Spotlight Interview: Iowa Heart Center

Iowa Heart Center’s Heart Rhythm Center was established in 1989, performing ablations and device implants. In addition, we have been performing left atrial appendage occlusion device therapy for 6 years. Our program for atrial fibrillation ablation started in 1999.

Iowa Heart implants more pacemakers and defibrillators as well as performs more ablation procedures than any group in Iowa. Its electrophysiologists are also national leaders in evaluating new devices and treatment options for their patients through participation in clinical research trials. In addition, Iowa Heart has developed a regional referral program for lead extraction procedures.

The electrophysiology (EP) labs at Mercy Medical Center-Des Moines and Mercy West Lakes, where the Iowa Heart Center performs the majority of its procedures, were the first labs in the nation to earn accreditation in cardiac EP by the Intersocietal Accreditation Commission (IAC).

The three-year term accreditation applies to testing and ablation, chronic lead extraction, and device implantation.

What is the size of your EP lab facility?

Our main campus has 3 EP rooms: one is for device implants only, and the other 2 are used for EP studies, ablations, device implants and extractions, and left atrial appendage (LAA) procedures. Our smaller campus, Mercy West Lakes, has 1 EP room for EP studies, ablations, and device implants.

What types of procedures are performed at your facility? 

We perform EP studies, all cardiac ablations (cryotherapy and radiofrequency), LAA closures utilizing the LARIAT (SentreHEART, Inc.) and WATCHMAN device (Boston Scientific), all device implants (including transvenous and leadless pacemakers, as well as ICD and subcutaneous ICD implants), insertable loop recorder implantations, and device extractions.

Has your EP lab recently expanded in size? 

We recently upgraded one lab to a hybrid room to be used for lead extraction procedures as well as LAA procedures. We currently have a second hybrid lab under construction. 

Approximately how many catheter ablations (for all arrhythmias), ICD and pacemaker implants, and LAA closures are performed each week or month? 

We perform approximately 10 ablations and 20 ICD/pacemaker implants per week, and 6 LAA closures per month. 

What are your techniques for LAA occlusion? Do you have a primary approach?

The LARIAT (SentreHEART, Inc.) and WATCHMAN device (Boston Scientific) are our preferred approaches. LARIAT procedures are primarily offered through the aMAZE clinical trial. In selected cases, our surgeons also perform minimally invasive LAA ligation or utilize the AtriClip (AtriCure, Inc.).

Who manages your EP lab? 

Angie Oakie, RN, BSN, MHA is our nurse director for both our Mercy Main and Mercy West Lakes campuses. Karen Burdick, RN, BSN is our nurse manager for our Mercy West Lakes campus, and Sawyer Bowers, BS, RT(R), RCIS is the Mercy Hospital Manager-Staff Educator.

What is the number of staff members? What is the mix of credentials at your lab?

Our EP staff includes 3 RNs and 6 cardiovascular technicians. We also utilize radiology technicians who float between the cath and EP labs to help with cases. 

Are employees cross-trained? 

Yes, our dedicated EP labs are adjacent to the coronary labs. We have a separate group of 3 principal EP lab staff dedicated only to EP; they do not work in coronary cases and do not take cath lab call. Several of the nursing and radiology tech staff are mostly dedicated to EP, but do rotate in the cath and EP labs, and are part of the interventional call pool.

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

Mercy is a community hospital and regional tertiary referral center. We have residency programs in internal medicine, family practice, and general surgery. We are also actively developing a cardiology fellowship program. Mercy is the flagship hospital for the Mercy Health Network, which is a statewide system of 15 other community hospitals — many with their own cardiology programs.

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

We have 3 WorkMate Claris Recording Systems (Abbott). We have 3 EnSite Precision Cardiac Mapping Systems (Abbott) and 1 RHYTHMIA Mapping System (Boston Scientific). We use catheters from Medtronic, Abbott, and Boston Scientific. We have 2 cryoablation consoles (Medtronic).

What new technology has been recently added to the EP lab? How have these technologies changed the way you perform procedures? 

The RHYTHMIA Mapping System (Boston Scientific) is our newest addition. We also recently upgraded to the latest EnSite Precision Cardiac Mapping System (Abbott). There has been a steady decrease in our mapping and ablation times due to increased mapping speeds and more effective ablation lesion creation.

What imaging technology do you utilize? 

We use biplane fluoroscopy (Siemens Healthineers), intracardiac echocardiography (Zonare/Mindray), the Site~Rite Ultrasound System (Bard) to obtain vascular access, and transesophageal echocardiography (Philips). 

How is shift coverage managed? What are typical hours? 

Our staff is scheduled from 0700-1730. On days when our cases run late, our EP staff will stay to finish those cases. There is no callback involved for our EP staff.

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

On a typical day, complex ablations will be taking place in 3 rooms, and a device implant will be taking place in an additional procedure room.

Who handles your procedure scheduling? Do they use particular software? 

Our clinic’s full-time procedure scheduler, Donette Ramsey, schedules patients through Caris, which is our scheduling and data collection system.

How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?

We have both an inventory specialist and an inventory manager that work closely with our physicians and EP cardiovascular techs as well as our Purchasing department.

What type of quality control/assurance measures are practiced in your EP lab? 

We have monthly EP provider meetings to review complicated cases, adverse outcomes, and plans for future growth. Colleagues share complex cases with the team for review. We review every ICD, BiV ICD, and BiV pacemaker for appropriate implant criteria prior to device implant. We participate in the NCDR AFib Ablation, ICD, and LAAO Registries. 

How has managed care affected your EP lab and the care it provides patients? 

There has been a steady increase in the difficulty to provide evidence-based care to patients as insurers set their own definitions of what technologies are considered investigational, even if they are FDA approved and considered appropriate in society guidelines. There are also increasing barriers to receiving payments for services rendered due to constant changes in reimbursement criteria from year to year. The trend of managed care providers is to delay new care technologies as long as possible until the technology becomes cheaper.

Have you developed a referral base? 

Yes, throughout the state of Iowa, we have a very large referral territory, largely due to outreach clinics and a favorable public opinion. Our EP physicians currently service 7 locations outside the metro Des Moines area. 

In what ways have you helped to cut/contain costs and improve efficiencies in the lab? 

We formulated physician preference cards to help guide staff with different procedures and pulling of equipment. We have tried to standardize several procedures between the different physicians so that equipment, disposables, staff expectations, and case duration are more predictable. 

We also have monthly meetings with the anesthesia physician lead to discuss ways to improve efficiency between our lab and their staff. 

Catholic Health Initiatives (CHI) supply chain negotiates contracts nationally to help manage supply costs.

How do you ensure timely case starts and patient turnover? 

We have monthly meetings between anesthesia, our EP physicians, and the EP scheduling department to discuss our start times and patient turnover times. We continue to work with staff to ensure timely room turnover time. We have also added additional help for staff from our coronary team to get the first patient prepped and started on time. In addition, we have recently assigned a member of the staff in each room as the key coordinator for the cases scheduled in the room that day — as a result, we have seen some significant reductions in case turnover times. They also help to coordinate lunch breaks and stay in communication with anesthesia and the EP physician. We encourage regular communication between physician staff from anesthesia and the EP physician scheduled to that room, so that they are all on the same page about the patient flow.

Does your EP lab compete for patients? 

There are other EP programs in our area, but we are the only program offering a full range of services including LAA closure, lead extraction, and the latest clinical trials for device and ablation therapy.

How are new employees oriented and trained at your facility? What types of continuing education opportunities are provided to staff members? 

We train our own staff. We also have in-services given to staff by company reps throughout orientation, and provide ongoing continuing education as needed.

Each year, we send our staff to the Heart Rhythm conference. We are also blessed by our talented EP physicians, who provide one-on-one and group continuing education to our EP lab and office clinical staff.

How do you handle vendor visits to your department? 

Vendors are only in the department when they are requested for a case or for in-servicing. 

Does your lab use a third party for reprocessing or catheter recycling? 

We have started to send our catheters out, but we currently do not use any reprocessed catheters. 

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

We do approximately 39% RF, 55% cryo, and 16% both. More than 80% of our atrial fibrillation ablations are done with cryoablation. Around 50% of our cryoablations are for AVNRT or paraseptal pathways.

What are your thoughts on the use of NOACs in patients with non-valvular atrial fibrillation? 

We extensively utilize NOACs for non-valvular atrial fibrillation, primarily based on evidence of less intracranial bleeding and more ease of use compared to warfarin. Many of our warfarin-treated patients do weekly home-based INR testing, which we believe has led to increased time in therapeutic range (TTR).

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution? 

We have evaluated the hybrid epicardial approach, but have decided not to pursue it at this time. For selected cases of persistent atrial fibrillation, we routinely perform LA posterior wall isolation using endocardial catheter ablation, rather than utilizing the epicardial hybrid approach.

Our cardiothoracic surgeons are very accomplished with the Cox-Maze IV procedure, and have been successfully performing this for many years. 

Do you utilize lifestyle modification as therapy for your patients with atrial fibrillation?

Absolutely, we highly encourage all of our patients with atrial fibrillation to be evaluated for sleep-disordered breathing and weight loss counseling consistent with the robust literature that has highlighted the importance of these conditions on the progression of the disease.

Do you perform only adult EP procedures or do you also do pediatric cases? 

We typically treat patients aged 16 years and over (about >95% adults and 5% noncongenital pediatric cases).

What measures has your lab taken to reduce fluoroscopy time? What types of radiation protective shielding and technology does your lab use?

We utilize upgraded mapping systems, contact force sensing ablation catheters, intracardiac echocardiography, and ultrasound-based access techniques for ablations and device implants.  

We also set our fluoroscopy lower, and make the setting a part of our timeout with the physician. 

What are your methods for device infection prophylaxis? 

We routinely give an antibiotic within 30 minutes of cut time for devices. We utilize standard surgical techniques, the TYRX Antibacterial Envelope (Medtronic) or similar pouches in selected high-risk patients, same-day discharges, vancomycin for inpatient cases, and chlorhexidine baths the night before and morning of implants.

What are your thoughts on EHR systems? Does it improve your quality of care?

It is a valuable tool, but it is incompletely utilized by hospital systems due to multiple reasons,  including lack of standard expectations for utilization. We are actively working to improve our EHR systems to improve and standardize patient care, increase the quality of documentation, and maintain procedural databases to monitor quality and facilitate clinical research.

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

In 2004, we were already performing RF ablation for pulmonary vein isolation, and added in focal cryoablation as an alternative with less risk for pulmonary vein stenosis. By 2007, cryoballoon technology had developed, which we initially used in the STOP AF trial. When the cryoballoon was approved commercially in 2011, we quickly adopted this technology, and it continues to be our preferred method for PVI. We started His bundle pacing in 2002, and are definitely aware of an increased utilization for this technique. With VT ablation, the trend is for decremental evoked potential (DEEP) mapping, with a combined epicardial/endocardial approach, often with mechanical support for advanced congestive heart failure patients with frequent ICD therapies. We utilize implantable loop recorders whenever possible in our patients with atrial fibrillation. We look forward to newer ablation energy sources, Bluetooth-enabled devices, fluoroscopy reductions with technologies such as MediGuide (Abbott), and continued development of lead extraction technologies such as the Bridge Occlusion Balloon (Spectranetics/Philips IGTD). Integration of imaging modalities such as MRI to evaluate underlying arrhythmia substrate also continues to improve.

How does your lab handle device recalls? 

They are managed on the office side. Our clinical coordinator, Amy Leiserowitz, RN, CCDS, FHRS, who has >30 years of device experience, works with the local device manufacturer representatives to identify and contact each affected or at-risk patient to schedule their device check in the office and/or see a provider to determine a plan of care. 

How is outpatient cardiac monitoring managed? 

Iowa Heart Center was one of the first in the nation to embrace remote monitoring and establish it as our way of following up with device patients. Our team of 16 device-trained RNs, who work in our Iowa Heart EP offices across the state, manage patients via in-office checks and remote monitoring. In recent years, we have been able to move to performing in-office pacemaker and ICD checks every other year for stable device patients due to the automaticity and extensive diagnostics available in today’s implantable devices.

Do you utilize digital tools and wearable technologies in your treatment strategies for patients?

Iowa Heart Center and Mercy Medical Center have their own Holter monitoring services. We utilize 30-day event monitors and mobile outpatient cardiac telemetry services, and have recently been reviewing leadless patch monitors for arrhythmia monitoring. A number of our patients at risk for sudden cardiac death are monitored and protected by wearable cardioverter defibrillators (LifeVest, ZOLL Medical Corporation); our techs routinely review these cases for recorded arrhythmias and/or shock treatments. We also encourage use of ambulatory monitors such as FitBit (Apple) or KardiaMobile (AliveCor, Inc.) in our patients with AFib.

Is your EP lab currently involved in clinical research studies? 

Yes, we have a very robust research department. Our physicians are involved with research opportunities such as the aMAZE trial, Attain Stability Quad clinical study, Appraise ATP trial, and STOP AF First trial.

What are your thoughts on 2-year ACGME-accredited EP training programs? 

There should be a 2-year minimum. It is not realistic to expect a fellow to be proficient in all the procedures and clinical experiences within a 1-year period. The field has grown so much and there are so many new treatments, that anything less than 2 years may produce EP graduates with inadequate exposure to provide a high level of expertise across the broad range of EP skills needed in clinical practice.

Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic? 

Each of the EP physicians will provide consultation for patients with a suspected inherited arrhythmia; however, we do not have a separate dedicated genetics clinic. We work with Ambry Genetics for genetic testing.

How do you see social media changing the field of healthcare? 

The Iowa Heart website is continually updated, and we see a lot of potential for social media as an important part of patient education regarding our services. 

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

We are located in the capital, which is the largest city in the state of Iowa. We are committed to providing cardiac tertiary referral services for a wide surrounding geographic region.

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

Our EP lab staff is very team-oriented and dedicated to helping the EP program grow. They are eager to learn, and continually look for ways to improve. Our EP physicians have a strong commitment to clinical research. We actively enroll in clinical trials, and were early adopters of many advanced technologies needed to more effectively treat difficult cases. Our physicians are engaged with ongoing education of the staff, and are excited about working as valued members of a team to develop the EP lab protocols needed to deliver advanced therapies for our patients.

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