Spotlight Interview

Spotlight Interview: The Texas Cardiac Arrhythmia Institute (TCAI) at St. David’s Medical Center

Andrea Natale, MD, FACC, FHRS, FESC, Executive Medical Director at TCAI

Austin, Texas

Andrea Natale, MD, FACC, FHRS, FESC, Executive Medical Director at TCAI

Austin, Texas

The Texas Cardiac Arrhythmia Institute (TCAI) at St. David’s Medical Center is an international treatment, training, and research center specializing in the care of heart rhythm disorders. TCAI’s team of physicians is one of the largest and most distinguished electrophysiology practices in the U.S., representing unparalleled experience, expertise, and exceptional care.

Our physicians are internationally recognized and specialize in different areas of cardiac electrophysiology. The Institute provides patients with superior patient care while advancing the overall level of cardiac arrhythmia treatment through research and technology.

TCAI’s leading-edge technology and use of emerging procedures and protocols attract visiting physicians worldwide to train on the latest, most advanced techniques available.

When was the EP program started at your institution? By whom?

Our electrophysiology (EP) services began in 1998 with Dr. Rodney Horton and just one EP lab. Over the years, the program grew to include 18 EP physicians. In 2008, when I joined St. David’s HealthCare, TCAI was created to meet the demand for a comprehensive, advanced, and collaborative partnership between St. David’s HealthCare and the EP physicians of Texas Cardiac Arrhythmia (TCA). TCAI includes EP lab services, the Atrial Fibrillation (AF) and Arrhythmia Center, and the research department. I am very proud to have served as the Executive Medical Director since 2008 — and to have witnessed TCAI grow in terms of procedure volume, research, and international recognition.

What is the size of your EP lab facility? Tell us about the recent expansion.

TCAI has just completed a new, state-of-the-art EP Center dedicated to treating patients with cardiac arrhythmias. The new EP Center, which will provide additional capacity to care for a growing number of patients coming here from across the nation and around the globe, is opening this summer. Our new EP Center occupies 72,000 square feet on two floors of the main hospital, with six EP labs and a shelled seventh lab for future expansion. The labs are equipped with state-of-the-art technology for the treatment of complex arrhythmias. The Center also has its own 12-room pre-procedure area and eight immediate post-procedure recovery units. In addition, the Center also has 20 private patient rooms and four private suites with adjoining family suites. It also features an international training center, which will allow TCAI to continue to share with physicians around the world the latest advances in interventional cardiac electrophysiology, improving outcomes for patients worldwide.

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

TCAI consists of 48 staff members, including registered nurses, EP technologists, nurse practitioners, patient care technicians, and administrative staff. We are in the process of recruiting additional staff for the six new labs.

What types of procedures are performed at your facility? What types of complex ablations are performed?

We are a full-service electrophysiology department. We offer procedures from simple EP studies to complex ablation procedures, including hybrid endocardial/epicardial ablation for AF and VT cases. This includes performing cardiac ablations for AF, ventricular tachycardia (VT), and supraventricular tachycardia. We also perform lead extraction and device implants of pacemakers, defibrillators, cardiac resynchronization therapy (CRT) and CRT-D devices, left atrial appendage (LAA) closure devices, and implantable loop recorders.

Approximately how many catheter ablations, device implants, lead extractions, and LAA closures are performed each week?

On average, our physicians perform 75-120 procedures each week. However, our physicians do many more procedures in our satellite locations.

  • AF ablations: 35-50
  • VT ablations: 8-10
  • Ablations (other): 6-8
  • Implants: 15-20
  • Lead extractions: 6-8
  • LAA closures: 8-10

What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?

Approximately 30%  to 40% of our implants use MR conditional devices, and about 10% use subcutaneous leadless devices.

Who manages your EP lab?

Salwa Beheiry, RN serves as the Director of EP and Arrhythmia Services at TCAI.

Are employees cross trained?

Since the EP lab is separate from the cath lab, each one has a unique team and staff are not cross trained.

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

TCAI is located on the campus of St. David’s Medical Center, part of St. David’s HealthCare, which was recognized with a Malcolm Baldrige National Quality Award in 2014. Located in Central Austin, St. David’s Medical Center includes a 356-bed acute care hospital and a 64-bed rehabilitation hospital providing comprehensive inpatient and outpatient care. St. David’s Medical Center was named among America’s 50 Best Hospitals by Healthgrades in 2018. Additionally, it was named by IBM Watson Health as one of the nation’s 100 Top Hospitals for the tenth consecutive year in 2019, as well as among the 50 Top Cardiovascular Hospitals in the nation.

What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?

At TCAI, we most commonly use the following EP equipment:

  • CardioLab Recording System (GE Healthcare)
  • Niobe ES System (Stereotaxis)
  • VantageView System (Abbott)
  • SwitchPoint Infinity 3 (Stryker)
  • Teletom equipment management system (Stryker)
  • Chromophare F 528 surgical lights (Stryker)
  • CARTO 3 V6 (Biosense Webster, Inc., a Johnson & Johnson company)
  • EnSite Precision Cardiac Mapping System (Abbott)
  • CryoConsole Cardiac Cryoablation System (Medtronic)
  • SMARTABLATE System (Biosense Webster, Inc., a Johnson & Johnson company)
  • Ampere RF Ablation Generator (Abbott)
  • Radiofrequency NRG Transseptal Needle (Baylis Medical)
  • KODEX-EPD system (Philips)
  • RHYTHMIA HDx Mapping System (Boston Scientific)

We also use the following imaging technology:

  • ARTIS pheno (Siemens Healthineers)
  • Artis Q.zen (Siemens Healthineers)
  • Artis zee (Siemens Healthcare) with MediGuide Technology (Abbott)
  • ACUSON SC2000 Ultrasound System (Siemens Healthineers)
  • ACUSON SC2000 Prime (Siemens Healthineers)
  • ViewMate Ultrasound Console (Abbott)
  • Vivid E9 (GE Healthcare)

What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?

Our EP services are continuously developing new techniques and acquiring new technology. We have been involved in many first-in-human investigative devices. We were also the first to use high power, short duration ablation with great results, augmented by the use of half-normal saline irrigation, which creates better and faster transmural lesions. Recently, we introduced vascular closure devices on all of our ablation procedures. We have received great feedback from our patients since they can ambulate in two hours after the procedure, rather than be immobile (lying on their back) for six hours post procedure. This will also allow us to discharge some patients the same day of the procedure, rather than spending the night in the hospital.

We are in the process of digitizing our patient education and instructions to be accessible online. It is visually more appealing, and the content contains videos that will help with patient compliance as well as retention of information. For our staff, we will also digitize our competencies/orientation into videos, which can be viewed at the learners’ own pace. While we have a large library of education in HealthStream, our EP hands-on competencies are still done through one-on-one contact. We think a self-paced learning system will allow us to increase the skill level of a larger group of lab staff.

How does your lab handle call? How is shift coverage managed?

We do not take call in our department. A typical day starts at 7 AM. We divide our staff into two shifts: the 7 AM to 4 PM shift, as well as a later shift that is rotated to cover the case volume until all cases are finished (around 7 or 8 PM).

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

We do not have what we can call a “typical” day in our labs — it varies according to the types of cases we have, and who (among our doctors) is working in the labs on that day. However, we usually have a good mix of cases, including implants, extractions, and ablations. Our highest volume of cases are AF and VT ablations.

Who handles procedural scheduling? Do they use particular software?

Our two schedule coordinators use LeadingReach for procedures.

What type of quality control and assurance measures are practiced in your EP lab?

Every year, we choose two process improvement projects. We also have several daily safety and compliance audits. Among our current process improvement projects is increasing lab efficiency. We are also starting a peer review committee for the EP department, with participation from staff, doctors, the anesthesia department, and sometimes other nursing units that help treat our EP patients.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

Our inventory is managed in collaboration with our material management department, which is also responsible for ordering and purchasing. Par levels are set for every room, and the par level is managed daily by the material management team. For capital equipment and large purchases, there is a hospital-wide process by which we submit new requests to administration for consideration and funding approval.

How has managed care affected your EP lab and the care it provides patients?

In general, managed care has not had a significant impact on our EP lab and the care we provide patients. We have a balanced mix of payors.

Have you developed a referral base?

Yes, we have developed a large referral base. Besides Texas, our patients come from all over the U.S. Additionally, patients from around the world — Europe, Asia, Latin America, and the Middle East — travel to TCAI for treatment of complex arrhythmias.

In what ways have you cut or contained costs and improved efficiencies in the lab and device clinic?

We continuously strive to eliminate inefficiency and waste in our department. We standardize our processes as much as possible. We are actively involved in our efforts to reduce wasteful practices. We also track unnecessary overtime as well as room turnaround times.

How do you ensure timely case starts and patient turnover?

We have an ongoing log to track room turnaround times. Additionally, we have set standards for first-case start times, which is no later than 7 AM. Room turnaround time is defined by “wheels out/wheels in,” and is 15 minutes or less. We look into deviations from these times and, during our weekly staff meetings, discuss causes of delays and how to avoid such instances.

How are new employees oriented and trained at your facility?

We provide our new employees with eight to 12 weeks of training. Each employee is assigned to a preceptor who closely trains and assesses the progress of the employee. Not all new hires have EP experience, but we hire highly motivated individuals, and we are willing to invest the time and effort to train them. It can take up to six months for a nurse or technologist to be able to completely function independently.

What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?

Our continuing education opportunities are numerous. We have an educational opportunity every other week during which we either focus on a skill, new equipment, or new initiative. Staff members are sometimes asked to teach their peers a skill in which they have excelled, or present an article they came across that they believe is of benefit to all.

Our staff members also attend the annual Heart Rhythm Society conference. Additionally, every other year, TCAI hosts an international symposium on complex arrhythmias called EPLive. Nearly 250 physicians and other allied health professionals from Europe, Asia, and Latin America, as well as experts from across the United States, attend this two-day educational conference. EPLive uses live and recorded cases with expert commentary as the primary teaching tool. Our staff is part of that program, and has the opportunity to be exposed to other professionals presenting and performing live cases. Our physicians are also invited to many other EP meetings all over the globe.

As President of the acclaimed Venice Arrhythmias meeting in Italy since 2003, I am also proud to say that our department and staff are part of the organizing committee, and they participate as faculty and attendees.    

How is staff competency evaluated? Does staff receive a bonus based on performance?

Competencies are assessed on a yearly basis. We are in the process of creating a career ladder for our staff to incentivize continued growth and development.

Have members of your staff taken the registry exam for the Registered Cardiac Electrophysiology Specialist (RCES)?

Yes, many of them have. Some of them are International Board of Heart Rhythm Examiners (IBHRE) certified, and many are RCES certified, and those certifications are one of the requirements for advancing through the career ladder.

How do you prevent staff burnout and turnover? What approaches do you use for team building?

We have a robust labor management program where staffing relative to volume is reviewed regularly to ensure that we are recruiting to support demand. We conduct employee engagement surveys to provide an anonymous forum to submit feedback. We also make leadership rounds on staff to ensure the teams have the resources needed to take exceptional care of patients as well as to identify needs, take action, and follow up with the team. In addition, we do our best to accommodate requested time off or schedule changes.

What committees are staff members asked to serve on in your lab?

We have an education committee to suggest and plan for educational topics and opportunities. Additionally, some of our staff members serve on the hospital-wide employee council, as well as represent our department on the hospital-wide IRB council.

How do you handle vendor visits to your department?

Vendors are usually present because they are either supporting cases or they are present with visiting physicians, who are often with us for training courses or for observing. Other vendors need to make appointments to visit our labs for any other reason.

All vendors are required to go through our Dependent Healthcare Professional credentialing and clearance process.

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

In our AF and Arrhythmia Center, our navigators and nurse practitioners frequently help provide education on resources and services that can help our patients cope with psychosocial issues that are common among cardiovascular patients. These may include stress reduction, meditation, or simple exercise programs.

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

A case that stands out is one in which we retrieved a dislodged WATCHMAN Device (Boston Scientific) from the left atrium using endovascular snares. With intense concentration, advanced superb skills, and superb technique of our physicians, we were able to successfully retrieve the device.

Does your lab use a third party for reprocessing? How has it impacted your lab?

Yes, we use a third-party vendor for reprocessing some of our catheters and intracardiac echo probes. We’ve managed to reduce our yearly cost by around $300,000.

Approximately how many ablation procedures are done with cryo vs RF in your lab?

We seldom use cryoablation in our labs — approximately 5% of our ablation procedures are performed with cryoablation.

Does your lab use contact force sensing technology during radiofrequency ablation of AF?

Yes, we were an early adopter of this technology, and we continue to use it.

Does your lab utilize remote catheter navigation?

Yes, we mainly use Stereotaxis for our VT cases.

Does your lab perform His bundle pacing?

Yes, this is performed when appropriate, given our high volume of CRT implants.

What are your techniques for LAA occlusion? Do you have a primary approach?

We use the WATCHMAN Device (Boston Scientific) and LARIAT Suture Delivery Device (SentreHEART, Inc.), as well as devices still under investigation, such as the AMPLATZER Amulet occlusion device (Abbott) and WaveCrest LAA Occlusion System (Biosense Webster, Inc., a Johnson & Johnson company). For further management of peri-device leaks, we also implant embolization coils.

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

We’ve transitioned almost completely to NOACs on all our AF patients.

Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?

Yes, we are very big advocates of lifestyle changes in the management of our arrhythmia patients. For example, we screen all our patients for sleep apnea and refer those with positive results to a pulmonologist for further management. We also refer obese patients to our bariatric center and cardiac rehab, as well as connect them with a nutritionist.

What other EP innovations are being utilized in your lab?

As mentioned above, we are continuously developing new techniques, including being the first to use high power, short duration ablation, augmented by the use of half-normal saline irrigation.

Another innovative technique we use is implanting coils to resolve persistent leaks post-LAA closure devices. (We may also use radiofrequency ablation in combination with the coils.) With persistent leaks after surgical closure of LAA or LARIAT procedures, septal occluders have proven effective in resolving this common phenomenon.

We have also started implementing the use of the SENTINEL Cerebral Protection System (Boston Scientific) for embolic protection during EP procedures on high-risk patients.

How are pediatric cases managed in your lab?

We perform procedures on pediatric patients with a body weight of at least 100 pounds. We refer patients with hereditary syndromes to a cardiovascular genetic program.

What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoro?

We perform fluoroless procedures on almost 35% of our AF ablations, and we follow all common compliance guidelines surrounding x-ray exposure. Of course, we use reduced frames and better use of collimation. Using robotic systems has also contributed to reduced exposure. We are really fortunate to have brand-new labs with the latest imaging technology, which are designed mainly to reduce exposure by using flat emitter technology.

What are your methods for device infection prophylaxis?

Our infection rate is less than 1% annually, well below the national average. We feel that following the standards for infection prevention is the most important measure.

How do you use the NCDR Outcome Reports to drive QI initiatives at your facility?

We participate in the ICD Registry, AFib Ablation Registry, and LAAO Registry. We discuss our outcome data from the dashboard with our physicians, and develop a plan of improvement. We continue to track these outcomes and review them quarterly.

What are your thoughts on EHR systems? Does it improve your quality of care?

Yes, EHR helps in terms of continuity of care as well as care coordination. Our hospital uses the MEDITECH system. Physicians and allied health professionals all over the U.S. often complain about how time-consuming EHR documentation can be. However, EHR can potentially be of great benefit if it is better streamlined and more user friendly.

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

We think that lifestyle modification is going to be a big part of patient management, and this is becoming an integral part of our practice. There are many new innovative techniques for stroke prevention post ablation. Ablation of non-paroxysmal AF has started to gain traction with many EP practitioners, and LAA isolation is becoming much more common. Additionally, within the next few years, we will witness the utilization of novel sources of ablation energy.

Do you utilize remote monitoring of CIEDs? What clinical and economic benefits have you seen?

Yes. Because our patients come from all over the U.S., as well as from other parts of the world, remote monitoring has helped us keep track of our patients and coordinate with their referring physicians in a timely manner in the management of these patients. From an economic standpoint, remote monitoring has greatly reduced labor hours on the part of our staff, as well as the cost to the patient for travel to our office for their device check-up.

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

Yes, we utilize many forms of wearable devices to follow up with our AF and VT patients post ablation, and closely monitor outcomes.

Tell us more about clinical research at TCAI.

Clinical research at TCAI is a top priority because it helps advance and shape the best practices and standards of care for the treatment of arrhythmias both nationally and internationally. TCAI spearheads research involving new technologies and techniques, including being the first to use innovative technology and systems.

Does your hospital offer a patient support group?

Yes, we have a group called “Living Well With Heart Failure,” which meets monthly.

Has your lab achieved EP accreditation, or does it plan to in the future?

We have not, but we may pursue this accreditation in the near future.

How do you see social media changing the field of healthcare? Are staff encouraged to participate in the EP community on social media? Are social media policies in place for this?

A growing number of our patients find us through word of mouth, and social media is certainly an avenue that some of our patients use to share their story. Our institution has Social Media Guidelines and an Appropriate Use of Communications Resources and Systems Policy.

There are two popular blogs, as well as two websites, for patients with rhythm problems who frequently highlight and interact with TCAI.

Describe your city or general regional area. How is it unique from the rest of the U.S.? What specific challenges does your hospital face given its unique geographic service area?

Austin, the state capital of Texas, is one of the fastest growing cities in the United States. In addition, Austin has earned the reputation as one of the best places to live in the nation. With the greatest growth in the region occurring in the outlying communities, suburban and outlying hospitals are continuing to invest in and develop tertiary services such as electrophysiology. With our hospital located in Central Austin, we're challenged in ensuring that our care and service are differentiated in a way that patients choose to drive past many other hospitals to seek care.

What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?

Besides being the U.S. center with the highest volume of procedures, we were the first group to assess in a randomized trial the role of left atrial appendage electrical isolation in atrial tachyarrhythmia relapse (BELIEF trial). We were also the first to report superiority of catheter ablation over drug therapy in patients with persistent AF and heart failure, showing a mortality benefit with ablation (AATAC trial). Recently, we pioneered a new technique to treat residual left atrial appendage leaks via endovascular coils in patients with incomplete appendage closure (TREASURE trial). We are now testing the effect of peri-device radiofrequency energy applications for the same issue. Looking back on the last decade, our doctors have been principal investigators in several international randomized trials, and have been the first in the country or in the world to test new technologies that are now commonly used in the EP field. It is these thousands of successes that have earned the TCAI team its stellar reputation and established the Institute as a global center of excellence in the treatment of heart rhythm disorders. This remarkable success rate draws people from all over the world in search of a normal, arrhythmia-free life.

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

Our EP lab staff members are among the best in our field. They are highly skilled and dedicated. Most of them have been here for many years. We would never have achieved the level of success we have reached without our wonderful staff. We can’t thank them enough.

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About the Author:

Andrea Natale, MD, FACC, FHRS, FESC, Executive Medical Director at TCAI, is a preeminent global leader in electrophysiology and a dedicated clinician, researcher, and academician.

An Italian native, Dr. Natale is U.S. trained and board certified, and one of the pioneers of ablation to treat AF. He is credited with performing epicardial ablation techniques for the management of various complex arrhythmias. Dr. Natale’s life’s work is to benefit patients’ quality of life through emerging cardiac technologies.