Texas Cardiac Arrhythmia Institute's New EP Lab

Last fall I had the pleasure of touring TCAI's new EP lab at St. David's hospital. It was amazing, and the photos don't really do it justice, but for those of you who've never been in an EP lab now you'll know what to expect.

Since we were in street clothes, we all had to wear hair nets, tyvek suits, and booties over our shoes just to enter the place.

https://drive.google.com/open?id=1-uf3Y2iN0ixrXfiER0GUO_yYnhPjwYPj

Almost makes me want to get an ablation! Love the St Jude’s Medical floor mat. What happens in the “control room” and who is in there during an ablation?

Awesome pictures Carey. As a former Process Engineer in Refinery and Chemical plants, I have seen a lot of changes since 1977. Dr. Natale is 1st class personally and his procedure/ operating room shows the same.
I will always remember these words of wisdom from Shannon to my Wife and I in late 2013;
Do you want a EP who does Ablations maybe 3X a month or the Former Head of the cardiac Clinic in Cleveland Ohio who now does 3-4 Ablations a day? AND as Shannon expressed, my issue was complicated because I was in Persistent AFIB.
It’s a no Brainer to me. Thank God for this Forum and all the wisdom that it brings.

I also have to say this. Jackie is a Gem.

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Daisy
What happens in the “control room” and who is in there during an ablation?

The people operating the mapping system, fluoroscope, and all that other gadgetry, perhaps an observer, perhaps a device rep.

I just got back from having a procedure done with Natale in the new EP lab. I flew half way across the United States to have him as my doctor. I can feel a huge difference already. He is such a blessing and I am so thankful for not only Natale and TCAI, but Shannon and all of the other wonderful people on this forum. Thank you all so much!



Edited 1 time(s). Last edit at 03/07/2020 05:52PM by allofus.

Thanks Carey. Truly amazing! I've suggested a number of friends and acquaintances use Natale and all have been effusive in their praise of him as a person and of his skill.

When one friend and his wife flew to Austin, the volunteer greeter at the hospital asked where they were from. They said, "Denver." The greeter replied, "You must be here to see that Italian doctor, people come from all over the world to see him!"

Thanks, Carey, for the update. When I was there for my last touchup in 2015, I had a few minutes to lie there and observe the surroundings; whereas, previously, I was sedated almost immediately. I joked then that I felt as if I were in a Space Lab. Awesome. Now, this new EP lab, almost makes me want to go again... emphasis on ALMOST!!!

Jackie

Smackman - Thank you. I am so glad you were able to go Dr. Natale in Austin and that you are doing so well now.
I think we all look back in hindsight and say, we are blessed to have had the benefit of his skill and knowledge.
Be well, J.

I've been surprised, the first time I entered such a room for an ablation. I hadn't thought it would not look like a typical operating room, with bright lights above the table and things like this; but it's logical, considering a lot work is made watching screens...
Yeah, it looks like a lab.
Thanks for the pictures!

If the monitoring room is separated by a glass wall, does that mean it’s avoids less risk of radiation accumulation for the cardiologist? I would think only a stereotactic procedure would be performed when the EP is separated by the patient in a remote monitored room? A regular RF would need the EP to be in close proximity to the patient and his monitors. IMHO.

I had my Natale ablation at los Robles hospital. The room was filled with oversized fancy monitors. However Los Robles’s stereotactic equipment is not the same level as his new equipment in Austin. I’m scheduled for a second ablation for my PVCs at Los Robles (instead of Austin where a pvc ablation is done by robotic equipment). The difference I was told was that he was going to ablate my left ventricle by hand and not robotic. If I was less fragile I would fly to Austin. It’s going solo for the procedure and flying back solo the deciding factor.

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susan.d
If the monitoring room is separated by a glass wall, does that mean it’s avoids less risk of radiation accumulation for the cardiologist? I would think only a stereotactic procedure would be performed when the EP is separated by the patient in a remote monitored room? A regular RF would need the EP to be in close proximity to the patient and his monitors. IMHO.

The EP is at the patient's side, not in the control room. Not sure about stereotactic procedures. Everyone around the patient wears lead aprons for protection from radiation but the people in the control room don't need to.

Yes, as Carey noted above, Dr Natale is right by the patients side during the vast majority of each of his ablations and, for sure, during the entire time the mapping and actual ablation lesions are being created, that is all solely done by Dr Natale ...100% .. and standing right next to the patient and in control of all catheters!

The only, exception is during the roughly 20 minute's near the final phase of a Natale AFIB ablation right after the patient's heart has been fully restored to NSR. At that point, Dr. Natale heads to the tech booth (as shown in the photos above) separated from the patient and rest of the EP Lab by the thick radiation resistant glass.

At this time, Dr Natale typically will have a snack while carefully observing, like a hawk, a big LCD screen in the booth showing a large number of separate real-time EKGs, all stacked from top to bottom of the large screen and each representing, with granular detail, all of the trigger areas addressed during the ablation. There will often be 4 to 6 separate EKGs representing the behavior around each one of the four PVs, as well as around and across the LA-Posterior wall, Superior Vena Cava. The Coronary Sinus (CS) and Left Atrial Appendage will also be targeted if, and only if, either of these last two structures prove to be consistent sources of on-going arrhythmo-genesis.

And, in addition, if real-time-detected discrete Non-PV triggers are seen that are unique to the given patient on the table and typically located throughout the LA and RA to variable degrees based on the patient's progression of their condition .. then these discrete triggers will also be addressed as part of an index ablation as well.

The purpose of this final phase of Natale's AFIB ablation protocol, after the Afibbers heart has been restored to steady pure NSR, is to then begin the Isoproterenol (Isuprel) Drug Challenge that will, in essence, give the patient a 'Two-fer' ablation!

By infusing IV Isoproterenol at 20mcg/min for 10 minutes on average, this super strong adrenaline-like drug will truly challenge the ablation that the person has just undergone in a very significant way. If, as is often the case, all of the discrete EKGs on the big screen representing all of the newly created lesions remain well behaved NSR during the full Isuprel drug challenge, then, that is the best one can possibly do, acutely at least, during any given ablation.

If one of more of these separate EKG electrograms become chaotic again and start jumping all over the screen, then Dr Natale will step back next to the patient in the EP Lab and re-isolate any offending re-activated trigger source(s) ... in effect, giving the patient a free touch-up ablation during their index procedure. The net effect is a huge overall increase in initial success rate of approximately 15% to 20% versus not doing an Isuprel challenge test with each index ablation.

I've been able to observe and learn so much thanks to the very fortunate and generous mentorship over the last decade plus Dr Natale has shared with me. Including, his inviting me to observe close-up around 20 AFIB ablations, and other procedures, whenever I have been in Austin (or one of his other ablation centers), usually for an EP-related conference.

This includes Natale's own Bi-Annual EP-Live Conference sponsored by St Davids Medical Center and which is one of my very favorite EP events that I try to attend every two years. I hope to attend the next EP-Live 2020 in just 3 weeks in Austin, depending on how the coronavirus travel restrictions play out in the coming few weeks?

My wife, Magdalena, will come with me (assuming we travel at all by then?) so that I can attend EP-Live with her help in traveling due to my recent hand surgery. I won't have the full green light to travel on my own until May 5, since it has been just one month (as of yesterday) that I had my CMC Thumb Joint Trapeziectomy with Suspension-plasty surgery on my left hand.

My right hand will have the same surgery done later in the summer or early fall once my left hand is more fully recovered, to hopefully restore my dysfunctional hands to relatively pain free functionality ... at long last! My excellent hand surgeon did give me the full okay to travel by March 31st, but only with Magdalena's help. So we will just have to see if it's all in the cards or not this time with so many variables going on at present.

Cheers!
Shannon

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Carey
Everyone around the patient wears lead aprons for protection from radiation but the people in the control room don't need to.

One should also be physically strong enough to wear 20 pounds of lead protection AMA qualification for being an interventional cardiologist--20 lbs!

Wow Shannon. That was so interesting!

Is the amount of radiation the patient gets during a typical ablation significant?

I was in Austin this weekend touring the ranches and speaking with Vets and Ag experts. Off topic I asked about Natale and his success. They all mentioned over 20 patients they had known of Natale and added that only one had need of a second visit which was most likely one of those complicated cases, but successful nonetheless.

Wow that's really encouraging! Especially since I'm going next week!

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hwkmn05
I was in Austin this weekend touring the ranches and speaking with Vets and Ag experts. Off topic I asked about Natale and his success. They all mentioned over 20 patients they had known of Natale and added that only one had need of a second visit which was most likely one of those complicated cases, but successful nonetheless.

FYI,

I mentioned above that I was hoping to attend the bi-annual EP-Live 2020 Conference sponsored by Texas Cardiac Arrhythmia Institute at St Davids Medical Center, and originally scheduled for April 2rd-3rd. My wife Magdalena and I, were hoping to spend an extra day or two at St Davids as well.

Alas, EP-Live 2020 conference has just now joined the ranks of many such conferences, such as the huge AHA (American Heart Association) 2020 Scientific Sessions scheduled for for Chicago. in also being cancelled due to the increasingly rapid spread of the Coronavirus in the US. We figured this might well happen and fully understand why they had to call it quits, but it is disappointing to miss this really great conference none-the-less, especially since it only occurs very two years.

Hopefully, by this time next year the novel coronavirus will be a thing of the past ... but only time with tell!

Shannon

That's quite the proficient typing you're achieving Shannon! Excellent hand surgeon indeed