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Spotlight Interview: Shanghai General Hospital
Shanghai General Hospital was founded in 1864 by French consuls as one of the largest and earliest Western medicine hospitals in China. For the past 155 years, Shanghai General Hospital has remained a leader in national and local medical circles. With two campuses — the north Hongkou campus and south Songjiang campus — Shanghai General Hospital occupies a land area of 303,333 square meters, currently the largest area for any hospital in Shanghai. There are 4,003 permanent staff members, including 1,297 physicians and 1,640 nurses. There are 2580 patient beds. In 2018, there were approximately 4 million outpatients, more than 110,000 inpatients, and around 80,000 surgical patients.
There are 48 departments and 53 wards in Shanghai General Hospital, 8 of which are national key clinic disciplines, such as the department of cardiology.
When was the EP program started at your institution?
In 2011, the EP program was initiated by the National Health Commission of China, as Shanghai General Hospital is one of its authorized centers.
What is the size of your EP lab facility? Is the EP lab separate from the cath lab?
We have 3 EP lab rooms that are managed by the cardiac catheterization center. The EP program is not completely separate from the cath labs; employees are cross-trained, but attending physicians are engaged in different subspecialties.
What is the number of staff members?
There are over 100 employees in the department of cardiology, including more than 40 physicians.
Who manages your EP lab?
Dr. Shaowen Liu is the director of the EP program and director of the department of cardiology.
What types of procedures are performed at your facility? Approximately how many catheter ablations (for all arrhythmias), device implants, lead extractions, and LAA closures are performed each week?
We treat patients with premature ventricular contractions (PVCs), ventricular tachycardia (VT), Wolff-Parkinson-White (WPW) syndrome, supraventricular tachycardia (SVT), atrial tachycardia (AT), atrial fibrillation (AF), atrial flutter (AFL), and other recurrent arrhythmias. Atrial fibrillation accounts for almost 70% of our annual radiofrequency ablation procedures.
Recently, there has been a 15% growth per annum in patient volume. We perform approximately 25 catheter ablations per week and 13 pacemaker implants per week. We do relatively fewer LAA closures, and even less lead extractions.
What percentage of your lab’s device implants use MR conditional pacemakers or ICDs? What percentage of implants use subcutaneous or leadless devices?
About 10% of our pacemaker implants are with MR conditional pacemakers. Subcutaneous and leadless devices not yet covered through government health insurance, and therefore, are not used on a regular basis.
What type of hospital is your EP program a part of?
Shanghai General Hospital is run by the government and is one of the affiliate hospitals to Shanghai Jiao Tong University.
What types of EP equipment are most commonly used in the lab? What imaging technology do you utilize?
We use the CARTO 3 system (Biosense Webster, Inc., a Johnson & Johnson company) and RHYTHMIA HDx Mapping System (Boston Scientific); EP stimulators from Abbott and Dongfang Inc., recording systems from Bard and GE; catheters such as the THERMOCOOL SMARTTOUCH and THERMOCOOL SMARTTOUCH SurroundFlow catheter (Biosense Webster, Inc.), cryoballoon catheter (Medtronic), and other diagnostic catheters; pacemakers from Medtronic, BIOTRONIK, and Boston Scientific; and imaging technology such as CT scans, transesophageal echocardiograms, and intracardiac echocardiograms.
What new initiatives or technologies have recently been added to the EP lab, and how have they changed the way you perform procedures?
We perform ablation from the right coronary cusp to eliminate PVCs originating from the proximal left anterior fascicle.
Since March 2017, we have also been performing ablation index (AI) guided pulmonary vein isolation (PVI) in patients with AF. This has improved the long-term success rate of our AF procedures.
We recently utilized the SOUNDSTAR Catheter (Biosense Webster, Inc.) to implement intracardiac echocardiography, effectively replacing pre-operational transesophageal echocardiogram in some AF patients and improving the procedural success rate in some PVC/VT patients, as well as largely reducing x-ray exposure to patients and electrophysiologists.
In addition, we recently experimented with high power short duration ablation for PVI utilizing the THERMOCOOL SMARTTOUCH or THERMOCOOL SMARTTOUCH SurroundFlow catheter (Biosense Webster, Inc.). This approach shortened the time of the procedure.
Tell us what a typical day might be like in your EP lab.
A typical day starts with clinical specialists setting up all the essential instruments and machinery at around 8 AM. We then transport patients into the lab at around 8:30 AM to perform routine procedures. We break for lunch at around 12 or 1 PM; however, the lunch hour largely depends on the complexity of procedures, and the same can be applied to the dinner hour as well. We typically close the lab at around 10 PM each night. We usually have 3 rooms working simultaneously on a single day. Our EP lab can handle approximately 10-12 procedures on an average day.
What type of quality control or assurance measures are practiced in your EP lab?
All procedures must reach the same endpoint. For example, paroxysmal atrial fibrillation procedures are performed with the “CASE” approach, or CT-merge guided Antrum ablation with Scientific Evaluation, case by case. PVI is guided by electroanatomical mapping integrated with computed tomographic images of the left atrium (CARTOMERGE technology, Biosense Webster, Inc.), and should achieve bidirectional conduction block with wide antral ablation. PVs are assessed for acute reconnection after a minimum 30-minute waiting period. Intravenous infusion of isoproterenol, burst pacing, and programmed stimulation are systematically performed to induce tachycardia and non-PV foci.
How is inventory and the purchasing of equipment/supplies managed in your EP lab?
This is centrally managed by a third-party supply, processing, and distribution (SPD) company.
Does your EP lab compete for patients? Has your institution formed an alliance with others in the area?
Yes, there are more than 20 hospitals in the area that routinely perform EP procedures. Our institution has a subbranch south of Shanghai that also provides a valuable source of patients.
Have you developed a referral base?
Family doctors refer patients from community health service centers to our hospital.
In what ways have you cut or contained costs and improved efficiencies in the lab and device clinic?
Local products are selected (eg, deflectable decapolar catheter) to manage overall cost while not compromising procedural outcome.
What types of continuing education opportunities are provided to staff? How many of your staff members attend medical conferences each year?
We provide local seminars and classes to our employees on a regular basis. Our doctors also attend academic conferences such as the Oriental Congress of Cardiology.
Describe a particularly memorable case from your EP lab and how it was addressed.
A 64-year-old male patient was referred for ablation for verapamil-sensitive idiopathic left ventricular tachycardia; the VT was characterized by right bundle branch block (RBBB) configuration and left axis deviation. During the index procedure at another hospital, the VT was successfully eliminated by ablation at the earliest ventricular activation with a fused presystolic Purkinje potential (PP) during tachycardia within the left posterior fascicular area. A new type of VT characterized with RBBB morphology and right axis deviation was documented one month after the index procedure. During the redo procedure at our hospital, the earliest PP during the right axis deviated VT was identified within the posterior fascicle area. The recurrent VT was successfully abolished by applying radiofrequency current at a more proximal site within the left posterior fascicular network guided by the earliest presystolic PP during the redo procedure in this patient. During 12-month follow-up, the patient was free of VT without antiarrhythmics. The fascicular VT with right or left axis deviation in this patient may share the same reentry circuit (Figure 8).
Does your lab use a third party for reprocessing or catheter recycling?
No, this is prohibited in China.
Approximately what percentage of ablation procedures are done with cryo vs radiofrequency?
We used cryoablation in 2005, but currently use it in less than 5% of our atrial fibrillation procedures; this is because another system and ablation catheter are needed if the patients present with non-PV foci or atrial tachycardia during the cryoballoon ablation procedure. We now use radiofrequency in more than 95% of our ablation cases.
Does your lab perform His bundle pacing?
Yes, but only in selected or applicable cases.
What are your thoughts on the use of NOACs in patients with non-valvular AF?
The safety and convenience of NOACs in non-valvular AF is significantly better than warfarin. In our center, non-valvular AF patients prefer NOACs, and more than 80% of patients with atrial fibrillation are taking NOACs. In recent years, intracranial bleeding caused by anticoagulation has been significantly reduced.
What other innovative EP techniques are being utilized in your lab?
We are also doing modified box ablations, procedures without fluoro, and high power ablations.
What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoro? What types of radiation protective shielding and technology are used?
AF ablation is regularly performed under the guidance of image integration technology. X-ray is generally not required after completion of atrial septal puncture. SVT cases are generally guided by 3D mapping to reduce x-ray. Some cases use ICE guidance with zero or minimal x-ray. About 10% of our atrial fibrillation cases do not use x-ray, and more than 90% of our PVC cases also do not use x-ray. We use conventional lead screens and lead clothing for protection. EP procedures opt for EP mode (with lower radiation dose), and assistant personnel can work outside the cath lab during procedures.
What are your methods for device infection prophylaxis?
We strictly adhere to an aseptic concept and practice. Therefore, we minimize operation time, apply sufficient pressure dressing for hemostasis, and have patients take antibiotics before surgery if necessary.
What are some of the dominant trends you see emerging in the practice of electrophysiology?
We have seen that (1) the percentage of atrial fibrillation cases has increased rapidly in recent years; (2) patients tend to be the elderly group; and (3) X-ray exposure is greatly reduced with the implementation of new instruments.
Is your EP lab involved in clinical research studies?
We participate in several clinical research studies, some of which we have initiated, such as the BOX-AF study (registration number ChiCTR1800015747; please visit https://bit.ly/2P7cDch for more information).
What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?
Our EP team is one of the most influential teams in China, and has academic influence in the field of EP. Dr. Shaowen Liu edited the first monograph on catheter ablation of atrial fibrillation in China in 2004 (Figure 11), and he first used CARTOMERGE technology in Asia in 2005. In recent years, some efforts and explorations have been made in professional education and fellow training. Nowadays, a large number of doctors are waiting to join our center for EP training.
In 2017, we were the first in China to complete AI-guided AFib ablation. In 2018, we performed radiofrequency ablation in a 94-year-old patient with persistent atrial fibrillation and heart failure. Since 2018, we have performed combined ablation procedures in patients with hypertrophic obstructive cardiomyopathy and atrial fibrillation. Since 2017, we have performed a new approach for eliminating PVCs originating from the proximal left anterior fascicle by ablating from the right coronary cusp.
Please tell our readers what you consider special about your EP lab and staff.
We are a dedicated, highly academic, and unified team. Our EP lab is beautiful and modern. We consider patient care, clinical research, and professional education to be our top priorities.
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