Spotlight Interview

Spotlight Interview: University of Washington Medical Center

Nazem Akoum, MD, MS, FACC, FAHA, FHRS

Seattle, Washington

Nazem Akoum, MD, MS, FACC, FAHA, FHRS

Seattle, Washington

What is the size of your EP lab facility? Where is the EP lab in relation to the catheterization department?

We have 2 dedicated EP labs at the University of Washington Medical Center-Montlake, and 2 hybrid operating rooms. We also have another EP lab at the University of Washington Medical Center-Northwest Hospital and a hybrid lab at Harborview Medical Center. There are dedicated cath labs in the same facilities that neighbor the EP labs.

What is the number of staff members? What is the mix of credentials?

Our lab has 14 staff members divided equally between nurses and cardiovascular/EP technicians.

What types of procedures are performed at your facility?

We perform all aspects of EP procedures, from the least to the most complex, including endocardial, epicardial catheter, and open chest ablations, device implants, and lead extractions.

What would you consider to be the most frequent procedures performed or the most common arrhythmias seen?

The most frequent procedure is ablation for atrial fibrillation (AF) due to the high prevalence of the disease.

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

The vast majority of our implants are MRI conditional devices. We favor subcutaneous ICDs when there is no need for pacing, including anti-tachycardia pacing. Our pacemaker implants are also a mix of leadless and conventional devices, depending on the patient’s needs and risks.

Who manages your EP lab?

The EP lab is managed by an assistant nurse manager.

Are employees cross-trained?

The 2 labs are separate, with dedicated staff for each specialty. A proportion of nurses and technicians are cross trained.

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

The device clinic is staffed by a team that includes nurse practitioners, nurses, and technicians. Duties including remote interrogations, in-person checks including wound checks, and non-MRI-conditional CIED programming and supervision for MRI scans.

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

We are an academic teaching quaternary care hospital that receives referrals and is a resource not only for the city of Seattle, but also for the whole state of Washington and the larger Northwestern United States.

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

Our labs are equipped with CARTO (Biosense Webster, Inc., a Johnson & Johnson company) and EnSite Precision (Abbott) mapping systems. Our program routinely uses advanced cardiac imaging with MRI to evaluate the arrhythmic substrate in atrial and ventricular arrhythmias.

How do you manage vessel closure?

We use mostly manual pressure. We also utilize some figure-of-eight suturing and closure devices on select cases, such as leadless pacemakers and WATCHMAN (Boston Scientific) implants.

Who handles procedural scheduling?

We have dedicated specialists who handle all aspects of scheduling, from patient contact and instructions, to insurance coverage and post-procedural follow-up appointments.

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

Our EP lab staff have a weekly educational conference. In addition, they attend our weekly EP fellow teaching conference and research conferences. There are funds to support 2 staff members to attend the Heart Rhythm Society’s Scientific Sessions each year.

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?

About one-third of our ablations for atrial fibrillation are done with the cryoballoon. The remainder are done with radiofrequency. Factors that influence the choice of catheter include anatomy, redo procedure, and atrial fibrosis. Since our center receives referrals for complex cases including persistent AF, recurrent AF, or atypical flutter following prior catheter or surgical ablation, more cases are done with radiofrequency rather than cryoballoon ablation.

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

Yes, we use force sensing catheters with our irrigated ablation catheters.

Does your lab utilize remote catheter navigation?

We do not use remote catheter navigation at this time.

Do you have a primary approach for LAA occlusion?

Our primary approach is the WATCHMAN and now WATCHMAN FLX device. We have also performed hybrid catheter ablation and WATCHMAN FLX device implants for select patients to overlap the time period of required anticoagulation for both procedures.

Does your program have a dedicated atrial fibrillation clinic?

We have established an atrial fibrillation clinic to provide comprehensive care for our patients. The AF clinic receives direct referrals from the community, internal medicine and family practice clinics, emergency department, and cardiology. Patients seen in the AF clinic are offered a comprehensive approach to their arrhythmia care, including various therapeutic options, risk factor management, and lifestyle changes.

Do you offer a multidisciplinary care for AF?

We have adopted a nursing-driven model which has been shown to improve AF care outcomes (see the feature on comprehensive AF care by Deanna Tregoning, ARNP in EP Lab Digest’s July 2020 issue at https://bit.ly/3a1r5ys). We partner with a dedicated cardiology sleep specialist, weight management, and metabolism clinic in addition to the experts in cardiology care for our patients with heart failure and valvular heart disease. In addition, our center offers advanced cardiac imaging with cardiac MRI and atrial fibrosis quantification for all patients. We also have ongoing multicenter and local research studies that our AF patients are offered participation in.

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

The city of Seattle and the University of Washington Medical Center are a hub and referral center for the Northwestern United States. The University of Washington Medical Center is a quaternary center that accepts referrals from the state of Washington, Alaska, Montana, and Idaho. The population in Seattle is diverse from a racial and ethnic perspective, and is highly educated and socially engaged.

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

Our EP lab and staff are a fun, cohesive, and competent group who are extremely dedicated to providing top-notch care to our patients. It’s a privilege to work alongside them. They make my job more fun and they set a high bar for excellence that we try to exceed together every single day. 

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