Experience from Winthrop University Hospital

cohenIn a new issue of EP Lab Digest®,Todd J. Cohen, MD, FACC, FHRS and colleagues from Winthrop University Hospital present a brief case of situs inversus totalis, a congenital condition in which all the major visceral organs are mirrored from their normal position. A 17-year-old male with a history of situs inversus totalis was referred by his internist to Winthrop University Hospital for clearance prior to joining the fire department. The referring internist was astute enough to reverse the limb leads and place the precordial leads across the right chest.

Dr. Cohen is the Emeritus Editor-in Chief of EP Lab Digest®, author of the Practical Electrophysiology series, and author of the Johns Hopkins Health Book entitled A Patient’s Guide to Heart Rhythm Problems. He is also the Director of Electrophysiology and the Pacemaker/Arrhythmia Center at Winthrop University Hospital.

In another recent article, Dr. Cohen and Dhimesh P. Patel, MD summarized the confusion between syncope and seizure disorder. They write that an electrophysiology consult should be considered in any patient suspected of having a seizure, especially when history points to a cardiac condition such as coronary artery disease or left bundle branch block.

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Cryo Technology in the EP Lab

In a new issue of EP Lab Digest®, Zhen Jiao, MD and colleagues describe a recent case in which they observed the usefulness of luminal esophageal temperature (LET) monitoring during the ablation procedure. The authors write that the LET monitoring protocol remains a useful monitoring tool during cryoballoon procedures, and that this case demonstrates that continued LET recordings through the ablation procedure are as important as the final nadir temperature for assessing collateral cold transfer to adjacent tissue structures.

This is part of a series of articles in EP Lab Digest® that discuss cryo technologies in the EP lab. In our September 2013 issue, Prasad Palakurthy, MD and colleagues reviewed the original Medtronic procedure guide of testing for PV occlusion via injection of contrast agent followed by fluoroscopy examination, and described their experience with a system that utilizes automated and measured delivery of the radiopaque contrast agent. The ACIST CVi fluid delivery system (ACIST Medical Systems) can be employed effectively to inject contrast agent and saline during a cryoballoon atrial fibrillation (AF) ablation procedure. In their current dual operator system, the ACIST device has become a welcomed asset to the cryoballoon procedure.

In May 2013, Eric Johnson, MD and colleagues discussed early procedural data from a multicenter study examining the enhancements of the first- and second-generation cryoballoon for the treatment of AF. In this registry examination, real and measurable benefits in procedural efficiencies were detected when comparing the new cryoballoon to the original Arctic Front catheter.

Lessons Learned in the EP Lab

In the October 2013 issue of EP Lab Digest®, Edward J. Schloss, MD, Medical Director of Cardiac Electrophysiology at The Christ Hospital in Cincinnati, Ohio, shares a list of “lessons learned” from his experiences in the EP field. In his 18 years working as a cardiac electrophysiologist, he has made a mental list of tips or “pearls” that aren’t usually written about in medical journals or textbooks. Some tips were passed down during training or were from colleagues, and others are original creations. Here are a few:

• You can deliver a lot of healthcare from your desk by careful review of device interrogation data.
• Patients should be encouraged (within reason) to use their arm soon after device implant. Lead dislodgments after the first day are much more rare than frozen shoulders.
• If you want to distinguish yourself from your competition, all you really need to do is care more about your patients. Any doctor can do this.

This is a follow-up to his previous article in EP Lab Digest®’s February 2013 issue, in which he compiled the first installment of lessons learned, including such tips as:

• When a patient gets to 90 years of age, they get to make all the rules. A doctor’s job at this point is to do as little as possible.
• Don’t ever forget how unnatural it seems to our patients to have a big hunk of metal implanted into their body.
• It is (almost) never appropriate to get upset at a nurse.

We encourage you to check out his helpful article and share your thoughts with him on Twitter at @EJSMD or at his blog, Left to My Own Devices. Thanks for stopping by!

Aggregation of EP and AF Patients: Follow-up from LGH

In a new issue, Susan A. Deck, MBA, RN, CEPS, CCDS, RCES and colleagues from Lancaster General Hospital (LGH) and the Heart Group of Lancaster General Health in Lancaster, Pennsylvania, explain how using LGH’s highly successful heart failure unit as a model, a multidisciplinary team created an arrhythmia unit to aggregate atrial fibrillation (AF) and arrhythmia patients and drive standardized treatment.

In September 2011, Lancaster General Hospital, a 623-bed community hospital, opened an arrhythmia unit dedicated to the care of electrophysiology patients, with a particular focus on patients with AF. They noted that aggregating EP patients is supported by the observation that AF/arrhythmia patients often exhibit a similar pattern of complexity, chronicity, and frequent readmission seen in the heart failure population. A review of the hospital census revealed that on any given day, there were about 40 EP/arrhythmia patients scattered throughout the hospital, many of whom carried the diagnosis of AF. Armed with this knowledge, they felt there was a critical mass of patients to support this initiative and designated 6 East, a 20-bed cardiac telemetry unit, as the new EP/Arrhythmia unit.

Their ultimate goals were to find ways to decrease barriers to timely diagnostic and interventional EP procedures, decrease length of stay, hospital cost, and readmission rates for AF patients, and to improve patient outcomes and satisfaction. This is a follow-up to their article in EP Lab Digest®’s May 2012 issue, in which their initial outcomes trended favorably. Their new article discusses their progress to date, with a concentration on the results with AF patients.

For more information on Lancaster General Hospital, check out our interview with their electrophysiology lab in 2004, or read about their CAAHEP-Approved Cardiac Electrophysiology Program at Lancaster General College of Nursing and Health Sciences.