Optimizing Efficiency and Outcomes in the Electrophysiology Lab
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EP LAB DIGEST. 2025;25(4):6.
Bradley P Knight, MD, FACC, FHRS
Editor-in-Chief, EP Lab Digest
Dear Readers,
As catheter ablation procedures increase, physician reimbursement decreases, and electrophysiology (EP) lab time becomes more valuable, there is more talk about efficiency in the EP lab. Efficiency is defined as being capable of producing desired results with little or no wasted time or materials. The embodiment of efficiency is Dr Fred Morady at the University of Michigan. He is never in a hurry but never wastes time. Time is valuable, but efficiency differs from effectiveness, which is probably more important in medicine than efficiency. Being effective involves producing a decided, decisive, or desired effect. Because the real focus should be on proficiency, defined as being able to do something to a higher-than-average standard, as in being skilled, it is important to consider how efficiency impacts outcomes.
The relationship between efficiency and outcomes can be viewed as an inverted U-shaped curve (Figure). The goal is to operate at the top of this curve to maximize both efficiency and outcomes. Why does efficiency matter? Spending too
much time during a procedure wastes valuable EP lab time and increasingly scarce anesthesia support. It is also well documented that long procedure times are associated with more complications. One of the strongest predictors of infection associated with pacemaker and defibrillator implantation is the length of the procedure.1 From the ablation literature, severe procedural complications directly correlate with procedure duration. For every 10-minute increase in the length of an atrial fibrillation (AF) ablation procedure, there is a 20% increase in the incidence of a severe procedural complication.2
However, focusing too much on efficiency can negatively affect patient outcomes when there is a loss of attention to detail. The amount of additional effort needed to reduce complication rates from 2% to 1% in the EP lab is much greater than the effort needed to reduce the rate from 4% to 3%.3 Emphasis on efficiency can lead to undue hurry. It is also important to avoid cutting some things out that take time but are critical to success. These absolutes include spending time with the patient and their family before and after the procedure to establish a relationship and establish trust.
So, what can be done to operate at the top of the efficiency/outcomes curve? The simplest answer is to not waste time. Performing tasks in series rather than in parallel when possible, switching to a different task when an obstacle is encountered that needs troubleshooting, and remaining focused will shorten procedure times without negatively affecting outcomes. A useful mindset is to operate like a variable speed drill. Go at a high speed when it is safe, such as when prepping equipment, etc, and then drop to a low speed during a critical portion of the procedure that requires attention and focus. Efficiency can also be improved by keeping the procedure as simple as possible. Vascular access using the fewest vessels and catheters as possible is important. For example, a standard ablation procedure for supraventricular tachycardia (SVT) can be performed with 3 venous sheaths placed in a single femoral vein. Also, for SVT cases, perform efficient pacing maneuvers and take advantage of any transition that occurs during the SVT to make an accurate and prompt diagnosis. When feasible, avoid time-consuming support systems and procedures such as general anesthesia, urinary catheters, and arterial line placement.
New technology and techniques have made considerable strides in reducing procedure times in the EP lab. The need now for a single transseptal catheterization to perform AF ablation procedures compared to a double transseptal with both a mapping and ablation catheter has improved efficiency. Powered transseptal needles and wires have reduced the time required to access the left atrium (LA). The use of cryoballoon technology, other single-shot devices, and high-power short-duration radiofrequency ablation techniques have reduced procedure times. Ultra-high-density mapping has revolutionized EP procedures by allowing the creation of very high-resolution local activation maps in a short period of time. However, it is important not to waste time creating an entire activation map for every arrhythmia that is encountered. For example, when AF converts to atrial flutter during LA ablation, and the flutter has eccentric coronary sinus (CS) activation, a more efficient approach than a new LA map is to determine the post-pacing interval within the CS and lateral mitral isthmus to make a diagnosis of mitral flutter.
Recently, the biggest impact on efficiency in the EP lab has been the adoption of pulsed field ablation (PFA). Although a first-time pulmonary vein isolation (PVI) procedure may not be much quicker with PFA than with a cryoballoon, the ability to ablate the posterior wall and other atrial arrhythmias with PFA has significantly reduced procedure times. Also, a first-time PVI case can now be performed with just intracardiac echocardiography and a transseptal sheath without a CS or other catheter when patients arrive in sinus rhythm. Integration of PFA catheters into 3-dimensional mapping systems, as well as the development of new PFA tools that will allow for both mapping and ablation, will continue to improve efficiency.
In summary, improving efficiency in the EP lab is an important goal. By striving to operate at the top of the efficiency/outcomes curve, we can minimize complications and ultimately improve outcomes.
Disclosures: Dr Knight has served as a paid consultant to Medtronic and was an investigator in the PULSED AF trial. In addition, he has served as a consultant, speaker, investigator, and/or has received EP fellowship grant support from Abbott, AltaThera, AtriCure, Baylis Medical, Biosense Webster, Biotronik, Boston Scientific, CVRx, Philips, and Sanofi; he has no equity or ownership in any of these companies.
References
1. Tarakji KG, Krahn AD, Poole JE, et al. Risk factors for CIED infection after secondary procedures: insights from the WRAP-IT trial. JACC Clin Electrophysiol. 2022;8(1):101-111. doi:10.1016/j.jacep.2021.08.009
2. du Fay de Lavallaz J, Badertscher P, Ghannam M, et al. Severe periprocedural complications after ablation for atrial fibrillation: an international collaborative individual patient data registry. J Am Coll Cardiol EP. 2024;10(7 Part 1):1353-1364. doi:10.1016/j.jacep.2024.03.024
3. Knight BP. Reducing the rate of serious adverse events in the cardiac electrophysiology laboratory from 2% to 1%. EP Lab Digest. 2024;24(8):6.
