When hospitals make
decision to expand cath lab to perform electrophysiology (EP) procedures, it is important to look into impact it will have on total cardiology program. Traditionally, hospitals have looked to recognized medical specialist societies to provide insight and direction regarding clinical policy and process. This is no different for EP procedures, which have been routinely conducted in cardiac catheterization lab setting. When looking for guidance and/or recommendations for EP catheter ablation treatment, North American Society of Pacing and Electrophysiology (NASPE) and American College of Cardiology (ACC) offer policy statements. Catheter ablation is one procedure which has transformed field of electrophysiology. Catheter ablation destroys atypical heart tissue which is responsible for abnormally fast heart rates. Previously, treatment for many tachycardiac arrhythmias required extensive open-heart surgery. Catheter ablation, through use of radiofrequency ablation, has, in many instances, made surgery and long-term drug therapy no longer necessary. Therefore, “the number of reported ablation procedures performed annually in United States has increased from 450 in 1989 to ? 15,000 annually.1 This increase in demand has made addition of EP services at many hospitals very attractive.When a hospital is considering expanding cardiology services to include EP and catheter ablation treatment, an assessment of existing clinical services is in order. One of first questions to address is whether hospital already has an established open-heart surgery program. While there are no defined regulations that require “on site” availability of open-heart surgery services when performing catheter ablations, it appears to be an accepted medical practice.
As previously stated, two recognized organizations that provide electrophysiology clinical competency recommendations are ACC and NASPE. However, ACC defers to NASPE for specific guidelines. NASPE produces clinical competency recommendations for EP services. Recommended guidelines state “Comprehensive catheter ablation programs require a fully equipped invasive electrophysiological laboratory and ready access to surgical support and facilities. It was felt that full cardiac surgical support was desirable; nevertheless, at minimum, facilities performing ablation should have thoracic surgical backup.”2 The guidelines are not specific regarding need to have open-heart surgery available “on site,” leaving this open for interpretation.
However, what NASPE policy statement on catheter ablation, as published in PACE, does present, are equipment and clinical process recommendations. Cine or digital imaging, and hemodynamic monitoring and recording of, at very least, arterial pressures and O2 saturation are recommended. Standard cath lab radiation exposure precautions must be maintained, especially in extended ablative procedures.
Equipment required for ablations includes an external defibrillator with non-invasive pacing, a radiofrequency current generator with temperature and impedance monitoring capability and a power output of at least 50 Watts. Other desirable equipment includes mapping equipment, and recording equipment capable of monitoring a minimum of three surface leads and at least four intra-cardiac leads concurrently. Hard copies of these recordings also need to be available for cardiologists’ immediate review.
Airway maintenance equipment, such as oxygen, suction and general anesthesia should be available. If your lab is doing pediatric cases, general anesthesia is mandatory.
Staff in cardiac cath/EP labs can differ from hospital to hospital. Members of EP team for ablation procedures generally will be similar to that of cath lab. In addition to cath lab training, EP staff requires experience and ongoing specialization with EP procedures. Ideally, if volume allows, there should be staff dedicated to EP lab.
Staffing for ablations should consist of at least three team members in addition to attending physician. It is “recommended that staff utilized for ablative procedures have experience with at least 30 catheter ablations before working independently in EP lab, and that they continue to assist on 30 cases per year.”3 The number of physicians involved in case, their experience, and difficulty of case can change staff composition to include more or less personnel.
The team should consist of a scrub person, a circulating nurse and a cardiovascular technician (CVT) monitoring person. Normal cath lab responsibilities for these positions remain same with exception of CVT monitoring person. Ideally, staff member monitoring case will be CVT certified and have familiarity with ablative procedures. Additional responsibilities charged to CVT monitoring person, besides observing patient and recording and documenting clinical information, will be operating radiofrequency generator used during ablation. The monitoring staff person will turn equipment on and off and feed information to physician throughout case. It is vital to have excellent communication between CVT monitoring person and physician. While operation of equipment on is not difficult, it requires intense concentration. It is vitally important not to activate ablator until instructed by physician. The ablator permanently destroys viable cells. This can be especially significant in AV ablations, where ablating inappropriate area can place patient into permanent heart block requiring a pacemaker. Unlike cardiac catheterization procedures, CVT staff member monitoring case needs to be informing physician every few seconds of measured value and length of time machine has been operating. The information physician needs to be aware of includes: power or temperature, impedance, and length of time generator is active. Any changes in these values need to be reported immediately. “If catheter loses contact with myocardium, blood around catheter tip may become superheated and boil.”4 For this reason, CVT monitoring person needs to be prepared to turn ablator off immediately by keeping his/her finger on or in close proximity to power button. If discontinued early, ablator can always be reactivated, but if left on too long, damage becomes permanent.
