Preparing Electrophysiology Labs for the Rise of Concomitant Ablation and Left Atrial Appendage Occlusion Procedures

Interview With Ricardo Lugo, MD

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In this feature interview, EP Lab Digest speaks with Ricardo Lugo, MD, electrophysiologist at Ascension Saint Thomas Heart West in Nashville, Tennessee.

What is your experience performing both left atrial appendage occlusion (LAAO) and cardiac ablation procedures during the same operative session? 

Up until October of this year, I had really only been able to do that a handful of times, the main reason being that it was not a financially sustainable procedure for our health system. So, until October 2024, those 2 procedures could be performed in the same setting as the hospital would only get reimbursed for one of them. Medicare reconsidered this, and starting in October of this year, Medicare will now reimburse the hospital for these procedures when they are done in the same setting. For the people in whom these 2 procedures are indicated, I think this significantly represents a win, not only for patient care, but also for our ability to take care of these folks. Both of these procedures are time and resource intensive, and by combining them, you are able to leverage the fact that some of these require similar equipment and approaches. So, we can take advantage of that and really help streamline timing and scheduling of the procedures. Also, I see it as a win for minimizing the amount of risk to patients. Because rather than having to put them through 2 transseptal punctures or 2 rounds of anesthesia, we are now able to streamline that into one.

What types of adjustments are required from an EP lab to start performing more concomitant procedures, specifically scheduling and procedural adjustments?

The biggest scheduling issue that we ran into was with our structural TEE imager. So, when I came to him and said that I wanted to start doing these procedures together, the first question for him was how he was going to be able to make this work, because we might have done 6 LAAO procedures in a day and now that number might drop a little, so his day may not be as busy or productive as it might have been otherwise. We started looking at alternatives to TEE, and as most EPs are fairly familiar with ICE, we began looking to see what we might be able to get from an ICE workflow. As we started looking at ICE technologies to be able to free up our TEE physician and be able to function independently of him, we first looked at 2-dimensional (2D) ICE, which I had done a couple dozen cases with in the past. What we noticed on the follow-up images was that occasionally we would see things on the follow-up TEE that we had not noticed on ICE. I think I am not alone when I say that it occasionally does not show you everything you need to see. So, we started investigating what the 3D ICE technology could do for us, and were very encouraged by the clarity and the various aspects that could be visualized with 3D echo that a 2D echo workflow was not able to show us. We identified early on that if we wanted this to succeed and be able to regularly do these procedures, that if we could use 3D ICE technology, then we might be able to make it happen on a regular basis for our patients.

What role does 3D ICE play in guiding these combined procedures from both a clinical and efficiency standpoint?

When you use 3D ICE for one of these procedures, it blows your mind. You do have to get the echo probe into the LA, so that can occasionally present an issue as you are trying to get the catheter transseptal. But the more of these that we do, the easier we find that. Once it is in there, you can pretty much park it and leave it where you can see the appendage. The level of clarity is incredible, because it is the closest you will ever get with an echo machine to that actual structure—you are right up against it. Half the time, I do not even have to touch the catheter from that point on out. With the various aspects of the 3D imaging, the echo tech can rotate around, omniplane, or do 3D multiplanar reconstruction. Right from one view, we can get every single measurement that we need, both pre and post deployment. So, what we found as we have started doing more of these with the 3D ICE is that procedurally it can be extremely fast. Another really nice thing about not putting something down the patient's throat is that you do not have to put them under general anesthesia to do this procedure. So, we can more frequently utilize monitored anesthesia care or conscious sedation to be able to perform the whole procedure. That actually saves you a significant amount of time, which might have otherwise been lost to turnover. I do not have the luxury of a flip room, so I have to do everything in one room. Being able to save a lot of time on the front and back end as the patient is getting prepped for the procedure and then waking up after the procedure is valuable for us to be able to have a busy schedule and take care of as many patients in the day as our schedule will allow.

What has been your experience using the Philips VeriSight Pro 3D ICE Catheter?

I have had the opportunity to use a number of different ICE catheters, and I really like the VeriSight. I feel as though the design of the catheter lends itself very nicely for both LAA and concomitant procedures. The location of the deflection is in a very convenient place, so once that catheter does get transseptal, you can deflect it inside of the LA, even in patients who might not have a markedly enlarged LA. Also, the bend is very soft, so there is not a lot of force that you can direct straight on with the catheter, which as you are trying to get transseptal, sometimes may be a little frustrating that the catheter will buckle instead of going across, but from a safety standpoint, I think it is huge. One of the unfortunate things that has been identified with LAAO procedures with ICE is that the rate of pericardial effusion may be slightly higher, and this has shown up on a couple of the studies. But it is important to note that none of those studies used this catheter. In my experience, I have not seen the catheter create any pericardial effusions, so I feel as we get more experience with this catheter and the unique features of how it is designed, that safety will continue to bear out in larger studies. The other unique aspect of how it is designed is the 3D aspect of it, which gives you incredible detail and clarity as you are looking at the LAA. So, compared to some of the other products out there, we have really found that this one gives us everything that we need and we use it fairly exclusively for these procedures.

How has VeriSight Pro improved patient experiences?

We have heard from a lot of our patients about how easy the procedure has become to get over[JE1] . Before, with TEE, every patient had to be intubated and go under general anesthesia, and when they would wake up after the procedure, they might be nauseated or have a sore throat. These are minor inconveniences, but as we are looking to try and roll this therapy out to as many patients as possible, sometimes the perception of going under general anesthesia can be somewhat daunting. So, being able to tell patients on the front end that we can do this with a lighter sedation helps to reassure them that it is something that they can get through with minimal inconvenience.

Considering the new DRG and the increasing adoption of 3D ICE, what is your view on the future of concomitant procedures?

The new DRG is a huge win for patients, physicians, and health systems, as well as for our whole health system as a country. I think that we are able to deliver the care that we need for our patients in a way that is more cost-effective, convenient, and lesser risk. For the patients in whom it is indicated, it is really poised to grow. There are going to be some parts that we need to figure out, such as how we are going to work it in and operationalize all the different moving parts, but I think if we can combine the procedural efficiencies of the 3D ICE with our ablation and mapping technologies, then we can truly deliver to our patients in one procedure almost everything they might need for managing their AF. At the end of the day, if we are able to accomplish that in one procedure in one day, then that freezes up the next day to be able to take care of another patient. So, it will only help us to be able to make the technology more accessible and be able to use it for as many patients as it is indicated for. I am excited about the future of AF management and I think as the epidemic of AF continues to grow, our specialty will be poised to be able to both tackle and improve it from a public health perspective. There is a lot to be gained from treating AF, and so we are excited about what the future will hold to hopefully improve more people's health. 

This content was published with support from Philips. 

Dr. Ricardo Lugo is a consultant for Philips. Dr. Lugo has been compensated by Philips for their services in preparing and presenting this material for Philips’ further use and distribution. 

The opinions and clinical expertise presented herein by Dr. Lugo are specific to the featured speaker and are for informational purposes only. The results from their experiences may not be predicative for all subject, physicians or patients. Individual results may vary depending on a variety of patient-specific attributes and related factors. Nothing in this video is intended to provide specific medical advice or to take the place of written law or regulations. 

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