Building a Hybrid Program. S. Patrick Whalen MD FHRS FACC Director, EP WFUBMC
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1 Building a Hybrid Program S. Patrick Whalen MD FHRS FACC Director, EP WFUBMC
2 Disclosures Speaker/consultant- Atricure Speaker- Boston Scientific, Medtronic, Biotronik
3 Building a Hybrid program Collaboration between EP and CTS in not the norm Clear advantages for physicians, patients, hospitals Requires concerted effort and teamwork
4 Building a Hybrid program Barriers to progress EP Surgeon Administration First Steps (Clinic) Illustrative Cases
5 EP Perspective Fellowship Lessions: Interventional EP begain in the operating room The electrophysiologist is the natural predator of the cardiac surgeon Call the surgeon only when you need to be bailed out
6 EP Perspective- Barriers Progress Collaboration is additive: volumes, outcomes (CRT, AF, Extraction, VT), innovation
7 EP Perspective- Advantages Extends EP toolset (limitations) Critical to Sustain an Extraction Program Completes AF Program Durable PVI, posterior box GP Ablation LAA isolation/closure CAB/Valve +Maze CRT, VT
8 Time Surgical Perspective- Barriers Comfort zone Training EP endpoints Communication and EP feedback Check the Ego at the door -Steve Hoff, MD
9 Surgical Perspective- Advantages Case Mix and Volume Better understanding of arrhythmia mgmt Wider application of AF therapies to CAB/AVR Feedback and validation of surgical ablation Veins, box, LAA, outcomes Close working relationship improve EP consultative service Post procedure management and follow-up Not bail me out
10 Hospital Perspective Model already exits (Lung Cancer, Heart Transplant, TAVR) Improved quality, outcomes Right intervention at the right time Patient experience Widen referral network Procedural volume with halo effect Improved utilization of shared spaces (hybrid labs) Case example failed LV lead implant
11 Getting Started at Vanderbilt AF Clinic EP Arrhythmia Surgeon EP NP Device Clinic Shared Space Comprehensive service for AF patient One stop shop from warfarin to hybrid ablation
12 Lead Extraction- Patient Selection Collaboration required lead extraction program Active Process Size of the vegetation Left sided endocarditis Dwell time of the leads Lead Design Structural/Congenital Heart Disease
13 Case #1 Extraction 55 year old with ICM and primary prevention ICD Device ERI Riata with exposed conductors and visible thrombus Normal parameters No suggestion of SBE On OAC x 2 months with no change
14 Case #1 Extraction
15 Case #0 Extraction
16 Case #1 Extraction Planned hybrid extraction Lead liberated with laser down to SVC/RA junction Fem/fem bypass Right mini-thoracotomy and lead removal New lead implant and generator change
17 Case #1 Extraction
18 Case #1 Extraction
19 ALMOND, RICHARD 04-Jan :07:34 Page 1 of 2 DOB: 06-Jul Years Male Dept: OHO Clinic Case #2 Oper: AH HR 72. ATRIAL FIBRILLATION, V-RATE ICD9: BORDERLINE T ABNORMALITIES, INFERIOR LEADS PR * NO PRIOR TRACING AVAILABLE FOR COMPARISON QRSD 88 QT 368 QTcB 403 QTcF 391 I -- AXIS -- P QRS 11 T -10 II VUMC - OHO Clinic ( ) III V1 avr avl avf - ABNORMAL ECG - V1 V2 V3 Standard 12 Edited Requested By: ELLIS Electronically signed by: Hood, Rob 04-Jan :59:24 Device: 100OAKSREMOT> Speed: 25 mm/sec Limb: 10 mm/mv Chest: 10 mm/mv F 60~ Hz W PH090A b LP? V4 V5 V6 55 yo male LSP AF ERAF on amio LA 5.2cm No prior chest surgery Normal LVEF
20 When do I call my surgeon? Failed catheter procedures (AF rather than AFL/AT) LSP/Chronic AF Failed diagnostic DCCV on Amiodarone LA >5.5cm HCM Valvular Heart DZ, surgical CAD Prior CVA or strong desire to come off OAC LAA Closure Morbid obesity Exclusions (LA thrombus, prior chest operation, lung dz)
21 Hybrid AF: Lesion Set Lesions mimic Cox-Maze III. Initial experience was for same day hybrid (n=33). Can be performed staged. LAA ligation evolved from GIA staples to Atriclip. N Contact pericardioscopic hybrid ablation (separate data). 2
22 Hybrid LAA
23 LAA and AF Triggers Benussii et al Circulation. 2011;123: Salzberg et al. Interactive CardioVascular and Thoracic Surgery 0 (2012) 1 3
24 Hybrid AF: Lesion Set
25 Continuous Monitoring
26 Oper: HR HR 145 RR 414 PR 90 QRSD 82 QT 320 QTcB 497 QTcF * SINCE PRIOR TRACING * SUPRAVENTRICULAR TACHYCARDIA,? A FLUTTER. BORDERLINE T ABNORMALITIES, LATERAL LEADS ECG AXIS -- P 0 QRS 35 T 98 - BORDERLINE ECG - PREVIOUS:11-Mar :40:31 - Borderline Confirmed VUMC - Vanderbilt Hospital ( ) ICD.9: ORDERID: Order #: Enc ID: Standard 12 Edited Requested By: WALKER, KRISTIE Electronically signed by: Page, Harry 17-Mar :13:28 I avr V1 V4 II avl V2 V5 III avf V3 V6 V1 Device: 2119 Speed: 25 mm/sec Limb: 10 mm/mv Chest: 10 mm/mv F 60~ Hz W PH090A LP?
27 EP LAB
28 Activation Map
29
30 Ventricular Tachycardia Support and Access
31 Case #3 52 y/o with h/o NICM s/p ICD Cardiac arrest in Germany in 2006 Had 2 EP studies and extensive work-up in one of the most reputed Heart Hospitals in Texas. Inability to achieve clinical success. ICD placement for decreased EF. Referred to for ERI. Continues to have frequent symptomatic PVCs and reduced EF despite medical therapy
32 ECG
33 Clinical PVC
34 RCC
35 LCC
36 LCC
37 RF in LCC
38 AIV
39 Surgical Approach Median sternotomy off-pump as patient was a Jehovah s Witnes Exposure of left main, LAD, left circumflex, and AIV from epicardial fat. Bipolar RF lesions were delivered under the displaced cardiac vasculature using an Atricure cool rail Subsequent point RF lesions were delivered with an Atricure pen device
40 Left main LA appendage AIV and LAD
41 AIV and LAD in epicardal fat
42 LAD in epicardal fat LA appendage Epicardial lesion set
43 ECG
44 ICD interrogation
45 Case #4-Ventricular Tachycardia 66 year-old male with coronary artery disease with prior inferior myocardial infarction (4-vessel CABG and MVR in 1993) Pt was transferred in the setting of VT storm. Previous endocardial study with identification of an epicardial VT originating from the inferior wall of the left ventricle(lv). Chronically occluded RCA and SVG to PDA
46 Ventricular Tachycardia- Access
47 Ventricular Tachycardia- Access Repeat endo and epi mapping with surgical subxiphoid access Blunt dissection of adhesions to expose the inferior LV wall to the mitral annulus Ablation with EpiSense surgical ablation catheter (ncontact)
48 Ventricular Tachycardia- Access Energy was delivered to a broad region in the inferior wall substrate with repeat mapping revealing signal attenuation and homogenization of scar in this region One ICD therapy in 3 years in setting of hypokalemia (PMVT)
49 Summary Interventional EP began in the operating room (nothing new under the sun) Training an EP surgeon requires work and effort (just like training fellows) Access to the surgical tool set expands what we can offer to our patients in multiple areas (CRT, AF, Extraction, VT) Collaboration between EP and CTS will facilitate more progress than we can accomplish individually
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that number is extremely high. It s 16 episodes, or in other words, it s 14, one-four, ICD shocks per patient per day.
Doctor Karlsner, Doctor Schumosky, ladies and gentlemen. It s my real pleasure to participate in this session on controversial issues in the management of ventricular tachycardia and I m sure that will