Spotlight Interview: Emory University Hospital Midtown

When was the EP program started at your institution? By whom? Approximately how many cases are performed annually? 

Emory University Hospital Midtown is one of the 3 major Emory-affiliated hospitals. This hospital is known for providing tertiary cardiac care to the state of Georgia and neighboring states. The EP lab was started in 1991 by Dr. Angel Leon, who trained at the University of Michigan under Dr. Fred Morady. The lab grew throughout the years, and currently performs around 2000 cases per year (60% ablations and 40% CIED implants). The lab is particularly known for being a referral center for a variety of procedures, especially complex lead extraction.

What is the size of your EP lab facility? Where is it located in relation to the catheterization department?

We have 2 dedicated EP labs and a hybrid surgical lab for performing lead extractions and convergent atrial fibrillation (AF) ablations. The EP labs are located adjacent to the catheterization labs.

How many staff members do you have? What is the mix of credentials at your lab? 

We have a total of 8 permanent staff in our department. There are 7 RNs and 1 CVT that assist with all of our cases. Currently, 3 are working on receiving their RCES.

What types of procedures are performed at your facility? What types of complex ablations are performed?

We complete a variety of procedures in our lab, including complex ablations, left atrial appendage (LAA) occlusions, and CIED implants. We routinely perform left atrial arrhythmias and ventricular tachycardia (VT) ablations in our lab.

What would you consider to be the most frequent procedure performed in your lab?

AF ablation is the most common procedure that we do in our lab.

In what ways has the COVID-19 pandemic impacted your hospital, EP lab, or practice?

During the peak spread of COVID-19 in Atlanta in March and April, we cancelled all of our elective procedures and performed mainly urgent/emergent procedures. We are now almost back to full capacity.

What percentage of implants use subcutaneous (S-ICD) or leadless devices?

We are a high-volume center for S-ICD and leadless PPM implants. This is a technology that we were early adopters of, and were part of the original IDE studies.

Who manages your EP lab?

Our EP lab manager is Willena Endsley-Byrd, BSN, RN.

Are employees cross-trained?

We are working to cross-train team members who are interested in working in both labs.

Tell us about your device clinic.

Our device clinic is separate from our EP lab. It follows 3,000 patients routinely.

Do you utilize telemedicine? Tell us about your approach. 

During the COVID-19 pandemic, we have moved our clinic visits to a telemedicine platform mainly using Zoom or Doximity. Even now that our clinics are open, we continue to see some patients via a telemedicine visit.

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

Our EP lab is part of an academic practice with 2 EP fellows rotating every month in our lab. Kaiser Permanente EP physicians also perform procedures in our lab twice a week.

What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?

We use CARTO (Biosense Webster, Inc.), Rhythmia (Boston Scientific), and EnSite (Abbott) 3D mapping systems.

How do you manage vessel closure?

We use a variety of techniques, including Figure of 8 closure, Perclose (Abbott Vascular), and Angio-Seal (Terumo Medical Corporation).

Tell us what a typical day might be like in your EP lab.

A typical day in our lab could be 2 AF ablations, 3 device implants, and an extraction. We try to perform lead extraction 2 days a week (on the days we have availability for surgical backup, an OR team, and a perfusionist on standby).

Who handles procedural scheduling? 

Our hospital scheduling department, in conjunction with our team in the clinic, handles the scheduling for our cases.

How do you ensure timely case starts and patient turnover?

Case start time and turnover time are recorded and reviewed weekly to try to improve on-time starts and turnover time.

Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?

All of our EP physicians have outreach clinics in the north and south part of the state to ensure a wide area of referral. A recent alliance was formed between Emory and Kaiser Permanente, which also increased our procedural volumes.

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

We make sure 2 of our employees attend the Heart Rhythm Scientific Sessions every year. We also send our employees to local or regional conferences.

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency (RF)? 

For paroxysmal atrial fibrillation, we have moved to a predominant strategy of cryo for pulmonary vein (PV) isolation. Most of us believe in single-shot technologies (which is provided by cryo) over point-by-point ablation (using the RF catheter). We use RF for persistent AF or redo procedures.

Is hybrid epicardial and endocardial ablation of atrial fibrillation performed at your institution?

For long-standing persistent AF or redo AF ablation, we have moved predominantly to convergent ablation and have a high-volume convergent AF ablation program.

What are some of the dominant trends you see emerging in the practice of electrophysiology? 

We believe leadless devices will be more mainstream in the next few years, and we will see dual-chamber and CRT systems that are purely leadless.

Is your EP lab involved in clinical research studies? 

We are proud of our robust research program. We are involved in multiple clinical trials and innovative technology trials. We were the highest enrolling center in the Micra IDE study, and were also a high enrolling center in the PRAETORIAN randomized study. We are currently participating in trials for the Micra AV (Medtronic), WATCHMAN FLX (OPTION trial; Boston Scientific), and the WiSE-CRT system (EBR Systems).

Please tell our readers what you consider special about your EP lab and staff.

I consider our EP staff as one large family. We cherish our time together, work hard for each other, and support one another. We are proud of both the excellent care we provide to our patients as well as our work on the forefront of innovation. n

Dedication: This article is dedicated to the memory of Carlyle Treadway — a great nurse, an amazing friend, and a loving husband and father.