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Spotlight Interview: Azerbaijan Medical University
What is the size of your EP lab facility? When was the EP program started at your institution?
We have 2 cath labs at Azerbaijan Medical University, one of which functions as an EP lab. The EP program at our university began in November 2013.
What is the number of staff members? What is the mix of credentials at your lab?
We have 5 (2 of them part-time) electrophysiologists, 2 full-time EP technicians, and 3 dedicated nurses. We also have an algologist on our team who performs radiofrequency (RF) and alcohol ablation of percutaneous stellate ganglion.
What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), ICD implants, and pacemaker implants are performed each week?
We perform endocardial and epicardial ablation of all types of tachyarrhythmias at our center.
RF and alcohol ablation of percutaneous stellate ganglion are performed in cases presenting with incessant ventricular tachycardia/fibrillation, electrical storm, and after failed RF ablation in patients with structural heart disease. We have a success rate exceeding 95%, and 0% complication rate.
We are the only center in our country performing ablation and implantation procedures in pregnant patients.
We also have a transesophageal EP system, which is generally used for diagnostic and therapeutic reasons in small children.
Another routine procedure performed in our center is selective His bundle and para-Hisian pacing, which is performed in all cases undergoing pacemaker implantation.
More than 80% of implants are for CRT-D devices. We also implant loop recorders.
The weekly number of ablation procedures varies between 10 to 15. Due to the absence of reimbursement, we have a relatively low number of implants. We implant around 50 ICDs and 100 pacemakers annually.
As for special noninvasive diagnostic methods, we utilize transtelephonic ECG monitoring, tilt table testing, and all types of pharmacological tests.
What type of hospital is your EP program a part of?
Our hospital is an academic university hospital. We are involved in education of medical students, cardiology fellows, and EP trainees.
What types of EP equipment are most commonly used in the lab?
The EP system and stimulator in our lab is the EP-TRACER (Schwarzer Cardiotek). We have two RF ablation devices produced by IBI and Medtronic, and one cryoconsole. We have a CARTO 3 system (Biosense Webster, Inc., a Johnson & Johnson company) and the EnSite Velocity Cardiac Mapping System (Abbott). We also have a transesophageal EP system that is generally used for diagnostic and therapeutic reasons in small children.
How is shift coverage managed? What are typical hours (not including call time)?
Excluding the emergent cases, all procedures are planned ahead of time. Planned EP cases are performed on Mondays, Wednesdays, and Fridays. We start procedures at 9 AM and finish at approximately 5 PM. Our EP technicians and nurses work in two shifts during procedural days.
Tell us what a typical day might be like in your EP lab.
I’ll describe a recent day. First, we had an ablation of an idiopathic left ventricular outflow tract (LVOT) VT. The procedure was uncomplicated. After this, we treated a patient with ventricular extrasystole induced tachycardiomyopathy. In this case, we had to ablate at four different sites (RVOT, LVOT, posterior fascicle, and the lower basal septal area in the right ventricle. Next, there was a typical flutter case. Finally, we planned to finish our day with implantation of an atrial lead in a patient with hypertrophic cardiomyopathy and a dual-chamber ICD. The device was implanted 3 years ago, but due to progressive atrial fibrosis, there was a loss of capture and undersensing in the atrial lead. During the procedure, we discovered the patient had thrombosis of the left subclavian vein. We performed angioplasty of the subclavian vein, but when we tried to pass the SVC, it was not possible. There was a 99% stenosis in the SVC, which was very difficult to pass with a peripheral angioplasty catheter. After successful angioplasty, we had a problem finding an appropriate place for lead implantation due to very extensive atrial fibrosis. The procedure was successful, but overall, it took about 3.5 hours.
What new technology has been recently added to the EP lab?
We recently added cryoablation and the EnSite Velocity Cardiac Mapping System (Abbott).
What imaging technology do you utilize?
We frequently use cardiac MRI, CT, and transesophageal echocardiography for cardiac imaging and guiding.
Do you implant MR conditional pacemakers or ICDs?
We rarely implant MR conditional cardiac devices.
Who handles your procedure scheduling?
Procedure scheduling is handled by our staff physicians.
What type of quality control/assurance measures are practiced in your EP lab?
We review results (success and complication rates) of our ablation and implant procedures every three months. Currently, we have 0% rate of implant infection at our center and a very high rate of ablation procedures.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
Our physicians order the necessary equipment and catheters. The university approves these orders.
Has your EP lab recently expanded in size or patient volume?
We have increased the number of ablation procedures by twofold in the last three months.
Have you developed a referral base?
Yes. We are the main EP center in our country, and physicians frequently consult with us and send their patients to us when necessary. Our clinic is also the referral center for VT ablation in our geographical area.
Has your institution formed an alliance with others in the area?
Our lab is a member of and founder of the Azerbaijan Arrhythmia Alliance, which represents the largest network of EP labs in our country. All of these centers are integrated, and our main EP staff work in these centers.
What types of continuing education opportunities are provided to staff members?
Our staff is encouraged to participate in educational activities. We also educate doctors who are interested in the management of cardiac rhythm disturbances. In addition, we host an annual arrhythmia school, providing 56 hours of educational programming.
Do you contract with vendors?
We have free contact with vendors. They help inform us before procedures and give their technical support when necessary.
Does your lab utilize any alternative therapies to help patients in the EP lab?
We utilize music therapy according to the wishes of the patient during procedures.
Describe a particularly memorable case from your EP lab and how it was addressed.
The most memorable case in our lab was a 56-year-old female patient who had a previous diagnosis of idiopathic dilated cardiomyopathy and an implanted CRT-D device. She presented with electrical storm, having had two ICDs replaced during a two-month period and also failing endocardial and epicardial VT ablation in another country. We had to resuscitate her three times during one week of observation in the intensive care unit. Her ejection fraction was approximately 10%. In this case, we first stabilized her with bilateral percutaneous stellate ganglion alcohol ablation. Despite this, she continued to have very frequent VT episodes during the day, necessitating electrical cardioversion. We then decided to proceed with repeat endocardial ablation. VT was unmappable because of frequent changes in morphology and cycle length. Substrate modification also did not work in this case. After obtaining informed consent, we performed an experimental procedure called ventricular denervation. We ablated the right bundle, then the left posterior fascicle and AV node. Incessant VT terminated at that stage. We finished the procedure with bilateral renal denervation. After seven months of follow-up, this patient has remained asymptomatic. Her ejection fraction has improved to 38%.
How does your lab handle call time for staff members?
We have staff responsible for off hours every day. We make this schedule monthly, so our staff is informed in advance about their on-call duty.
What are your thoughts on the use of the new oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation?
We frequently use NOACs in most of our patients with non-valvular atrial fibrillation. It is effective therapy that not only prevents ischemic stroke, but also prevents overloading of clinics with patients coming in for INR monitoring.
Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?
We are pioneers of epicardial ablation in our region. Our group began performing epicardial ablation in 2010. However, we do not perform hybrid epicardial and endocardial ablation of atrial fibrillation.
Do you perform only adult EP procedures or do you also do pediatric cases?
Unfortunately, absence of pediatric EP staff in our country makes us responsible for pediatric cases as well. However, our staff does not perform device implantations or EP procedures in patients under 5 years old.
What measures has your lab taken to reduce fluoroscopy time? In addition, what types of radiation protective shielding and technology does your lab use?
We have standard protective shielding. During fluoroscopic procedures, we use the smallest possible frame rate.
What are your methods for device infection prophylaxis?
We have had a 0% infection rate since our center was established. The protocol that we use in our lab is described below:
- We sterilize the room with an ultraviolet lamp 30 minutes before the procedure. We also use sterilizing sprays for disinfection of the table and C-arm.
- We sterilize the chest of the patient with an antibacterial solution 30 minutes before the procedure.
- The procedure is performed only by the primary physician and fellow, without a nurse as a sterile assistant.
- We irrigate the device pocket with antibiotics and 3% hydrogen peroxide.
- We do not leave any stiches on skin.
- We educate patients about the risk of infection and wound care.
- Dressing of the surgical incision is performed only by our staff physicians (not nurses and fellows).
- We administrate oral antibiotics with probiotics for 7 postoperative days.
What are your thoughts on EHR systems? Does it improve your quality of care?
We use an EHR system in our hospital. It allows for easy follow-up of the patient and for statistical analysis.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
For the last several years, we have started to understand the importance of the sympathetic nervous system in triggering and perpetuating cardiac arrhythmias. In near future, we think we will have to change our view on the genesis of tachyarrhythmias.
Leadless pacing is another important emerging trend that needs further development.
How is outpatient cardiac monitoring managed?
We use transtelephonic monitoring at our center for long- and short-term rhythm monitoring.
Is your EP lab currently involved in clinical research studies? Which ones?
Yes. Currently, we are investigating the effects of bilateral percutaneous stellate ganglion ablation (alcohol and RF) in patients with incessant and frequent ventricular tachycardia/fibrillation. We have very promising results that are going to be published soon. We are also investigating the impact of bacterial microbiota on atrial fibrillation, and new treatment modalities for vasovagal conditions.
Does your heart rhythm service offer patients with a suspected inherited arrhythmia a referral to cardiovascular genetics clinic?
Yes, for patients that require genetic evaluation, we refer them to a genetic clinic.
Describe your city or general regional area.
Baku is the capital and biggest city of Azerbaijan, as well as the largest city on the Caspian Sea and of the Caucasus region. Baku is located 28 meters below sea level, which makes it the lowest-lying national capital in the world as well as the largest city in the world located below sea level. It is located on the southern shore of Absheron Peninsula, alongside the Bay of Baku.
Baku is divided into 12 administrative districts and 48 townships, including the townships on the islands of Baku Archipelago, and the town of Oil Rocks built on stilts in the Caspian Sea.
The Inner City of Baku, along within the Shirvanshah’s Palace and Maiden Tower, were named as a UNESCO World Heritage Site in 2000.
Baku is the scientific, cultural, and industrial center of Azerbaijan. Many sizeable institutions have their headquarters here.
In recent years, Baku has also become an important venue for international events, including the 2015 European Games, the 2016 European Grand Prix, and the Azerbaijan Grand Prix in 2017. Baku will host the 2020 UEFA European Football Championship.
Please tell our readers what you consider special about your EP lab and staff.
We provide our geographic area with the most developed arrhythmia service. Our staff is educated in Turkey, European countries, Canada, and the U.S.
We are the founders of the Azerbaijan Arrhythmia Alliance, which is the biggest network of electrophysiology in our country.
We are also one of the main founders of the Silk Road Heart Rhythm Society, which connects electrophysiologists in countries such as Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Turkey, Turkmenistan, and Uzbekistan. We hope that the number of countries in this community will increase in the near future. This is a growing community of electrophysiologists, and the main aim of this society is to improve the care of patients through scientific collaboration, organization of educational courses and congresses, education of young electrophysiologists at experienced centers, and other activities.
