Spotlight Interview

Spotlight Interview: University of California, Irvine Medical Center

David M. Donaldson, MD, FACC, FHRS

Clinical Associate Professor of Medicine; Director, Electrophysiology; Division of Cardiology;​ Department of Medicine; The University of California at Irvine; Orange, California

David M. Donaldson, MD, FACC, FHRS

Clinical Associate Professor of Medicine; Director, Electrophysiology; Division of Cardiology;​ Department of Medicine; The University of California at Irvine; Orange, California

When and by whom was the EP program started at your institution?

The electrophysiology service at the University of California, Irvine (UCI) started with Dr. Lloyd Iseri, inventor of the Iseri wires1 used in code carts in many U.S. hospitals in the 1970s and 1980s for transthoracic temporary epicardial pacing. He performed the first permanent pacemaker implants at what was then Orange County General Hospital, which became UCI Medical Center in 1976, and greatly advanced research into antiarrhythmics and regional training for prevention of sudden cardiac arrest. In 1982, Dr. Michael Brodsky became the first fellowship-trained electrophysiologist at UCI.

What is the size of your EP lab facility?

There are currently 2 dedicated EP rooms and 1 swing room we can use for device implants. We plan on upgrading this room in 2021 to provide 3 dedicated EP rooms.

Tell us about your EP lab staff.

We have 12 dedicated EP staff, as well as other cath lab staff that are cross trained to help with devices, including RNs, RT(R), and paramedics.

Dr. Byron Allen joined the UCI faculty in 1986 and performed the vast majority of the pacemaker implants and most of the catheter ablations in the late 1980s and 1990s. UCI Health thoracic surgeon Dr. Richard Ott implanted UCI’s first ICD in the late 1980s  with epicardial leads and full median sternotomies. In 1991, after spending a week with Dr. Fred Morady and then fellow Dr. Hugh Calkins at the University of Michigan, Dr. Allen expanded ablation procedures and started performing AV node ablations and WPW cases. EP directorship under Dr. Brodsky was followed by Dr. David Cesario and Dr. Subramaniam C. Krishnan, and later Dr. Rahul Doshi, with great contributions from Dr. Rajesh Banker, Dr. Alicia Montanez, and Dr. Teferi Mitiku. In 2019, UCI Health added Dr. Michael Rochon-Duck as full-time faculty and Dr. David Donaldson as Director of EP Services.

What is the size of your EP lab facility? Has the EP lab recently expanded in size, or will it soon?

UCI Medical Center currently has 3 labs. Two rooms are dedicated to performing basic EP procedures and device implants, while the third is a hybrid operating room utilized for complex EP procedures as well as structural heart cases. Within the next 5 years, UCI Health plans to open a second hospital, which is expected to include additional cath/EP labs.

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

At present, the EP division has 2 full-time EPs, Drs. Rochon-Duck and Donaldson, a part-time staff physician, Dr. Rajesh Banker, and 2 community electrophysiologists (Drs. Montanez and Mitiku). UCI Medical Center has an electrophysiology nurse practitioner, Anne Hainley, and 2 nurses, Diane Parker and Mahsa Takhsha, who manage both the outpatient and remote clinics. Our EP lab is staffed by 8 RN-CCRNs with critical care certification and 7 RT(CV)s with cardiovascular-radiology certification. The 7 RT(CV)s are cross-trained for both EP and interventional cardiology/structural heart, with RN and CVT credentialing and some pursuing advanced training in cardiology.

What types of procedures are performed at your facility?

UCI Medical Center has a broad mix of cases including complex atrial and ventricular ablation, with an increasing number of complex ventricular ablations. We have developed a dedicated surgical hybrid ablation team in collaboration with our CT surgeons. The EP service also works with the surgeons for laser lead extractions, and we have an active ablation program using the convergent approach. We have seen an increase in complex ventricular rhythm cases with the expansion of our interventional and surgical heart failure services, with use of left and right ventricular assist devices (LVAD/RVAD) and ECMO when needed. In addition, we offer a complete range of cardiac rhythm device therapies and left atrial appendage (LAA) closure.

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

On a weekly basis, we routinely perform between 3 to 5 ablations, predominantly for atrial fibrillation, atrial flutter, and SVT. Our device volume is steady at 3 to 5 implants each week. Laser lead extractions are less routinely performed, usually with support of cardiothoracic surgery. We traditionally perform LAA closures once a month and average 3 to 4 cases each session.

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

We offer both CARTO (Biosense Webster, Inc., a Johnson & Johnson company) and NavX (Abbott) mapping systems. We currently utilize the EP WorkMate Recording System (Abbott) and the EP-4 Computerized Stimulator (EP MedSystems), and have purchased the WorkMate Claris System (Abbott). We have access to a broad selection of mapping and ablation catheters from both Biosense Webster and Abbott. We are fortunate to have access to all CRM vendors at the discretion of the implanting physician.

Who manages your EP lab?

We have a strong management team headed by Laurie Armendariz, RN, and Lan Truong, RN. UCI Health cardiology practice manager Sohayla Kharrat, RN, BSN, works very closely with the nurses that handle much of the daily workflow. This allows for seamless transition in patient care.

Tell us about your device clinic, including its staffing model.

One of the strengths of the UCI Health EP practice is our device clinic under the outstanding leadership of Diane Parker, RN, and Anne Hainley, NP, with assistance from Mahsa Takhsha, RN. They remotely follow our large patient population, with in-clinic device checks reserved for immediate post insertion or active EP issues, including input from the electrophysiologist. Anne Hainley, NP, manages a busy clinical practice in addition to helping manage complex device issues.

In what ways has the COVID-19 pandemic impacted your hospital, EP lab, or practice?

As at most healthcare systems, the COVID-19 pandemic has greatly affected UCI Health. Fortunately, through a commitment to patient care and the outstanding leadership from UCI Medical Center executives, administrative staff, and the entire team of healthcare professionals at UCI, we have been able to rapidly and effectively transition to utilizing telemedicine, aggressive screening protocols, and infection control strategies to offset significant impact. We have initiated “hospital at home” and “estimated date of discharge” programs to reduce hospitalization days. We are confident that with continued adaptation, we will continue to serve the UCI medical community.

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

In addition to the system-wide changes undertaken in light of the COVID-19 pandemic, we have adopted several other initiatives unrelated to this situation. We have begun protocols to minimize use of fluoroscopy during EP procedures, which to date have been highly successful thanks to improved utilization of advanced mapping systems and intracardiac echocardiography when appropriate. In addition, we have embraced the initiation and implementation of same-day discharge protocols on EP patients, both post-ablation and post-device insertion, when deemed to meet appropriate criteria. We continue to assess process improvements to streamline transition of patients in the outpatient setting prior to the day of their EP procedure in the hospital. We have employed comprehensive screening pre-operatively to improve the patient experience on the day of their procedure.

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

The typical workflow involves 2 anesthesia cases in our hybrid operating room — these traditionally are complex ablations requiring anesthesia. In the other EP rooms, the majority of cases are CRM device implants or right-sided EP studies and ablations. In order to optimize workflow, we have transitioned lower risk procedures such as cardioversions and tilt table tests outside of the EP lab, with insertion of injectable loop recorders performed at the discretion of the implanting physician.

How do you ensure timely case starts and patient turnover?

We have taken several aggressive protocols to ensure that the operative consent, anesthesia questionnaire, preoperative preparation, written instructions for medications, and all pre-operative labs including MRSA and COVID screens are completed on an outpatient basis. Cardiology lab schedulers and administrators Edward Valdez and Estefany Franco are critical and essential to the entire lab function; they schedule and communicate frequently with the patient and anesthesiology staff, minimizing delays or cancellations. In addition, we have been aggressive in transitioning our patients to direct oral anticoagulants, minimizing reliance on warfarin with the possibility of abnormal INR levels on procedure days. We also have dedicated cleaning services for the Division of Cardiology, and thus, are not dependent on the operating room staff to facilitate room turnover.

What are the best features of your EP lab’s layout or design?

We are very fortunate at UCI Health to have very modern facilities. All of the cardiovascular service line facilities, labs, and cardiothoracic surgery are in the same location in the main hospital. The team works closely with our cardiothoracic surgeons when necessary on complex cases. This is further supported by a robust structural heart program and advanced heart failure program.

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

We have worked very closely with our industry colleagues to bring the latest equipment and technology to our patients while operating in a cost-sensitive environment. We utilize catheter reprocessing and work closely with industry on bulk purchases of frequently utilized items, allowing us to pass cost savings on to our patients. In the device clinic, UCI Health has invested heavily in educating staff on devices and remote device management while relying infrequently on direct industry educational support.

What types of continuing education opportunities are provided to staff? What options for CE are available to your mid-career staff?

We offer our staff ongoing educational opportunities to help support their practice at the peak of their licensure. Continuing education is now offered virtually starting in 2020-2021, allowing them to maintain better balance work-life responsibilities. In addition, UCI School of Medicine faculty present educational opportunities throughout the year, including the annual UCI Cath Lab and EP Essentials course, drawing experts from throughout the West Coast.

Does your lab perform His bundle pacing?

At present, we do perform His bundle pacing utilizing vendor-specific technology. In addition, we perform left bundle branch pacing for select patients, and have plans to expand.

Tell us about your primary approach for LAA occlusion.

Since the initiation of our LAA closure/occlusion program, we have adopted a comprehensive approach to stroke prevention in non-valvular atrial fibrillation. We have established a dedicated weekly outpatient clinic so that referrals can be performed in a timely fashion with a comprehensive discussion over the course of several appointments, including a detailed description utilizing literature, patient education packets, and models of left atrial occlusion devices. All patients are seen by our team (Figure 5), made up of Dr. Ihab Alomari from the interventional cardiology/structural heart service, Dr. Donaldson, and LAAC program coordinator Anne Hainley, NP. Each patient is then presented at our weekly structural heart conference with representation from echocardiography attendings, radiology, surgery, interventional/structural cardiology experts, EP staff, and device representatives to review the TEE images or CT angiograms with 3mensio (Pie Medical Imaging) reconstruction. The patient is then seen by a second independent cardiologist to confirm appropriateness. Each LAA closure is performed by both Dr. Alomari and Dr. Donaldson. On February 5, 2021, Drs. Alomari and Donaldson also successfully inserted the first WATCHMAN FLX (Boston Scientific) device at UCI Health. In addition, we have an outstanding convergent program with epicardial LAA closure by Dr. Jack Sun, UCI’s chief of CT surgery.

Does your program have a dedicated atrial fibrillation clinic?

Under the leadership of the Division of Cardiology Chief Dr. Pranav Patel, UCI Health has an atrial fibrillation clinic staffed by Dr. Rochon-Duck, Dr. Donaldson, and Anne Hainley, NP. The UCI Health AF clinic sees patients every other Friday at the UCI Medical Center campus to facilitate patient access and timely referral for a broad spectrum of management strategies.

What approaches has your lab taken to reduce fluoroscopy time?

In recent years, this has been a strong focus in our lab. We utilize advanced mapping systems and ICE to safely perform ablation with minimal fluoroscopy. The ultimate objective is to safely offer procedures free of fluoroscopy in the near future.

How do you manage radiation quality checks of the imaging equipment?

The UCI Medical Center performs weekly QA radiation checks, with the reports being uploaded directly to Radiology. Any issues are immediately addressed by the cath lab RT supervisor and radiation SOS officer. In addition, the Registration and Certification Support Unit of the State of California’s Radiologic Health Branch as well as the California Department of Public Health have strict licensure criteria for use of radiation equipment.

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

We are excited for the potential of pulsed field ablation and electroporation, as well as advances in catheter and balloon technology.

How do you utilize digital tools or wearable technologies in your treatment strategies?

We have embraced outpatient ambulatory home monitoring systems from various vendors and have been very aggressive with wearable monitors for enhanced diagnostic therapies for patients. We offer implantable loop recorders to clinically appropriate patients.

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

The University of California, Irvine is the only academic health system in Orange County, which is one of the largest metropolitan areas in the U.S. with a population of 3.2 million citizens and a catchment area of nearly 4 million people. We are near the undergraduate and graduate UCI campus, featuring a vibrant research community and the UCI School of Medicine as well as the main health sciences campus. California has the largest biomedical industry in the U.S., and Orange County has multiple leading biomedical engineering companies, allowing us to offer our patients the latest advances in technology.

What specific challenges does your hospital face given its unique geographic service area?

As a world-class research institution, the University of California, Irvine is uniquely positioned to work closely with our colleagues across the University of California system, one of the world’s preeminent public universities.

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

Like all successful organizations, our staff at UCI Health is our number one strength. When combined with a vibrant and growing Division of Cardiology led by Dr. Patel and the UCI Department of Medicine under the leadership of Dr. Alpesh Amin, the future is very bright at UCI. With great support from the medical school and UCI’s proximity to multiple internationally prominent biomedical research companies, we can continue to provide outstanding care driven by the UCI Health mission to “Discover. Teach. Heal.” 

References
  1. Kodjababian GH, Gray RE, Keenan RL, Iseri LT. Percutaneous implantation of cardiac pacemaker electrodes. Am J Cardiol. 1967;19(3):372-376. doi: 10.1016/0002-9149(67)90450-x
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