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

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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