In the next episode of The EP Edit podcast, we speak with Dr. Jose Osorio, medical director of the EP lab at Grandview Medical Center in Birmingham, Alabama, about his techniques for eliminating the use of fluoroscopy in EP procedures. Enclosed here are the edited transcripts of the podcast.
Tell us about your EP program at Grandview Medical Center.
When Grandview Medical Center opened in 2015, we initially had two EP labs. However, within six to nine months, we had four EP labs. We have a total of six electrophysiologists, with four doing atrial fibrillation (AF) ablations and two primarily doing device implants. We have a staff of 10 techs and 10 nurses, and the labs are also staffed by CRNAs and anesthesiologists for every procedure.
How long have you been utilizing a zero fluoro approach?
The first zero fluoro ablation I performed was in 2010. It was a pregnant woman in the second trimester with incessant RVOT ventricular tachycardia. I had to look for techniques to safely do the ablation, and mostly using 3D mapping, I was able to do it. From that point, I started using zero fluoro techniques for less complex procedures, and then for AF ablations. What that allowed me to do was practice putting in the diagnostic catheters without fluoro, and then I would use fluoro for transseptal access; I then got to the point where I did not need fluoro once transseptal access had been obtained. For probably two to three years, I was limiting fluoro. I made a strong effort to limit it, but was using about one or two minutes for my AF ablations. In 2013, I started performing atrial fibrillation ablations entirely without fluoroscopy, so for six years I’ve been consistently doing all of my procedures without fluoroscopy.
What makes you passionate about this technique? Why is a zero fluoro approach important?
There are several aspects about this that interest me. Once you understand intracardiac echo and 3D mapping and you learn the techniques to do a zero fluoroscopy approach, I think it is actually safer than doing with fluoro. I think this is something you achieve as a natural progression of learning this technique — I don’t think you walk into the lab with the idea that you are not going to use fluoro one day. You should first try to reduce, and at some point, if you find you are constantly asking yourself if you need fluoro for this step of the procedure, what you are going to find is that you don’t. When using fluoro, we are largely using the cardiac silhouette, which is not representative of the left atrium. We’re spectators of watching catheters bend when pushing something, so all of the steps can be removed. Fluoro adds safety when using wires and going transseptal, but as you become proficient with intracardiac echo, that step can be safely eliminated. Once an operator becomes really proficient with zero fluoro, it adds safety by simply becoming very good at navigating with intracardiac echo and 3D mapping. Moreover, one of the reasons for being passionate about this is because the lead apron is no longer needed for doing procedures. To walk into a procedure without a lead apron, and to have your entire staff not having to wear the lead apron every day, I think improves our quality of life as well. This is for the health of not just the patient, who is no longer being exposed to radiation, but it’s also important for us to not be exposed to radiation and not have to deal with the problems that can be created by years of using a lead apron.
Can you describe your technique utilizing a zero fluoro approach during a typical case? Has your technique evolved over time?
Starting from access, if we obtain access and there are any issues getting the catheters from the leg up to the heart, we exchange the sheaths to long sheaths. We always have long sheaths available. We use intracardiac echo for atrial fibrillation and ventricular tachycardia ablation procedures most of the time. Once the ablation catheter is in the right atrium, the first step is to obtain some key anatomical landmarks, and I like to start by tagging the His. If I have a CARTOSOUND catheter (Biosense Webster, Inc., a Johnson & Johnson company), then we also like to trace the aorta and sometimes the coronary sinus. It’s important because once you obtain the His, it’s easy to find where the coronary sinus is and then perform the 3D rendering of the coronary sinus to position diagnostic catheters and the quadripolar catheter. So starting by tagging an anatomical landmark and then positioning diagnostic catheters is a step that can be challenging to learn, but I think it’s an important step. It can be done safely in most of your procedures, and you will be training in this technique of zero fluoro in a really important way. Then, to obtain transseptal access, the most important part is to become proficient with intracardiac echo. I think a lot of operators tend to use intracardiac echo to simply visualize the fossa, but you have to get away from that and really try to use intracardiac echo to look at the entire cardiac anatomy and get good visualization of the SVC, and then use that to push the wire and transseptal sheath. With this view, we can also watch the transseptal apparatus being pulled back into the fossa — performing transseptal access without fluoro becomes safer that way. Once we are transseptal and in the left atrium, then we start with the 3D reconstruction of the left atrium using a multipolar catheter. For the ablation, what has really made the zero fluoroscopy technique safer is the fact that we now use contact force sensing catheters 100% of the time. The more important tools we have today for zero fluoroscopy would be intracardiac echo, the 3D mapping systems, and finally, contact force sensing catheters.
As a high-volume center, how do you optimize the AF ablation process? What key aspects of workflow before, during, and after a zero fluoro ablation procedure have helped to drive efficiency?
We have been looking at efficiency as a key aspect of our program, and it was achieved as part of a quality improvement process. We have been adhering to Lean Six Sigma standards and methodology to improve our efficiency. The first step we have today is the careful planning of the procedures that are scheduled. We always try to have a few initial cases in the day that are not going to be AF ablations, so that they are easier to prep for the team. For example, we may start our day with a device or an SVT ablation or PVC ablation followed by the AF ablations. There is careful planning for every day of our procedures, and it starts with our lab manager arriving at Grandview at 4:30 AM, looking at the cases and mapping them out, and assigning to each room a team of two technicians, a nurse, and a CRNA (we also have one or two nurses that float). Once the team is assigned, our techs will start prepping the table for the particular case. So once the patient is coming into the room, we have established standards and goals for every step of the patient journey — I think that was an important first step. For example, the first patient gets to the hospital at 5:30 AM, gets into pre-op at 6, and this is what we want. At 6:45, they are transported to the EP lab with the goal of starting the first procedure at 7 AM. It’s careful planning to get to that level. Another important aspect is the working relationship we have with our anesthesia colleagues — they are truly part of our team. We try to have a patient entering the room and ready to start a procedure within 15 minutes. The only way to do that is having the anesthesia and EP lab team working together. At some centers, the steps are done one after the other. We do things concurrently, so as the patches are being put onto the patient’s chest and back, the anesthesiologist and CRNA are starting to work with the patient, and we do all of it together. After the procedure, it’s the same with the recovery of the patient. It’s all happening at the same time — we’re both getting a patient ready and getting a patient out of the room. We have established a goal of 15 minutes so that we have a 30-minute room turnover time. For that to happen, the only way is with the close communication and collaboration with the anesthesiologist and nurse anesthetist. We start recovery prior to the procedure being ready, we make changes to the propofol rate, and also change the ventilator setting so we have a quicker extubation time. One thing that has also significantly increased efficiency for us is that the patients that were intubated in the EP lab no longer go to the PACU. Instead, in our EP and cath lab prep and recovery area, we have trained all of our nurses in PACU, so the post-anesthesia recovery now happens at the prep and recovery area from the cath and EP lab. That has significantly shortened the time that it takes for our nurses and nurse anesthetists to get back to the room, so they can get to the prep and recovery area, give a report, and get back in a few minutes as opposed to 30-45 minutes because they had to give a report to the nurses in the PACU area. I would summarize that to improve efficiency, what we have done is really careful planning of the day, so by 4:30 AM someone is looking at the schedule and mapping it out. On top of that, we have great collaboration with not only our staff, but the nurse anesthetists and anesthesiologists in the different parts of the hospital as well. We sat with them and established the goals for each step of the patient journey, and try to abide by it.
What are your techniques for maintaining safety during a zero fluoro approach?
As I started doing atrial fibrillation ablation without fluoro in 2013, the first thing that we did shortly thereafter in early 2014 was to create our own database and start monitoring all AF ablations for safety, and then follow up with patients for one year to look at success rates. I think that is key, because in as much as I am a firm believer that zero fluoroscopy can improve safety, I’m not advocating for anyone to simply walk into the lab and eliminate their fluoroscopy. I think this has to be done in a step-wise approach, and it starts with the willingness to follow the outcomes and make sure there is not an increase in complication rates. So we started by making sure we were following our outcomes, monitoring not just interprocedural complications, but also monitoring success rates. We have many of the processes now that we did during our accreditation back in 2015 and early 2016, when we looked at all of our protocols and made sure we had protocols for emergencies and cardiocentesis protocols. We really used the process of the IAC as the time to look at everything we had here in place, and made sure that the entire staff was well trained to handle any potential complications. I think the key is monitoring, and making sure as you are going to change a technique and change how you are doing the AF ablation, that you are monitoring to make sure there is not an untoward consequence from that.
What do you believe is limiting widespread adoption of catheter ablation of atrial fibrillation with a zero fluoro approach?
The zero fluoro approach is spreading in a safe way as more physicians are slowly adopting it, which is good. We’ve had a few hundred physicians visit us to watch this technique, and I would say that a large number have now adopted zero fluoroscopy. That is true for other centers in the country that have received visitors as well, but there are still some that don’t believe. They believe it is unsafe, and I think that has to do with that fact that they were trained using fluoroscopy for largely all EP procedures, so this is a paradigm shift. There are obviously physicians that have a great technique utilizing fluoroscopy, have truly leveraged that to improve safety, and have done so for 20-30 years, that for them it’s hard to understand why they should change. With that said, the concept of ALARA, the risk of radiation, and the orthopedic burden of wearing lead is becoming more evident for all of us as AF ablation becomes the number one procedure we do. A lot of the time, wearing lead continues to increase for many operators, and they are seeing the effects that wearing lead for 10 hours a day can have on their bodies. Along with the risks of fluoro, I think there is a really significant incentive now for many to learn. I think there has been good progression. We now have a zero fluoro consortium of operators that have been doing this for many years who are trying to look at ways to spread the word to educate physicians on this. There was recently a book published by Drs. Mansour Razminia and Paul Zei on the techniques of zero fluoroscopy — that book has a fantastic amount of information. There are online educational modules for those that want to learn. There are also opportunities for visiting labs as more physicians are using this technique. So there are ways to learn. I think the barriers are slowly being peeled away.
Is there anything else you’d like to add?
To finalize, I think it is key to highlight the important resources that we have today, that so that physicians that want to engage in this journey of reducing fluoroscopy know that a book on this is available, a lot of webinars are available, and they can also visit the centers that are performing this approach. I believe that is the safest way to start this journey of fluoroscopy reduction.
Disclosures: Dr. Osorio has no conflicts of interest to report regarding the content herein. Outside the submitted work, he reports that he is a consultant for Biosense Webster and Boston Scientific.