Spotlight Interview: Montreal Heart Institute

Founded in 1954, the Montreal Heart Institute constantly aims for the highest standards of excellence in the cardiovascular field through its leadership in clinical and basic research, ultra-specialized care, professional training, and prevention. It houses the largest research center in Canada, the largest cardiovascular prevention center in the country, and a cardiovascular genetics center.

The Institute is affiliated with the University of Montreal and has more than 2,000 employees, including 245 doctors and more than 85 researchers.

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

We have 4 dedicated EP labs (3 clinical, and 1 research and development lab) and 1 hybrid surgical room for device lead extraction. There are also 5 interventional cardiology labs (4 clinical, and 1 research and development lab) in our institution. The EP and interventional cath clinical labs are separated by a set of doors. The research and development labs are adjacent in the research center, with a corridor separating them from the clinical labs. 

We also have a dedicated animal lab equipped with all ablation and mapping technologies. We perform basic research studies in the animal lab, and participate in the development of future ablation and device technologies. In addition, we have basic science EP research labs in our research center, where more than 20 research students (Masters, PhD, and post-doc students) work.

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

Our hospital is an academic center affiliated with the Université de Montréal. 

What is the number of staff members? What is the mix of credentials at your lab? Describe your lab staffing and structure. 

There are 14 EP physicians at our institution, and all are involved in education, research, or administration in addition to their clinical role.

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

We perform all types of EP procedures. We implant devices such as implantable loop recorders, temporary pacemakers, permanent pacemakers (eg, single, dual, CRT, leadless), and defibrillators (eg, single, dual, CRT, subcutaneous). The types of cases performed include EP studies, SVT cases (eg, flutter, AV nodal reentry, accessory bypass tract), complex ablations for atrial fibrillation (AF), ventricular tachycardia (endo and epicardial access) and congenital cases. We also do pharmacological testing and have a lead extraction program.

What would you consider to be the most common arrhythmia seen?

This would definitely be AF!

Approximately how many catheter ablations (for all arrhythmias), device implants (ICD, pacemaker, ICM, ILR, etc.), lead extractions, and LAA closures are performed? 

On an annual basis, we perform more than 3500 procedures, including more than 1100 EP/ablations and more than 1700 device procedures.

Are employees cross-trained?

Many employees are cross-trained but due to our high volume of activity, we have dedicated teams for both the EP and cath labs. 

Does your program have a dedicated atrial fibrillation clinic? 

Yes, we have 3 nurses and 6 EP physicians involved in our AF clinic.

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

Lifestyle modification is strongly encouraged. Patients are referred to our cardiac rehabilitation center. Widespread screening of obstructive sleep apnea is also performed. 

Tell us about your device clinic, including its staffing model.

We have a very busy device clinic. We have 4 EP technologists and 1 secretary who manage 28,850 pacemaker and ICD visits per year. Since 2014, 100% of devices implanted at our site have remote monitoring capacity. We now have more than 4500 patients followed remotely (vs 2500 patients in 2014). Of the 28,850 pacemaker and ICD visits last year at our institution, 21,173 were remote visits. This change in practice is very useful in the COVID-19 era.

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

We have access to all ablation and mapping technologies. We perform all types of device implantations.

How do you manage vessel closure?

We use manual compression, figure of 8 stitches, and closure devices.

Who handles procedural scheduling? 

We utilize dedicated administrative staff along with a charge nurse and on-call physician for EP consultations. 

How is inventory managed at your EP lab? Who handles the purchasing of equipment/supplies?

This is managed by the purchasing department via a dedicated staff from the EP and cath lab. 

What are the best features of your EP lab’s layout or design? 

We would consider this to be the control rooms because of the versatility of use with access to multiple different imaging systems in each lab.  

Have you developed a referral base?

Yes, much effort is made to offer access to EP labs to our referring hospitals. Annual continuing medical education activities are offered throughout the year by our team to our referring physicians. 

What changes have you made to improve lab efficiency and workflow as well?

We used Kaizen programs to increase productivity and efficacy.

How do you ensure timely case starts and patient turnover?

We prepare by releasing the schedule before the end of working hours on the previous day. Cases are reviewed by staff and fellows ahead of cases. Time-outs are done prior to cases. 

What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year? How is travel/out of office time to conferences determined and managed? 

Members of our staff attend medical conferences (Heart Rhythm and other cardiology conferences) and continuing medical activities. About 5-7 members of our staff (nurses, EP techs) involved in the EP lab, pacemaker clinic, AF clinic, and in clinical research attend these meetings every year.

What options for continuing education are available to your mid-career staff?

Continuing medical education is mandatory. There are many opportunities ranging from rounds and conferences to courses.

What committees, if any, are staff members asked to serve on in your lab?

Our members are involved in numerous national and international cardiology and EP societies, as well as in national and international guidelines committees.

In addition, members of our EP service are involved in hospital administration (chief of medicine, site director of the cardiology residency program), and many of our staff are involved locally. The following committees are a sampling:

- Radiation protection committee

- Resuscitation committee

- Infection prevention committee

- Research committee

- Ethics committee

- Training program committee

How is patient education managed? 

Brochures and videos for patients are offered on the hospital website for all arrhythmia disorders and procedures. Additionally, one-on-one teaching is provided by nursing staff and physicians, as well as group teaching from technical staff. 

Does your lab use a third party for reprocessing or catheter recycling? 

This is not permitted provincially, but we have built a program for resterilized devices for third-world countries.¹ 

Approximately what percentage of ablation procedures are done with cryo vs radiofrequency? Why?

The ratio of ablations with cryo vs radiofrequency is about 50/50. Both technologies are available and are taught to our learners. We aim to maintain technical ability using both, thus maintaining an excellent standard of care to our patients and allowing us to be leaders in new research with different technologies. 

Does your lab use contact force sensing technology during radiofrequency ablation of AF?

Yes, 100% of radiofrequency cases are performed with contact force sensing catheters when not part of a research protocol testing new technologies.

Does your lab perform His bundle pacing? 

Yes, this field is evolving fast. We perform His bundle pacing as well as left bundle branch pacing as part of a research program at our institution.

Are pediatric cases performed in your lab? Do you offer a formal transition program between the pediatric and adult clinic? 

Yes, we are affiliated with Hôpital Ste-Justine, the pediatric hospital affiliated with Université de Montreal. Cases are done at one site or the other depending on age, patient size, and the required technology to perform the case. Transition to the adult congenital clinic at the Montreal Heart Institute follows upon reaching adulthood.  

Does your institution also have an associated cardiovascular genetics research clinic?

Yes, we have a genetic cardiovascular center integrated in our institution. Four of our 14 EP physicians are part of that clinic for inherited arrhythmia disorders.

What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoro? 

We offer staff education, reduced number of fluoro images per second, and 3D imaging systems for complex ablations to help reduce fluoroscopy time. Pediatric cases, cases in pregnant patients, and an increased number of adult cases are now being done without fluoro.  

What types of radiation protective shielding and technology are used? 

Leaded cabins and Zero-Gravity systems (BIOTRONIK) are available. MediGuide Technology (Abbott) is installed in one of the EP labs, and Stereotaxis is installed in another, thus helping significantly reduce fluoro needs.

Is your EP lab involved in clinical research studies? 

Yes, our lab is indeed involved in many research programs, both for devices and ablations. These are initiated locally or in collaboration with other researchers across the world, with funding from national and international health institutions.  

Annually, we train 4 to 8 fellows from around the world. Fellows are enrolled in our programs for 1 to 3 years depending on their prior training and their training goals. 

We offer technical training in the EP laboratories, but also include a research and clinical training component to our program. We aim to ensure that upon program completion, our trainees are ready to start their own practice from patient selection and education, to EP procedures, to monitoring and managing potential complications. 

In addition to our fellowship program, we offer multiple workshops, conferences, and live case observation sessions for groups of electrophysiologists from around the world. 

What specific challenges does your hospital face given its unique geographic service area? 

Patients come from far distances, some from remote communities, and some from other provinces. 

What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”? 

We have done pioneering work in the development of cryoablation; this technology was developed in our research lab many years ago.

Recently, Montreal Heart Institute announced the first ablation performed using the Durablate catheter (Thermedical) and degassed saline for the treatment of ventricular tachycardia. 

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

We have a team of dedicated professionals that are open to integrating new technologies and supporting research programs. Our learners come from many areas of the world, thus bringing different experiences and diversity. Our staff have contributed to scientific literature in many aspects of EP. 

1. Khairy TF, Lupien MA, Nava S, et al. Infections associated with resterilized pacemakers and defibrillators. N Engl J Med. 2020;382(19):1823-1831. doi: 10.1056/NEJMoa1813876.