Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest

Building a Hybrid ProgramS. Patrick Whalen MD FHRS FACC

Director, EP WFUBMC

Wake Forest Baptist Medical Center

Disclosures

• Speaker/consultant- Atricure

• Speaker- Boston Scientific, Medtronic, Biotronik

Building a Hybrid program

• Collaboration between EP

and CTS in not the norm

• Clear advantages for

physicians, patients,

hospitals

• Requires concerted effort

and teamwork

Building a Hybrid program

•Barriers to progress

–EP

–Surgeon

–Administration

•First Steps (Clinic)

• Illustrative Cases

EP Perspective

Interventional EP begain in the operating room

The electrophysiologist is the natural predator of the cardiac surgeon

Fellowship Lessions:

Call the surgeon only when you need to be “bailed out”

Progress

Collaboration is additive: volumes, outcomes (CRT, AF, Extraction, VT), innovation

EP Perspective- Barriers


• 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

EP Perspective- Advantages


Surgical Perspective- Barriers

• Time

• Comfort zone

• Training

• EP endpoints

• Communication

and EP

feedback

“Check the Ego at the door”-Steve Hoff, MD


• 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”

Surgical Perspective- Advantages


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


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


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


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


Case #1 Extraction


Case #0 Extraction


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


Case #1 Extraction


Case #1 Extraction

. ATRIAL FIBRILLATION, V-RATE 61-82 . BORDERLINE T ABNORMALITIES, INFERIOR LEADS * NO PRIOR TRACING AVAILABLE FOR COMPARISON

391QTcF

035205251 04-Jan-2013 13:07:34ALMOND, RICHARD

DOB: 06-Jul-1955 57 Years Male Dept: OHO Clinic

Oper: AH

HR 72

PR

QRSD 88

QT 368

QTcB 403

-- AXIS --

P

QRS 11

T -10Requested By: ELLIS

ICD9:427.31

Page 1 of 2

Standard 12- ABNORMAL ECG -

Electronically signed by: Hood, Rob 04-Jan-2013 14:59:24

Edited

VUMC - OHO Clinic (1-91-01)

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

V1

Chest: 10 mm/mVLimb: 10 mm/mVSpeed: 25 mm/secDevice: 100OAKSREMOT> F 60~ 0.5-150 Hz W PH090A b LP?

• 55 yo male

• LSP AF

• ERAF on amio

• LA 5.2cm

• No prior chest

surgery

• Normal LVEF

Case #2

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 pericardioscopichybrid ablation (separate data).


Hybrid LAA


LAA and AF Triggers

Salzberg et al. Interactive CardioVascular and Thoracic Surgery 0 (2012) 1–3

Benussii et al Circulation. 2011;123:1575-1578.


Hybrid AF: Lesion Set


Continuous Monitoring


ECG

* SINCE PRIOR TRACING * SUPRAVENTRICULAR TACHYCARDIA , ? A FLUTTER . BORDERLINE T ABNORMALITIES, LATERAL LEADS

429

414RR

QTcF

022560718 17-Mar-2010 16:14:15BILLMAN, JAY

DOB: 18-Sep-1951 58 Years Male Race: 9999 Dept: Outpatient

5212Room:

Oper: HR

HR 145

PR 90

QRSD 82

QT 320

QTcB 497

-- AXIS --

P 0

QRS 35

T 98Requested By: WALKER, KRISTIE

Enc ID: 603617020076

Order #: 00033001

ORDERID:1268858807050

ICD.9:427.31

Standard 12- BORDERLINE ECG -

Electronically signed by: Page, Harry 17-Mar-2010 17:13:28

EditedPREVIOUS:11-Mar-2010 17:40:31 - Borderline Confirmed

VUMC - Vanderbilt Hospital (1-10-03)

I

II

III

aVR

aVL

aVF

V1

V2

V3

V4

V5

V6

V1

Chest: 10 mm/mVLimb: 10 mm/mVSpeed: 25 mm/secDevice: 2119 F 60~ 0.5-150 Hz W PH090A LP?


EP LAB

Activation Map



Ventricular Tachycardia Support and Access


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 ICD @ ERI. Continues to have

frequent symptomatic PVCs and reduced EF

despite medical therapy


ECG


Clinical PVC


RCC


LCC


LCC


RF in LCC


AIV


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


LA appendage

Left main

AIV and LAD


AIV and LAD in epicardalfat


LA appendage

LAD in epicardal fat

Epicardiallesion set


ECG


ICD interrogation


• 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

Case #4-Ventricular Tachycardia


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)


• 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)



• 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

Summary

Building a Hybrid Program · •Prior CVA or strong desire to come off OAC –LAA Closure •Morbid obesity •Exclusions (LA thrombus, prior chest operation, lung dz) Wake Forest

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