Spotlight Interview Update: Concord Hospital

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EP LAB DIGEST. 2023;23(12):1,29-31.

Adam Chodosh, MD, FHRS; Amanda Fernandez, RN, RCIS; and Stacy Shelto-Smith, RT(R), RCIS, MS; Cardiac Cath Lab, Concord Hospital, Concord, New Hampshire

What is the size of your cardiac electrophysiology (EP) lab facility? Has the EP lab expanded in size, or will it soon?

Concord Hospital, a not-for-profit community hospital located in the capital region of central New Hampshire, is home to a modern EP laboratory that provides an array of interventions for the diagnosis and treatment of heart rhythm disorders. Our facility consists of 2 EP labs: 1 dedicated EP lab and 1 crossover lab. Both are equipped to perform ablations, device implantations, or other departmental needs such as cardiac catheterization procedures. Each lab is approximately 750 square feet, and includes the EP lab and a team room. We anticipate an extensive renovation of our main EP lab in 2024.

Who manages your EP lab? What is the number of staff members?

Ours is a split model, meaning that we have a lab manager who oversees both the EP and cardiac catheterization laboratories. This is further divided into 2 resource positions, one of whom is responsible for EP daily operations, orientation, training, and supply management, and the other with similar responsibilities related to cardiac catheterization. Our EP lab is comprised of 19 staff members from various backgrounds. Five of these staff members are dedicated to our prep and recovery area.

What types of procedures are performed at your facility?

Our dedicated EP program provides a wide variety of complex yet minimally invasive procedures. These include foundational components such as EP studies to complex rhythm management including radiofrequency (RF) and cryoablation of atrial fibrillation (AF), atrial flutter, atrial tachycardia, supraventricular tachycardia, ventricular tachycardia (VT), PVCs, and atrioventricular junction ablation. We utilize advanced techniques including vein of Marshall alcohol ablation and epicardial ablation.

From an implantable device perspective, we offer a vast array of services including pacemakers, implantable cardioverter-defibrillators (ICDs), biventricular pacemakers or ICDs, leadless pacemakers, left bundle branch block (LBBB) and His bundle pacing (HBP), subcutaneous ICDs, and implantable loop recorders.

We are proud to be one of only a few hospital facilities that perform lead extractions in Northern New England.

Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and left atrial appendage (LAA) closures are performed each year?

We routinely perform 300+ catheter ablations each year. We also insert approximately 350+ pacemaker/ICD devices each year and average 20+ implantable loop recorders. We perform over 80 LAA closures each year.

What are some of the new equipment, devices, and products recently introduced at your lab? How have they changed the way you perform procedures?

Since our previous interview in 2016, we have adopted several innovative technologies that have enhanced the quality of our existing program and allowed us to maintain our patient-forward philosophy.

The most recently introduced technology has been the TactiFlex Ablation Catheter, Sensor Enabled (Abbott). This has allowed for high-power short-duration ablation with improved signal quality, real-time temperature tissue feedback, better catheter contact, and improved maneuverability, resulting in reduced procedural and patient recovery times.

We have also incorporated a third mapping system, the Rhythmia HDx Mapping System (Boston Scientific). This has allowed us to expand high-density mapping capabilities.

Additionally, we have begun using the ensoETM (Attune Medical) esophageal cooling device, which has increased our ability to obtain first-pass isolation of pulmonary veins and reduced the potential for esophageal-related damage. The Sensitherm Multi Esophageal Monitoring System (Abbott) is used during ablations to map out and provide real-time feedback on esophageal temperature, which minimizes the risk of esophageal damage during RF ablations.

Our lab also routinely utilizes VersaCross (Baylis Medical) in all transseptal procedures. This technology has significantly decreased our transseptal times.

Higher density mapping and improved voltage maps of the LA have accompanied the addition of Octaray Mapping Catheter (Biosense Webster). The Optrell Mapping Catheter (Biosense Webster) assists in the earlier diagnosis of late potentials and slow conduction during VT ablation.

Our ultrasound imaging quality has been augmented using the Vivid S70 Ultrasound System (GE Healthcare), which offers additional 3-dimensional (3D) imaging capabilities.

Closure devices such as the Vascade MVP System (Haemonetics) have expanded our same-day discharge program via earlier ambulation times and reduced use of anesthetics and heparin reversal medications.

What measures has your lab implemented to cut or contain costs?

We have a robust catheter reprocessing protocol that is linked into daily inventory management routines to ensure adequate stock and prevent excess. All our main lab staff members are cross-trained in a variety of roles, allowing for flexibility and cost savings when patient needs fluctuate.

Tell us about your approach to conduction system pacing.

We were relatively early adopters of HBP; however, we found that many of these leads demonstrated chronically elevated thresholds and placement could be time-consuming. We have been performing an increasing number of conduction/LBB pacing over the last 1-2 years. Initially, we placed these as a “bailout” after failed left ventricular lead placement or for nonresponders. More recently, we have implanted these devices in an expanding array of patients who are expected to predominantly ventricular pace.

What is your primary approach for LAA occlusion?

We have implanted the Watchman device (Boston Scientific) since 2015. Demand for this procedure has increased dramatically over the last year. We have a multidisciplinary approach involving a team of implanters that include a dedicated interventionalist, electrophysiologist, anesthesiologist, and 2 advanced echocardiography noninvasive cardiologists. Also involved are several dedicated staff, including echocardiography technicians and members of our lab. Importantly, we have an arrhythmia coordinator who has been key to our success.

We have overcome challenges and maximized good outcomes by incorporating a dedicated and diverse panel of team members into every case. We worked with our interventional radiology colleagues to perform transhepatic venous access for implantation of a Watchman in a patient with a congenitally absent inferior vena cava. We have also performed vascular plugs and coils in peri-device leaks.

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

We have had a dedicated AF Clinic for about 2 years at our institution. This has allowed patients initially diagnosed with AF in the emergency department (ED) or primary care to avoid lengthy hospital stays while obtaining timely, appropriate, cost-effective, and uniform treatment. We designed an algorithm specific to our institution for ED providers to facilitate this process. Our clinic is staffed by 2 dedicated advanced practice providers, a noninvasive cardiologist, and an electrophysiologist.

We are one of only a few hospitals in the state that perform lead extraction. Our lab staff and physicians work in a coordinated effort with our cardiothoracic (CT) colleagues so that a CT surgeon is in attendance during each case.

What approaches has your lab taken to reduce fluoroscopy time?

Reducing fluoroscopy time is a priority in our lab. Over the last few years, we have achieved zero fluoroscopy time for the majority of our AF ablations. Our approach has been to optimize our available mapping system technology, which includes using 3D mapping for catheter placement and ablation. Visualization of cardiac structures is enhanced using intracardiac echocardiography, which has greatly advanced our ability to reduce fluoroscopy.

What are some of the dominant trends you see emerging in the practice of EP?

The dominant trends we see emerging are same-day discharge for LAA closures, high-power short-duration ablation, bipolar ablation, true dual-chamber leadless pacing, pulsed field ablation, and nonfluoroscopy procedures.

How do you use digital health and wearable technologies in your treatment strategies?

Digital health and wearable technologies are important strategies for our program. Our physicians routinely recommend the KardiaMobile EKG Monitor (AliveCor), which records a medical-grade electrocardiogram (EKG) on a smartphone. Similarly, we also recommend the Apple Watch for its EKG application, which can record a patient’s heart rhythm using a sensor and check the recording for AF.

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

Our EP lab has several features in its layout that assist us in performance. For example, both of our labs are connected to dedicated equipment storage, which is easily accessible from either lab. Similarly, we have a ceiling-mounted equipment boom that is easily maneuverable and contributes to efficient room turnover. Two of our mapping systems are portable, which adds to a more flexible design. Lastly, each lab is equipped with headsets for improved communication between staff members and enhanced patient experience.

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

Our rapport with our community helps us to support the health of our community and has been a fundamental aspect of our success. Since the beginning of our program, community support has been integral. Numerous fundraisers have been organized by members of the community to help bring various technologies over the years, including funds for construction, fluoroscopy, and cryoablation. Conversely, various initiatives, including an ICD support group and outreach programs, demonstrate our commitment to our community. Commitment to our patient population has been the glue that has enabled our team to coalesce, grow, and strengthen. This is on display every day in our EP lab, with every interaction and with each team member’s promise to go the extra mile to ensure a safe and positive patient experience. Pride in what we do as a team is paramount here and is what makes our lab special. 

See their original Spotlight Interview at:

https://www.hmpgloballearningnetwork.com/site/eplab/articles/spotlight-interview-concord-hospital