Spotlight Interview: Virginia Heart
© 2023 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates.
EP LAB DIGEST. 2023;23(5):1,12-13.
Chirag Sandesara, MD, Falls Church, Virginia
What is the size of your cardiac electrophysiology (EP) practice?
Our EP practice is based within Virginia Heart, which is led by 50 cardiologists and over 20 advanced practice providers (APPs). We currently have 6 electrophysiologists and 4 APPs providing EP services across 5 different hospitals in Northern Virginia. We provide care at multiple EP labs across 3 separate health systems (Inova [Inova Health System], Reston Hospital Center [HCA], and Virginia Hospital Center [Mayo Network]). We operate in 5 EP labs at Inova Fairfax, 1 EP lab at Inova Alexandria Hospital, 1 EP lab at Inova Loudoun Hospital, 1 lab at HCA, and 2 labs at Virginia Hospital Center.
Who manages the Virginia Heart team? What is the number of staff members?
Our group primarily operates in the Inova System. Dr Haroon Rashid is the director of the EP section at Virginia Heart.
James O’Hara, PhD, DrPH, DMSc, PA-C, is the lead for our EP APPs. In addition to the 10 providers (6 physicians and 4 APPs) providing care for EP patients, we have an EP administrative director, Sibyl Burton, who oversees EP operations. Christine Lewis, RN, is the director of EP nurses. Millie Marin oversees scheduling operations to help manage and organize EP procedures and add-on cases across all 5 hospitals. We have 4 nurses, 6 medical assistant/cardiac techs, 2 remote monitoring technicians, and 3 device technicians who cover outpatient care at 6 EP offices across Northern Virginia.
What types of procedures are performed at your practice?
Procedures cover the entire spectrum of EP with some regional variances (eg, not all hospitals have surgical support available). We perform complex bi-atrial ablations, atrial fibrillation (AF) ablations (both cryoballoon and radiofrequency), vein of Marshall alcohol ablations, atrial flutter ablations (both typical and atypical), supraventricular tachycardia (SVT) ablations, premature ventricular complex ablations, and endocardial and epicardial ventricular tachycardia (VT) ablations.
Our group implants left atrial appendage occlusion (LAAO) devices, single- and dual-chamber as well as cardiac resynchronization therapy (CRT) pacemakers and defibrillators, left bundle branch area pacing (LBBAP), leadless pacemakers (Micra [Medtronic] and Aveir [Abbott]), subcutaneous implantable cardioverter-defibrillators (ICDs) and implantable loop recorders, lead and system extractions, as well as CRT optimization, along with His bundle and deep septal pacing optimization.
Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAAOs are performed each week?
In 2022, our team performed 650 AF ablations, 310 SVT ablations, 52 VT ablations, 450 pacemaker implants, 160 ICD implants, 20 leadless pacemaker implants, 25 LAAOs, and 27 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?
We started using the Optrell and Octaray mapping catheters (Biosense Webster, Inc, a Johnson & Johnson company) for more complex ablations and redo AF ablation procedures. We have been using the Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott) and Pentaray (Biosense Webster) catheters for several years. These advanced catheters have enabled us to be more precise with lesion delivery, and in some cases, have shortened our procedural time by improving ablation efficacy. We are becoming much more facile in the adaptation and utilization of these catheters, and in learning which patients would benefit most, while being mindful of the value and cost of the catheters. We hope to soon perform ablations with the QDot catheter (Biosense Webster) for high-power short-duration lesions and especially for achieving isolation in the posterior wall, as well as begin use of pulsed field ablation (PFA).
Dr Brett Atwater, Director of EP for the Inova Health System, has been instrumental in bringing new products to improve the lives of our patients. He has been adamant about including all electrophysiologists across all practices at Inova in the decision-making process regarding new product purchases. We recently had an EP retreat to discuss new products; on every account, we take a vote as to what products we would like to bring to the lab based on its value and cost/budget.
How did the COVID-19 pandemic impact your EP lab, hospital, or practice?
The onset of the pandemic certainly affected us, as it did all other EP groups and proceduralists across the nation and world. EP lab operations were at a brief halt in the spring of 2020. Only those procedures that were deemed necessary, utilizing a tiered triage system, were performed. Once the halt on elective procedures was lifted, there was a large cohort of procedures that needed to be performed, which increased provider/staff hours and led to burnout. Nevertheless, we quickly caught up to the backlog after a few months.
COVID-19 testing was required for all patients requiring intubation and this reduced our ability to provide immediate point-of-care procedures at times, as we had to rely on testing timeliness and results. Regardless, the greatest impact from the COVID-19 pandemic was the implementation of same-day discharges for most of our procedures, which was immensely positive. This has allowed us to discharge home many of our patients same day. Prior to the pandemic, patients for most procedures (except right atrial ablations) were admitted for overnight observation. We quickly learned via staffing shortages that most, if not all, patients could be safely and efficiently discharged the same day. This improved patient satisfaction and elevated their overall experience. From the hospital side, less beds were needed for observation, thereby reducing staffing in holding areas and associated costs.
What measures has your lab implemented in order to cut or contain costs?
The EP section meets routinely to review product utilization and cost. Each individual electrophysiologist has access to their catheter and device use as well as associated costs. As a group, we look for trends and outliers to provide feedback and guidance on how to best reduce utilization of products that often may not improve care.
Tell us about your approach to His bundle pacing and/or LBBAP.
We initially implanted select cases with His bundle leads. However, over time, it became clear that lead stability was variable. Given the initial issues involving lead dislodgement and late threshold rising, we quickly transitioned to LBBAP. Now, most of our electrophysiologists are performing deep septal (LBBAP) ventricular pacing for all patients requiring pacemakers. In addition, traditional coronary sinus (CS) lead placement for CRT patients is being replaced with deep septal pacing instead, when there is unfavorable anatomy.
Tell us about your primary approach for LAAO.
LAAO with the Watchman device (Boston Scientific) is the primary approach for patients deemed appropriate and performed by the EP section.
Does your program have a dedicated AF clinic and/or a dedicated lead extraction program?
We have a dedicated AF center, in addition to our regular EP clinic, and we also have a dedicated lead extraction service. The AF Center of Excellence is a comprehensive multimodality clinic where patients with newly diagnosed AF present and meet in a single office visit with several health care providers. Patients meet the electrophysiologists, sleep physicians for sleep apnea assessment and management, and a dietician. This clinic is dedicated to streamlining the care processes involved in AF management. It allows for a robust approach to AF management while providing more timely care by way of upstream rhythm control options, including ablation if needed.
What approaches has your lab taken to reduce fluoroscopy time?
We have several electrophysiologists who perform right- and left-sided ablations using zero fluoroscopy. The rest of our team minimizes fluoroscopy use and maximizes use of intracardiac echocardiography as an alternative means of imaging to reduce radiation exposure to not only our patients, but our entire EP team.
What are some of the dominant trends you see emerging in the practice of EP?
LBBAP is a dominant trend for pacing, and with further studies, it will be an additional tool for CRT, particularly for those patients without suitable anatomical targets for a traditional CS pacing lead. In addition, considering catheter ablation instead of antiarrhythmic medication for early-onset AF in younger cohorts will become more common. The utility of novel technology for AF procedures such as PFA is not yet clear. As data emerges, we will all have a better understanding of its true safety and efficacy at targeting and ablating triggers of AF. In addition, screening earlier for obstructive sleep apnea and engaging patients in meaningful dialogue regarding weight loss will be the cornerstone to AF prevention in the future.
How do you use digital health and wearable technologies in your treatment strategies?
We fully embrace technologies such as wearables and telemedicine, which are affordable alternatives to our patients. Wearable technology offers the option of potentially avoiding an implantable cardiac monitor, which may save the health care system thousands of dollars over time, and may provide similarly accurate and reliable data. Our current electronic medical record (EMR) system, Epic, allows for full integration of wearable data into our day-to-day operations, and allows for patients to send their wearable electrocardiogram strips directly into the EMR for review without having to come into the office.
What do you consider special about your EP team?
We have an incredibly diverse and extremely talented EP team. Additionally, our team of APPs are the sole point of contact for patients in the hospital and manage a complex variety of patients while the EP physician is in the lab. This allows for more ownership of the service by the APP, allows the MD to focus on ablations and device-related procedures, and has dramatically affected patient satisfaction because of the continuity of care from the APP. Our APPs rotate between a full week of office or hospital for continuity of care each week. Our EP APP Lead has also been invaluable in helping to advance the scope of practice of our EP APPs to allow for them to take even greater ownership of our patients and EP service. His most recent endeavor was to create a rotation between our 2 main hospitals to allow for the APPs to have continued exposure to the full gambit of EP procedures.
Our EPs engage in the health care system on many levels. Dr Rashid is not only the director of our EP program, he is the director of AF ablation, he implants LAAO devices, and he has been instrumental in helping to bring research trials in the AF ablation space to our practice and hospital system. Dr James Duc was the previous EP lab director at Inova Alexandria Hospital and works closely with both our hospital and the Virginia Hospital Center. Dr Robert McSwain is our senior lead extractor and implants LAAO devices. Dr Adam Fein works closely with the system leadership in developing protocols and tools to improve our quality of care, and he also leads the VT ablation program. Dr Sandesara is the EP lab director at Inova Loudoun Hospital, section chair of the Cardiology division, and he started the AF ablation program at Inova Loudoun Hospital in 2021. Dr Jeff Lee is a notable lead extractor and developed our LBBAP program; he has been instrumental in developing protocols for LBBAP pacing for the hospital system to reduce variation and improve the outcomes of our patients.
