outreach clinics are covered by Dr. Najib Al Rawahi.
What types of EP equipment are most commonly used in the lab?
We use the LabSystem PRO EP Recording System (Boston Scientific), WorkMate Claris System (Abbott), CARTO 3 (version 6.0), including the CARTOUNIVU and CARTOSOUND modules (Biosense Webster, Inc.), and the EnSite Precision cardiac mapping system (Abbott). We use the most recent ablation catheters for both mapping systems (force enabled or high-resolution mapping catheters), including the PENTARAY (Biosense Webster, Inc.) and Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott). ICE is used in most of our complex procedures, especially with uninterrupted anticoagulation or papillary muscle-related ablation. Transseptal punctures are always performed under contrast and with a fluoroscopy-guided approach, and we’ve had no complications in the last 4 years. A radiofrequency needle is occasionally used for high-risk punctures. We also use the cryoballoon and console (Medtronic).
How do you manage vessel closure?
We achieve this with manual compression and, if anticoagulation is not reversed, with a figure of 8 suture for veins. We use manual compression for arterial punctures as well. We have had excellent results; our complication rate is less than 0.05%, including for device implantations.
What new technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
We have updated software for our 3D mapping systems. In addition, two of our brilliant technologists have been hired by Biosense Webster (Saleh Al-Shidhani) and Abbott (Nasser Alkalbani), and provide added support and continuous presence in our center during most procedures. Fellows Dr. Suhail Shahzad and Dr. Ahmed Shams also assist in procedures and provide dedicated care to patients.
How is shift coverage managed? How does your lab handle call?
Typical hours are from 7:30 am to 2:30 pm. However, on most days, our EP service continues until 3:30 pm. We rarely perform cases during afternoon hours, especially if a workshop is planned. Weekends are reserved for urgent device implantations only.
Call can last from 7 to 14 days for managing overflow cases, referrals, and urgent procedures.
Tell us what a typical day might be like in your lab.
The priority goes to unstable patients in the cardiac care unit, then the older patients, and finally to the younger patients or simple procedures. Our lab technologists prepare the lab pre-procedure, assist with 3D map preparation, place irrigation lines, and if needed, assist the anesthetist with general anesthesia. An arterial radial line is required for invasive blood pressure monitoring.
Doctors and junior staff have morning meetings, do inpatient rounds, and finish inpatient referrals from our colleagues in cardiology or other related departments, which can vary between 4 and 12 patients according to emergency admissions.
Who handles procedural scheduling?
Most patients are scheduled in advance through the clinic by Dr. Ghaliah Almohani and Dr. Najib Al Rawahi, with a waiting time of 4 months due to delays from COVID-19. Flow management personnel (Ahmed Al Farsi) calls the patients one week in advance to ensure their presence or replace them with one of the patients on our waiting list. Emergency procedures, including post-cardiac surgeries and complete heart block or ventricular arrhythmias referred from other hospitals, are fit into the schedule. The on-call physician manages the daily schedule and flow of patients in the lab, including transferred patients from other hospitals, and performs procedures until usually 3 pm.
What type of quality control/assurance measures are practiced?
We perform continuous auditing of statistics, and review complications and mortality in our monthly meetings. We also review cases with visiting professors if critical decisions are needed. All complications are tracked by the cath lab team. We monitor procedure starts to avoid delays whenever possible. We also monitor key performance indicators, and discuss cases as a group.
What would you include on a “wish” list?
- ECMO support and/or Impella (ABIOMED) for high-risk ablation cases;
- Rhythmia HDx Mapping System (Boston Scientific), especially for adult congenital cases;
- RF balloon ablation; new software for CARTO (version 7);
- New technologies to be initially tested at our center;
- Participation in additional international registries;
- Zero or near-zero fluoro procedures for complex arrhythmias;
- Participation in live cases in international conferences;
- Dedicated days for atrial fibrillation ablations only.
Have you developed a referral base?
Yes, our on-call physician covers all the referrals, including e-referrals, after first being filtered by our general cardiologist. They arrange a time of transfer from other hospitals (including emergencies), and manage ER arrivals when a patient is high risk and needs to be admitted.
In what ways have you cut or contained costs in the lab and device clinic?
We consider conventional ablation in most SVTs, except redo ablations, septal AP, in young pediatric patients, and in dilated hearts with typical flutter.
Transseptal punctures have been performed with fluoroscopy guidance with minimal complications over the years, with the exception of one failed transseptal puncture in 2016 due to septal dissection.
For PVC ablations, I usually use only one mapping and ablation catheter for 80% of procedures with a high success rate; if an LV summit arrhythmia is expected, one decapolar catheter is added in the coronary sinus.
CRT-Ps are considered in almost one-third of CRT-indicated patients, and selection is based on nonischemic cardiomyopathy, female gender, borderline low ejection fraction of 30-35%, or left bundle branch block with no detected scar on echo or MRI. Until now, no patient in our series has required an upgrade to a CRT-D.
Another major cost containment occurred thanks to our brilliant technologist Abdulla Alhebsi, who saved us more than $2 million in 2019 by comparing the quality and price of vendors, speaking directly with companies in order to negotiate better prices for items, having the option to change out available items according to our needs, and encouraging staff to use items with the earliest expiration date to avoid losing them.
What changes have you made to improve lab efficiency and workflow? How do you ensure timely case starts and patient turnover?
One week in advance, all cases are reviewed and vendor assistance is determined. The clinic ensures pre-cath preparation the night before, with patient consents completed by Dr. Suhail Shahzad and Dr. Ahmed Shams. Early arrival time is confirmed with the requested patient. If a patient cannot make the appointment, they are replaced with another patient from our waiting list. Urgent referral patients from peripheral hospitals usually arrive at least 12 hours before to be evaluated and prepared; paperwork is prepared in advance, especially for those patients with complete heart block. Our cath lab team also arranges their breaks so they do not affect patient turnover times.
How are new employees oriented and trained at your facility?
Junior staff members on our team assist in procedures, and additional education is available as well through discussion of cases in-between procedures. Visiting professors also offer on-site education to the whole team.
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?
We alternate participation on an annual basis for the most important meetings. For the sake of time and our service coverage, I personally attend only the conferences in which I’m invited as faculty.
Our technologists attend educational and practical courses (either regional or international), and I’m personally keen on involving them as much as possible with the Heart Rhythm Society’s Scientific Sessions. They are eager to learn, and our cath lab is a place for continuous discussion and review of tracings, IGMs, and training of other technologists or fellows. With an advanced background and self-development, our EP technologist Walid AlQusaibi continuously educates attendees. Sponsorship is available from various companies and organized through our administration. Our junior staff members are also encouraged to participate in educational events, especially exam preparation courses.
How do you prevent staff burnout and turnover?
All of our staff are very hardworking, passionate, and driven; therefore, we try to avoid adding extra hours to their shift. There is positive collaboration in the cath lab, and it is one of the most preferred labs to work in by all staff.
How do you manage vendor visits to your department?
They have limited access to the cath lab, except for clinical support. This strategy was created by administration to avoid disturbance and distraction.
Does your lab use a third party for reprocessing or catheter recycling?
No, recycling and reprocessing of items is prohibited.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?
Selection is based on clinical presentation. For patients with paroxysmal lone AF or low comorbidities, cryoballoon ablation is preferred. For persistent or redo cases, RF is the preferred approach, and accounts for almost 50% of ablations.
Does your lab use contact force sensing technology during radiofrequency ablation of AF?
Not always, but when it is used, it is either with the TactiCath (Abbott) or SMARTTOUCH (Biosense Webster, Inc.) catheter.
Does your lab perform His bundle pacing?
Not yet, but we soon plan to. In regular implants, a mid or high septal implant is targeted in 80% of cases, with QRS targeted to be as narrow as possible with good lead readings.
Do you have a primary approach for LAA occlusion?
Yes, we use the WATCHMAN device (Boston Scientific) guided by TEE under general anesthesia, with excellent outcomes in our series. Deep sedation and/or ICE is thought to be considered in future implants.
What are your thoughts on the use of NOACs in patients with non-valvular AF?
It is used in most patients on a regular basis. Use of warfarin has also shifted to NOACs due to easier compliance and better diet options. This is offered at all health centers managed by the ministry of health.
Discuss your methods for lifestyle modification as therapy for your patients with atrial fibrillation.
These patients are referred to nutrition and bariatric surgery if morbidly obese. They are also referred to sleep apnea experts, including before ablation. Exercise and strict control of diet are highly recommended, as well as close monitoring of blood pressure if not well controlled.
Our preferred strategy is to put a clear rhythm control plan in place, and since the average age of our population is much younger than Western countries, we discuss the superiority of this option with patients.
Tell us more about the pediatric cases performed in your lab.
Pediatric cases are performed by Dr. Ismail Al Abri, who has performed ablations on children as young as 10 months old (left lateral WPW) up to the age of 13 years, including complex cases. He also does adult cases. He maintains a zero fluoro approach using 3D mapping in most cases. He uses the cath lab once per week for his patients, and supports the pediatric cardiac surgeons in performing device implantations and procedures in the pediatric population. Dr. Ismail Al Abri is the head of pediatric cardiology department and develops lean management solutions.
What approaches has your lab taken to reduce fluoroscopy time?
We are using a low fluoro dose/frame technique as well as the CARTOUNIVU Module (Biosense Webster, Inc.) to help reduce the use of fluoroscopy. We also use collimation to limit exposure and reduce the radiation field. Dr. Ismail Al Abri also uses a near-zero fluoro approach in our pediatric population.
Discuss your methods for cardiac device infection prophylaxis.
- Intravenous antibiotic administration 1 hour before skin incision and continued for 24 hours postoperatively.
- If there is sepsis or recent fever, implantation is amended.
- Strict orders in the cath lab, as this is open-heart surgery.
- With 3 expert operators, the rate of hematoma is minimal.
- We suture with an absorbable suture in three layers, and recommend that the patient not touch, wet, or sterilize the wound for the next 10 days.
- After 2 weeks, we review the pocket to assure the patient and for device checkup.
What are some of the dominant trends you see emerging in EP? What trends are you seeing with your patient population?
Some of the dominant trends we see in the EP field include bipolar ablation (especially for septal VTs or deep circuits), high power short duration ablation, zero-fluoro procedures, and His bundle pacing.
Awareness about arrhythmias is increasing, and patients with atrial fibrillation are now being referred more.
Is your EP lab involved in clinical research studies?
Yes, we participate in the ICD Registry and the CRT-MPP Post Approval Study. We are also currently part of the Cryo AF Global Registry.
How do you see social media and digital technologies changing the healthcare and EP fields?
Professionals from all over the world are sharing their cases and experiences on social media, which offers increased discussions and solutions.
Digital technologies can help determine arrhythmias or even sinus tachycardia in the short term. We have recently begun to recommend new technologies such as the Apple Watch, which can be used to monitor and assess a patient’s heart rate and tracings. We occasionally share difficult cases with regional colleagues to discuss approach and management.
What specific challenges is your hospital facing?
As a result of the continuous growth we are experiencing, there are long waiting times for booking outpatient procedures. More daytime procedures were created to enhance flow and reduce bed occupancy, which has been limited recently due to COVID-19. In addition, lead extraction cases are currently sent to a specialized center, but we aim to do these cases in our center in the future. Due to the high burden of patients, fair time slots for atrial fibrillation procedures are compromised. The younger population affected by complex inherited arrhythmic syndromes is still not well studied or explored. The other challenge is the availability of ECMO and related support for severe heart failure and ventricular arrhythmias.
Please tell our readers what you consider special about your EP lab and staff.
Our center covers the whole country of Oman, so we’re able to have a clear look at results, complications, and recurrences from this patient population. We have a strong team of technologists and nurses, which allows for high efficiency, productivity, and quality. We are grateful for the international visitors who support our services. Our center treats all types of arrhythmias and other interesting cases, including our pediatric cases. Despite having limited space in our cath lab (5-6 sessions per week), we still completed 1,288 procedures last year. With steady progress and growth, we hope to be considered a highly ranked EP service in the region and become a recognized training center for new technologies acquired in the region.
Correction: Dr. Najib Al Rawahi started the service in July 2007, and has been heading the unit since then. Before that, pacemaker implantations were mostly done by Dr. Rasheed Majeed Shahrabani. Dr. Said Abdul-Rahman also assisted Dr. Al Rawahi for several years.