Spotlight Interview

Spotlight Interviews Revisited

Interviews with Kent R. Nilsson, Jr., MD, FACC, Piedmont Athens Regional Medical Center, Athens, Georgia;

and Steven Zweibel, MD, FACC, FHRS, CCDS, Director of Cardiac Electrophysiology, and Jonathan Farlow, RN, BSN, Hartford Healthcare Heart and Vascular Institute, Hartford, Connecticut

Interviews with Kent R. Nilsson, Jr., MD, FACC, Piedmont Athens Regional Medical Center, Athens, Georgia;

and Steven Zweibel, MD, FACC, FHRS, CCDS, Director of Cardiac Electrophysiology, and Jonathan Farlow, RN, BSN, Hartford Healthcare Heart and Vascular Institute, Hartford, Connecticut

This month, we feature updates of Spotlight Interviews from our previous issues! Athens Regional Medical Center originally appeared in EP Lab Digest’s April 2014 issue; we follow-up with them here. Following this interview, we feature an update from Hartford Hospital, which originally appeared in EP Lab Digest’s February 2010 issue. 

How has the size of your EP lab facility changed since the publication of your Spotlight? Are there plans to expand the EP lab? 

In September 2015, Piedmont Athens Regional replaced the existing EP lab with a newly constructed, 775 square foot, state-of-the-art lab equipped with two 56˝ HD widescreen Vantage Vue monitors (Davis Instruments) capable of displaying up to 8 of 16 video inputs simultaneously, a fluoroscopy system (Siemens), EnSite Precision Cardiac Mapping System (Abbott), and the MediGuide Technology (Abbott). We have begun preliminary discussions to add an additional EP laboratory in 2022-2023. 

In 2016, our hospital merged with the Piedmont Heart Institute (PHI), which currently spans 11 hospitals throughout Georgia. Electrophysiology is concentrated in a few hubs, with complex ablations and left atrial appendage occlusions (LAAO) performed at only Piedmont Athens and Piedmont Atlanta. Integration with a larger health system has increased our volumes and allowed for increased specialization in procedures such as LAAO. Our system now has 14 electrophysiologists, including 11 at Piedmont Atlanta/Fayetteville/Newnan, one at Piedmont Henry, and two at Piedmont Athens Regional. Collectively, we have seven dedicated EP laboratories, with catheterization labs also being used for the implantation of devices. 

By working together in a coordinated and collaborative system, we are able to provide state-of-the-art care across our entire footprint, with general EP care provided locally and complex EP care at our two tertiary centers in Athens and Atlanta.

What is the current number of staff members? 

Piedmont Athens Regional has 11 cross-trained staff members who also support the catheterization lab, including STEMI call. Piedmont Atlanta has 19 dedicated staff members, who solely focus on electrophysiology.  

Approximately how many catheter ablations (for all arrhythmias), device implants (ICD, pacemaker, ICM, ILR, etc.), lead extractions, and LAA closures are performed each week? 

System wide, with over six hospitals performing ablations and device implantations, we perform approximately 1,400 pacemaker implants, 750 ICD implants, 1,300 atrial fibrillation (AF) ablations, 150 VT ablations, and 100+ LAA closures. Locally, at Piedmont Athens Regional, we perform approximately 175 pacemaker implants, 75 ICD implants, 100 CRT implants, 175 AF ablations, and 50 LAA closures per year. 

As one of the leading enrollers in the LEADLESS II trial, we have extensive experience with leadless pacemakers including Nanostim (Abbott) and Micra Transcatheter Pacing System (Medtronic). We anticipate being a part of the upcoming dual-chamber Nanostim trial as well. 

One of the advantages of being integrated into a large system such as PHI is that we can concentrate our research efforts into trials that we consider to be of immense scientific importance, including: (1) the aMAZE trial, which is evaluating the safety and effectiveness of LAA ligation as an adjunct to pulmonary vein isolation (PVI) for patients with persistent AF (PI: Kent Nilsson); (2) the NODE trial, which is evaluating an intranasal calcium-channel blocker to terminate supraventricular tachycardia (PI: Bruce Stambler); and (3) the STELLAR trial, which is looking at a novel multi-electrode radiofrequency balloon catheter for the treatment of paroxysmal AF (PI: Sandeep Goyal).

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

Abbott, Medtronic, Boston Scientific, and BIOTRONIK all have a CRM presence across the entire system, with each hospital individually determining vendors based upon provider preferences. For both ablations and devices, Piedmont Athens uses predominantly Abbott products. 

For ablations, both Abbott and Biosense have a presence across the system. In Athens, a typical AF ablation is performed with the EnSite Precision system. Disposables include an Inquiry octapolar catheter (Abbott) that is placed in the coronary sinus, a TactiCath Quartz Contact Force Ablation Catheter with an Agilis sheath (Abbott), an Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott), and a ViewFlex Plus ICE Catheter using ViewMate Z Ultrasound Console (Abbott) powered by Zone Sonography technology (ZONARE). We prefer the Advisor HD Grid to a spiral catheter, as it provides superior multidimensional imaging that we believe shortens procedure times and improves outcomes. All ablation cases except SVTs (which are done completely fluoroless) are done with MediGuide Technology to reduce radiation exposure. Recording is performed with the WorkMate Claris Recording System (Abbott). 

Who manages your EP lab? 

The EP and catherization laboratories are under the direction of Gail Kinder and Misty Autry. Day-to-day issues are managed by our senior lab flow coordinator, Amy Pulliam. 

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

From a procedural perspective, we added the WATCHMAN device (Boston Scientific) to our repertoire of strategies (including the LARIAT device [SentreHEART] and AtriClip [AtriCure]) for addressing the left atrial appendage. 

Two changes to our ablation approach have shortened both procedure time and room turnover. First, we have transitioned from standard 30W ablation to high power short duration ablation at 50W. This has dramatically shortened procedure time, with comparable — if not superior — outcomes. Second, we routinely use figure-of-eight retention sutures rather than manual pressure when we remove catheters and sheaths. Figure-of-eight sutures can be placed and catheters can be safely withdrawn with ACTs between 325-375. This has decreased room turnover by 20-30 minutes as well as reduced the incidence of groin complications. The sutures are typically removed two (not anticoagulated; eg, SVT) to six hours (anticoagulated) post ablation. 

Finally, the small size and ease of delivery of implantable loop recorders has changed long-term monitoring. We perform these either in the EP lab or outpatient holding, usually by an APP under the supervision of one of the EP physicians. 

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

When we designed our new EP laboratory, we engaged the EP lab staff, anesthesia, hospital engineers, and Abbott engineers in order to create a laboratory space that showcased the most state-of-the-art equipment while maintaining a workspace that facilitated workflow. 

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

With the integration of our hospital with the Piedmont Healthcare System, we joined a 22-hospital collaborative that negotiates on behalf of the aggregate group for CRM pricing. This has resulted in a dramatic reduction in the price of pacemakers, ICDs, and CRTs. In addition, we have sought to streamline practice patterns and reduce variation in provider practices, thereby reducing pricing while augmenting quality of care.  

Does your lab perform His bundle pacing? In addition, do you have a primary approach for LAA occlusion?

We have been performing His bundle since 2018. We primarily use it in patients who: (1) are anticipated to have a high burden of RV pacing; (2) have undergone an unsuccessful CRT; or (3) are CRT non-responders. 

Regarding LAA occlusion, we began using the LARIAT in 2013 and the thorascopic AtriClip shortly thereafter. Our LAAO program is a team-based approach that incorporates our cardiothoracic surgeons. With the introduction of the WATCHMAN device in 2017, we now offer three methods (WATCHMAN, AtriClip, and LARIAT) to address stroke prevention in patients deemed to be poor long-term oral anticoagulant candidates. Patients are initially evaluated for the WATCHMAN device. If they are deemed to be poor candidates (eg, anatomy), then they are referred for either the thorascopic AtriClip or LARIAT, depending on 3D imaging. 

Does your program have a dedicated atrial fibrillation clinic, or have plans to implement one? 

We currently do not have a dedicated AF clinic, but have been working to coordinate inpatient and outpatient management to ensure that patients hospitalized with AF have a defined treatment strategy designed to reduce readmissions and ED visits. We recently hired a designated EP navigator (Sue Phelps, RN) to facilitate inpatient-outpatient transition, drug loads, referrals, and education. As patients engage the healthcare system in multiple geographies, we have found that coordinating care across the Piedmont footprint has improved care, decreased costs, and facilitated seamless treatment strategies. 

What percentage of cases are done without fluoro? 

Approximately 95% of SVT cases are done without fluoro. At Piedmont Athens, ablations for atrial fibrillation and ventricular tachycardia are done with MediGuide Technology; this virtual biplane is particularly useful for performing double transseptal puncture, and helps facilitate esophageal temperature monitoring. 

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

The results of the CABANA and CASTLE-AF trials, coupled with reduced complications, increased single procedure success, and decreased procedural times, have increasingly thrust PVI to the forefront of AF management. This is especially true for patients with heart failure with reduced ejection fraction (HFrEF). In addition, AF is increasingly viewed as a chronic disease and PVI is one tool in the armamentarium to improve quality of life. A reoccurrence of AF post PVI is no longer viewed as “ablation failure” in much the same way that an NSTEMI 6 months post PCI is not viewed as “revascularization failure.” 

In addition to PVI, providers have embraced SVT ablation as first-line therapy, especially in patients with frequent reoccurrences. 

With improved door-to-balloon-time in STEMI patients, we have seen a decrease in ischemic VT cases. 

Finally, as the community is becoming more familiar with LAAO, we are seeing an increase in referrals, especially from neurologists and gastroenterologists. 

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

When the Apple Watch first became available, we saw such a dramatic uptick in self-referrals that we set up an APP-managed protocol. However, self-referrals appear to have decreased over the past few months. There is no hospital or institutional approach to wearable technologies. Future alignment of reimbursement with physician and patient utilization will likely guide how these technologies are integrated with contemporary practice. On an anecdotal level, we find the Apple Watch and Kardia (AliveCor) to be more useful than Holters and 30-day event recorders, but less useful than implantable loop recorders. 

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

Piedmont Athens Regional is fortunate to have state-of-the-art equipment and a dedicated, highly trained staff. The staff’s dedication to the EP lab is exemplified by their willingness to tackle difficult EP cases even after they have been on STEMI call the night before. Such dual responsibilities are highly unusual for a staff responsible for the complexity of procedures that we regularly perform. We are deeply grateful for their commitment and dedication. 

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We also get an update from Hartford Hospital, which originally appeared in EP Lab Digest’s February 2010 issue. 

How has the size of your EP lab facility changed since the publication of your Spotlight? Has the EP lab recently expanded in size?

Our EP lab facility consists of two full-time biplane labs and a third biplane lab that is shared 50% of the time with interventional neuroradiology. The second full-time lab was completed almost three years ago as a part of a significant lab renovation that included the construction of the new lab, technology and fluoroscopy upgrades, along with the construction of a new eight-bed pre-op/post-op unit for EP cases.

 What is the number of staff members? 

Our unit has eight physicians (soon to be 10), and is staffed by 11 full-time registered nurses, one radiology technician, and one cardiovascular technologist.

What are the most frequent procedures performed or the most common arrhythmias seen?

We have a high volume of atrial fibrillation (AF) ablations (using cryo or radiofrequency), as well as complex left atrial flutter and ventricular tachycardia (VT) ablations (endocardial and epicardial). In addition, we perform many supraventricular tachycardia ablations (AVRT, AVNRT, typical flutter, Wolff-Parkinson-White, etc.). Device cases include implantation of single-chamber, leadless, dual-chamber, His bundle, and CRT pacemakers and defibrillators, as well as lead extractions ranging from straightforward to high risk.

Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week? 

Over the course of a recent week with a typical caseload, we completed 14 device implants, 15 catheter ablations (4 SVT, 2 VT, and 9 AF cases), and 2 lead extractions. Our volume has been steadily increasing. We do not perform left atrial appendage (LAA) occlusion procedures in our EP lab, but we are presently initiating a program with our interventional cardiology colleagues.

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

We use the WorkMate Claris Recording System (Abbott) in each lab with its associated stimulator. Each lab is also equipped with the EnSite Precision Cardiac Mapping System (Abbott), CARTO 3 and CARTOSOUND (Biosense Webster, Inc., a Johnson & Johnson company), Rhythmia Mapping System (Boston Scientific), and the Topera System (Abbott). We use catheters from all three companies, but our most popular catheters are the bidirectional TactiCath Quartz Contact Force Ablation Catheter (Abbott), FlexAbility cardiac ablation catheter (Abbott), and Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott), as well as the Arctic Front cryoballoon (Medtronic) and THERMOCOOL SMARTTOUCH SF Catheter (Biosense Webster, Inc.). A large volume of our device implants are from Medtronic, with whom we also live-stream device implant procedures (both high power and His bundle pacing cases) for their virtual preceptorship program.

Who manages your EP lab?

Our lab is managed by Noreen Gorero, RN.

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

Our device clinic is staffed by Dr. Jeffrey Kluger (director), one nurse practitioner, and four highly trained registered nurses. Our clinic is unique in our region to the extent that they perform device checks and programming changes for the inpatient population, operating rooms, and MRI at Hartford Hospital for all device brands. In addition, our staff is responsible for the remote monitoring of outpatient clinic patients as well as follow-up and monitoring appointments at Hartford Hospital and remote locations throughout the greater Hartford region.

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

We have been increasing our volume of His bundle pacemakers, which has significantly improved the well-being of our pacemaker-dependent patients. Additionally, we are participating in the Medtronic ECG Belt study, which aims to optimize LV lead placement in CRT implant procedures to improve response to therapy in patients with more non-traditional indications for CRT (ie, more narrow LBBB or RBBB patients).

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

Our nursing staff begins their work an hour before our first case of the day. During that time, they prepare the labs for the day’s work, and communicate with the team covering the hospital’s electrophysiology service to ensure prompt and prioritized scheduling of emergent or add-on cases that have presented after hours. Our staff is constantly in communication with our physicians to facilitate proper equipment, supply, and staffing allocation for each case. The team conducts a daily “huddle” during which we apply LEAN process management techniques to find ways to improve our efficiency, reduce our costs, and optimize our delivery of care. All staff participate in this process.

How do you ensure timely case starts and patient turnover?

Through our LEAN process management, we take responsibility as a team and as individuals to ensure that our goals are not only met, but are constantly being monitored for improvement. Through this process, our room turnover is typically under 30 minutes. When we do not meet our goal, root causes are identified and we work to eliminate or mitigate those causes in future.

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

The best feature of our lab’s layout is that all of our lab spaces are equipped to handle any and all cases. The nursing staff has spent a great deal of time organizing each of the labs, so they are nearly identical in terms of where items are stored. They also maintain specific par levels of frequently used items and emergency supplies. In addition, all three labs are situated in a common unit with quick and easy access between individual labs and our storeroom, as well as being directly adjacent to our pre- and post-op units.

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

Our team aggressively contains costs in the lab by reprocessing used catheters as well as utilizing reprocessed equipment. We take great care with our equipment to prevent costly repairs and reduce downtime related to equipment failure. 

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

Our staff has access to continuing education, including coursework toward RCES and other certifications related to cardiology and electrophysiology for our more experienced staff members. Our team of vendors is also very involved in staff development, providing after-hours educational opportunities, simulations, and lectures.

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

We had performed an innovative technique for accessing the epicardium in a particular high-risk patient who was in need of epicardial ablation. A balloon-tipped catheter was inserted into the right atrium, where it was positioned into the distal end of the appendage. The sharp end of a 0.014˝ guidewire was then inserted in the lumen of the balloon catheter to make a small perforation in the atrial appendage, and a microcatheter was advanced over this wire into the pericardial space. Carbon dioxide gas was then injected through this microcatheter to temporarily create a large gas space within the epicardium. This allowed for safe and successful needle and guidewire access from the subxiphoid region with minimal risk of RV injury with the access needle. This also allowed the physicians to see the pericardium separate from the epicardial LV pacing lead, which is where the focus of VT was successfully ablated.

What can you tell us about your His bundle pacing cases? 

Our volume of His bundle pacers has increased steadily over the past few years. We have also broadcast several His bundle pacemaker implantations via the Medtronic virtual preceptorship program. 

Does your program have a dedicated atrial fibrillation clinic? 

Yes, at the Atrial Fibrillation Center at Hartford Hospital, we have developed relationships across multiple disciplines to provide comprehensive care for our patients based on best practice standards and current research.

Discuss your methods for lifestyle modification as therapy for your patients with AF.

All of our patients within our AF population receive counseling and education about increasing physical activity and the importance of regular exercise, healthy diet, and reduction of behaviors that contribute to or increase risk of episodes of AF. We work with the patients and their referring MDs to help better control blood pressure and maximize their medical therapy. Patients are typically screened for obstructive sleep apnea (OSA) and are encouraged to participate in treatment if they are positive for OSA.

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

All of our physicians utilize the lowest frame rates and radiation settings that their procedures will allow. We are increasingly depending more on our mapping systems as opposed to fluoroscopy, and have been completing some of our cases without any fluoroscopy at all. In the future, we expect to see this trend continuing and further improving.

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

In the future, we will likely see a lot more ablations for ventricular tachycardia as the data supporting the efficacy of those cases becomes more robust. An aging population with more complex health needs will likely create an uptick of patients requiring ablations for AF, which is already our largest area of growth.

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

In our clinic, many patients with symptoms of palpitations who lack documentation of their arrhythmia are encouraged to utilize a digital device. Many use the Apple Watch, and recently, many have been relying on the KardiaMobile (AliveCor) for its convenience and significant cost savings for the patient. We have also instituted a telehealth program for wound checks after device implantation for our patients. All patients are offered a telehealth visit a few weeks after their device procedure, which allows them to send a remote device transmission and visit virtually with one of our APRNs. This has resulted in improved patient satisfaction, as many of our patients need to travel long distances to see us in our clinics. It has also resulted in improved clinic efficiencies, giving our staff more time to see patients who really need to be seen in person. We have plans to expand the use of telehealth to provide EP consultations to our patients who live a distance from one of our offices.

What trends have you seen in your procedures and/or patient population?

We have certainly noticed the trend of an aging population with increasingly complex healthcare needs and increased risk. In the future, it is all but certain that we will be performing procedures on patients of more advanced age with greater needs. We have also seen an increase in the number of AF ablations that we are performing.

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

What makes our lab special is our highly dedicated team of career professionals who work collegially across multiple disciplines to deliver high-quality coordinated care and patient experience. 

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