Allina Health Minneapolis Heart Institute

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EP LAB DIGEST. 2024;24(11):1,12-15.

Daniel Melby, MD
Medical Director, EP Laboratory, Minneapolis Heart Institute, Minneapolis, Minnesota

When was the cardiac electrophysiology (EP) program started at your institution, and by whom?
The EP program at the Minneapolis Heart Institute was started in 1990 by Dr Simon Milstein. 

What drove the need to implement an EP program? 
In the late 1980s, with the development of catheter-based ablation techniques and expanding indications for implantable pacemakers, a growing patient population who needed specialized EP care was identified. This led to a dedicated subspecialty EP program.

What is the size of your EP facility? Has the EP laboratory recently expanded in size, or will it soon?  
Our current main EP facility consists of 4 EP procedure rooms, with 750 square feet per room. We have 2 additional EP procedure rooms used at an offsite stand-alone surgical center, both of which have 600 square feet per room. Due to the progressive growth in our EP program over the last 10 years, we are currently in the process of building a new hospital wing with 6 EP procedure rooms. We will be transferring to these new procedure rooms in 2026. 

Does your institution offer EP-related procedures in an ambulatory surgical center (ASC)? 
Yes, we perform simple cardiac device procedures such as generator replacements and pacemaker implants in a stand-alone ASC. This center consists of 2 EP procedure rooms.

Who manages your EP laboratory, and what is the mix of credentials and experience?
Our EP laboratory is managed by David Fernald, RCIS, and Matt Pavlovec, RN, MBA. David has over 20 years of experience managing cardiovascular and EP laboratories at the Minneapolis Heart Institute. 

What is the number of staff members? 
We currently have 18 EP technical staff as well as 20 registered nurses (RNs) to circulate between the EP, interventional, and vascular laboratories.

What types of procedures are performed at your facility? Approximately how many ablations (for all arrhythmias), device implants, lead extractions, and left atrial appendage (LAA) closures are performed each week? 
Our EP program performs the comprehensive range of EP procedures, including implantable cardiac devices, cardiac device extractions, arrhythmia ablations, both simple and complex, epicardial ablations, and LAA closure procedures. Approximately 90-100 procedures are performed per week at our institution.

What types of EP equipment are commonly used in the laboratory? 
For x-ray imaging, we have 2 Artis zee (Siemens Healthineers) biplane systems, 1 Artis Q.zen (Siemens Healthineers) biplane system, and 1 Artis Q (Siemens Healthineers) ceiling-mounted, single-plane system. We utilize the Odyssey system (Stereotaxis) for in-room image routing. For mapping, we use the Carto (Johnson & Johnson MedTech) and EnSite Precision (Abbott) systems. 

Discuss your techniques for preventing esophageal injury during atrial fibrillation (AF) ablation.
Careful esophageal temperature monitoring, esophageal location mapping on Carto using the Esophastar catheter (Johnson & Johnson MedTech), and appropriate lesion management when in proximity to the esophagus are essential for preventing esophageal injury during AF ablation. Typically, Carto QMODE+ (Johnson & Johnson MedTech) would be used when ablating near the esophagus to minimize risk. In addition, lesions are not stacked in close proximity to one another until at least 60 seconds has elapsed to allow for esophageal cooling.

Discuss your program’s use of pulsed field ablation (PFA).
We have used PFA in clinical trial settings and will soon be performing it commercially as well.

How is inventory managed in your EP laboratory?
We use a combination of PAR Excellence, QSight, and Workday for inventory management.

Tell us about your device clinic, including its staffing model and day-to-day function.
We have a dedicated device clinic with about 20 RNs who perform over 20,000 device interrogations per year. They submit the summary reports to our electronic medical record (EMR) and scan the complete device printouts into the EMR separately. All device checks are reviewed, interpreted, and approved by EP physicians.

Discuss your approach to remote monitoring of arrhythmias, including management of data deluge from cardiac implantable electronic devices.
We have dedicated protocols for all arrhythmias such that our team of nurses can triage arrhythmia alerts, separating those that are clinically of low significance with those that need further attention.

Tell us what a typical day might be like in your EP laboratory.
Our cases begin at 7:30 AM, with 4 procedure rooms going. Typically, we have 1-2 rooms busy until 6-8 PM.

Can you describe the extent and use of vascular closure devices at your laboratory? Tell us about your approach for same-day discharge. 
We use vascular closure devices for arterial access only. The majority of ablation procedures are discharged same day. Implantable cardiac devices are often discharged same day. We have a relatively large patient population who travel more than 1 hour from their home to the Minneapolis Heart Institute. These long-distance patients are usually observed overnight. 

How do you ensure timely case starts and patient turnover?
Maintaining timely case starts and efficient patient turnover requires constant attention. We automatically track these parameters and address any shortcomings on a monthly to quarterly basis.

How does your laboratory schedule team members for call?
We schedule 1 team for long call to accommodate late procedures in the day. We also have 2 additional teams with short call who are expected to complete procedures by 5-7 PM.

Do you have flexible or multiple shifts? How do you handle slow periods?
We currently have only 1 shift, which starts at 7 AM until case completions or according to our late call schedule. Slow periods in our laboratory are exceedingly rare.

How are vendor visits managed?
We have a number of vendors actively participating in all of our procedures. They go through a vendor screening procedure prior to access to our laboratories. They also have a daily check-in prior to entering the procedure areas.

What are the best features of your EP laboratory’s layout or design? 
Some of the highlights of our EP laboratory design include a control room that is not isolated from the procedure area. This allows for easy communication from the technical staff in the control room to the physician and other members of the team at the patient table. We also have a Carto workstation boom (Johnson & Johnson MedTech) that allows for the clinical mapper to be in close proximity to the physician, which greatly improves communication during complex ablation procedures.

What measures has your laboratory implemented to cut or contain costs?
We are constantly working to maintain lower costs per procedure. Predominantly, this focuses on ensuring good vendor contracts based on high-volume repetitive use.

What quality control measures are practiced in your laboratory?
Quality control is a team effort in our laboratory, and we utilize feedback from all team members to identify practices and procedures that are not optimal.

What works well in your laboratory for onboarding new team members?
Allowing sufficient time to become acquainted with the complex new language of EP is key to successfully starting new team members. Often a 3- to 6-month training is needed before we can anticipate higher level understanding.

Discuss the role of mid-level practitioners in your laboratory.
We currently have several mid-level practitioners who work in our EP pathology laboratory. They function both as technical staff members, but in addition, see patients prior to procedures and discharge patients same day postprocedure.

Does your laboratory use a third party for reprocessing or catheter recycling? How has it impacted your laboratory?
We have been using resterilized catheters for more than 10 years. This has reduced the cost of certain catheters. However, we restrict this practice to catheters that are not ablation related and do not have central flush tubing, which could become contaminated.

Discuss your program’s approach to conduction system pacing. 
We have an active program utilizing both His bundle pacing, and more commonly, left bundle branch area pacing, to improve outcomes with chronic right ventricular pacing. Due to some of the limitations with long-term pacing thresholds and sensing with His bundle pacing, left bundle branch area pacing has become the more commonly chosen objective.

Discuss your approach to lead extraction and management. 
Lead extraction is performed at the Minneapolis Heart Institute using a multidisciplinary approach. We have cardiovascular surgery on standby for all procedures, and immediate access to perfusion and other lifesaving interventions if needed. All procedural technologies are available, including laser extraction and superior vena cava balloon occlusion catheters.

Discuss your program’s approach to lifestyle risk factor modification for reduction of AF. 
We manage AF patients comprehensively in our routine EP clinics. At the Minneapolis Heart Institute, we understand that AF can often represent a manifestation of other health conditions and comorbidities. All patients receive counseling on weight loss, physical activity, alcohol moderation, and other important factors. Screening for obstructive sleep apnea is performed routinely.

Discuss your approach to treatment of AF in patients with heart failure (HF).
Patients in HF with AF are a high-risk cohort. If HF is suspected to be secondary to AF, then restoration of sinus rhythm is typically pursued. Antiarrhythmic therapy is often utilized as an initial step, but with a very low threshold to consider ablation in these patients.
In patients who have a preexisting cardiomyopathy, with subsequent unrelated development of AF, we ensure good heart rate control during AF and then pursue rhythm control strategies if symptoms or evidence for worsening HF are observed.

Discuss your approach to arrhythmia management in athletes. 
Arrhythmias in athletes can be challenging. In those with a structural cardiac abnormality or genetic arrhythmia, counseling for moderation in physical activity is advised, as well as treatment and risk moderation of their underlying condition. For those who develop arrhythmias such as AF directly related to long-duration, high-intensity aerobic exercise, we often favor treating the arrhythmia to allow for continued healthy exercise levels.

Discuss your program’s initial treatment and management (including referrals) for patients with postural orthostatic tachycardia syndrome (POTS) or long COVID. 
We manage patients with autonomic dysfunction, including POTS, in our EP clinics. Additional resources, such as the Penny George Institute for Health and Healing, are available for these patients as well.

How does your EP laboratory handle radiation protection for physicians and staff?
Dose reduction techniques are utilized for all procedures, including zero-fluoroscopy ablations. All staff wear routine radiation dosimetry badges that monitor for excessive exposure.

What approaches has your laboratory taken to reduce fluoroscopy time? What percentage of cases are done without fluoroscopy? How do you record fluoroscopy times/dosages?
Approximately 85% of all our ablations are performed without fluoroscopy. For implantable cardiac devices, decreasing frame rate to 1-3 frames per second in addition to utilizing low versus high fluoroscopy dosing (through a Siemens x-ray system) is used during these procedures.

What are some of the dominant trends you see emerging in the practice of EP? 
An increasing need and indications for AF ablation will likely be the dominant trend in the coming years.

How do you use digital health and wearable technologies in your treatment strategies? Have you seen an increase in the number of patients using digital health technologies? What challenges or benefits do you associate with that? 
Digital health and wearable technologies are used by a high percentage of our patients. The quality of electrogram tracings is reasonably high but insufficient for diagnostic purposes and the majority of scenarios. Often, long-term monitoring through a wearable device is preferred and more beneficial compared to traditional short-term Holter monitoring. This has been a great improvement.

Is your EP laboratory involved in clinical research studies? 
We are actively involved in multiple research studies, including new ablation technologies such as PFA, new ablation techniques such as advanced mapping software for treatment of persistent AF (Ripple Frequency software, Johnson & Johnson MedTech), a 4 French implantable cardioverter-defibrillator lead study (Medtronic), and many others.

What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”? 
We have participated in several interesting first-in-human techniques and technologies, including being the first in the United States to use the ThermoCool SmartTouch SF Catheter (Johnson & Johnson MedTech), having the highest worldwide enrollment in the SMART SF research study, performing the first-in-human use of Ripple software for mapping AF driver sites, performing the first-in-human use of advanced Ripple Frequency software for mapping AF driver sites, and being named the US lead for the multicenter trial evaluating Ripple Frequency software for improving persistent AF ablation outcomes.

What challenges does your hospital face given its unique geographic service area? 
The biggest challenge is that we serve patients from throughout Minnesota as well as the surrounding states as a quaternary referral center. This makes follow-up and patient transport quite challenging at times.

Please tell our readers what you consider special about your EP laboratory and staff.
We have a special community in the EP laboratory. Our staff are good people who work hard and dedicate long hours to serving the needs of our patients. They do this with care, attention, and compassion. In addition, we see many unusual and interesting cases every week. There is always something new or challenging to discover.