When was the EP program started at your institution? By whom?
The EP program at Sunnybrook’s Schulich Heart Centre was developed by Dr. Eugene Crystal, director of arrhythmia services. He has demonstrated exemplary leadership and innovative skills in this role. Dr. Crystal was instrumental in introducing complex mapping and ablation, as well as having one of the first EP laboratories in Canada with Stereotaxis technology.
What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization department?
We currently have one full-time electrophysiology laboratory and one device implant room. We are in the process of developing a second electrophysiology laboratory, and are integrating this with pre-, intra- and post-procedural imaging (predominantly utilizing MRI) in collaboration with Dr. Graham Wright, director of the Schulich Heart Research Program. We feel that this integration between our advanced imaging program and electrophysiology represents an important research and treatment strategy in the future of our services.
What is the number of staff members? What is the mix of credentials at your lab?
We have four full-time electrophysiologists as well as four part-time electrophysiologists that work in other centers. Our EP lab, device lab, and device clinic are staffed by EP nurses. We also have three electrophysiology fellows, as well as researchers and students.
What types of procedures are performed at your facility? What types of complex ablations are performed?
We perform all complex ablations, including for paroxysmal and persistent atrial fibrillation, endocardial and epicardial ventricular tachycardia, SVT, and atrial flutter. We also implant CRT devices, ICDs, and pacemakers, as well as perform left atrial appendage closure. We are also developing a hybrid ablation program.
Approximately how many catheter ablations (for all arrhythmias) and device implants are performed each week?
On a weekly basis, we perform approximately 15 ablations (about 75% of which are complex) and 20 device implantations (pacemakers, ICDs, CRTs, and loop recorders).
Are employees cross trained?
Although the EP laboratory is separate from the cardiac catheterization laboratories, there is still cross training with cath lab nurses, who rotate through the EP lab in order to diversify training and enable for future growth.
What type of hospital is your EP program a part of?
The Schulich Heart Research Program is affiliated with the world-renowned University of Toronto, which was ranked as the number one university in Canada in 2019 by U.S. News & World Report.
Has your EP lab recently expanded in size or volume?
Our EP lab is growing significantly, and our volumes of complex ablation are expanding by approximately 25 percent per year. Volumes of non-complex ablation are relatively unchanged and appear to be keeping with national figures.
What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?
We currently utilize the EnSite Precision Cardiac Mapping System (Abbott) and CARTO System (Biosense Webster, Inc., a Johnson & Johnson company). We also use the CardioLab Recording System (GE Healthcare) and the Niobe Robotic Magnetic Navigation System (Stereotaxis).
What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
We use the newest technology available in EP. For example, we have been using novel catheters such as the Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott) for some time now, and Dr. Glover was both the first operator of the EnSite Precision Cardiac Mapping System in North America as well as the first physician to use the Advisor HD Grid in Canada. The use of these high-definition catheters has increased our speed and accuracy of mapping. We are closely assessing our outcomes to assess the impact on recurrence rates of arrhythmia.
Tell us what a typical day might be like in your EP lab.
The day normally starts at 7:15 AM, when we speak with the patients who have already been seen at the clinic and been pre-assessed by anesthesia. We normally start with complex ablations performed under general anesthesia. An average day normally consists of two complex and one non-complex ablation, with the overall aim of finishing by 5:30 PM. Non-complex ablations are generally performed with sedation.
Have you developed a referral base?
We have a strong referral base throughout the Greater Toronto Area. We have maintained this by providing a rapid referral process in which patients in need of catheter ablation are assessed and stratified according to clinical need. We also provide educational presentations to our referrers in order to ensure they are kept up to date on the current indications for catheter ablations for different arrhythmias.
How do you ensure timely case starts and patient turnover?
We have increased the efficiency of the lab by reducing the time taken between cases. This involves active engagement of the cleaning staff as well as senior EP staff presence between cases in order to ensure a more efficient turnover time. This has a significant impact on the number of cases performed on an average day.
What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?
We have weekly teaching for our fellows and nurses. We also organize case-based teaching every three months, specifically for nursing staff. We encourage our nurses to submit work to national and international meetings, and provide support for those who get accepted to present their work.
Describe a particularly memorable case from your EP lab and how it was addressed.
We have found that with the development of high-definition mapping, while there are still memorable cases that continue to be challenging, many are now are associated with improved success. Personally, I find the most memorable cases are those in which the patient has a significant improvement in their quality of life or left ventricular ejection fraction as a result of catheter ablation. I have countless patients who write to me to thank me for “giving them back their lives” off antiarrhythmic medications and beta blockers.
Does your lab use contact force sensing technology?
We utilize contact force for the treatment of atrial fibrillation, and understand the limitations of this technology. It does provide important information not only on contact, but on directionality as well. We have found from our data that contact force also improves the time taken to achieve acute pulmonary vein isolation.
What are your thoughts on the use of DOACs in patients with non-valvular AFib?
Direct oral anticoagulants are an extremely effective method of anticoagulation and provide stroke prevention in patients with non-valvular atrial fibrillation. It is now relatively uncommon for us to see patients on warfarin. In regards to catheter ablation, my practice is to continue with oral anticoagulation, which eliminates the need for heparin bridging.
Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?
We actively encourage our patients to lose weight and increase their exercise prior to undergoing catheter ablation for atrial fibrillation. This has been a challenge in most practices throughout the world, as they are not adequately set up for this purpose. Kathryn Hong, MSc from Schulich Heart Centre has recently shown that patients who undergo catheter ablation for atrial fibrillation have increased exercise tolerance and psychological well-being after the procedure, which leads to weight loss. This important work has helped us gain a better understanding in the complex relationship between rhythm management and weight loss.
What other innovative EP techniques are being utilized in your lab?
We are continually testing novel methods of mapping and various technologies in order to optimize treatment for our patients. We are particularly interested in the integration of MRI technology for the pre-evaluation and follow-up of patients undergoing catheter ablation.
What approaches has your lab taken to reduce fluoroscopy time?
I have been heading up the Canadian CAREFL Database, which is involved in the prospective collection of data in low fluoroscopic procedures. We strive to minimize or eliminate fluoroscopy in all of our cases; however, we are also aware of and working on the technological limitations that currently exist.
What are your methods for device infection prophylaxis?
Patients receive a single dose of antibiotics pre-procedure, and are risk stratified as to whether or not they will receive an antibiotic envelope.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
We are involved in the integration of imaging into catheter ablation of atrial fibrillation and ventricular tachycardia. There is a strong need to develop a more effective strategy for catheter ablation of persistent atrial fibrillation, and I believe that this is where we should invest our resources. We also need to focus our ablation methods on the critical circuits in both atrial and ventricular arrhythmias.
Is your EP lab involved in clinical research studies?
We have many investigator-initiated studies as well as multicenter trials. Canada has a great reputation for multicenter national trials that have a significant international impact.
Do you utilize digital tools or wearable technologies in your treatment strategies for patients?
Yes, patients often utilize many wearable technologies in which they bring the data to our clinics. We have not yet developed a strategy for remote transmission and interpretation of this data.
How do you see social media changing the field of healthcare?
Social media has reformed the penetration of clinical data into the medical and general community. It is important that all information be kept confidential. New methods of data sharing are changing the way in which we gain education and share medical information.
Describe your city or general regional area. What specific challenges does your hospital face given its geographic service area?
We are based in midtown Toronto, and serve a large community both within Toronto and the suburbs. We aim to cover a wide region of Ontario, and often patients have to travel a significant distance in order to have their procedures performed. Although this may at times appear challenging, we have received very positive feedback given the high level of care provided.
Please tell our readers what you consider special about your EP lab and staff.
The real strength in our program is our chief of cardiology, Dr. Brad Strauss, who is an exceptional individual with incredible vision and purpose. He demonstrates true leadership and is an individual who possesses many qualities that most of us would want to emulate. Our EP and device nurses are also exceptional and provide a very high level of service to our patients, which is extremely important. In addition, our director of operations, Susan Michaud, displays incredible vision and foresight for the growth of our program.
For more information, please visit https://sunnybrook.ca/content/?page=schulich-heart-centre