Spotlight Interview: University of Cincinnati Medical Center

When and by whom was the electrophysiology (EP) program started at your institution?

Our program was started in the early 1990s by Dr. Westby Fisher. Dr. Mehran Attari and Dr. Alexandru Costea joined the program in 2005-2006.

What is the size of your EP facility?

Our facility at the University of Cincinnati Medical Center (UCMC) includes 2 EP labs and 1 hybrid room that is shared with cardiac surgery and used for high-risk procedures, specifically, lead extractions. We also have affiliated EP programs within UC Health, including 2 EP labs at the VA Medical Center and 1 EP lab at West Chester Hospital. Those are also covered by our team physicians and nurses.

The hybrid room was part of an expansion to our program in the last 4 years. There are additional plans for expansion, as our needs are growing due to a higher volume of patients.

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

We have 11 staff members, with 8 RNs and 3 RTs. We also have an atrial fibrillation coordinator, 1 nurse practitioner for the inpatient service and 1 nurse practitioner for the outpatient service, 4 physicians, and 1 physician scientist.

What EP procedures are performed at your facility?

We perform all EP procedures at our facility, including device implantation (pacemakers, defibrillators, biventricular defibrillators, and leadless pacemakers), His pacing, and lead extractions, and are considered one of the busier programs in the area. We also perform ablation for atrial fibrillation, supraventricular tachycardia (SVT), PVCs, ventricular tachycardia (VT), epicardial VTs, and VT ablations on cardiopulmonary support.

Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and left atrial appendage (LAA) closures are performed each week?

Each week, we perform approximately 10 ablations at UCMC (not including the VA Medical Center or West Chester Hospital), 3 to 4 Watchman device (Boston Scientific) implants, 1 to 2 lead extractions, 4 ICD implants, and 2 to 4 pacemaker implants.

What types of EP equipment are most commonly used?

We use Carto V7 (Biosense Webster, Inc., a Johnson & Johnson company) for mapping. We also use devices from Medtronic and Biotronik.

Who manages your EP lab?

Robin Baldauf is our EP lab director and John Groh is our supervisor.

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

Our device clinic has 2 nurses, 1 nurse practitioner, 2 to 3 medical assistants, and a dedicated device nurse. The clinic provides coverage every day. We strive to see patients within 24 hours of referral. Devices are checked by our device nurses and occasionally by the company representatives. The clinics can be very busy, with up to 40 patients in a full day. However, our staff is very experienced and we are able to provide high-level care to our patients.

In what ways has COVID-19 impacted your hospital?

COVID-19 was a strain for all the health care systems in the area and throughout the country. We certainly had a decrease in procedures and in-person visits in the clinics for 2 or 3 months at the peak of the pandemic. We were able to replace in-person clinic visits with remote visits, and have been effective and successful in maintaining the same amount of patient visits. As far as the EP lab, we functioned at emergency status for only 3 months around the peak of COVID-19. Afterwards, we continued to serve our patients, respecting strict safety measures from the CDC and our local governing entities. As a result of the pandemic, we implemented a same-day discharge protocol for our atrial fibrillation ablations, discharging more than 100 cases since that time. We also now discharge routine device implants, very straightforward lead extractions, and idiopathic VT or PVC ablations the same day. We are still monitoring lead extractions, VT ablations with hemodynamic support, and Watchman implants. We also continue to use jet ventilation after adapting the circuit in a way that provides safety and no contamination of the air in the room, which usually happens with a typical jet ventilation.

What new initiatives have recently been added to the EP lab?

In addition to implementing a same-day discharge program, we also now routinely perform ablations without x-ray. This initiative was started back in 2016 and has continued since. To date, we have performed more than 1,000 cases without fluoroscopy. Those cases include all types of ablations, including VT ablations on hemodynamic support.

We still use fluoroscopy for Watchman device implants; however, we are planning to move towards performing Watchman devices with minimal to no fluoroscopy. Most of our procedures are performed under TEE guidance alone, while fluoroscopy is minimized to less than a minute per case.

In addition to this, we have started to employ vascular closure devices such as VASCADE MVP (Cardiva Medical), which allows ambulation in the same day. Jet ventilation has also reduced the procedure time for paroxysmal atrial fibrillation ablation to less than an hour and 50 minutes. For example, for paroxysmal atrial fibrillation ablation cases, patients are intubated under general anesthesia with jet ventilation. We perform the procedure without fluoroscopy, and access to closure takes about 1 hour and 15 minutes. The patient is monitored for 6-8 hours and sent home the same day.

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

Our EP lab usually runs very efficiently, with a room turnover of 15-30 minutes between 7:30 am-5:00 pm. Of course, we occasionally have to accommodate more patients from the inpatient service and stay late. We occasionally have to come in over the weekend. Our staff is very accommodating. If there are emergencies or if the patient’s discharge is pending a procedure, we do those procedures on the weekends. On a regular day, we typically perform 3 to 4 atrial fibrillation ablations in the 2 labs. On average, Watchman implants take 20 to 30 minutes, so usually by 11:00 am, we have performed about 3 Watchman implants. Typical SVT and atrial flutter ablations usually take less than 40 minutes per procedure.

How do you ensure a timely case starts and patient turnover?

In our institution, there is a very strong collaboration between our cardiac anesthesia and EP teams. We have strong teamwork between staff, physicians, cardiovascular recovery, and cardiac anesthesia. We try to start cases on time, ensuring that consents are obtained, the physicians arrive on time, and room turnover is effective. For lead extraction or Watchman implant cases, we make sure that patients are consented, cardiothoracic surgery backup is available, and the type and cross for blood is taken care of.

What are the best features of your EP lab layout and design?

We have very large rooms and an open floor plan. Both rooms can accommodate procedures of all types.

In what ways have you cut or contained costs in the lab or device clinic?

In the lab, we have worked closely with our industry partners for more competitive pricing. We have also limited the amount of catheter and device types to create a more uniform approach for all of our procedures. Introducing less variability in what is being used for each case has led to significant cost containment, increased efficiency, and ultimately, better patient outcomes. In the EP clinic, our major breakthrough was hiring a device nurse who could provide device interrogation without the need for industry support. This has created uniformity, consistent outcomes for our patients, and improved efficiency in patient visits.

What types of continuing education opportunities are provided the staff? What options for continuing education are available to your mid-career staff?

We are very excited about providing continuing education for our staff, as we strongly believe this is where better outcomes and higher quality care reside. Over the years, we have organized a number of local symposiums and educational events, the most notable being a yearly EKG course that has been held for 6 consecutive years with Dr. Josef Brugada and Dr. Costea. This course involves our attending physicians, fellows, and staff. We also have regular conferences and grand rounds designed for the fellows and that also include our staff members. Moreover, we are partnering with industry to help educate our staff on new technology, new developments, and new approaches for various procedures.

Over the years, we have also visited other institutions to help improve our workflow, efficiencies, and outcomes. These visits include physicians as well as mid-career staff and EP lab staff. Similarly, we engage our staff in educational events through our industry partners for clinic management, device management, mapping, and ablations.

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

A patient with severe anatomical abnormalities developed complete heart block post-cardiac surgery; the patient also previously had a permanent pacemaker implanted. When heart failure later occurred, the device was extracted, with the plan to implant a cardiac resynchronization therapy defibrillator (CRT-D). CT imaging with 3D electroanatomic mapping, intracardiac echocardiogram, and a 3D printed heart model were used to plan the procedure as the anatomy was very complex. Successful CRT-D upgrade was achieved while using a combination of advanced techniques, with subsequent clinical improvement.

Tell us about your primary approach for LAA occlusion.

Our LAA occlusion procedures are primarily performed with the Watchman device. We have partnered with our primary care physician colleagues for a second opinion on Watchman indications. Our Watchman/atrial fibrillation coordinator is in charge of screening patients, getting them through testing and procedures, and following up with them. Our Watchman procedures are performed with general anesthesia. A transesophageal echo (TEE) is performed while the electrophysiologist deploys the Watchman. The patient stays overnight and is sent home the next day.

Tell us more about your dedicated atrial fibrillation clinic.

We have recently started our dedicated atrial fibrillation clinic and are planning to expand it to our cardiac surgeons as a joint approach. The clinic has been very effective, as most patients seen in the clinic are in need of a procedure in the immediate future.

How do you manage radiation quality checks?

In-house physicists perform routine checks on our equipment.

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

As the population ages, it seems that the number of patients needing an atrial fibrillation ablation is increasing. Fortunately, new technologies allow for more effective and shorter procedures with lower complication rates. Our complication rates are below the national average, below 0.5 to 1%. As a result, we are very aggressive in treating atrial fibrillation early on, and I believe that this trend will expand slowly in the whole EP arena. Moreover, I believe there will be a need for increased lead extractions, and that VT/PVC ablation will become more frequent. I also estimate there will be consistent replacement of anticoagulation with LAA closure devices. Finally, I believe that we will hopefully soon be able to perform atrial fibrillation ablations and Watchman device implants at the same time.

How do you utilize digital tools and wearable technologies in your treatment strategies?

We have maintained our affinity for external monitors. Smartphone or Kardia (AliveCor) monitors are used selectively in patients. Diagnosis and treatment are based on standard recording devices. Of importance, we have a very strong loop implant program and a nurse practitioner that manages these patients. This has allowed us to not only perform more procedures, but also have faster turnover between the clinic visit and procedure time. It has also allowed the EP physicians to perform more involved procedures such as ablations or other device implants.

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

Our hospital is the only academic institution in the area. As a result, we get referrals from other centers within and outside of Cincinnati. We also occasionally get second opinion consults for EP from other areas of the country.

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

The most important parts of our EP lab and staff are the human interaction, teamwork, appreciation for patient care, dedication, reliability, and eagerness to provide optimal medical care. We also benefit from the support of our institution for growth and development.

Our relationships with other centers around the world have been crucial. We have benefitted from interaction with multiple other centers throughout the U.S., Europe, and Asia (specifically Japan). This has allowed us to have access to new technologies and provide benefits that are otherwise unavailable in our area to patients.