Redefining Cardiac Electrophysiology: A Practice Model Beyond Clinical Excellence

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EP LAB DIGEST. 2024;24(12):1,10-11.

Kamala Tamirisa, MD, FACC, FHRS, and Javier E Sanchez, MD, FACC, FHRS
Texas Cardiac Arrhythmia, Dallas, Texas

With the increasing prevalence of atrial fibrillation (AF), the demand for specialized electrophysiology (EP) care is growing, encompassing diverse

patient populations with varying socioeconomic backgrounds, geographical distributions, and cultural and language differences.¹ The advent of pulsed field ablation (PFA), integration of artificial intelligence (AI) algorithms into 3-dimensional (3D) mapping systems, extravascular defibrillators, and leadless pacing systems call for a quick and safe adoption of technology. Furthermore, the intersection of disease processes such as AF in patients with cancer or pregnant patients highlights the necessity for further data collection, multidisciplinary and extradisciplinary research, and the development of specialized niches within EP. 

There is also pressing concern regarding the predicted shortage of EP fellows,² necessitating the creation of dedicated training programs that leverage high-volume clinical cases for comprehensive education. Early exposure to EP is crucial for fostering increased interest in the field, which was identified as one of the barriers for low EP fellow recruitment.² Moreover, retaining EP physicians hinges on offering flexibility, encouraging unique niches, and ensuring representation in governance and leadership within the service line.

Texas Cardiac Arrhythmia, Dallas (TCA-Dallas) is part of Texas Cardiac Arrhythmia (TCA), based in Austin, Texas, with offices across Austin, Dallas-Fort Worth, Houston, El Paso, Corpus Christi, McAllen, Bryan/College Station, Amarillo, and Odessa. Founded by Rodney Horton, MD (who practices in Austin and Dallas), TCA includes 28 practicing electrophysiologists specializing in complex catheter ablations, device implantation and extraction, and the adoption of cutting-edge technology. Apart from expansive clinical experience, clinical research continues to stay on the forefront under the direction of Andrea Natale, MD, executive medical director of the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center in Austin. He also serves as the national EP director for HCA Healthcare. Amin Al-Ahmad, MD, director of clinical research and medical education, works closely with TCA-Dallas, supporting the academic and educational initiatives.

TCA-Dallas exemplifies a private practice model that addresses the critical aspects of EP care, specifically demand, unique needs, and supply,

through an intentional strategy for expansion. In this article, we highlight our unique practice setting in the Dallas Metroplex.

Team Structure

Figure 1 demonstrates the 4 main areas within our clinical practice model, which includes a high-volume EP program, niches and governance, education and research, and EP fellowship training. Included below is an outline of key leadership roles in those areas. 

Javier E Sanchez, MD, Executive Medical Director of TCA-Dallas (Medical City, Dallas/Heart and Spine), is known for his passion for teaching and his role as a principal investigator in AF research registries. He is a relentless advocate for patient care quality and EP physician autonomy. He is a high-volume and quality operator who is actively involved in health care system governance to ensure the sustenance of the successful and safe EP practice. With a strategic vision for dynamic growth and expansion keeping reimbursements in mind, he balances practice development with personalized patient care. Under his care and direction, TCA-Dallas has completed more than 200 PFA procedures with excellent outcomes. Dr Sanchez extends EP care to suburban and rural areas, connecting effectively with Spanish-speaking patient population to close the gap and earn the trust of his patients.

Senthil Thambidorai, MD, is the Program Director of the Medical City Fort Worth EP Fellowship. Central to the mission of Medical City Fort Worth is the EP Fellowship Program, which is dedicated to training the next generation of cardiac electrophysiologists while providing top-tier care to patients with complex arrhythmias. Under his mentorship, fellows gain proficiency in a wide range of EP procedures, including ablation, left atrial appendage occlusion (LAAO), 3D mapping, and management of AF/ventricular tachycardia (VT). Starting with its first fellow in July 2024, this 2-year program is designed for cardiologists seeking specialized training in EP. Fellows are expected to perform over 350 ablations and 150 device implantations in their first year, gaining invaluable experience in a high-volume clinical setting. He leads the fellowship program with other core faculty, with dedication and commitment to research and education, involving the fellow in clinical research projects and encouraging contributions to the field’s knowledge. 

Arun Kannan, MD, with Medical City, Plano, is dedicated to advancing patient care and cardiovascular research. His extensive knowledge and compassionate approach have earned him the trust of patients and colleagues alike. Dr Kannan’s commitment to excellence is evident in his clinical practice, where he provides comprehensive, individualized care. Beyond his clinical work, he actively engages in medical education and community outreach, striving to improve heart health awareness and outcomes. His main focus areas include involvement in clinical trials and contributing to the research program. 

Michelle Khoo, MD, with Medical City, Alliance, and Medical City, Decatur, is passionate about integrating prevention and wellness into EP care. Her focused interests include sudden death prevention and the integration of AI in EP. 

William Nesbitt, MD, MPH, Medical Director of the EP Lab at Medical City North Hills, primarily performs procedures at Medical City North Hills, Texas Health Heart and Vascular Hospital in Arlington, Methodist Southlake, and Medical City Dallas/Heart and Spine Hospital. He is passionate about performing complex ablations for AF and VT, as well as device implantation. He helped develop a VT program that included establishing a standardized referral pattern, safe endocardial and epicardial ablation strategies, integration of cardiac anesthesia and backup cardiothoracic surgery, and incorporation of alcohol and bipolar ablation techniques as needed.

Kamala P Tamirisa, MD, Director of Cardio-Obstetrics at Medical City Dallas/Heart and Spine, launched the Cardio-Obstetrics program at TCA and expanded cardiac MRI services at Medical City, Dallas. Passionate about teaching and research, she focuses on advancing careers for women in EP, addressing EP care disparities, and managing arrhythmias in pregnancy. Along with AF management, leadless devices, and conduction system pacing, her expertise includes AF ablation and subcutaneous implantable cardioverter-defibrillator (ICD). She also serves as a principal investigator for the site for research initiatives, including cardiac contractility modulation therapy and cardiac resynchronization therapy for non-left bundle branch block patients. She is the site lead for the national COPPER Registry with a focus on collecting cardiovascular data surrounding pregnancy. A core faculty member of the EP fellowship program, she mentors trainees in the United States and internationally. She developed the Cardiac Arrhythmia Management Symposium (CAMS) in Dallas, with the inaugural event in 2023. Her main focus is on advancing arrhythmia management in pregnancy, implanting cardiac implantable electronic devices in adult congenital patients and those with challenging venous access, and empowering the next generation in EP. 

Summary

At TCA-Dallas, we are committed to advancing EP through innovative procedures, patient-centered and integrative care, cutting-edge technology, and training future EP physicians. The group’s growth and expansion are strategically driven by integrating individual skills and interests, while fostering collaboration to address evolving clinical and procedural needs (Figure 2). With a focus on excellence, we proudly stand at the forefront of cardiac arrhythmia management as a model organization—effectively addressing demand, reimbursements, supply, and specialized niches. n

Acknowledgement. Our vision and strategy owe much to our administrative/practice manager, Pashtanah Farid, MBA. Her expertise, dedication, and passion for excellence are instrumental in ensuring seamless patient care and visibility as well as growth and expansion of TCA-Dallas.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They report no conflicts of interest regarding the content herein. 

References

1. Ohlrogge AH, Brederecke J, Schnabel RB. Global burden of atrial fibrillation and flutter by national income: results from the Global Burden of Disease 2019 Database. J Am Heart Assoc. 2023;12(17):e030438. doi:10.1161/JAHA.123.030438

2. Patel H, Zughaib M, Rajpurohit D, et al. Dearth of electrophysiology fellows: perspectives from cardiology fellows-in-training. Pacing Clin Electrophysiol. 2022;45(8):950-957. doi:10.1111/pace.14554