Spotlight Interview: Columbia University Medical Center

When was the EP program started at your institution? What is considered historic about your EP program or hospital?

Cardiac electrophysiology has been deeply enrooted at Columbia for over fifty years. In 1963, Dr. Brian Hoffman became chair of the Department of Pharmacology at Columbia, and spread the use of the technique of micro-electrode recording of heart tissue in the U.S. He put together a team of clinical cardiologists and cardiac surgeons, including Dr. Albert L. Waldo, Dr. Benjamin J. Scherlag, and Dr. John T. Bigger, to record His bundle activity during open-heart surgery and in animal models. 

Together with his colleagues, Dr. Andrew Wit and Dr. Michael Rosen, they laid the groundwork for the core of clinical and experimental cardiac electrophysiology by describing properties of automaticity in latent pacemakers and the differences between normal and abnormal automaticity, triggered activity caused by delayed afterdepolarizations, as well as the necessary role of slow conduction and block in partially depolarized Purkinje tissue for reentry. These discoveries paved the way to the development of the His bundle electrode catheter recordings and programmed stimulation, which is still used today in all electrophysiology studies. His bundle pacing has also now become a new EP trend and area of research.  

More recently at Columbia, under the leadership of Dr. Hasan Garan, we have incorporated modern technology of 3D electroanatomical mapping, contact force sensing, high-density mapping, and ultrasound imaging, to further understand and ablate complex arrhythmias. 

Who manages your EP lab?

This is a multidisciplinary management, including Lynsey Lipowicz, RN, BSN (Patient Care Director), Dr. Angelo Biviano (Director of Cardiac Electrophysiology Laboratory), and Dr. Garan (Director of the Cardiac Electrophysiology Department). Dr. David A. Rubin, former director of the Cardiac Electrophysiology Department, oversees all inpatient consultations.

What is the size of your EP lab facility? Where is the EP lab in relation to the catherization department?

We have three available EP labs five days a week, in which two labs have biplane capability and are staffed by cardiac anesthesiologists for complex ablations, extractions, and device implants in patients. We have three-dimensional mapping systems (CARTO, Biosense Webster, Inc., a Johnson & Johnson company; and EnSite Precision Cardiac Mapping System, Abbott) in all of our rooms. Our EP labs are steps from our catheterization laboratories. 

What type of hospital is your EP program a part of?  

We are an academic EP program consisting of 12 full-time, board-certified cardiac electrophysiologists committed to exceptional clinical care, teaching, and scientific research. We published 12 papers this year and had 7 posters at the Heart Rhythm conference this past year. Many of our physicians are also recipients of NIH grant funding.

What clinical research is your EP lab involved in? 

Our physician-scientists are well-trained in all of the current EP technologies,  and perform basic and translational research to better understand why cardiac arrhythmias occur, in order to develop new drugs and ablative strategies to treat atrial fibrillation and ventricular tachycardia.

Dr. Elaine Y. Wan is the Principal Investigator (PI) of a NIH K08 Mentored Career Development Award conducting research on a mouse model with spontaneous and sustained atrial fibrillation and vascular dysfunction in heart failure. 

Dr. John P. Morrow is PI of a R01 on metabolic disorders and sudden cardiac death.

Dr. Angelo Biviano was a NIH K23 recipient in the field of atrial signal analysis. 

Dr. Marc Waase leads comprehensive cardiovascular genetic evaluations for individuals with known or suspected inherited cardiovascular conditions, such as long QT syndrome, Brugada syndrome, arrhythmogenic right ventricular cardiomyopathy, catecholaminergic polymorphic ventricular tachycardia, and familial atrial fibrillation. We were fortunate to have Professor Arthur Wilde of Amsterdam University spend a 7-month sabbatical to help initiate the Cardiogenetics Clinic.

Dr. Deepak Saluja recently joined our faculty from Rutgers-Robert Wood Johnson University Hospital, where he was director of the EP lab. His research interests include novel mapping algorithms and changes on pulmonary vein electrophysiology with ablation. 

Dr. Jose Dizon, the Director of the Electrophysiology Device Clinic, performs outcomes research on TAVR patients with arrhythmias.

Dr. Hirad Yarmohammadi recently joined us from Brigham and Women's Hospital. His research interest is in genetics of atrial fibrillation and the predictors of left atrial remodeling in patients with atrial fibrillation.  

Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions are performed each year? 

We perform almost 500 ablations a year. Last year, we implanted 1200 cardiac implantable electronic devices, including subcutaneous implantable cardiac defibrillators (S-ICDs), His bundle pacemakers, and leadless pacemakers. Last year, we implanted 200 loop recorders. We perform 50 extractions a year with backup extracorporeal membrane oxygenation, perfusion, and cardiothoracic surgery available for each case. Dr. Frederick Ehlert is our senior specialist in extractions. Our complication rates for catheter ablations as well as device implants are consistently under national benchmark figures.

What procedures do you do?

We perform the full spectrum of EP procedures, including: 

• Tilt table studies
• Cardioversions (DC and chemical)
• Subcutaneous monitor cardiac rhythm implants/explants
• Percutaneous catheter ablation of simple and complex arrhythmias, including: supraventricular tachycardias, atrial fibrillation (AFib) using radiofrequency as well as cryoablation technologies, ventricular tachycardia (including epicardial, intra-aortic balloon, and Impella [Abiomed] assisted), and complex arrhythmias in adult congenital disease patients
• Leadless pacemakers (Micra TPS, Medtronic)
• His bundle pacemakers
• Subcutaneous ICDs
• Device and lead extractions
• Left atrial appendage occlusion procedures such as the WATCHMAN (Boston Scientific) - performed in conjunction with the structural interventional cardiology team in a dedicated hybrid room (Artis zeego, Siemens)

Columbia University Medical Center participates in many national and international multicenter clinical trials in different topics in cardiac electrophysiology, including the CABANA trial for atrial fibrillation and the PRAETORIAN trial for subcutaneous cardiac defibrillators. The list includes a prospective cardioversion trial using the anticoagulant apixaban, a prospective trial of cardioverter-defibrillator implantation in relatively preserved left ventricular function, and an epidemiological trial investigating the genetic trends in atrial fibrillation.

What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? 

We strongly believe that our patients should have MR conditional devices, so nearly 100% of our new implants are MR conditional. We believe in offering our patients a range of devices that is best suited for their needs. We have implanted 40 S-ICDs and 15 leadless pacemakers this year. 

Has your EP lab recently expanded in size or patient volume?

Our growth rate of procedures is about ~15% a year. 

What is the number of staff members? What is the mix of credentials at your lab?

Currently, there are 21 full-time staff RNs with a Bachelor of Science in nursing, of which more than 50% are CCRN-certified and 100% are BLS-, ACLS-, and board-certified nurse practitioners. We have 4 physician assistants. We also have 6 nurse practitioners that manage our device clinic. 

What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?

The nursing staff is entitled but not limited to 37.5 hours of continuing education. They are provided yearly mandatory training, and on-site continuing education symposiums are also provided. There are unit in-services held by nurses, doctors, and other multidisciplinary staff. This year, five staff members attended the Heart Rhythm Society’s annual Scientific Sessions in Boston. 

How is staff competency evaluated?

The Patient Care Director evaluates the staff annually, and peer reviews are also conducted periodically. 

What approaches do you use for team building? What committees, if any, are staff members asked to serve on in your lab?

We have bimonthly Operations meetings, in which nurses, PAs, administrators, and MDs participate to identify workflow challenges and address areas for improvement. All staff is involved in council meetings within the hospital, which fosters autonomy and collaboration throughout the institution. Recognition for exceptional effort is rewarded through the Everyday Amazing Rewards Program.  

Described a particularity memorable case from your EP lab and how was it addressed.

An example that epitomizes how our EP team works together to take care of critically ill and complex patients was a recent case of a 59-year-old woman with chest pain and syncope found to have ventricular tachycardia (VT) storm and a LVEF less than 10%. She quickly decompensated into cardiogenic shock and multiorgan failure, requiring intubation and hemodynamic support with both right and left ventricular assist device (VAD) implantation. Electrophysiology attending and Associate Chief Medical Officer, Dr. James Peacock, together with nurses, physician assistants, perfusionists, and anesthesiologists, worked for a whole day to ablate four different VT morphologies and performed significant substrate modification of her entire anterior wall. At the end of the case, no further ventricular arrhythmias were inducible. We are happy to share that after ablation, this patient was extubated, weaned from her right heart VAD, and has had no further VT. She is now undergoing workup for cardiac transplantation.  

Does your lab perform His bundle pacing?

We believe in being at the forefront of EP technologies, so after shared decision-making, we perform His bundle pacing in patients who are appropriate for and who would benefit from this technology. 

Do you utilize digital tools or wearable technologies in your treatment strategies for patients?

We have a stellar group of EP nurse practitioners who manage our remote interrogations and downloads. We use the latest advances in mobile health home monitoring and a team-based approach to care that integrates the state-of-the-art implantable and mobile technology, in order to capture cardiac arrhythmias in real-time to better guide treatment and management as well as improve quality of life. 

Every working day, a dedicated cardiac electrophysiology nurse practitioner and attending cardiac electrophysiologist see and evaluate an average of 20 patients with cardiac pacemakers and cardiac defibrillators, and up to 30 remote cardiac rhythm recording samples. We anticipate this volume to grow rapidly, as remote cardiac rhythm monitoring technology makes an increasing number of devices available for patient use.

In fact, Dr. Kathleen Hickey, Professor of Nursing at Columbia University Medical Center, has an NIH-sponsored R01 on using iPhones for remote evaluation of atrial fibrillation. 

Are you ACGME approved for EP training?

Yes, we have 2 EP fellows for each of the two years of accredited training. Graduates from our program have taken a wide variety of positions all around the country, such as funded physicians-scientists, hospital executives, and private practice clinicians. 

How do you see social media changing the field of healthcare? 

Fostering continued physician-patient relationships is important to us, to ensure our patients have a good experience under our clinical care. Follow us on Twitter (@EPNYP) to see how our EP team of nurses, physicians, and care coordinators work together to safeguard our patients and ensure they have a pleasant experience at our hospital. 

Describe your city or general regional area. How is it unique from the rest of the U.S.?

We are located in the Washington Heights area of NYC and serve the tristate area, including New York (NYC, Upper West Side, Bronx and Hudson Valley), New Jersey, and Connecticut. Our hospital is the home of complex congenital cardiac care, a high-volume transplant center, and many pivotal trials such as the PARTNER trial for TAVRs and MOMENTUM 3 for new-generation LVADs, allowing us to take care of highly complex and unique patient populations. Our diverse patient population from a highly urban population also allows us to provide care to patients with special heart conditions such as cardiac amyloidosis, sarcoidosis, Chagas disease, LVAD VTs, and congenital heart disease, as well as to patients after transcatheter heart valves. 

What do you consider special about your EP lab and staff?

We are a collegial team of academic cardiac electrophysiologists in the Big Apple. We take pride in working shoulder to shoulder with all of our nursing and physician assistant staff to take care of a diverse and complex patient population.