Building a Collaborative Management Team: Sentara Heart ... · Building a Collaborative Management...
Transcript of Building a Collaborative Management Team: Sentara Heart ... · Building a Collaborative Management...
Building a Collaborative
Management Team: Sentara
Heart Experience
Philip J Gentlesk, MD, FACC, FHRS
Sentara Cardiology Specialists
Sentara Heart Hospital, Norfolk, VA
Disclosures
None
Outline
• Background of current program
– Rationale/Development
• Benefits
• Challenges
• Focus on VT ablation
• Future plans
Sentara Heart
• Busy tertiary care
center
• 800 ablations
• 1500 device implants
• 3 EP labs (4th nearly
completed)
• 1 Hybrid OR
• Integrated and private
practice cardiology
• Single cardiothoracic
surgery group,
MACTS
Rationale
• Pt death with lead extraction – lead to development of hybrid OR and enhanced collaboration
• Patients’ felt to benefit from concomitant procedures– Valve surgery/ maze
– LVAD – VT ablation
• Others felt to benefit from surgical approach– Longstanding persistent /LA myopathy
• Surgical substrate modification/Cox Maze
– Epicardial AP – cryoablation
Development
• Interested EPs and cardiac surgeon with
arrhythmia surgery interest
• Lead extraction initially with desire to
develop lead management program
• Hybrid afib ablation shortly after hybrid OR
opening
• Then VT ablation – epicardial,
concomitant, LVAD
• Ad hoc - LAA management, WPW
Hybrid EP Service Line
• Joint effort of Cardiac Electrophysiology, Cardiac Surgery and Cardiac
Anesthesiology
– 5 EP’s and 3 CT surgeons
• Biweekly multidisciplinary meeting with CTS, EP, program coordinator
• Lanes of Effort
– 1) Ventricular Tachycardia to include Hybrid VT Ablation Program
– 2) Atrial fibrillation to include Hybrid AF ablation, Cox Maze IV Program
(stand alone and concomitant)
– 3) Device lead management to include Thorascopic Minimally Invasive
LV Lead Implantation and Complex / High Risk Laser Lead Extractions
– 4) LAA Exclusion Service (Also with Structural Heart Program)
– 5) Ad Hoc arrhythmia management ( hybrid WPW)
Hybrid OR
• Capability for lead extraction/
reimplantation, hybrid
ablation
• OR table
• Flouroscopy
• EP recording and monitoring
system
• Non flouroscopic 3D mapping
Benefits
• Complementary strengths offset weakness
– Surgical understanding of anatomy. approach, visualization
– EP understanding of arrhythmias, mechanism, ablation
targets
• Enhanced ablation toolset, cryoablation
• Trial of new approaches/technologies
• Use of thoracoscopy to visualize SVC with high risk
extraction
• Blended mapping/ablation technologies
Hybrid Map Setup
Challenges
• Increased time
• Opportunity cost
• Scheduling difficulties
• Hybrid OR time – working around structural heart
• Working in the hybrid OR – compromise at times
• Mixed practice model, employed and private practice
• Resource intense staffing with second order effects on schedule/other cases
Lead management• 341 extraction cases over last 5 years
• No deaths
• Scheduling and reimbursement challenges
• 58 patients
• 5 converted to open Cox Maze (early)
• 6 repeat EP study and ablation outside
planned
• 12 5-box procedures (last 3 months
with Dr Sirak)
Thoracoscopic/Hybrid AF
LAA management
• EP, CTS, Structural heart
• Watchman, Atricure clip
• Increasing volume
• Multiple venues, hybrid OR, OR, cath lab,
EP lab
VT Ablation
• “In the hierarchy of therapy of
ventricular tachyarrhythmias,
prevention of the arrhythmia by
preventing substrate formation or
destruction of the substrate by
surgical or catheter ablation should
be the highest goal.”
Josephson, ME. PACE 2003; 26:2052-67.
Endo-Epi Homogenization of Scar vs
Limited Substrate Ablation
Di Biase L, et al. JACC 2012; 60:132-41.
Target Patients
for Concomitant Ablation
• Ventricular arrhythmia circuit with epicardial involvement
• Prior MI with need for surgical revascularization
– Rare epicardial involvement with anterior scar
– 15-39% epicardial involvement in posterior-inferior MI
• Valvular and other nonischemic cardiomyopathy with need
for cardiac surgery
• Advanced heart failure – need for LVAD support
Yoshiga, et al. HR 2012;9:1192-1199. Sosa et al. JACC 2000;35:1442-49.
Sacher et al. JACC 2010; 55:2366-72.
LVAD and Ventricular Arrhythmias
• Ventricular
arrhythmias
compromise LVAD
flow
• LVAD may not
prevent recurrent
VA
• VT/VF in 22%-53%
of patients post
LVAD
• Survival
Bedi M et al. Am J Cardiol 2007;99:1151-3. Garan AR. JACC 2013:61:2542-50
Concomitant
LVAD/VT Ablation• Early limited data promising
• One study evaluated 14 pts with preoperative VA ( out of 50
consective pts with Heart mate II LVAD implant)
• 7 underwent intraoperative localized epicardial and endocardial
cryoablation via LVAD ventriculotomy
• Cryothermal lesions created to connect scar to fixed anatomic
borders in region of clinical VA
• Cyroablation group had decreased postop resource use,
complications and no postop VA
Mulloy DP, et al. J Thoracic Cardiovasc Surg 2013: 145: 1207-13,
Sentara Heart
Hybrid VT Case Series
• Three year program history with 10 cases (limited
acceptance due to concern for increased
time/bleeding)
• Three patients with prior MI concomitant CABG and VT
ablation
• One patient with ARVC with epicardial patches
• Two patients with PVC failing prior ablation attempt
(concern for proximity to coronary, deep intramuscular
focus)
• Four patients with advanced heart failure
– Concomitant LVAD and VT ablation
Concomitant
CABG/VT ablation
• 70 yo male
• VT storm –
Monomorphic
recurrent placed on
amiodarone and
mexiletine
• NSTEMI
• Cath demonstrates
3VCAD
• Referred for CABG
and VT ablation
Hybrid
Epicardial Mapping• Manual epicardial
mapping with 4 mm
Mapping catheter
• Defined scar (set 0.5 – 1
mV) with basal to mid
inferior scar on 3D electro-
anatomic map
• LV endocardial access
thru right superior
pulmonary vein with a #8-
French sheath
Hybrid VT
Endocardial Mapping
• 4 mm deflectable Navistar
mapping catheter used to map LV
endocardial surface for scar and
mark EP substrate (fractionated
signals, long pace to stim) and
potential VT channels
• Large inferior LV scar and regions
with diastolic potentials were
marked
• EP study to induce VT
• Pacemapping to clarify VT
exits/circuits
Hybrid VT Cryoablation
• Placed on bypass
then epicardial
cryoablation followed
by CABG
• ATS cryo -150
degrees C for 3
minutes and repeated
from apical border
zone of scar to the
mitral annulus
• Followed by coronary
artery bypass grafting
with a LIMA to the
Hybrid Ablation
for Arrhythmogenic RV Cardiomyopathy
• 57 yo female with
ARVC and VT with
ICD using epicardial
patches placed 1993
• Prior endocardial VT
ablation with
demonstration of
epicardial scar
• Recurrent VT storm
• Failed sotalol,
amiodarone,
mexiletine
Epicardial Mapping
and AblationEpicardial biploar RAO
viewEpicardial bipolar LAO
view
• Manual mapped epicardium with map/ablation catheter
• Cryoablation with ATS at -150 C for 3 minute lesions
LAD
Endocardial mapping,
Induction of VT and ablationEndocardial Bipolar RAO
view
Endocardial Bipolar LAO
View
• Placed sheaths in femoral veins, standard endocardial mapping
• Irrigated RF titrated to 30-35 watts to tricuspid annulus and separate lesions
for inducible VT from the moderator band
Sentara Heart Hybrid VT
Outcomes• Mean 1 year follow up
• Single redo VT ablation 1 year
• Transient LBBB in one, persistent in
another (control of lesion depth)
Hybrid VT ablation
• Hybrid VT ablation can synchronize EP strengths with mapping,
arrhythmia understanding and CTS strengths with anatomy and
enhanced ablation
• Enhance outcomes in difficult to treat populations
• Consider in procedural planning for
– VT with CABG, particularly prior VT ablation, inferior MI
– VT with LVAD
– VT in cardiomyopathies with concomitant surgical need such as
valve replacement/repair
• Challenges include septal circuits, ablation depth control,
synchronization of teams, workflows
• Future directions – development of mapping, ablation toolset
Future Plan• Shared clinic space
– Allow for seeing pt simultaneously
• Enhance/dedicated coordinator/scheduling
support
• Second hybrid lab
• Database
Summary
• Collaborative EP approach has been
professionally rewarding
• Treat challenging cases more safely and
effectively
• Challenges remain
Thanks
• Drs Jonathan Philpott, John Sirak, Michael McGrath,
• Drs Robert Bernstein, Ian Wollett, Jon Grammes, Venkat Iyer,
• Drs David Schinderle, Bill Dickinson, Steve Murphy,
Franchesca Meachem, Linda McLeish, Min Yang, George
Vretakis
• Linette Klevan
• Candice Keen, Carrie Ziemer, Lauren Madey
• Lori Seaman, Julie O’Neill, Sarah Northrup
• Sentara Heart EP/OR teams
Questions
EP Targets (Substrate)
Josephson, ME. PACE 2003; 26:2052-67. Cassidy et al. Circulation 1986; 73:645-52.
Marchlinski et al. Circulation 2000; 101:1288. Bogun et JACC 2006; 47:2013-9.
Catheter VT Ablation Results
Wisner et al., Eur Heart J 2012; 33: 1440-50
3
7
Current State of Electrophysiology Cox Maze, Surgical Ablations
2009 2010 2011 2012 2013 2014
Cardiac Ablation 27 20 19 23 19 17
Cardiac Ablation ! MAZE Cryo & RFA 8 11 5 9
Cardiac Ablation ! MAZE Cryo Only 8 1 1
Cardiac Ablation ! MAZE RFA Only 7 1
Cardiac Ablation | MAZE Cryo & RFA 2
Cardiac Ablation | MAZE RFA Only 2
CRYO AND RADIOFREQUENCY CARDIAC ABLATION 4 14 6
CRYO CARDIAC ABLATION 1
Hybrid Thoracoscopy Atrial Fibrilliation 7 13 10 4 10
RADIOFREQUENCY CARDIAC ABLATION 1
Grand Total 27 20 19 23 19 17
3
8
Current State of Electrophysiology Lead Extractions
2009 2010 2011 2012 2013 2014
Cardiac Defibrillator ICD Lead Repl/Rev 3 5 8 21
Cardiac Defibrillator Generator ICD Repl 2 6 1 3
Cardiac Defibrillator Ins/Rem ICD 17 18 19 10
Cardioverter-Defibrillator Pacing Generator Ins/Rem 7
Cardioverter-Defibrillator Pacing Transvenous Lead/s Ins/Repl/Repair 11
Cardioverter-Defibrillator Subcutaneous Lead Rep/Ins/Repl/Rem 7
Epicardial Pacemaker and Electrode Removal via Thoracotomy 1
Pacemaker Insertion 1 1
Pacemaker Generator and Transvenous Lead/s Repl 1
Pacemaker Generator Rem/Repl/Ins 5 1 2 1
Pacemaker Lead Repl/Rev/Rem 8 10 14 28 3
Implantable Cardiac Defibrillator/Pacemaker Lead Rem/Repl/Rev 16 61 22
Ventricular Lead Ins/Placement/Reconstr 12 16 17 19 18 10
Grand Total 42 60 60 99 80 64
Sentara Heart
Hybrid VT Case Series
• One year program history with 4 cases (out of total of
nearly 700 ablations last year)
• Two patients with prior MI
– Concomitant CABG and VT ablation
• One patient with ARVC
– With epicardial patches
• One patient with advanced heart failure
– Concomitant LVAD and VT ablation
Hybrid VT Ablation
• Background
– Surgical VT ablation
– Catheter VT ablation
• Patient subgroups for hybrid VT ablation
– LVAD experience
• Sentara Heart Experience
• Conclusions
Epicardial Involvement by MI
Location• Rare in anterior MI
• 15-39% epicardial involvement in
posterior-inferior MI
Yoshiga, et al. HR 2012;9:1192-1199. Sosa et al. JACC 2000;35:1442-49.
Sacher et al. JACC 2010; 55:2366-72.
LVAD does not prevent
recurrent VA
• 94 patients with
continuous flow
LVAD
• Late (> 30 day post
implant) seen in 22
(23%)
• Major predictor
was preexisting VA
Garan AR. JACC 2013:61:2542-50.
ARVC Observations
• More extensive epicardial scar
• Increased RV wall thickness
with 46% > 1 cm in one series
• Midmyocardial layered effect
with different patterns of
activation
• Epicardial late potentials and
pace map match well beyond
endocardial border zone
• 79% of VT’s with epicardial
circuits in one study
Garcia FC, et al. Circulation 2009; 120:366-375. Polin GM et al HR 2011; 8:76-83.
Haqqani HM, et al. Circ Arrhythm Electrophysiol 2012;5:796-803.
LVAD Catheter VT
Ablation Limitations• Arterial access in continuous flow LVAD
• Aortic valve closure complicates LV access
• Transeptal access discouraged : resultant right to left shunt
• LV unloaded with small LV volume – increased difficulty with
catheter manipulation
• Inflow cannula is a mechanical and electrical obstacle
• Epicardial access difficult
Our Experience Building a Collaborative
Management Team
Mark La Meir
Centre for Heart Disease, University Hospital, Brussels - Maastricht
Disclosures: consultant Atricure
Centre for Heart Disease, University Hospital, Brussels - Maastricht
The real interest of AF ablation
lies within the heart team approach
Centre for Heart Disease, University Hospital, Brussels - Maastricht
Hybrid ProcedureTeam Work
TEAM
Together Each Achieve More
Centre for Heart Disease, University Hospital, Brussels - Maastricht
Centre for Heart Disease, University Hospital, Brussels - Maastricht
“ Catheter ablation begets catheter ablation “
“EP begets surgeon”
“ AF begets AF “
Centre for Heart Disease, University Hospital, Brussels - Maastricht
Surgical versus endocardial catheter ablation
• Patient selection
• Invasiveness
• Ablation catheters
• Lesion set
• LAA
• Complications
• Success rates (on/off AAD)
• Follow-up
• Literature
Happiness = baseline average mood + what you can settle for (CR) +
what you'll get on average if you gamble (EV) + the difference between
that and what you actually get (RPE). The recurring ∑-function weights
each factor in turn by its recent history.
+ +
Happiness= the longest english word
SMILES
Surgeons Minimal Invasive Love Electrophysiology Studies