New Technology Adds New Energy in EP Lab

We have done extensive training with this three-dimensional advanced mapping and navigation system, and continue to build on our knowledge with hands-on experience in cases. Our teamwork has reached a higher level with further cross-training and collaboration with the physicians in the lab. We now effectively take on more complex rhythm problems such as atrial tachycardias, RVOTs, left ventricular tachycardias and left-sided atrial fibrillation which would have been more difficult to do without the system.

Addressing a Growing Patient Population

Banner Baywood Heart Hospital specializes in cardiac catheterization, electrophysiology, non-invasive cardiology and vascular care. We serve the Mesa, Apache Junction and Queen Creek areas of Arizona which have a heavy concentration of elderly patients. The average age of our patients is 71 years. Due to dramatic growth in the number of patients we treat, we recently added another 51 patient beds to the 60 we already had. By nearly doubling in size, we are now considered the second-largest free-standing heart hospital in the nation. The Heart Hospital is part of Banner Health, a health care system which includes 19 hospitals, six long-term care centers and an array of services, including family clinics, home care services and home medical equipment services in the western United States. Although the Heart Hospital is a separately licensed facility, we share an emergency department, radiology suite, laboratory and chest pain unit with Banner Baywood Medical Center, a full-service Banner Health hospital next door. The Heart Hospital offers a wide range of cardiac procedures and services, including diagnostics, nuclear cardiology services, cardiovascular surgical procedures and more. We have four cardiac catheterization labs, one of which is dedicated solely to electrophysiology. We have received funding to open a fifth lab yet this year, and there are plans to eventually expand to seven or eight labs. Over the course of a year, approximately 6,000 patients visit our labs, and we perform more than 8,300 procedures. In the EP lab, we focus on implants (ICDs, pacemakers and bi-ventricular devices), EP studies, and ablation procedures for all types of arrhythmias. Several physician groups perform procedures in the cath labs, and the two most active electrophysiologists in the EP lab are Andrew J. Kaplan, MD and Rodrigo Chan, MD, from Tri-City Cardiology Consultants, a group of eleven cardiologists with two offices in Mesa. Dr. Kaplan was the first electrophysiologist in the east valley, and has been practicing at the heart hospital since it opened in November 2000. Dr. Chan joined Tri-City Cardiology and began practicing in our lab two years ago. Drs. Kaplan and Chan are actively seeking a third electrophysiologist to join them. To more effectively care for a growing population of patients with complex arrhythmias, Drs. Kaplan and Chan suggested that the heart hospital obtain an advanced mapping and navigation system. After reviewing several different options, the physicians and hospital staff chose the EnSite System and purchased it in February of this year.

A Better View of Arrhythmias

The EnSite System helps us gather the information our physicians need and translates the real-time electrical information onto a three-dimensional (3D) graphical map. The system s powerful computer workstation allows us to use either the EnSite Array balloon catheter or the EnSite NavX navigation and visualization technology. The balloon catheter maps complex arrhythmias (such as atrial flutter and VT) in a single heartbeat by collecting data from 64 electrodes. The EnSite NavX technology transmits electrical signals between three pair of surface electrode patches placed on the patient. Catheters sense the signals and translate them into 3D computer images called geometries that assist us in navigating the heart and terminating simple arrhythmias such as AVNRT. One of the most enjoyable things about using the EnSite System is creating the geometry or three-dimensional computer model of the heart chamber and structures. The physician moves the catheter around the chamber, and we collect points to create the geometry. We can fine-tune or smooth the geometry by deleting points or collecting additional points so that the physician has an accurate depiction of the cardiac structure. Our geometry creation has improved immensely from when we were just learning to gather the points. We have gone from 20 minutes down to seven minutes or less. The more cases we do with the system, the better we can assist the physician in navigating the catheter and identifying the best place to burn. Having this technology has helped us decrease our procedure and fluoroscopy times. It also has allowed us to more effectively treat a wider variety of arrhythmias than we have in the past. For example, we have recently started performing more atrial fibrillation procedures by utilizing the EnSite NavX technology. Atrial fibrillation procedures can be very complicated, but with the 3D mapping and navigation technology, it is not the impossible, daunting task that it used to be. The EnSite NavX technology enables us to build accurate geometries or models of the left atrium to guide the safe delivery of radiofrequency (RF) ablation lesions. Another capability of the system we use is importing a segmented CT model of the cardiac structure into the system and displaying it on the computer screen next to the EnSite System geometry. The CT scans allow us to verify cardiac structures and create even better geometries. If we are having trouble navigating a catheter, for example, we can compare the cardiac ridges and structures on the highly detailed CT scan with the geometry to see where we need to improve upon the geometry creation. The EnSite System also is useful in verifying bi-directional block. In the past, we had been verifying bi-directional block in atrial flutter cases by using the EGMs or electrical signals acquired from standard electrode catheters or basket catheters. The first one or two times we used the EnSite Array balloon catheter to check bi-directional block, we could see the isthmus block, and how the pathway was traveling around and not going through. We got to the third case, and the block was not as clear-cut, but the additional information from the balloon catheter made the interpretation easier. Now that Dr. Kaplan uses the EnSite Array catheter to confirm the block, we have found the other methods less accurate. In one of our most recent cases, the patient had an inappropriate sinus tachycardia, and we had to measure from the sinus node to the area that was activating first. Our previous protocol was to use pace mapping to identify the location of structures. The measurements were not very accurate, which forced us to closely watch the ablation catheter for any movement into the sinus node area. There was no room for error, as we did not want to end up with a pacemaker-dependent patient. With the EnSite System, we take accurate measurements and collect data from the activation map. We are more confident about finding the exact location of the sinus node and the pattern of the arrhythmia. The preciseness of the measurements allows our physicians to safely apply RF energy. We are still learning all the ways the system can be used. It provides an incredible amount of information, making it challenging to decide which to use in a particular case. However, it has added to our overall confidence in diagnosing and treating any arrhythmia. The outcomes are well worth the effort it has taken to learn how to use it.

A "Stepping Stone" Training Approach

In learning how to use the EnSite System, we have increased our knowledge of electrophysiology. We are learning much more about anatomy, pathophysiology and how the cardiac anatomy correlates with the fluoroscopic images. This ongoing education motivates us and prevents us from being stagnant. We have been following a stepping stone training plan with the system. Each step has seemed challenging until we have mastered it. When we obtained the system in February, a clinical team from ESI provided two formal days of training in our lab. The mornings were devoted to didactics in the classroom. In the afternoons, we were introduced to the use of the EnSite System in actual cases. We started by using it in atrial flutter and AVNRTs arrhythmias our physicians were already very familiar with treating. Since the initial training, we have undergone other training with Harlie Ferguson, our Clinical Educator from ESI. As one part of our education, Harlie simulated everyday situations by creating glitches in the nuts and bolts of connecting the components. He would unplug a piece of equipment or plug it in backwards. We had to go back and make sure we had completed all of the steps, which prepared us for trouble-shooting during a case. We now have enough confidence and competence to pull in the equipment when needed, set it up and create a geometry. We also are learning more during cases. Harlie helps us build on our existing knowledge by providing a little more information every time we do a case. For example, if what our physicians are seeing with their signals is not being represented on the activation map when the two aren t really making sense to the physician Harlie will say: Well, let s change filters here and see if this will make more sense. Last month, we further expanded our knowledge during a series of focal atrial fibrillation cases with the EnSite NavX technology. Along with Dr. Chan, we tried several different approaches, starting with creating the geometry and then going back and doing a linear ablation. We tried a case where we just built the geometry as we were doing the linear ablation. We did one where we created a semi-geometry and completed it as we were doing our linear ablation. After trying several different approaches, Dr. Chan could compare and decide which approach was most effective. One of the most challenging as well as most satisfying things about using the EnSite System is interpreting the activation maps created by the EnSite Array balloon catheter. While our physicians have mastered interpretation, we are still learning. We want to have as great an understanding as possible regarding where the arrhythmia is starting and where it is breaking out. This way, we can capture the right information and correctly illustrate it on the 3D map. Our job is to give the physicians the best clinical data from which they can interpret the arrhythmias and base their treatment decisions. We feel that we are about two-thirds of the way toward our goal of being able to function independently on the EnSite System. We expect to have an additional day of instruction in the near future, which will provide more advanced information. Because the interpretation takes experience, and because the system and ablation therapy is constantly evolving, we expect our training to be ongoing rather than finite. We hope to be constantly learning new things and applying the system in new ways.

The True Meaning of Teamwork

In many EP labs, the division of labor is often very defined. A nurse may have responsibility for sedation and recording documentation of the procedure, and that is strictly her job. However, in our lab, we have a lot of flexibility, and our physicians trust us and give us the autonomy and encouragement to develop our skills. Traditionally, physicians make the decision and nurses carry it out. In our lab, we have collaborative input with the physicians on diagnosing. They listen to our thoughts on what might work and what might not work, and we dialogue during the procedure: "This is what I'm seeing"; "Do you see this?"; "Could it be that?" We have only worked with three different physicians over the last three and a half years. They have seen our zeal for learning and our ability to take in new information and apply it. We have developed a bond and trust, and they have helped us in our growth. They are teaching us to be more cognizant of the signal changes and what is happening with an arrhythmia. We learn from them each and every time we do an ablation procedure, and we become more knowledgeable and comfortable with what we are seeing. We have two nurses in our lab at any one time either of the two of us, and/or Rachel Arvayl, RN. We frequently trade responsibilities among ourselves and our cardiovascular radiologic technologist, Vicki Maestas, CVRT, who brings an additional level of professionalism that contributes to the success of our procedures. Under the guidance of the physician, the nurses do the majority of the stimulation protocols to initiate the tachycardia. Vicki is going to be expanding her role and adding that to her expertise within the next few months. She may also take on the role of documenting the procedure. We take turns setting up or prepping the patients and connecting them to the appropriate equipment. Vicki scrubs in with the physician, preps the catheters (including the EnSite Array balloon catheter when it is used), and assists with inserting the catheters. She sets up the x-ray equipment and the RF generator. In the state of Arizona, the x-ray equipment can only be run by a certified technologist, so Vicki runs it. Once the case starts, one of the nurses monitors the patient, and one runs the EnSite System. Since Vicki is fairly new to our lab, she has not had the chance to learn to use the EnSite System, but eventually she will. The monitor circ nurse makes sure the patient is comfortable and appropriately sedated, keeps an eye on the blood pressure and level of consciousness, and titrates heparin to prevent clots. We have worked together in this room for so long that we talk back and forth So what was the last ACT? so that we are all aware of the information. We know our physicians well enough, and they trust us enough with sedation, that we rarely have to ask how much more or what they want. We have an understanding with them, a lot of trust. Each case is a little different. Sometimes we do the electrophysiology study first, and sometimes we will go right into creating a geometry with the EnSite System. Whoever is operating the EnSite System opens up the study, goes through the checklist of which features to use, sees if any signals are not transmitting properly, and troubleshoots until everything is ready. We need to be aware of which chamber or area of the heart we are working in, what information needs to be collected in that area, and how the physician is going to collect the information. Once we have gathered enough points to create a good model of the cardiac structure or identified the pattern of the arrhythmia, the physician can decide where to place treatment. When first learning to use the system, we were not sure whether we should be watching the catheter on the screens or looking at the waveforms. Once we compared the chamber models from the EnSite System to the x-ray and learned what the signals were telling us, it became easier. We also learned to focus on our own roles. Vicki runs the RF generator, and she focuses on the catheter movement on the EnSite System monitor so that she will know when to stop the RF energy. (The physicians rarely use fluoroscopy during the EnSite procedures.) Her level of attention has allowed the rest of us to watch the images and the signal degradation so that we know we are effectively using the RF. Now that we are past the initial learning curve, we see that the EnSite System actually gives us a more detailed three-dimensional picture of the cardiac anatomy than fluoroscopy or conventional methods. We are becoming more and more adept at navigating ablation procedures with the system. Input from all of us enhances the patient care we provide and our performance in the lab.

Impacting Patient Care

Many of the patients that come into our lab say they have had heart problems for 10 years or longer and did not know there was a cure. They lived with symptoms for years and tried many medications. Their condition caused them anxiety, and their quality of life just was not what it should be. With the new technology in our lab, we can find the right area to treat. We want to eliminate the arrhythmia, not just treat it with medications. We want to prevent them from having to worry about driving down the freeway, becoming syncopal and possibly having a car accident. We are excited to be able to offer our patients the most advanced arrhythmia treatment strategies available today and to be part of an area of medicine that is quickly expanding. Our colleagues in other parts of the hospital do not understand the opportunities for professional development and teamwork we have in the EP lab. If they did, they would be clamoring to join us. For the most part, we keep it a secret. However, we assure our patients that we will be here if they need to come back in ten years.