Implementing a Stereotaxis Program: Interview With Dr. Hetal Bhakta

In this interview we speak with cardiac electrophysiologist Dr. Hetal Bhakta from Desert Regional Medical Center about his use of Stereotaxis technology. Desert Regional was also one of the first hospitals in the U.S. to implement the Ablation History software module in its Stereotaxis lab.

Can you first give us a brief introduction about your background?

I trained at USC for my internal medicine and cardiology fellowships, and then trained at the Kaiser/UCLA program for electrophysiology. After that, I started the electrophysiology program here at Desert Regional Medical Center in Palm Springs, California in 2010. In the past four years, with strong support of the hospital and local physicians, we have been able to develop a comprehensive electrophysiology program with a dedicated state-of-the-art electrophysiology lab.

How did you become interested in electrophysiology, and where did you receive your fellowship training?

I was always on the interventional track, up until the last part of the second year of fellowship in cardiology. I did the electrophysiology rotation at Kaiser and really loved the science behind it. I enjoyed the thinking that it involved during the case, and I enjoyed the fact that EP was a young field that was going to evolve over time. As far as the interventional field, those technologies have already evolved pretty thoroughly. However, EP was just starting to see its uptick in terms of new technologies and tools becoming available for more complex arrhythmias, making it easier for physicians to deliver better therapy and get better results.

Were you exposed to Stereotaxis technology during your fellowship training?

No, I wasn’t.

Can you briefly share some background information regarding your hospital and its electrophysiology program?

There was no electrophysiology presence at Desert Regional Medical Center prior to my arrival. When I came here in 2010, the hospital purchased some basic lab equipment such as the mapping and recording systems to start the EP program.
In my first year, I focused heavily on education of the medical staff in the hospital and the outpatient physician community about the expanded capabilities in treatment for patients suffering from arrhythmias. Next, with hospital support, we also raised significant awareness amongst the patient population regarding the available options for management of heart rhythm disorders. We also hired an experienced EP nurse and EP scrub technician. The other members of the EP team were identified during cross training of the cath lab staff. As our program started to grow, we decided to invest in a dedicated EP lab.

What is the number of techs, nurses, and electrophysiologists?

I am the only electrophysiologist here at Desert Regional. We also have a core team of five nurses and technicians that make up the EP team.

What factors were considered when choosing to implement a Stereotaxis Remote Magnetic Navigation program at Desert Regional Medical Center?

When we started the program, as I mentioned before, we bought only the basic mapping and recording systems. As our program grew, we decided to invest in a dedicated EP lab. We wanted to build a state-of-the-art lab with technologies that would enhance our capabilities to perform EP procedures. We looked at different technologies which included a biplane room, robotic technologies, and a Stereotaxis lab. Of all these technologies, I believed Stereotaxis showed the best promise in terms of what it could deliver. I was also particularly impressed with their safety profile compared to the other robotic technologies. Their precision and navigation accuracy was also far superior.

What Stereotaxis technologies are available in the lab? For example, tell us about the Ablation History software module and the benefits it provides when treating your patients?

We have the most advanced types of technology that Stereotaxis delivers. More recently, we started utilizing the Ablation History module, which is a new tool that helps us assess how much power is delivered and at what exact location in the heart. That is critical, because in cases where we deliver a lot of RF applications, we have to go back and look at areas that might not have been completely ablated. Ablation History is a powerful tool that allows for a quick assessment to pinpoint areas where significant energy might not have been applied. This helps us quickly identify locations that might be the areas of leak where the tissue is not completely ablated. This has helped decrease our mapping time post ablation, thus shortening our procedure times.

How many cases do you perform using Stereotaxis each week? For what types of arrhythmias do you treat using Stereotaxis?

We perform about 4-5 cases a week with Stereotaxis. At our hospital, we perform all types of electrophysiology procedures, from simple SVT ablations to complex arrhythmia ablations. We use Stereotaxis for our complex ablation procedures that require 3D electroanatomic mapping, such as complex left atrial procedures, atypical flutter, ventricular tachycardia, atrial tachycardia, accessory pathway, and PVC ablation.

How has implementing a Stereotaxis program at Desert Regional Medical Center advanced your capabilities in the treatment of complex arrhythmias?

Using Stereotaxis has definitely made a big impact on our program. Prior to Stereotaxis, we were doing 2 complex ablations a week. This has increased to 4-5 cases per week. With Stereotaxis we have been able to perform more ablations because of shortened procedure times and because there is less operator fatigue associated with long procedures. Use of the Stereotaxis system has also allowed us to access difficult-to-reach areas with more ease compared to manual ablation.

What decisions have you or your hospital made that have contributed to the success of your Stereotaxis program?

When you implement new technology like this, you have to really want to understand the technology and be open to investing the time up front to make the most use out of it. When we initially started the program, I had made the conscious decision to do an “all or nothing” approach. What I mean by this is that for the initial cases, Stereotaxis recommends operators use their system for 90 minutes before converting over to a manual approach. However, from the beginning, we have been doing complete cases with Stereotaxis. To date, I believe there has been only one case in which I had to switch over to a manual catheter, and that was very early on (our third case). The cases initially took longer compared to manual approach, but the procedure times were comparable to a manual approach after 15-20 cases. Today, I find that the complex cases are much faster with Stereotaxis than with the manual approach.

Have you been able to increase awareness of your EP program by offering treatment with Stereotaxis?

Yes, that has increased quite a bit. When I started in Palm Springs, most of the ablations were being sent out to tertiary centers a hundred miles from here. Once we started doing the complex arrhythmias at Desert Regional, the majority of people in our area now get their treatment here instead of having to travel far from where they live. With the increased awareness of the available ablation therapies for arrhythmias in our area, more and more people are opting for ablation over lifelong medications.

Has this allowed you to still attract patients from outside your primary market?

Yes, we’re starting to see that. Our Stereotaxis lab has been open for about a year at this point, and as awareness grows, we’re seeing more people from outside our market attracted toward this kind of technology, especially nowadays where people are more savvy about identifying different options they have in terms of treatment.  

What advice about Stereotaxis would you give to physicians preparing to pursue an EP fellowship or those nearing the end of their fellowship?

Stereotaxis is a powerful and precise navigation system which can make your cases a lot easier if you utilize the technologies embedded in it to their potential. The system is easy to learn, and the learning curve is not very long if you commit the time up front. So my advice for someone in fellowship is to focus on learning the fundamentals of electrophysiology. As our field advances, it is our understanding of arrhythmias that guides us to utilize the new technologies such as Stereotaxis to deliver therapies more effectively and efficiently for our patients.

For those physicians who are considering implementation of a Stereotaxis program, what would you say to them?

My recommendation to a physician considering a Stereotaxis program would be to invest the time up front in terms of understanding the technology and using it to its best potential. Each member of the team should be identified to learn a particular task of the workflow to make the process efficient. I would strongly recommend scheduling only one case per day for the first 7-8 cases, in order to understand the workflow and analyze each step in the process. Scheduling the initial 15-20 cases in a 4-6 week period will allow you to efficiently move through the learning curve — you will be able to continually analyze and change the process to make the technology work with your lab processes. In the beginning, we scheduled 5 cases in 5 consecutive days, then another 10 cases over the next 3 weeks. By 4 weeks, our procedure times had improved to the point where they were faster than our manual ablation times. In our case, we had a learning curve of about 15-20 cases, after which the comfort level was pretty good and our lab was able to operate the system without the need for extensive support from the company. That is because as a team we invested the time up front, and each step of the process was identified, thoroughly analyzed, and learned. ■

Disclosure: The author has no conflicts of interest to report.