Spotlight Interview: Endeavor Health Cardiovascular Institute at Glenbrook Hospital

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EP LAB DIGEST. 2024;24(10):1,12-15.

Mark Metzl, MD
Glenview, Illinois

When was the cardiac electrophysiology (EP) program started at your institution, and by whom?

Our program has a rich history dating back to the early years of clinical cardiac EP. Dr Steven Swiryn, who trained with Dr Ken Rosen at the University of Illinois-Chicago, started the EP program at Evanston Hospital in 1982. We were 1 of 3 EP programs in the Chicago area at the time. Dr Wes Fisher was recruited in 2001 to expand the interventional procedures of the clinical EP service line. 

What is the size of your EP facility? Has the EP lab recently expanded in size, or will it soon? 

We opened the Cardiovascular Institute (CVI) at Glenbrook Hospital in May 2024, which centralized EP procedures from 4 of our 9 hospitals. The CVI has 4 large, dedicated EP laboratories and a shared “combo” room for cardiac implantable electronic device (CIED) implantation. All our rooms are designed to also be full cardiovascular operating rooms (ORs). The co-localizing of the EP, cardiac catheterization, structural, cardiothoracic (CT), and vascular surgery teams allows for more efficient staffing models to be implemented, improves safety of high-risk procedures, and serves as an incredible opportunity for collaboration.

What types of procedures are performed at your facility? 

We perform the full complement of ablation and CIED implantation (including atrial and ventricular leadless pacemakers, as well as extravascular and subcutaneous defibrillators), left atrial appendage occlusion (LAAO), including both the Watchman (Boston Scientific) and Amplatzer Amulet (Abbott), and lead extraction procedures.

What type of EP equipment is commonly used in your EP program? 

Four EP laboratories (Siemens Healthineers) opened in May 2024. We integrated Carto (Biosense Webster, Inc, a Johnson & Johnson company) in 3 of them and the EnSite X (Abbott) and Rhythmia (Boston Scientific) systems into the fourth EP laboratory. We use the Farapulse pulsed field ablation (PFA) system (Boston Scientific). The Philips laser is used for lead extraction. We have echocardiogram machines from GE HealthCare, Philips, and Siemens Healthineers. We equipped one of our EP laboratories with an integrated video system (Karl Storz) to stream and review live cases.

What are some of the new technologies and techniques recently introduced in your EP program? How have these changed the way procedures are performed?

We have been doing 4-dimensional intracardiac echocardiography (ICE) LAAO under nurse-led sedation for nearly 2 years, which has helped facilitate same-day discharge (SDD) of most of these patients. We began using Farapulse for PFA of atrial fibrillation (AF) with its commercial launch in the United States this spring. Single-shot PFA procedures have made AF ablation procedure times slightly shorter and more consistent, and have decreased concerns for collateral injury.

Discuss your technique for preventing esophageal injury during AF ablation.

We were early adopters (October 2019) of esophageal cooling with the ensoETM device (Attune Medical, now part of Haemonetics) and contributed much to the literature on its benefits. We found not only that it decreases risk of esophageal injury, but it also improves ablation efficiency and efficacy as a result of its implementation in our program.

Tell us more about your program’s use of PFA, including patient selection and initial experience.

Our initial PFA experience has been very positive. The benefit is that it gives us a more consistent and less anatomy-dependent workflow. We are looking forward to 3-dimensional mapping integration of this technology, since we have been fluoroless and lead-free for several years for ablation procedures.

Can you describe the extent and use of vascular closure devices in your laboratory? Tell us more about your approach for SDD. 

We use both the Vascade MVP venous vascular closure system (Haemonetics) and Perclose ProGlide suture-mediated closure system (Abbott) in our laboratory. We discharge more than 90% of our patients the same day after their procedures.

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

The EP physicians, nurses, and laboratory technicians were involved throughout the design process. From the placement of the table in the room to the location of electrical outlets, the EP laboratories were designed with each staff member’s role in mind. Since each EP laboratory is designed as a full cardiovascular OR, the space is much larger than a standard EP laboratory.

Discuss the role of mid-level practitioners in your laboratory.

We have a growing team of advanced practice providers (APPs) who support periprocedural and consultative services. We also have a well-developed APP-run AF Clinic.

Discuss your AF clinic, including goals, members of the comprehensive care team, and development of team-based care pathways. 

We have a comprehensive approach to patients with AF at Endeavor. We have an Epic integrated pathway that allows for safe discharge from the emergency department to early follow-up with our AF clinic. Our AF Clinic APPs provide patient education on risk factor reduction (eg, alcohol moderation, weight loss, physical activity, and stress management) and provide treatment options to prevent stroke. Patients can quickly obtain sleep studies, echocardiograms, and cardiology follow-up appointments from our AF Clinic to facilitate their care.

Discuss your approach to lead extraction and management.  

We have a “cavalry in the room” approach to lead extraction, with a cardiac anesthesiologist, CT surgeon, and cardiovascular perfusionist in the room. We monitor with transesophageal echocardiography and stage with a Bridge occlusion balloon (Philips). Now that all of our EP laboratories can also serve as cardiothoracic ORs, we are less dependent on hybrid OR availability for scheduling. We have an electronic medical alert (EMA) in Epic for bacteremia in the presence of a CIED that is monitored by our EP consult service. We have published data showing more timely workup and extraction with the adoption of our EMA.

How does your EP program handle radiation protection for physicians and staff? What approaches have you taken to reduce fluoroscopy time? How do you record fluoroscopy times/dosages?

We have been using zero fluoroscopy for most ablations for many years. It has been wonderful for our staff to “shed the lead.” However, we still use fluoroscopy for CIED implantation, CIED extraction, and LAAO procedures. These procedures are most often performed in the EP laboratories where we installed an EggNest system (Egg Medical). We have been very impressed with the reduction in both radiation dosage and radiation scatter. We have been working with Egg Medical to develop future systems that would completely negate the need for lead in all our procedures.

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

Ablation and CIED procedures are becoming more streamlined and less invasive, which allows for treating an older and more complicated patient population.

Is your EP laboratory involved in clinical research studies? 

We are currently enrolling in the Biosense Webster-sponsored Omny-IRE trial evaluating the safety and effectiveness of the Omnypulse Catheter with the Trupulse Generator for treatment of paroxysmal AF. We are enrolling in the REAL-AF and DISRUPT-AF Registries sponsored by Heart Rhythm Clinical and Research Solutions, compiling prospective real-world data on radiofrequency (RF) ablation and PFA for AF. We are also proud to be a part of the FACT-CRT and REACT-AF studies sponsored by the National Institutes of Health. Our EP physicians have academic appointments at the University of Chicago Pritzker School of Medicine and are active in their own investigator-initiated studies. 

Has your program or hospital recently experienced any “firsts”? 

We have been leaders or fast followers of many procedures, from esophageal protection during AF ablation, fluoroless ablation, techniques to improve ablation catheter stability, 4D ICE guidance of LAAO, leadless pacing, and lead management. We were recently among the first in the world to use the Hotwire (Atraverse Medical) for RF transseptal puncture. While we have been leaders in our region in many instances, we favor the value of delivering exceptional care to our patients over promotional social media posts. 
What specific challenges does your hospital face given its unique geographic service area? 
We are fortunate to take care of a wonderful community in the Chicago area. We are composed of several hospitals at Endeavor but think of ourselves as one hospital with several sites of care. 

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

The EP laboratories at the Glenbrook CVI are beautiful, state-of-the-art, and are designed to foster collaboration and efficiency. So is our team! We are hiring for our dedicated EP-only team. We have a comprehensive training program for staff, so please reach out. n

Find the Endeavor Health CVI at Glenbrook on X at: @EndeavorHlth