Opening a MediGuide-Enabled Lab: Interview With Brett Faulknier, DO, FACC, FHRS

In this interview, we speak with Dr. Brett Faulknier, Director of Electrophysiology at Indian River Medical Center (IRMC) in Vero Beach, Florida, about the hospital’s new $5 million electrophysiology lab that features MediGuide™ Technology (St. Jude Medical).  

Tell us about the EP program at Indian River Medical Center. How long have you been with  IRMC?

We are a brand-new program. I arrived at Indian River Medical Center on August 1st, and the EP lab opened on September 14th, 2016. We are a Duke Heart Center Health affiliate, and in conjunction with them, we have utilized their guidance. I’ve worked directly with Dr. James Daubert, Director of Electrophysiology at Duke Medical Center — he was my mentor in fellowship at the University of Rochester from 2007-2009. After that, I worked at West Virginia University in Charleston, and then had the opportunity to come to IRMC. Starting a new program was very appealing to me, and being able to come back and work with Dr. Daubert also made the opportunity very beneficial as well. I worked with IRMC by phone for several months before my arrival. They already had plans in place for building the lab — they were just waiting on the right person for this opportunity. IRMC then began the construction phase, and had already made the decision to go with an equipped lab from St. Jude Medical. That worked out well for me, because I was primarily a user of St. Jude Medical equipment. They had also planned to have their MediGuide Technology, and while I had not used that in my previous institution, I was excited to begin the process of seeing how MediGuide could impact my device procedures as well as potentially my ablation procedures. 

Our lab at IRMC is beautiful. St. Jude Medical describes this technology as their lab of the future, so I think the hospital made a good investment in terms of equipping the lab. The technology will not need to be upgraded for some time. Purchasing MediGuide was really ahead of the curve — IRMC was the first center in Florida to use the MediGuide Technology. That is a big deal! 

We are trying to advance the technology as best we can, as we become comfortable. It’s one thing to use new equipment, but we also have some new staff, so we are going one step at a time. St. Jude Medical support has been very good to help with 3D mapping. So we just go day by day, and do a little bit more each time. 

What types of cases overall are performed in your EP lab? 

The EP cases we have performed so far at IRMC include an ischemic ventricular tachycardia (VT) case and ablation for VT in an ARVC patient who was experiencing ventricular arrhythmias from the right ventricle despite antiarrhythmic drug therapy. We’ve worked on two WPWs, a few standard SVT ablations, and an AV node reentry case. So it’s been interesting as we advance to more higher level EP procedures. 

What types of cases do you primarily perform with MediGuide, and how many cases have you performed so far?

I use MediGuide 100 percent of the time for biventricular device implants (pacemakers or defibrillators). It is particularly helpful with implantation of the LV lead. 

Since September 14th, I’ve done around 30 ablations, with a majority of them being atrial fibrillation (AF) ablations. I am currently using MediGuide in approximately 20 percent of ablations. I’m slowly bringing it on for ablation procedures, because I want to have my lab up to a certain level of expertise first. 

What benefits have you seen so far from switching to MediGuide? What impact has MediGuide had on your EP procedures?

For EP procedures, including when a Livewire catheter is used, I think it helps you reduce your fluoroscopy times. You can also locate different landmarks and be able to utilize those landmarks without having to use fluoroscopy to see where you’re at. 

Describe a recent case.

During an implant procedure such as for a biventricular ICD, I use a minimal amount of fluoroscopy to gain my access and then place the right atrial and right ventricular leads. Next, when I get to left ventricular implantation with the coronary sinus lead, I’m able to utilize a sensor-enabled catheter and sensor-enabled sheath to be able to obtain access to the coronary sinus. You can then do your venogram with a very limited amount of fluoroscopy. I recently had a difficult case in which the wiring was not easy, and involved the use of multiple inner sheaths and several wires. Normally this would have been a case where if you did not have this advanced technology, you might have utilized a significant amount of fluoroscopy. However, by not having to keep coming on fluoroscopy while doing the wiring and using the different sheaths, I was able to keep the fluoroscopy time at a minimum for the patient. In total, I think I used 10 minutes of fluoroscopy in that case. You might think that still sounds like a lot, but I felt that this case could have ultimately used up to 60 minutes of fluoroscopy or gone even further because of the difficult anatomy of the coronary sinus. We were able to be successful in implanting the lead and give that patient the opportunity to have much-desired biventricular pacing to improve their heart failure. On that day, I commented to my staff and to the St. Jude Medical representative that if we didn’t have the MediGuide, it would have taken a tremendous amount of fluoroscopy to accomplish that case, but the MediGuide was able to extensively reduce that. To me, that is where the maximal utility is at this point. I’m looking forward to seeing more benefits, especially in ablation cases and in treating atrial fibrillation, as additional catheters become available that have sensors in them that can be seen by the system.

Is there anything you’d like to add?

It is important to note that this is only our initial experience with this technology, and because we are also a new lab, there are many considerations we have to take into account. The first and foremost is patient safety, so we always make sure to take care of the patient and do what is right.

Disclosure: The author has no conflicts of interest to report regarding the content herein.