Nebraska Methodist Hospital

EP Lab Digest. 2023;23(2):1,14-15.

We provide an update on the cardiac electrophysiology (EP) program at Nebraska Methodist Hospital, which was originally featured in our March 2013 issue.

What is the size of your cardiac EP lab facility? Has the EP lab expanded in size, or will it soon?

We currently have one large EP laboratory and one hybrid room. All catheter ablations are done in the EP laboratory, all left atrial appendage (LAA) closures are done in the hybrid operating room (OR), and device cases are done in both rooms. We are planning on adding another EP laboratory in 2 years.

Who manages your EP lab? What is the number of staff members?

Jessie Mozena, our dedicated EP specialist, manages the lab. We split most of our staff with the cardiac catheterization laboratories. We have 8 radiologic technologists and 15 registered nurses.

What types of procedures are performed at your facility?

We perform the full array of ablations, including for atrial fibrillation (AF), supraventricular tachycardia (SVT), and both ischemic and idiopathic VT. We also perform the full spectrum of device implants, including subcutaneous implantable cardioverter-defibrillators (ICDs), as well as leadless and conduction system pacing. We are a trial site for the WiSE CRT System (EBR Systems, Inc). We perform LAA closures in partnership with the structural and interventional cardiology departments. In addition, we have a busy convergent hybrid ablation program in partnership with the cardiothoracic (CT) surgery department. We are one of the top 5 centers in the United States in volume for convergent ablations. Outside of the lab, we recently implemented an intravenous to oral sotalol initiation program that cuts the usual 3-day sotalol hospital stay down to 24 hours.

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

It can vary quite a bit from week to week, but in general, we do about 10-12 ablations and 12-15 LAA closure cases per week. The number of device cases is highly variable. We have seen a significant reduction in the number of ICD implants, but our pacemaker volume is more constant. We perform about 15 devices of all types each week. To date, we are not performing lead extractions.

What are some of the new equipment, devices, and products recently introduced at your lab? How have they changed the way you perform procedures?

One of the newest services we provide is convergent hybrid ablation. This starts with a minimally invasive epicardial ablation of the posterior wall by our CT surgeon. Often, this also involves clipping the LAA. Several weeks later, the patient undergoes pulmonary vein (PV) isolation (using cryo energy) as well as any further ablation necessary. This is facilitated by newer high-density mapping catheters. To build on our leadless pacing program, which previously used only the Micra transcatheter pacing system (Medtronic), we recently started implanting the Aveir VR Leadless Pacemaker (Abbott). We have also been using intracardiac echocardiography (ICE) for device access. We have used it for groin access for a number of years, and have found it to be a safe and effective tool for subclavian/axillary access as well.

How did the COVID-19 pandemic impact your EP lab, hospital, or practice?

COVID-19 substantially impacted us all. During the height of the pandemic, we canceled elective procedures, which included most of our ablations and LAA closures. When we opened back up, we had to accommodate a large backlog of cases. We still experience staffing shortages and high staff turnover. As is the case with many of the hospitals in our community, our hospital is also consistently at or nearly at capacity. This has made same-day discharge—which we routinely do with ablations, most LAA closure cases, and even many device implants—essential to being able to accommodate our patients.

What measures has your lab implemented to cut or contain costs?

We do a fair amount of negotiating product prices with vendors to control spending. Before any new product is introduced in the lab, our value analysis team negotiates with the manufacturer.

Tell us about your approach to conduction system pacing.

For the most part, we have abandoned His bundle pacing for left bundle branch area pacing. This is an evolving field, and our staff has done a great job with setup for these cases and the patience that is involved with selecting optimal lead location.

Discuss your LAA occlusion procedures.

We have a busy LAA closure program. We usually do 6 cases on our full days, or 3 during a half day. We use transesophageal echocardiography (TEE) for all of our screening, including intraoperatively and at 45 days. We have outstanding TEE support and all of our cases are done with general anesthesia, so we have not attempted ICE and only rarely use preop computed tomography scans. We continue to do all of our cases with both EP and interventional cardiology. We feel that having 2 operators with different yet complementary skills improves the efficacy and safety of the procedure.

Does your program have a dedicated AF clinic?

We do not have a dedicated AF clinic, but we do have a dedicated EP nurse practitioner. She is primarily outpatient and sees many of our follow-ups and device patients to allow for more new patient openings for our electrophysiologists. We are hoping to soon have an inpatient advanced practice provider as well.

What approaches has your lab taken to reduce fluoroscopy time?

We use ICE and 3-dimensional mapping to reduce use of fluoroscopy during procedures. For most SVT ablations, we no longer even wear lead. All of our AF ablations are with cryo energy, which traditionally involves contrast injections to verify PV occlusion, but as an alternative, I use pressure monitoring to avoid fluoroscopic imaging. This substantially reduces the radiation dose during AF ablation. However, some of our newer procedures such as Watchman device (Boston Scientific) implantation and leadless pacing require fluoroscopy.

What are the dominant trends you see emerging in EP?

I believe there is an evolving paradigm shift in our management of AF, especially persistent AF. We are now viewing it more as a chronic illness rather than something that is generally “curable” in the EP lab, such as SVT. This is not to say there is no role for ablation, but it is part of an overall plan that often involves treating obstructive sleep apnea (OSA), reducing alcohol use, recommending weight loss, and managing the LAA. Despite our successful convergent hybrid program, I generally have an honest conversation with patients, particularly those with longstanding persistent AF, that the treatment plan may involve multiple procedures, continued medication, and management of comorbidities such as blood pressure and OSA. As with any chronic illness, there will be episodes of relapse, and just because a patient needs a cardioversion despite ablation and antiarrhythmic medications, it does not mean the treatment was a “failure.” We are now looking at success in improved functional status and reduced arrhythmia burden rather than complete freedom from any arrhythmia.

How do you use digital health and wearable technologies in your treatment strategies?

Remote monitoring of devices has completely changed the management of patients with pacemakers, ICDs, and implantable loop recorders. It is probably time to reconsider the necessity for annual in-person follow-up for nondependent patients. Telehealth visits are great for simple follow-up, particularly for our patients who live far away. If somebody travels 200 miles for an SVT ablation and is doing well after, there is no reason for another 200-mile trip for an in-person follow-up visit. Wearable/portable technology is also useful for arrhythmia follow-up, particularly given that with current devices, patients can usually email high-quality tracings. If patients are having symptoms, they can send me a portable electrocardiogram (ECG) rather than having to come into the office for an ECG or monitor.

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

The best feature of our EP lab is its size. It is much larger than most, so we are not crowded, especially with the growing amount of products kept on our shelves. Or hybrid room is also large and perfectly situated between the catheterization laboratories and CT surgery ORs.

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

What makes our staff so special is how engaged they are in procedures. A specific example comes to mind. Recently, a clinical specialist visited our lab to cover a full day of cases. When we have a full schedule, we start fairly early, and the clinical specialist commented on how much energy was in the room so early, that everybody involved in the case was interested and happy to be there.

Our staff is always excited to take on new procedures and review interesting cases. Before the pandemic, we even had a monthly journal club in which staff would take turns presenting cases; we are hoping to reinitiate that soon.

We have also been involved in a number of clinical studies on pulsed field ablation and leadless cardiac resynchronization therapy. Our staff is always eager to be involved in new cases and learn from them. It is an absolute pleasure to work with such an intelligent group of professionals, who are always up for learning new procedures and techniques. As the saying goes, “if you love your job, you never work a day in your life!” 

Related Reading 

Nebraska Methodist Hospital's Spotlight Interview From March 2013