Spotlight Interview: Massachusetts General Hospital

When was the EP lab started at your institution?

Dr. Jeremy Ruskin is the founder and director of the MGH Cardiac Arrhythmia Service and Clinical Electrophysiology Laboratory, the first subspecialty service dedicated to the care of patients with cardiac arrhythmias in New England. Since its inception in 1978, this service has been dedicated to excellence in clinical care, the training of fellows in clinical cardiac electrophysiology, and research on the mechanisms of and innovative therapies for the treatment of cardiac arrhythmias.

What is the size of your EP lab facility and number of staff members? What is the mix of credentials at your lab?

The MGH Cardiac Electrophysiology Lab is among the most clinically active and academically productive arrhythmia services in the world. Since 1997, a number of extremely talented new staff members have joined the MGH Cardiac Arrhythmia Service. These individuals have all established themselves as skilled proceduralists and productive independent investigators. In addition, the Pacemaker Service, formerly independent, was officially integrated into the Cardiac Arrhythmia Service in 2000, expanding substantially the clinical volume and responsibilities of the service. With this expansion, the service has grown to seven attending physicians, six clinical and research fellows, 10 nurses and a full-time clinical engineer, as well as a large research group.

What types of procedures are performed at your facility?

Over the past five years, the MGH Cardiac Arrhythmia Service has emerged as the leading referral center in New England for its pioneering work on catheter ablation for atrial fibrillation (AF). Other evolving areas of therapeutics in which the service is active include biventricular pacemaker/defibrillator implantation for patients with advanced congestive heart failure and catheter ablation for drug-resistant ventricular tachycardia (VT). In addition to early-stage research on new devices and energy sources for catheter ablation and new approaches to MRI-CT guided ablation, the MGH Cardiac Electrophysiology Lab is engaged in a large number of active clinical research protocols in the areas of catheter ablation, device therapy for arrhythmias and CHF, and new antiarrythmic drugs.

What are some of the new equipment, devices and products introduced at your lab lately? How has this changed the way you perform those procedures?

With three newly renovated procedure rooms, we are proud to be the first lab in New England to work with the ARTIS-NIOBE Stereotaxis Magnetic Navigation System with Siemens Axiom Xray as well as the new Philips Integris System with three-dimensional rotational imaging. With this new state-of-the-art technology, we are capable of performing a wide variety of increasingly complex and demanding diagnostic and interventional procedures with greater safety, efficacy and efficiency, particularly in the areas of catheter ablation for atrial fibrillation and ventricular tachycardia as well as cardiac resynchronization therapy.

What type of quality control or quality assurance measures are practiced in your EP Lab?

The EP lab staff is a highly skilled and dedicated team. With larger staff-to-patient ratios, we ensure the highest quality and safest patient care. We follow our patients closely, from initial pre-procedure phone calls to follow-up calls after discharge. This service helps monitor patients progress after complex procedures, alleviates anxiety and concerns of patients and families, and maintains continuity while increasing patient satisfaction.

Is your EP lab currently involved in any clinical trials or special projects?

The Cardiac Arrhythmia Service has a large clinical research team. The clinical research efforts involve both investigator-initiated as well as industry-sponsored research studies. The spectrum of research ranges from studies on the genetics of lone atrial fibrillation to new drug and catheter ablation therapies for AF and VT. The use of MRI/CT to guide catheter ablation procedures, a technique developed by Dr. Vivek Reddy at MGH, is currently being used to guide clinical AF ablation procedures. This technique, known as image integration, has revolutionized the way in which we approach complex catheter ablation for AF and is expected to be applied to VT ablation in the near future. Our group is also involved in several multicenter device trials for both bradycardia and tachycardia indications. Some of the ongoing studies include the ABCD trial, LIFE study, and BLOCK-HF. On the cardiac resynchronization therapy front, we are active participants in the ongoing RHYTHMICD, HRV-CHF Registry and soon to start MADIT-III study. We have state-of-the-art equipment, inclusive of Stereotaxis, rotational venography and three-dimensional echocardiography, which are all being studied in independent clinical projects to help better understand and facilitate cardiac resynchronization therapy. Additionally, we have several ongoing basic and clinical studies directed at optimizing patient and lead site selection for cardiac resynchronization therapy.

What trends do you see emerging in the practice of electrophysiology?

The results of the MADIT-II, SCD-HeFT and COMPANION trials have fueled a substantial growth in the use of prophylactic ICD therapy in high-risk patient subsets. It is anticipated that ICD and CRT-D device implantation procedures will continue to grow at a significant rate over the next five years. In addition, because of the leadership role of the MGH in the area of non-pharmacological therapy for atrial fibrillation, catheter ablation procedures for AF continue to grow at a rapid rate. Our work with the ARTIS-NIOBE Stereotaxis Magnetic Navigation System has also convinced us that robotic catheter navigation will play an increasingly important role in interventional electrophysiology procedures in the future.

How are new employees oriented and trained at your facility?

The training program in Clinical Cardiac Electrophysiology (CCE), which Dr. Ruskin founded in 1978, was among the first EP training programs in the country and has graduated 77 fellows to date. The senior staff of the MGH Cardiac Arrhythmia Service supervises the training of both clinical and research fellows and meets regularly with the fellows for formal clinical teaching rounds and core curriculum conferences. Staff members serve as mentors and advisors to the fellows as they prepare to enter careers in clinical electrophysiology. A majority of fellows who have trained in the MGH CCE program have pursued careers in academic medicine and now include directors of cardiac arrhythmia services and electrophysiology laboratories at more than 30 academic centers worldwide. Nursing orientation is individualized and customized to the needs of the nurse. With exceptional resources and the extensive knowledge base of our current senior nurses, the new orientee receives a well-rounded training in clinical cardiac electrophysiology.

What procedures do you perform on an outpatient basis?

Most simple catheter ablation procedures for supraventricular tachycardia as well as some device implantations and all pulse generator replacement procedures are performed on a bedded outpatient basis. The complexity of current pacemakers and implantable defibrillator technology results in the need for more regularly scheduled patient follow-up. Our outpatient PACER/ICD Clinic is conveniently located next to the EP lab and physicians offices. The device clinics conduct more than 3,500 patient visits annually.

Please tell our readers what you consider unique or innovated about your EP lab and staff?

With 56 members of the MGH Cardiac Arrhythmia Service staff, we pride ourselves in a 26-year history of providing the highest quality and most advanced care to patients with cardiac arrhythmias. Our skilled and experienced staff is dedicated to the well-being of our patients and their families and committed to our mission of excellence in clinical care, research and training the next generation of electrophysiologists in a safe, innovative and supportive environment.