Spotlight Interview: Traverse Heart and Vascular – Munson Healthcare

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

Dr Brian Jaffe originally joined what is now Traverse Heart and Vascular - Munson Healthcare in 1994. He retired in 2020. Dr Robert Kennedy, our current EP program director, joined in 2013. Drs John Coatney, Patrick Dillon, and Sina Jame have since joined Dr Kennedy. The 4 originally connected through their EP fellowship.

What is the size of your EP lab facility?

There are 2 full-time EP labs. Structural cases such as percutaneous left atrial appendage occlusion (LAAO) are typically performed in the structural interventional lab.

What is the number of staff members?

At Traverse Heart and Vascular, we have 4 EP faculty within a group of 25 cardiologists.

Two nurse practitioners (NPs) practice in the outpatient setting. The EP lab has 10 lab staff members. Four dedicated EP nurses work in the outpatient setting.

What types of procedures are performed at your facility?

At Traverse Heart and Vascular, we perform EP studies and ablations for atrial fibrillation (AF), typical and atypical atrial flutter, supraventricular tachycardia, premature ventricular contractions, and ventricular tachycardia. We offer transvenous, leadless, and subcutaneous implants of cardiac implantable electronic devices (CIEDs), as well as a comprehensive extraction and lead management program. We also offer percutaneous LAA closure.

What types of EP equipment are most commonly used in the lab?

For ablations, we use the Carto system (Biosense Webster, Inc, a Johnson & Johnson company) in each of our full-time EP labs. For CIED implants, we continue to work with 4 vendors, including Medtronic, Boston Scientific, Biotronik, and Abbott.

Who manages your EP lab?

Dr Kennedy is the EP program director. Dino Deponio is the director of nursing for the integrated cath/EP lab. Rebecca Avers is the lab manager.

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

Our team has 6 full-time device nurses and technicians. We use a third-party software as a service vendor to manage device data. Device nurses and technicians rotate among outreach centers to meet the needs of our community.

What new initiatives have recently been added to the EP lab, and how have they changed the way you perform procedures?

We aim to provide up-to-date and comprehensive care with data-driven initiatives. As a group, we will frequently review and standardize our approach to limit variability and ensure new trial data are incorporated into our practice. For example, we were among the first groups in the country to offer monitored intravenous (IV) sotalol load, decreasing the burden on inpatient hospitalization for initiation of antiarrhythmic treatment. We offer fluoroless ablation where appropriate. We offer same-day discharge to many of our patients following both ablation and CIED implant, when clinically appropriate. To promote efficient use of resources in the postoperative setting, we use a commercially available extravascular subcutaneous closure device to minimize bed rest time for our ablation patients.

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

Both ablation and CIED cases are scheduled in all EP labs. Cases start at 7:30 AM. To ensure a timely case start, our patients are greeted by our nursing staff, anesthesia provider, and electrophysiologist in the dedicated prep room, and then introduced to our lab staff shortly after. Between procedures in the lab, we perform loop recorder implants, cardioversions, and monitored IV sotalol load in prep and recovery, which is located on the same floor as the EP labs. Our EP lab staff rotate to allow for minimal turnover time between cases.

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

When the Webber Heart Center at Munson Medical Center was designed and built, an entire floor was dedicated to the cath and EP labs as well as prep and recovery. This maximizes both patient comfort and our efficiency in providing clinical care.

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

We participate in a catheter reprocessing program, which has contributed to annual cost efficiency for several consecutive years.

Does your lab perform His bundle pacing and/or left bundle branch pacing?

We are currently reserving conduction system pacing (CSP) for cases in which conventional chronic resynchronization therapy has not had the expected clinical effect and for patients where coronary sinus (CS) anatomy prevents use of a CS lead. Emerging data for CSP are promising and we anticipate it will become a regular aspect of our practice as this area continues to mature.

Tell us about your primary approach for LAAO.

We perform percutaneous LAAO using the Watchman device (Boston Scientific). Patients are offered an evaluation and shared decision-making discussion in our structural heart clinic. The implants are performed in the structural interventional lab by operators in both our EP and interventional cardiology teams.

Does your program have a dedicated AF clinic and/or a dedicated lead extraction program?

We incorporate outpatient AF care into our comprehensive outpatient EP clinic, which includes urgent access availability. In addition to our 4 full-time EP physicians, we are fortunate to have 2 dedicated outpatient EP NPs on our team. We offer a comprehensive lead management and extraction program in a collaborative effort with our cardiothoracic surgery team.

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

Many of our ablations are performed without fluoroscopy, when clinically appropriate. Instead of focusing on complete lack of fluoroscopy, our approach is to optimize our workflow with available tools such as intracardiac echocardiography (ICE) and three-dimensional electroanatomic mapping. The by-product is that we minimize or eliminate fluoroscopy. With iterative improvements in ICE expected in the near future, we anticipate ICE will continue to play an integral role in many of our procedures.

Describe your city or general regional area. How is it unique?

We provide care for patients located in a large geographic area in northern Michigan. It is not uncommon for patients to live several hours from our primary medical campus in Traverse City, Michigan. Traverse Heart and Vascular - Munson Healthcare strives to meet the needs of our community by offering several outreach locations.

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

We are incredibly fortunate to have caring, intelligent, hardworking, thoughtful, and friendly lab staff, nurses, device nurses/technicians, and NPs who provide exceptional care to our patients every day.