Spotlight Interview: The University of Kansas Hospital

The University of Kansas Hospital cardiac electrophysiology (EP) program has experienced tremendous growth from the time of its inception to its present-day status as a major referral center in the Midwest. Through the visionary leadership of its early pioneers, the program has predicated its success on a comprehensive approach to patient care, early adoption of innovative technologies, firm commitment to scientific investigation and fellow education, and engagement of the broader electrophysiology community through regional, national, and international professional society activity.

When was the EP program started at your institution? 

The cardiac EP program at The University of Kansas Hospital began in 2001, with the introduction of the Mid-America Cardiology group to The University of Kansas Hospital. The University of Kansas Hospital also includes the 72-bed, state-of-the-art Center for Advanced Heart Care, which opened in 2006. In February 2007, we moved into the Richard and Annette Bloch Heart Rhythm Center, which is inside the Center for Advanced Heart Care. 

What is the number of staff members? What is the size of your EP lab facility? 

The program is housed in the Division of Cardiovascular Diseases and has over 40 cardiologists on staff. The EP staff has grown from two to seven full-time faculty in a 15-year span.

The EP program at The University of Kansas Hospital, under the flagship of the Richard and Annette Bloch Heart Rhythm Center, offers a vast array of traditional and cutting-edge diagnostic and therapeutic services. Our facilities currently feature 4 dedicated electrophysiology laboratories for ablation, structural heart, and device implantation procedures, as well as a hybrid operating room used for complex procedures such as lead extractions, epicardial left atrial appendage closure, and others. 

Tell us more about your EP staff. Who manages the EP lab?

The Mid-America Cardiology/KU electrophysiology team consists of Drs. Loren Berenbom, Martin Emert, Rhea Pimentel, Dhanunjaya Lakkireddy, Raghuveer Dendi, Madhu Reddy, and Seth Sheldon. As with every large program, there is a division of labor and niche expertise that each of these individual physicians are recognized for on the national front. This fantastic team is supported by a very talented advanced practice provider team, which is comprised of Courtney Jeffery, Katie Christensen, Christina Maenle, Maria Schulte, and Huma Baig. 

Melinda Loy is the manager of the EP labs, and she is supported by a team of technologists and nurses. The outpatient team, overseen by Stephanie Wynn, RN, consists of 25 nurses and technicians who manage all outpatient visits, device clinics, tilt and autonomic test units, telemonitoring services, and prompt patient navigation. 

What types of procedures are performed at your facility? Approximately how many EP cases are performed each year?

A commitment to outstanding, patient-centered clinical care has been the hallmark of the EP program at The University of Kansas Hospital. The program offers the full spectrum of therapies within the realm of clinical EP, including complex ablation for atrial fibrillation (AF) and ventricular tachycardia (VT), as well as the newest technologies for left atrial appendage closure (LAAC) and other device-based therapies. Surpassing other centers in the surrounding six-state region, the EP program performs over 2500 patient procedures per year. 

The ever-increasing procedural volume and breadth of expertise in contemporary EP therapies would not be sustainable without an excellent team of EP nurses, technologists, and other staff who are crucial to ensuring efficient day-to-day operations. The University of Kansas Hospital utilizes a multidisciplinary team approach with various departments, including anesthesia, Cardiac Recovery and Treatment, the Cardiac Intensive Care Unit, and Mid-America Cardiology Clinic. Whether in the context of direct patient care, coordination of services, patient education, or any other necessary support to patients receiving EP services, a team-based approach has always been the key to success at KU. Furthermore, the AF ablation and LAA closure programs feature a strong partnership between Cardiothoracic Surgery and the EP team.

The overall quality and success of the program over the past 15+ years has been due not only to excellent vision and leadership at the institutional and divisional levels, but also strong collaborative relationships with cardiology colleagues focused on heart failure, cardiovascular imaging, and interventional cardiology, as well as cardiothoracic surgery, neurology, immunology and sleep medicine, among others. This interdisciplinary environment has helped nurture the development of centers of excellence in the following specialty areas: (1) atrial fibrillation, ventricular tachycardia, and complex arrhythmia management; (2) syncope and autonomic dysfunction; and (3) inherited arrhythmia disorders. 

How is outpatient cardiac monitoring managed?

Outpatient EP care is provided at five locations in the Greater Kansas City area, as well as more distant satellite locations in both Missouri and Kansas, although patients referred to KU are located well beyond these borders. Devices are supported with an extensive remote monitoring system interfacing with the electronic medical record, which enables appropriate escalation of any relevant events or other concerns to be dealt with by EP physicians and staff in a timely fashion.

What innovative EP techniques are being utilized in your lab? How have these technologies changed the way you perform procedures?

Early adoption of promising new EP therapies has been a large part of the program’s sustained growth. Among many firsts, electrophysiologists at the Bloch Heart Rhythm Center were the first in the region to adopt the Stereotaxis magnetic navigation system to optimize catheter precision in complex ablation procedures, and the first in the United States to utilize St. Jude Medical’s MediGuide™ Technology to augment traditional fluoroscopic visualization and reduce radiation exposure. More recently, under the leadership of Dr. Lakkireddy, the KU EP program has made tremendous strides as a national and international leader in LAAC therapies such as the LARIAT^® Suture Delivery System (SentreHEART, Inc.) and the WATCHMAN™ Left Atrial Appendage Occluder (Boston Scientific), as well as other exciting LAAC technologies in various stages of development, including the AMPLATZER™ Amulet™ (Abbott), which is currently under investigation in the international Amulet IDE trial. Furthermore, we routinely implant pulmonary artery hemodynamic monitoring systems (CardioMEMS™ HF System, Abbott) and leadless pacemakers (Medtronic Micra™ and Abbott Nanostim™) where indicated. Lastly, we maintain a comprehensive atrial fibrillation ablation program, offering both routine ablative therapies and hybrid procedures for complex cases.

Are you ACGME-approved for EP training? What are your thoughts on two-year EP programs? 

The KU EP program has had a longstanding commitment to fellow education, offering a two-year ACGME-accredited clinical cardiac EP fellowship. The two-year program was in place before the most recent ACGME designation of EP as a two-year fellowship, reflective of the program’s commitment to producing graduates who are both skilled in the clinical assessment of EP patients and fully facile in the gamut of contemporary EP diagnostic and therapeutic procedures. These and other goals are achieved through a robust training experience in a high-volume setting and augmented further through weekly didactic sessions and clinical conferences, as well as monthly journal clubs, morbidity and mortality conferences, a monthly research conference, and cardiology grand rounds.

Tell us about your EP program’s extensive involvement in clinical research.

The University of Kansas Hospital has a robust and multifaceted research program, which is comprised of a vast array of single-center and multicenter investigator-initiated studies spanning the full breadth of contemporary problems in clinical EP. Areas of particular interest include optimal management of atrial fibrillation and ventricular tachycardia, stroke prevention in atrial fibrillation, left atrial appendage closure techniques and outcomes, device-based technologies for diagnostic and therapeutic applications in EP, utilization of cardiac biomarkers in the management of EP patients, and infection prevention strategies for quality improvement. These investigator-initiated efforts are complemented by very active involvement in over 30 national and international clinical trials funded by industry partners to help advance the field of EP on as many fronts as possible, as well as to maintain the program’s commitment to providing high-quality, cutting-edge care to its patients through early adoption of novel, efficacious therapies. 

The EP program’s passion for ongoing clinical research activities has resulted in numerous textbook chapters, review articles, peer-reviewed publications in leading journals, and abstract presentations at premier cardiovascular and electrophysiology conferences. Furthermore, KU faculty have been invited as speakers to numerous regional, national, and international conferences to disseminate knowledge and advance the field of EP. Dr. Lakkireddy currently serves as national principal investigator for two major clinical trials of left atrial appendage closure devices: (1) the aMAZE trial (ClinicalTrials.gov Identifier: NCT02513797), which studies the safety and efficacy of the LARIAT device to percutaneously isolate and ligate the left atrial appendage as an adjunct to pulmonary vein isolation for the treatment of symptomatic persistent or longstanding persistent atrial fibrillation, and (2) the Amulet IDE study (ClinicalTrials.gov Identifier: NCT02879448), which is designed to evaluate the safety and efficacy of the AMPLATZER™ Amulet™ LAA Occluder (Abbott) as compared to the commercially available WATCHMAN™ device (Boston Scientific). Lastly, KU is also involved in the ongoing clinical trial evaluating the Parachute Implant System (CardioKinetix, Inc.) for percutaneous ventricular restoration in chronic heart failure due to ischemic heart disease. 

Some of the many pioneering contributions of the EP group include: use of uninterrupted novel oral anticoagulants in EP procedures, the adjunctive role of LAA LARIAT ligation along with AF ablation in non-paroxysmal AF patients, investigation of the systemic homeostatic effects of LAA ligation, therapeutic application of yoga in AF, reinventing safe pericardial access using a micropuncture needle, and physiologic gut dysmotility after AF ablation. Research from this program has addressed many critical questions that are relevant to practical patient management. 

Looking towards the future, we plan to embark on a number of exciting multicenter studies, addressing such questions as: (1) utilization of NOACs for systemic anticoagulation post-VT ablation for stroke prevention (STROKE-VT; NCT02666742), (2) comparison of ablation versus medical therapy for CRT non-responders with persistent atrial and/or ventricular arrhythmias (ABLATE-CRT), and (3) the potential benefits of regular yoga in patients with neurocardiogenic syncope (SYNC-YOGA). 

The EP research team is comprised of the following: 

• Research nurses: Donita Atkins, BSN, Misty Jaeger, BSN
• Research coordinator: Margana Morgan, BS
• Database support: Sudha Bommana, MPhil 
• Research assistant: Nikki Schwab, BS 
• Cardiac arrhythmia research fellows: Drs. Mohammad-Ali Jazayeri and Venkat Vuddanda 

Tell us about your organization of scientific meetings.

Dr. Lakkireddy currently serves as the Kansas State ACC Chapter Governor and has worked extensively with cardiologists and others throughout the state to organize and provide physician and patient advocacy. In addition, the organization has grown under his leadership to offer meaningful educational activities and CME opportunities, such as those offered through the yearly Kansas ACC conference, which is now entering its fourth year of existence.

More specific to electrophysiology, the KU EP program was proud to host its eighth consecutive Kansas City Heart Rhythm Symposium (www.kchrs.com) in August 2016. Featuring speakers from all over the world, the program was highly successful in providing a comprehensive scientific session for physicians, fellows, allied health professionals, and industry partners. 

Dr. Lakkireddy is a founding member and course co-director for the International Symposium on the Left Atrial Appendage (ISLAA; www.islaasymposium.com). The unique program, now in its fifth year, aims to provide attendees with a comprehensive overview of left atrial appendage closure modalities and emerging technologies in this promising and rapidly evolving space. ISLAA 2017 will be held in Austin, Texas from March 3-4. 

Tell us more about your community engagement and patient advocacy efforts.

The EP program at The University of Kansas Hospital has been heavily involved in community engagement and patient advocacy efforts for many years. The Global Atrial Fibrillation Alliance (GAFA), a 501(c)(3) non-profit organization, aims to bring together affected patients and their families, healthcare providers, industry partners, and others with a mutual goal of increasing knowledge regarding AF and its sequelae, promoting awareness and early detection in an “upstream” approach, and providing support to patients afflicted with AF and their loved ones. The GAFA organization of the Greater Kansas City Area has been instrumental in planning and organizing a series of events including yearly commemorations of World Atrial Fibrillation Awareness Day, which takes place on the second Saturday of September each year, following official proclamations by Kansas Governor Sam Brownback and Arkansas governor Asa Hutchinson. In previous years, programs have included 5K run/walk events, yoga instruction, and nutritional education, in addition to hosted speakers to educate attendees regarding the state of current AF prevention, diagnosis, and management strategies. During the 2016 World Atrial Fibrillation Awareness Day event, we held a patient education event with physician speakers from the KC area followed by a guided yoga session for those interested.

What do you consider special about your EP lab and staff?

The clinical EP program at The University of Kansas Hospital has enjoyed enormous success since its founding due to the contributions of many dedicated individuals among its faculty, nurses, trainees, support staff, and others who have helped it evolve and progress over time. As a regional referral center, it continues to grow rapidly through a combination of efforts rooted in the provision of world-class patient care and heavily supported by complementary initiatives in the dissemination of scientific research, physician and trainee education, professional society engagement, and patient advocacy. The future is bright for The University of Kansas EP program, and through sustained efforts in these various arenas, the program will continue to provide its patients and other beneficiaries with the outstanding quality and leadership they have come to know and trust.