Spotlight Interview: Loma Linda University Medical Center

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

Currently, we have a 4-room cardiovascular lab, with one designated EP laboratory for ablations located directly above our outpatient cardiology clinic and connected to our medical center. Our interventional cardiology, structural heart disease, pediatric cardiology, heart failure, and EP divisions work closely together, sharing space and cross training staff as needed. Our EP program has grown exponentially with the addition of 2 new electrophysiologists in the last 3 years and a concomitant increase in EP procedure volume. 

The cardiovascular lab provides care to multiple service lines, and EP procedures are frequently performed (about 3-4 days per week) in other cardiovascular lab suites in order to accommodate our volume. This will change when we move into our new hospital at the end of 2020, as we will have three designated EP laboratories for adults and one for pediatrics, with the ability to add rooms as needed, including a hybrid suite.

What is the number of staff members?  

The current core clinical electrophysiology team includes 5 physicians (including 1 pediatric electrophysiologist), 4 nurse practitioners, 1 RN coordinator, and 1 dedicated electrophysiology scheduler. The EP lab has 2 dedicated nurses, 3 cardiovascular techs, and other RN/CVTs that rotate in the EP lab as well. The clinic has 4 medical assistants, with an additional lead medical assistant who helps with scheduling. Our clinical and administrative assistant is also a part of our team, who helps coordinate care at our off-site locations including Loma Linda University Medical Center at Murrieta, Arrowhead Regional Medical Center, and Riverside University Health Center.

How many cases are performed each week?

We perform approximately 20 scheduled cases per week, with inpatient add-ons based on room availability.

Who manages your lab?

The lab is managed by our Director of Patient Cardiac Care, Jennifer Pruitt, RN, MSN, CCRN. She works closely with the EP lab director, Tahmeed Contractor, MD, as well as the charge nurses, to ensure smooth functioning of the EP lab along with the other service lines of the cardiovascular lab.

What types of procedures are performed at your facility? 

Our team performs all types of catheter ablations, including complex atrial and ventricular tachycardia ablations (epicardial ablations, Impella-assisted ablations), as well as mechanical/laser lead extraction and device implantation (including single, dual, and biventricular defibrillators and pacemakers, as well as His bundle pacemakers, leadless pacemakers, and subcutaneous defibrillators). We also perform left atrial appendage occlusion device implantation (WATCHMAN Device, Boston Scientific)and loop recorder implants. We are one of the few centers in the region that offers ablation, device implantation, and extraction in both the pediatric population and adults with congenital heart disease population. 

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

Loma Linda University Medical Center (LLUMC) is an academic medical center that operates six hospitals, a physician practice corporation, remote clinics in the western U.S., and affiliate organizations around the world. This mutual pursuit of excellence allows for outstanding care to our patients and learning opportunities for students. As a Seventh-day Adventist institution, Loma Linda University Health is physically, intellectually, emotionally, and spiritually committed “to making man whole.” LLUMC treats more than 1.5 million outpatients every year, and serves as the only Level 1 trauma center for our region in Southern California. Our hospital was ranked among the top hospitals in the metro area for 2019-2020 by U.S. News and World Report, and also named “high performing” in seven areas. 

What would you consider to be the most frequent procedures performed or the most common arrhythmias seen?

Our EP lab performs procedures reflective of the greater cardiology population’s needs. Presently, our most common procedures are atrial fibrillation (AF) ablations, as this remains the world’s most common arrhythmia. Our patients affected by AF are given education on arrhythmia management and stroke prevention, and several treatment options are discussed. Ultimately, we make recommendations for ablation procedures using shared decision-making. Complex atrial arrhythmias are also increasingly common due to a growing population of patients with prior cardiac surgery and ablation procedures. Activation mapping using new technologies, including Sparkle (Abbott) and Ripple (Biosense Webster, Inc., a Johnson & Johnson company) mapping, is being used to identify critical elements of the circuit to target ablation. 

Describe your patient volume. Have you seen a recent increase? 

Our patient volume has grown tremendously due to advancements in technology, an increased referral base, and an expanded team of five dedicated electrophysiologists. Additionally, we are now the premiere facility performing mechanical and laser lead extractions in the Inland Empire region of Southern California. We recently reached a milestone of 100 cases since the inception of that program in 2017. As a tertiary hospital system, our population includes adult and pediatric patients, and our referral base is rising and continues to grow. By the end of 2020, we will be moving into our new hospital, and we anticipate expansion and an increase in our volume. 

Tell us about your approach to His bundle pacing. 

LLUMC has a large cohort of patients, including pediatric patients, who have received His bundle pacemakers. We perform at least 15-25 cases per year. His bundle pacing offers resynchronization with more physiologic ventricular activation through recruiting the native conduction system. We typically map with a pacing lead and use the C315 His sheath (Medtronic)  to help guide the lead to the His. In some patients, EP-guided His bundle pacing and left bundle pacing are also performed. 

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

In collaboration with our CT surgery team, the EP program at LLUMC now provides patients with longstanding persistent atrial fibrillation with an effective treatment option known as the convergent procedure. We are in the process of screening more of our patients for this newer hybrid AF ablation procedure, and offering more of our population with this procedure if they qualify as ideal candidates. In some of these patients, left atrial appendage occlusion with an AtriClip (AtriCure) is also performed. 

Do you offer multidisciplinary care for AF?

One of our biggest strengths is our multidisciplinary team approach. Multidisciplinary care is the approach to all care at LLUMC. More specifically, our EP program works closely with our heart failure, echocardiography, adult congenital heart disease, and cardiothoracic surgery teams to provide an individualized care approach. We make consultations with team members a priority. We understand that patients deserve a thoughtful approach to the management of their arrhythmia, which is oftentimes linked with another heart condition and is best treated collectively.  

Discuss your methods for lifestyle modification as therapy for your patients with atrial fibrillation. 

We work very closely with our colleagues in sleep medicine to evaluate and manage obstructive sleep apnea (OSA), a contributing cause of atrial fibrillation. In conjunction with our general cardiology and lifestyle medicine colleagues, we promote routine exercise, smoking cessation, and weight loss through referral programs and patient education. 

Describe a particularly memorable case from your EP lab and how it was addressed.

Our EP program strives to offer our patients with the safest methods in performing cardiac catheter ablations. Not only do we use intracardiac echocardiography to guide our ablations, we have also begun to minimize fluoroscopy exposure using fluoroless or low-fluoroscopy procedures. Most recently, we were able to perform a successful fluoroless ablation to treat Wolff-Parkinson-White syndrome and pre-excited atrial fibrillation in a female who was 33 weeks pregnant. We take pride in being able to safely offer these opportunities to our patients.

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

With the emergence of the #cardiotwitter and #EPeeps hashtags, physicians can now post case examples and get recommendations from a global audience to provide feedback and help expand treatment options for patients. Having feedback from others in the field can greatly help physicians improve their practice and impact their clinical decision-making. With the COVID-19 pandemic, social media has been heavily utilized to compare practice changes made by outside institutions and share knowledge on how to manage arrhythmia patients with COVID-19.

Do you utilize remote monitoring of CIEDs?

Yes, we utilize remote monitoring of CIEDs for our established clinic patient population, with dedicated staff available to read and interpret device interrogations to allow for timely attention to urgent cases. As a result of the COVID-19 pandemic, we have also initiated remote monitoring of inpatient devices to help expedite care for critical patients and limit clinical staff exposure.

Has your program or hospital recently experienced any “firsts”? 

Yes, we have performed several “firsts” in the last 2-3 years:

1. We reported our experience performing His bundle pacing for rate-related bundle branch block in the setting of nonischemic cardiomyopathy for the first time. It was first published as a case report and then as an abstract at the 3rd Annual Physiology of Pacing Symposium in 2019.
2. We were also the first to report lead extraction in a patient with severe aortic stenosis for device endocarditis, in which balloon aortic valvuloplasty was performed prior to lead extraction in a single procedure to decrease procedure-related risk.
3. We reported lead explantation of the right ventricular lead, which was placed inadvertently via an atrial septal defect (ASD) into the left ventricle and removed with the help of a cerebral protection device, to protect against stroke. Concomitant ASD closure was performed with help of our interventional cardiology colleagues.
4. We recently performed the first hybrid lead extraction with concomitant open heart surgery in a patient with congenitally corrected transposition of the great arteries, where systemic atrioventricular valve replacement was performed at the same time as pacemaker lead extraction, and an upgrade was made to a biventricular ICD.
5. We have also performed left atrial appendage occlusion device placement in a patient with complex congenital heart disease and a large left atrial appendage with a pre-existent thrombus.
6. In March 2020, our EP program performed the region’s first dual-chamber leadless pacemaker implant (Micra AV, Medtronic). We have placed the Micra AV pacemaker in a growing number of patients, and have had overall positive outcomes.

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

At Loma Linda University Medical Center, our team uses the values of teamwork, wholeness, integrity, compassion, and excellence in providing care each day to our patient population. In addition, our specialists have access to the latest technology in the field. Currently, we are a training center for two mapping systems, CARTO (Biosense Webster, Inc.) and EnSite Precision (Abbott). Our EP program is the leader in EP care in the region, and has tripled in case volume thanks to a dedicated EP staff with a high level of expertise. Most importantly, LLUMC is a friendly and collegial institution that puts the care of its patients first. We look forward to our expansion in the new hospital, which will allow us to continue to serve and meet the demands of our growing EP community.