Spotlight Interview: Medical City Heart and Spine Hospital
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EP LAB DIGEST. 2024;24(2):1,9,23.
Jodie L Hurwitz, MD, FHRS, Director of the Electrophysiology Laboratory, Medical City Heart and Spine Hospital, Dallas, Texas
When was the cardiac electrophysiology (EP) program started at your institution, and by whom?
We have been functioning as a busy and high-level EP program since the early 1990s. Electrophysiologists William Black, MD, and Christopher Wyndham, MD, were the first to join the program. Over the years, we have had many electrophysiologists working in our laboratories. To this day, the laboratories function as "open labs” servicing different physician groups.
What is the size of your EP facility?
We currently have 3 dedicated EP laboratories, plus 2 hybrid rooms for extractions and combined procedures.
Who manages your EP laboratory, and what is the mix of credentials and experience?
The current director of the EP laboratory is Jodie Hurwitz, MD, who has been leading the program since 1995. We have about 10 electrophysiologists who perform cases here on a regular basis. Our EP laboratory supervisor is Rachel Dobbs, RN. We have 2 registered radiography technologists, 5 registered nurses, and 3 registered cardiovascular invasive specialists, and everyone has the ability to scrub and monitor cases. Every case has a circulating registered nurse. We have cardiac anesthesia support for our cases, but our nurses are trained to perform conscious sedation as well.
What types of procedures are performed at your facility?
Our most common procedure is catheter ablation of atrial fibrillation (AF), but we also perform all other types of ablation, including for supraventricular tachycardia, premature ventricular contractions (PVCs), ventricular tachycardia (VT), epicardial ablation, alcohol septal ablation, and bipolar radiofrequency (RF) ablation. We perform implantation of pacemakers, defibrillators, and cardiac resynchronization therapy devices, as well as cardiac contractility modulation therapy, conduction system pacing, leadless device implantation, and left atrial appendage occlusion (LAAO). We also perform lead extractions, convergent procedures, and when needed, open chest surgical ablations with 3-dimensional (3D) mapping.
What EP technologies are commonly used in your EP program?
RF and cryo energy are used for our catheter ablation procedures. We use mapping systems from Biosense Webster, Abbott, and Boston Scientific. We use ensoETM (Attune Medical) for esophageal temperature management during RF ablation of AF. A new technology introduced to the laboratory is the nGen with Carto (Biosense Webster, a Johnson & Johnson company), which allows for use of the Qdot Micro Catheter (Biosense Webster) during ablations.
How is inventory managed?
Inventory is managed in our laboratories by a computerized inventory system; supplies are scanned for each case. Our supply chain manager ensures we are fully stocked, and keeps doctors and staff up to date on backordered items and alternatives whenever there is a roadblock.
Tell us about your device clinic, including its staffing model.
We do not have a dedicated device clinic in the hospital. Each practice performs their own device follow-up, including remote monitoring. We frequently utilize technical support from the manufacturers and do all our checks and reprogramming with each physician’s office personnel.
Tell us what a typical day might be like in your EP program.
On a typical day, there are cases taking place in 2 or 3 rooms. Besides AF ablations, the most frequent type of cases performed here are device implantations and LAAO. We perform 1-2 PVC or VT ablations per week. About once per month, we have a more complex VT ablation procedure that perhaps requires either epicardial access or hemodynamic support in patients supported by a left ventricular assist device. Those patients requiring hemodynamic support already have an Impella (Abiomed) or extracorporeal membrane oxygenation in place for hemodynamic reasons independent of the ablation procedure. About once a month, we also perform procedures such as device placement or ablation with the advanced heart failure and heart transplant departments.
Can you describe the extent and use of vascular closure devices? Tell us about your approach for same-day discharge.
Almost all our physicians use vascular ultrasound for access, very often with micropuncture needles and wires. Over the last few years, we have moved away from manual compression. We almost always use a closure device; this is most frequently the Vascade MVP System (Haemonetics), but the Perclose (Abbott) or a figure-of-8 suture is also used.
How do you ensure timely case starts and patient turnover?
We always try to have the first patient on the table by 7:30 AM at the latest so the physician can start promptly at 8 AM. The same anesthesiologist for the day is used in each laboratory, which also helps reduce room turnover times.
How does your program schedule team members for call?
We do not have an on-call team for EP; we prefer that all our dedicated EP staff have weekends off. If an urgent procedure needs to be done on the weekend, the on-call catheterization laboratory team is used. It is rare for an ablation to be performed over the weekend; very sporadically, there might be a PVC ablation for patients with PVC-induced ventricular fibrillation refractory to antiarrhythmic therapy. In that instance, the EP team is asked to come in. Any necessary pacemaker implantations taking place over the weekend are performed by the catheterization laboratory team.
How are vendor visits managed?
Our industry partners help with educational activities in the laboratory as well as provide morning and evening sessions when needed.
What are the best features of your EP program’s layout or design?
Our EP program is housed in a dedicated heart hospital, which is a fairly new facility. Everything is very modern. We have the same work area as our cardiologists, cardiovascular surgeons, overnight intensivist/critical care physicians, and vascular surgeons. Everything is close by and conveniently located, including the break rooms and physician’s lounge.
What measures has your program implemented to cut or contain costs?
We have contained costs in our laboratories through reprocessing of equipment. We also recently won a gold level award for sustainability; in 2020, our institution received the Practice Greenhealth Environmental Excellence Award for our sustainability efforts.
How does your EP program manage onboarding of new team members?
There is a prolonged training process lasting several months, during which time each new employee is educated, proctored, supervised, and mentored. For more experienced staff members who come into our program, we still go through the process of demonstrating how things are done in our laboratories to keep a consistent workflow and safety as a priority. We want all staff to feel comfortable scrubbing and monitoring, and to feel empowered to intervene at any time if there is any concern.
Discuss the role of mid-level practitioners in your program.
We do not have mid-levels in our laboratories. We have general cardiology fellows who rotate with us and participate in procedures.
In both our hospital and medical communities, it is important that the physician see each patient. All our practices use physician assistants or nurse practitioners, but not in our EP lab.
Share a memorable case from your EP program and how it was addressed.
One case in particular occurred on “Bring a Kid to Work Day.” We ensured that we had the patient’s permission for the son of one of our technicians to be present during the case. When the patient developed acute pulmonary edema during the procedure, it was all hands on deck, with the boy watching from the control room. The patient ultimately did well, and the technician’s son told us how amazed he was at what happened, developing a newfound respect for his dad and his work.
Tell us about your primary approach for LAAO.
Our approach is directed by physician preference. Almost all use preprocedural cardiothoracic imaging. For ultrasounds, we have access to transesophageal echocardiography (3D and 4D) or intracardiac echocardiography (ICE). For left atrial ablations, physicians prefer ICE. The Watchman device (Boston Scientific) and Amplatzer Amulet (Abbott) are used according to physician preference and patient anatomy. Our physicians ensure that if there is any leak on follow-up, subsequent procedures are performed to completely occlude the LAA.
What percentage of cases are done without fluoroscopy? How do you record fluoroscopy times/dosages?
While some of our physicians perform zero fluoroscopy procedures, most of our physicians wear radiation protection lead, even if the expected fluoroscopy time is less than .1 seconds. Our x-ray technicians closely supervise case dosing and cumulative dosing for each provider.
How do you use digital health and wearable technologies in your treatment strategies?
We have effectively implemented telemedicine, so patients can be seen either in person or via telehealth. Device patients are enrolled in remote monitoring prior to discharge from the hospital post procedure.
Please tell our readers what you consider special about your EP lab and staff.
Our physicians believe and expect that everyone in the room can and must contribute. If anyone in the room takes note of low blood pressure or low saturation, they should bring it up and measures should immediately be taken to address it. Also, we expect everybody in our program to have a sense of duty and obligation toward the patient, above and beyond their specific job description. Our patients always comment on how comfortable the lab staff made them feel, starting in the preoperative area! Our lab is a great example of teamwork as well as a collective effort toward patient safety and satisfaction.
