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Spotlight Interview: Yeditepe University Hospital
Yeditepe University Hospital has been caring for patients since August 2005. Yeditepe University Hospitals and Affiliated Institutions were accredited in 2007 by the Joint Commission (JCI). It was the first Turkish university hospital group to document its quality and success at an international level.
When was the cardiac electrophysiology (EP) program started at your institution, and by whom?
It was created in March 2021 by Tolga Aksu, MD, a world-renowned electrophysiologist.
If you are a new lab, what growing pains or learning curves did you experience the first few years?
Since the EP lab was founded, our team has become more experienced every day, improving with each case. We have also become highly proficient in the use of three-dimensional (3D) mapping.
What is the size of your EP lab facility?
We have 2 fully functional labs in the cardiology department. One of these labs is specially equipped for EP studies. Part of the EP lab is used for fluoroscopy and the other part is used as an operative area.
What is the number of staff members? What is the mix of credentials at your lab? Describe your lab staffing and structure.
We have a large team in the arrhythmia department. We have 1 electrophysiologist (Tolga Aksu, MD), 1 EP fellow (Ferit Onur Mutluer, MD), 1 EP nurse (Esra Yeşilyurt, BSN), and 1 radiology nurse (Yasemin Ivlinger, BSN). During cases, 2 radiology technicians, 2 part-time EP technicians, and an anesthesia team accompany us in the lab. Service nurses are also part of our team, working in coordination with us before and after cases. We have also 1 medical student (Alara Ece Dagsali) who actively works in research projects.
What types of procedures are performed at your facility? What types of complex ablations are performed?
Our EP team performs all EP procedures, including diagnostic EP studies and cardioneuroablation (CNA).
We perform ablations for atrioventricular nodal reentrant tachycardia, accessory pathways, focal atrial tachycardias, Wolff-Parkinson-White syndrome, typical and atypical atrial flutter, paroxysmal and persistent atrial fibrillation (AF), premature ventricular contractions, and endocardial and/or epicardial ventricular tachycardia (VT). We perform approximately 10-12 catheter ablations per week. We also offer temporary and permanent pacemaker (PPM) insertion, implantable cardioverter-defibrillator (ICD) implantation, biventricular PPM/ICD implantation, PPM/ICD generator changes, cardioversions, and transesophageal echocardiograms (TEEs).
What would you consider to be the most frequent procedures performed or the most common arrhythmias seen?
AF ablation and CNA procedures are the most frequently performed procedures in our clinic. The majority of ablation cases are referred after failed attempts by electrophysiologists from other centers.
Who manages your EP lab?
The manager of our EP lab is Tolga Aksu, MD. In the absence of our director, Ferit Onur Mutluer, MD, serves as coordinator of the lab. Lab organization is carried out by Esra Yeşilyurt, BSN. Medical equipment in the lab is overseen by the senior radiology supervisor.
What type of hospital is your EP program a part of?
Our EP center is a part of Yeditepe University Hospitals, which was accredited by the JCI for the fourth time in 2017, a demonstration of the sustainability of our quality.
What types of EP equipment and imaging technology are most commonly used in the lab?
Both Abbott and Biosense Webster are greatly supportive of our EP service. For mapping, we use both the Carto 3 System V7 and Carto Prime Module (Biosense Webster, Inc, a Johnson & Johnson company), as well as the EnSite Precision Cardiac Mapping System (Abbott). For transseptal punctures, we use intracardiac echocardiography (ICE) with the ViewFlex ICE catheter (Abbott). Our catheters include the TactiCath Contact Force Ablation Catheter (Abbott), FlexAbility Ablation Catheter, Sensor Enabled (Abbott), Therapy Cool Flex Ablation Catheter (Abbott), Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott), Agilis NxT Steerable Introducer (Abbott), BRK transseptal needle (Abbott), Fast-Cath Introducer Sheath (Abbott), Carto PentaRay Nav eco Catheter (Biosense Webster), NaviStar ThermoCool Uni-Directional Catheter (Biosense Webster), and ThermoCool SmartTouch SF Bi-Directional Catheter (Biosense Webster). We also use quadripolar and decapolar catheters from Abbott. We primarily use devices from Biosense Webster and Abbott. We use Philips imaging in our labs.
What new initiatives have recently been added to the EP lab, and how have they changed the way you perform procedures?
We are considered to be one of the most experienced centers in CNA. We have a clear workflow for patients with vagally-mediated bradycardias. All vasovagal syncope cases are evaluated with a head-up tilt table test to confirm the dominant cardioinhibitory component. Our EP nurse and fellow conduct the test, and all results are checked by Dr Aksu for suitability of CNA. All patients who are selected as a potential candidate for CNA undergo an atropine challenge test performed by an EP nurse in the outpatient clinic. We use a special bandpass filter for evaluation of electrograms in our EP recording system (WorkMate Claris, Abbott) during CNA procedures. In addition, we attempt zero fluoro ablation whenever possible using ICE.
Tell us what a typical day might be like in your EP lab.
At 8 AM, our teams are ready for the day. Except for emergencies, our case plan is scheduled a day in advance. When patients arrive to our center for their case, the service nurses greet them and they are informed about the case by the electrophysiologist. The service nurses then inform the patient about the process and make the necessary preparations. The lab staff also begins preparing with the anesthesia team for the case. After preparations are completed, the 3 separate departments work in coordination and the cases are started. Shifts are over when the cases are complete.
Who handles procedural scheduling?
Our secretary, Sultan Akkurt, manages the sequence of cases, coordination with the anesthesia team, completion of appropriate hospital procedures, and daily schedules.
How is inventory managed at your EP lab? Who handles the purchasing of equipment and supplies?
The catheter procurement process is managed by the hospital’s purchasing department. The purchase is made by the tender procedure. The amount of materials to be purchased is determined by the EP director. During every EP case, the EP nurse and technician record all used equipment. The EP nurse checks the equipment inventory on a weekly basis, and if the minimum inventory threshold is reached, she orders additional supplies from the hospital warehouse.
How has managed care affected your EP lab?
To shorten the medical observation period, procedures are performed on an outpatient basis. COVID-19 testing is done before the procedure. Patients are admitted to the hospital the day of the procedure. Our trained service nurses meet all patient needs before and after the procedure. After a successful procedure, thorough patient care helps to reduce many risk factors. Outpatient follow-up is continued after the procedure.
How do you ensure timely case starts and patient turnover?
Every member of the team works together to ensure good communication, teamwork, and timeliness. From patient check-in to preparation of the procedural area, our dedicated staff makes sure there are no interruptions. Our advanced practice nurses (Elif Fidan, Oznur Balkan, Ilknur Altindag, Merve Koc, Immihan Bindal, Gizem Kilic, Melisa Yigit, Selin Bagic) and general practitioner Aras Cinaroglu, MD, round on all of our inpatients and are excellent facilitators who communicate to the lab about the type of procedures needed.
How is patient education managed?
Patient education is managed on multiple levels. It begins with our physicians in the outpatient clinic, where information about the upcoming procedure is discussed and an educational brochure is provided. On the day of the procedure, instructions are provided beforehand using a nurse-led patient education model. The patient and their companion or accompanying relative are educated about what to expect from the time of the procedure to discharge. Questions about outpatient follow-up and incision site control are also answered at this time.
Describe a memorable case from your EP lab and how it was addressed.
While every case is memorable for us, one of our most unforgettable patients was a CNA in a female who was 14 weeks pregnant and expecting twins. This patient had a previous abortus history during pregnancy due to frequent syncope episodes. We decided to proceed with catheter ablation, taking great care to protect the pregnant patient from radiation exposure. During the case, fluoroscopy was rendered inactive and 3D mapping was done with the EnSite Cardiac Mapping System. Transseptal puncture was accompanied by TEE. While our EP fellow performed the TEE, Dr Aksu guided the catheter into the left atrium. CNA was successfully treated without the use of fluoroscopy and without harm to the twins. After the babies were born, they came to visit us as a family. It was a great feeling to see them all in good health, and it became a lasting memory for our team.
What percentage of ablation procedures are done with the cryoballoon vs radiofrequency energy?
We use radiofrequency for all our AF ablation cases. We only use focal cryoablation for anteroseptal accessory pathways if radiofrequency ablation fails at the noncoronary cusp.
Does your lab use contact force sensing technology during radiofrequency ablation of AF?
Due to financial reasons, we rarely use contact sensing catheters in our ablations.
Do you offer a multidisciplinary care for AF?
In all our cases, we consider a multidisciplinary, team-oriented approach to care as the ideal. Overweight or obese patients with AF are referred to a dietician for further treatment. Patients with AF are also questioned about possible sleep-related disorders such as sleep apnea, and high-risk patients are referred for sleep study. Our nurse also provides AF patients with educational brochures on lifestyle modification. Patient compliance is managed through periodic follow-up over the phone.
What other innovative EP techniques are being utilized in your lab?
Using anesthesia for all of our ablation procedures has significantly improved the flow of cases in our lab. All patients first undergo a detailed preanesthesia evaluation by our dedicated anesthesiologists (led by Sibel Temur, MD; Derya Kayacan, MD; and Onur Erdagoz). One anesthesiologist and 1 anesthesia technician (Serhat Atalay) accompany all cases. With this current model, we have improved the efficiency and safety of our EP cases.
With an excellent support team from Biosense Webster (led by Gizem Ertürk, clinical development specialist) and Abbott (led by Berat Unlu, clinical account specialist), we have also been able to perform complex AF and VT ablations, thus reducing procedural time and increasing the weekly number of cases. For CNA cases, we have high-frequency stimulation available for specific research protocol purposes.
What approaches has your lab taken to reduce fluoroscopy time?
In the last 2 months, we have begun using ICE to minimize fluoroscopy during cases. In cases where ICE is not used, we try to minimize fluoroscopy time with careful mapping. For personal protection, we use a lead apron, thyroid shield, and radiation glasses. There is also protective glass shielding in the lab.
How do you manage radiation quality checks of the imaging equipment?
Our radiology supervisor routinely checks all imaging equipment at the center. In addition, radiation protection training is provided at routine intervals. All team members in the lab have dosimeter wristbands that measure radiation. Statistics are generated by reporting the measurements on a monthly basis.
What types of continuing education opportunities are provided to staff?
Although there is no regular in-service training provided, any unusual measures, findings, or complications during procedures are typically followed by a briefing session between the physician and staff. In addition, it is optional for EP staff to attend and participate in online or onsite teaching and research conferences. All nurses and EP techs also participate in complex case discussions and electrogram analysis during procedures.
How do you see social media changing the field of health care?
Social media is an effective and universally accepted tool in health care today. Patients, clinicians, and health care organizations all use social media. The role of social media in global health cannot be ignored—it is possible to strengthen the worldwide health network and more quickly distribute information using a platform such as Twitter. Dr Aksu is active on Twitter and also serves as social media editor for the Journal of İnterventional Cardiac Electrophysiology.
Describe your city or general regional area. How is it unique?
Istanbul is one of the oldest cities in the world. With an estimated population of 20 million people, Istanbul is a transcontinental city that is home to the Bosphorus strait, which separates Europe and Asia. Our EP center is easily accessible, located close to the center of Istanbul. In addition, our department organizes the transport and accommodation of international patients, so while these patients are here to undergo a procedure such as an ablation, they can also visit our beautiful city.
Please tell our readers what you consider special about your EP lab and staff.
Every member of our team is essential. We are highly motivated, eager to learn, and dedicated. We work hard, but we also have a lot of fun.
For more information, please visit:
https://www.linkedin.com/company/yeditepeunihst/
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