The Christ Hospital Heart and Vascular Institute
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EP LAB DIGEST. 2025;25(8):1,21-26.
Kate Warren, RN, BSN, Clinical Coordinator; Daniel J Pelchovitz, MD, FHRS; Andrew Noll, MD; Alexandru Costea, MD; and Edward J Schloss, MD
Cincinnati, Ohio
When was the cardiac electrophysiology (EP) program started at your institution, and by whom?
Arthur B Simon, MD, was the first cardiac electrophysiologist in Cincinnati. In 1986, Ted Waller, MD, joined Dr Simon in performing EP studies on patients for evaluation of syncope and evaluation and management of supraventricular arrhythmias (SVTs) and ventricular tachycardias (VTs). The first defibrillator was placed at The Christ Hospital (TCH) through open heart surgery in 1987.
Rick Henthorn, MD, was recruited to join the practice in 1989, followed by Jefferson Burroughs, MD, in 1993. By collaborating with EP physicians in the Midwest (Fred Morady, MD; John Swartz, MD; and Wes Fisher, MD) to learn the complexities of EP procedures, the practice continued to grow. TCH dedicated the first EP lab in Cincinnati 1992, which was further strengthened with the addition of Wes Fisher, MD, and Edward Schloss, MD, in 1997.
What drove the need to implement an EP program?
There was a large population of patients referred to cardiology with syncope and arrhythmias, for whom a dedicated EP team was needed. The practice began modestly in a double-wide trailer adjacent to the cardiac catheterization laboratory before relocating to the D-level of the main hospital under the leadership of Dr Schloss.
What is the size of your EP program? Has the EP lab recently expanded in size, or will it soon?
In April 2024, the EP lab was relocated to a newly renovated facility comprising four 675-square-foot procedure rooms, including a fully equipped 870-square-foot hybrid operating room (OR), as well as a minor procedure room designated for loop recorder implants and cardioversions. Attached to the EP lab is a 16-bed preoperative and recovery unit specifically for our patients.
Who manages your EP lab, and what is the mix of credentials and experience?
Our lab is managed by Judean Morris, RN, BSN. She has worked at TCH for 35 years and in EP as a staff RN, educator, and now manager for 19 years. The team includes 2 clinical coordinators and a part-time educator, all dedicated to EP. The assistant manager of inventory is shared with the cath lab. The department is led by Daniel Pelchovitz, MD, and supported by Kathy Ziegler, Director of Heart and Vascular Services.
What is the number of staff members?
We have 27 staff members: 24 RNs and 3 registered technologists (RTs). Our staff bring diverse clinical experience from cardiovascular step-down units, cardiovascular and medical intensive care units (ICU), the emergency department (ED), OR, and imaging departments. The EP team includes 7 attending physicians: Daniel Beyerbach, MD, PhD; Alexandru Costea, MD; Madhukar Gupta, MD; Andrew Noll, MD; Daniel Pelchovitz, MD; Edward J Schloss, MD; and Ted Waller, MD.
What types of procedures are performed at your facility?
We perform a full range of endocardial ablation procedures using radiofrequency (RF), cryoablation, and pulsed field ablation (PFA)for the treatment of atrial fibrillation (AF), atrial tachycardias (AT), SVT, premature ventricular contractions (PVC), and VT. Since the introduction of PFA, we have seen a 9% growth in ablations performed compared to the prior fiscal year. Our volume of epicardial ablation procedures continues to increase as well. We collaborate with the cardiovascular OR to perform epicardial ablations during open heart procedures, as well as combined endocardial and epicardial ablations using a minimally invasive approach in our hybrid OR.
Our device procedures include implantations of pacemakers (left bundle branch area pacing [LBBAP], biventricular [BiV], and leadless devices), implantable cardioverter-defibrillators (ICDs) (BiV, subcutaneous [S-ICD], and endovascular devices), loop recorders, and left atrial appendage occlusion (LAAO) devices (Watchman, Boston Scientific).
Approximately how many ablations (for all arrhythmias), device implants, lead extractions, and LAAOs are performed each week?
On a weekly basis, we perform 33 ablations, 27 device implants, 3 LAAOs, and 1 extraction. This fluctuates week to week, but we typically perform 12-18 cases per day.
What types of EP equipment are commonly used in the lab?
All 4 procedure rooms are equipped with the following ablation systems: nGEN and Varipulse (Johnson & Johnson MedTech), EnSite X (Abbott), cryoablation (Medtronic), and the Farapulse PFA System (Boston Scientific). The primary ablation catheters used are the QDOT (Johnson & Johnson MedTech), TactiFlex Ablation Catheter, Sensor Enabled (Abbott), Farawave PFA Catheter (Boston Scientific), and Varipulse. For imaging, we use the ViewFlex Xtra ICE Catheter (Abbott) and SoundStar Ultrasound Catheter (Johnson & Johnson MedTech). We implant new devices with Medtronic (Aurora extravascular [EV]-ICD System, Micra Transcatheter Pacing System, and LBBAP) and Boston Scientific (Emblem MRI S-ICD System and LBBAP).
What are some of the new technologies and techniques recently introduced in your lab? How have these changed the way procedures are performed?
Our team has moved toward PFA as a treatment for first-time pulmonary vein isolation (PVI) cases and selectively with redo patients. The use of PFA has reduced procedure times for AF ablation and offered a safer, more effective modality for ablation.
We have also recently incorporated the use of 2 new ablation tools. The EPi-Ease Epicardial Access System (AtriCure, Inc) allows us to safely obtain epicardial access by providing direct visualization of the pericardial space. Additionally, inHEART is an AI cloud-based program that generates 3-dimensional (3D) cardiac models compatible with our mapping systems, which are used to visualize the coronary arteries. We are hopeful that both solutions will provide another layer of safety and help decrease procedure times.
The introduction of the EV-ICD has also offered an alternative to traditional transvenous systems in patients with prior device extraction. Our team has increasingly adopted EV-ICD reimplantation in patients who do not require pacing.
Discuss your techniques for preventing esophageal injury during AF ablation.
Our strategies for monitoring and prevention include the use of products from CIRCA Scientific, the EsoCool system (Nuvaira, Inc), and the ensoETM system (Haemonetics). One advantage of PFA is that it does not require esophageal monitoring, thereby enhancing safety and reducing patient-associated costs.
Tell us more about your program’s use of PFA.
We have experienced a smooth transition to PFA, with positive results in safely ablating the PVs and posterior wall (PW). A few noted procedural changes include reinstituting the use of fluoroscopy for Farapulse, adapting to less 3D mapping, and managing large-bore sheaths that were previously only for cryoablations. Some initial considerations include a limited number of applications that are allowed due to the risk of hemolysis and renal toxicity, as well as careful manipulation of the Farawave catheter to avoid creating narrowing channels of conduction in patients with smaller atria. We are using a mix of Farapulse and Varipulse.
Discuss your use of hybrid AF ablation.
We have a strong relationship with TCH cardiac surgeons J Michael Smith, MD, and Geoffrey Answini, MD, who are both highly qualified at transthoracic MAZE. We often refer selective longstanding persistent AF patients directly for this procedure, but if they are unable to undergo a MAZE, we will complete a Convergent procedure in our EP hybrid OR. As we can more safely ablate the PW with the introduction of PFA, the role of hybrid procedures is more uncertain.
How is inventory managed in your EP lab?
Our inventory is managed by an assistant inventory manager, who is shared with the cardiac catheterization laboratory, along with 2 clinical coordinators and a dedicated materials team member. Daily supply usage lists are used to manage supply ordering, and we continually monitor any fluctuations in usage based on physician preference and caseload.
Describe your device clinic, including staffing, daily operations, and tools or software used.
Our dedicated device clinic is the largest in Southwest Ohio. The clinic is staffed by office-based EP RNs who perform device interrogations, with interpretations provided by our electrophysiologists. They have considerable experience with all types of EP devices and collaborate effectively with the nurse practitioners (NPs), physicians, and industry representatives. Pacemate is used for remote monitoring and Paceart is used for office device checks. Device checks are performed in clinics at both the main hospital and satellite locations.
Discuss your approach to remote monitoring of arrhythmias, including management of data deluge from cardiac implantable electronic devices (CIEDs).
We have a greater capacity to treat patients in a timely and efficient manner by using a third-party monitoring system. With the ability to quickly turn around reports, we are able to quickly treat patients and with expertise, from the initial triage to the final physician read. Because the third-party system monitors and reaches out to patients for our practice, we see fewer patients losing contact with the office, and the volume of data has become more manageable.
Tell us what a typical day might be like in your EP lab.
Staff arrive between 6:30-7:00 AM, take their assignments, and start setting up for the day. Typically, supplies are pulled and labs are set up with the specific procedure equipment the night prior. Our goal for the first case in room time is 7:45 AM, with physicians scrubbing in between 8-8:15 AM. EP staff is here until 7 PM to accommodate later case start times for add-on procedures.
Describe the extent and use of vascular closure devices in your lab. Tell us about your approach for same-day discharge (SDD).
We use vascular closure devices (eg, Vascade [Haemonetics] and Perclose [Abbott]) on most patients who are discharged the same day. Occasionally, a figure-of-8 suture is placed. We aim for SDD of all AF and SVT ablation patients who meet TCH criteria.
How do you ensure timely case starts and patient turnover?
We monitor and review our first case start times and room turnover data on a monthly basis. Our clinical coordinators help facilitate efficient room turnover by relieving staff to prep for the following case, verifying add-on patients are appropriately prepped, and cleaning and flipping rooms if an extra procedure room is available. Typically, our team is ready to bring the patient into the room between 7:30-7:45 AM because our rooms are set up the night prior, and we have staff who arrive at 6:30 AM to finish setup and start the day early. With our recent practice of designating room leads, we hope to improve communication to assist in troubleshooting and addressing the needs of each procedure room.
How does your lab schedule team members for call?
Our staff do not take call shifts. If emergency temporary pacemakers are needed after lab hours, the cath lab staff places them with the EP physicians.
Do you use flexible or multiple shifts, and how are slow periods managed?
Our staff work 10- or 12-hour shifts. During slow periods, our educator sets up learning opportunities, and staff are occasionally assigned infection prevention and auditing tasks throughout the hospital.
How are vendor visits managed?
Vendors are scheduled for cases when the physician sends orders from the office, so the only vendors present in the lab are those who are relevant to the cases. This helps contain the volume of vendors and ensures we have the resources present when needed. All vendors check in with our coordinators to discuss scheduling and supply ordering. New vendor visits are coordinated through and assessed by our leadership team.
What are the best aspects of your EP lab’s design?
Use of a hybrid OR has dramatically improved our ability to schedule complex cases. We are able to stay in our own environment to perform extractions, epicardial ablations, Impella (Abiomed)-assisted ablations, and combined procedures with the OR. Additionally, since all labs are equipped with the same technology, we can easily flip rooms to decrease turnover time. Our minor procedures room has allowed us to perform loop recorder implants between cases, keeping our main labs free to continue with our standard cases.
What measures has your lab implemented to cut or contain costs?
We recently began trialing reprocessed catheters and are interested to see how this affects our procedure costs. Our supply management team has been working with physicians to streamline supply usage and stay updated on physician preferences and supply needs. Additionally, through implementation of PFA, we have stopped using esophageal monitoring probes, which assists in containing costs.
What quality control measures are practiced in your lab?
One exciting quality control measure is that all discharged patients receive a call from procedure navigator RNs the day after discharge, which allows for timely identification of postoperative complications and more urgent follow-up if necessary. Additionally, we track readmission and revisit ED rates, and are involved in the LAAO Registry.
What works well in your lab for onboarding new team members?
We do not hire new graduates, as we believe staff need a strong foundation in the medical field prior to learning EP. Our orientation process is 12 weeks and takes staff through the helper (learning setup, technology, and supplies), circulator (documentation), and scrub (from simple to complex cases) roles. During orientation, new team members meet weekly with our manager and educator for a performance evaluation in which feedback is provided and opportunities for growth are discussed.
What continuing education opportunities are provided for staff members? How do staff typically maintain and renew their credentials?
Currently, our educator has monthly sessions set up with Johnson & Johnson MedTech for education on various ablation-related topics requested by staff. In the past, we have participated in heart dissections and seminars related to EP studies of complex VT. We are also able to send 2 staff members to the Heart Rhythm conference every year. Recently, several staff members have been trained to deploy vascular closure devices, including Vascade and Perclose. This has expanded their skill set as well as allowed our physicians to be relieved immediately after case completion to perform consultations and evaluate patients in the preoperative area, with the goal of improving overall throughput. Our required hospital education and recertifications are housed online, while EP-related competencies are completed on a yearly basis and managed by our educator.
Discuss the role of mid-level practitioners in your lab.
Two EP NPs support the physicians in the laboratory: Jessica Otis, NP, oversees the perioperative setting, and Carrie Myers, NP, manages the inpatient caseload. They navigate pre- and postoperative care and manage and prepare consults, allowing the physicians to dedicate more hours to procedures during their lab days. Our office-based NPs (Kory Billiter, NP; Jennifer Gastenveld, NP; Grace Goodwin, NP; Christina Jones, NP; and Melinda Sheppard, NP) also rotate through the inpatient and lab service as needed.
Share a memorable case from your EP lab and how it was addressed.
Several years ago, a patient was identified as having swallowing-induced AT. They were brought into the lab where an EP study was performed with minimal sedation. We were able to create an activation map while the patient was swallowing using the Advisor HD Grid Mapping Catheter, Sensor Enabled (Abbott), which pinpointed the arrhythmia as originating from the right superior PV. A single cryoablation application was performed, and several years later, the patient had no recurrence of symptoms.
What impact has a third party for reprocessing or catheter recycling had on your lab?
In recent months, we have begun incorporating reprocessed catheters into our practice and are interested in evaluating the associated cost savings. For several years, we have participated in a catheter recycling program, allocating the resulting reimbursement to support staff attendance at the annual Heart Rhythm Society Scientific Sessions.
Discuss your program’s approach to conduction system pacing (CSP).
CSP is superior on many levels—it is easier and quicker to implant, and more reliable thresholds can be obtained. We have adopted this practice and employ it for most ventricular pacing indications. However, for cardiac resynchronization therapy (CRT), the traditional BiV is still favored, and LBBAP is used as a bailout. We are involved in the Left vs Left trial comparing the outcomes of these techniques.
Tell us about your primary LAAO approach.
We have extensive experience placing Watchman devices for LAAO. Our team collaborates closely with the structural heart team to provide advanced transesophageal echocardiography (TEE) and computed tomography (CT) imaging, frequently obtaining preoperative CT scans to help determine the most appropriate treatment approach for each patient. We recently began performing concomitant AF and Watchman procedures for patients requiring both interventions, thereby reducing the need for multiple procedures, anesthetic exposures, and hospitalizations.
Is there a dedicated AF clinic?
We do not have a dedicated AF clinic; however, our patients receive thorough care regarding their procedure and treatment. Our office-based 3 RNs are dedicated to providing preprocedural education and postprocedural follow-up for each patient. This approach has been well received, with patients expressing appreciation for feeling informed and prepared regarding their treatment plans. In addition, patients are scheduled for follow-up visits with a provider at 1, 3, and 12 months, promoting continuity of care and supporting optimal clinical outcomes.
Discuss your approach to lead extraction and management.
Our lead extraction program has expanded over the last few years, and we have become a referral center for complex lead extractions and management in the Cincinnati and Dayton areas. Drs Noll and Costea, our lead extraction operators, have access to the full range of standard extraction tools, the capability to evaluate emerging technologies, and the readiness to escalate techniques based on individual patient complexity. Preoperative case discussions with the referring EP, structural cardiologist, and cardiac surgeon facilitate planning for complex device management. Additionally, our initiation of lead extraction for percutaneous tricuspid valve disease continues to expand. We believe that patients with CIEDs who require tricuspid valve repair should be evaluated by a multidisciplinary team to facilitate appropriate lead extraction and consideration of leadless device placement. We are fortunate to collaborate effectively with CT surgery and cardiac anesthesia, allowing us to maintain a high volume and to more urgently schedule cases. Due to our proximity to Cincinnati Children’s Hospital Medical Center, we have participated in the care of several adult patients who received a cardiac device before age 10 for congenital heart block. We have been able to effectively manage these cases and observed favorable outcomes.
Discuss your program’s approach to lifestyle risk factor modification for reduction of AF.
Counseling regarding lifestyle/risk factors is standard prior to ablation, and we work closely with the primary care providers and general cardiologists to accomplish this. Emphasis is placed on interventions for sleep apnea, evaluation of pulmonary and thyroid disorders, weight reduction, increased physical activity, and reduction of alcohol consumption.
Discuss your approach to treatment of AF in patients with heart failure (HF).
We collaborate closely with our colleagues in HF to proactively manage AF in patients with HF, given the association between AF and adverse outcomes in this population. These patients often undergo catheter ablation more promptly than the general AF population.
Discuss your approach to arrhythmia management in athletes.
Since we are a referral center for extractions, we see many patients with fractured leads due to specific exercises (eg, pull-ups and bench presses), which can increase the complexity of the case and require more precise tools and techniques. Patients can then be reimplanted with a subcutaneous or leadless device, lowering the potential of recurrent damage or infection. We have also noticed that aggressively active patients (eg, weightlifters) tend to develop right atrial flutter more so than AF. In these patients, it is important to perform ablation, evaluate their stroke risk, and advise them on appropriate exercise routines as well as use of dietary supplements and energy drinks. Contrary to popular belief that extensive exercise protects patients from cardiac issues, we have noticed that patients who participate in endurance activities (eg, marathons and triathlons) more commonly develop AF. In these patients, ablation can be successful, but we recognize there is a high degree of fibrous tissue in the LA; therefore, ablation alone may not be adequate.
Discuss your program’s initial treatment and management (including referrals) for patients with postural orthostatic tachycardia syndrome (POTS).
A dedicated dysautonomia clinic is operated by Dr Waller, in collaboration with EP registered nurses (RNs) and a patient care assistant.
We receive referrals from the greater Cincinnati area and beyond, attributed to Dr Waller’s expertise and the advanced technology available. Treatment options explored for these patients include medication, increased fluid and salt intake, wearable compression garments, and consistent aerobic exercise. Not all patients can tolerate these lifestyle changes, but emphasis is placed on aerobic exercise, as their symptoms will likely not improve if this is not routine. Extensive education is provided prior to the patient leaving the clinic, and these patients are often very grateful for the time Dr Waller and his team spend navigating the complex and rapidly changing understanding of POTS.
How does your EP lab handle radiation protection for physicians and staff?
Our ablations are typically performed without fluoroscopy, but since implementation of PFA, we have used a small amount of fluoroscopy with Farapulse. After moving to our new location, we moved forward with the installation of the EggNest system (Egg Medical) to reduce fluoroscopy exposure. This will soon be set up in all 4 EP labs to better protect patients, staff, and physicians from excessive radiation exposure.
What approaches has your lab taken to reduce fluoroscopy time? What percentage of cases are done without fluoroscopy? How do you record fluoroscopy times/dosages?
Most of our RF ablations are performed without fluoroscopy. For those cases requiring fluoroscopy, a minimal amount is used. Exposure is limited as we use low frame rates. We have the Azurion system (Philips) in every procedure room, which provides decreased doses compared to previous systems. Fluoroscopy times are recorded in the electronic log at the end of each case and are accessible for staff and physician review.
What are some of the dominant trends emerging in the practice of EP?
There is an increasing preference for CSP over traditional endocardial pacing. Our physicians would like to see more data regarding CSP before completely converting, but believe it will become the favored method of CRT. Additionally, we have increased our implantation of leadless devices, which is similarly reflected in industry trends.
How do you use digital health and wearable technologies in your treatment strategies? What challenges or benefits do you associate with that?
Newer digital technologies have largely replaced the Holter monitor in our EP practice. Kardia monitors and Apple Watches are commonly used to record data and direct treatment. When patients share this data, we can assess the rhythm alongside the patient’s complaint of symptoms to determine the optimal treatment plan. Some limitations we see are that these monitors can be misled by PVCs and premature atrial contractions (PACs), and are not as accurate in monitoring heart rhythms with rates past 120 beats per minute. We are enrolled in the REACT-AF trial, which is using smartwatches to help guide patient-initiated anticoagulation.
Is your EP lab involved in clinical research?
The ablation studies we are involved in include the REAL-AF National Registry (we are one of the highest enrolling centers in general and in the QDOT subgroup; we have started enrolling for PFA as well), the DISRUPT-AF Registry, and STOP AF First. The device studies we participate in include Left vs Left for CRT, and previously, the LEADR study for LBBAP. We work closely with the Lindner Research Center to enroll patients and collect intraoperative data.
What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?
TCH was the first lab in the Cincinnati area to perform a defibrillator implant as well as catheter ablation for arrhythmias such as Wolff-Parkinson-White Syndrome and SVT.
Recently, we became the first area hospital to acquire the TruPulse Generator (Johnson & Johnson MedTech) and perform PFA with their fully integrated Varipulse system.
Describe your city or general regional area. How is it unique?
Cincinnati sits in the tri-state area of the Midwest, so we receive referrals from Ohio as well as greater Kentucky and Indiana. We have recently begun a partnership with several hospital systems in the Dayton area, which has boosted our extraction referrals and given us partners with whom we collaborate to better manage resources.
What challenges does your hospital face given its unique geographic service area?
Some challenges relate to being a single-hospital system as we are surrounded by significant competition. However, our reputation as the heart hospital of Cincinnati does bring in many referrals from the tri-state area. We emphasize the extensive tertiary care we provide as a way to differentiate us from other local hospitals.
Please tell our readers what you consider special about your EP lab and staff.
We would not be able to care for our patients as effectively without the dedication and passion of our staff. We have a cohesive team that works well together and provides patients with high-quality care and consistent and thorough education, all with an encouraging spirit. Patients routinely comment on the comprehensiveness of our care, from the office to the procedure staff, and let us know how much confidence they have in our team.
