Cardiovascular Business - January/February 2009 - (Page 7)

n Natale l Steinberg n Wilkoff Andrea Natale, MD, executive medical director for the Texas Cardiac Arrhythmia Institute at St. David’s Medical Center, Austin, Texas Jonathan S. Steinberg, MD, chief of the division of cardiology and Al-Sabah Endowed Director of the Arrhythmia Institute, St. Luke’s-Roosevelt Hospital Center, New York, N.Y. Bruce L. Wilkoff, MD, director of cardiac pacing and tachyarrhythmia devices at the Cleveland Clinic, Cleveland, Ohio complexity. Therefore, an AV node reentry is probably going to be an outpatient procedure and is going to be paid less than a complex ablation. n Wilkoff: Another part for people who are looking ahead is the ability prove outcomes, being able to measure quality and ensure compliance with national standards. It’s always easier if you do it systematically from the beginning. Adhering to national standards, quality reporting and keeping track of complications— such as deep vein thrombosis, pulmonary emboli, perforations, surgery, death and infections—are going to become essential to opening up a lab, and for operating experienced labs as well. l Steinberg: Electro-anatomic mapping has made complex ablations much easier, much more reliable and safer. We use it on all our complex cases. I agree with Dr. Natale regarding the use of intracardiac ultrasound to reduce risk. A successful atrial fibrillation ablation depends on proper positioning of the catheter for both mapping and ablation. Fluoroscopy only gives you an indirect image of catheter position relative to heart anatomy. With an ultrasound, you can visualize simultaneously the various structures of the heart and the catheters. u Haines: There are a number of new technologies that are in trials right now, a variety of balloon ablation catheters for pulmonary vein isolation and preformed catheters that are going to potentially aid the less-experienced operator in pulmonary vein isolation. It’s going to get down to safety versus cost. Intracardiac echo imaging is the one tool we use on every A-fib case that truly enhances our understanding of the minuteto-minute changes in the anatomy, catheter relationships and transseptal puncture, but it does add cost. The tradeoff with any new ablation tool, such as the cryo-balloon, is that it will be very expensive. A simple pulmonary vein isolation procedure, for example, might take three hours with a conventional cooled-tip catheter. With newer technology, you might be able to reduce lab time to two hours, but you may end up spending twice as much for the equipment. The per-case cost with A-fib ablation can get very high very quickly, particularly, if you add in robotic navigation and amortize the cost of those devices over the case load. : How do you handle device recalls and the fear they might instill in potential candidates for ICDs? n Wilkoff: It’s a complex question. It’s as much a problem with the language as anything else. It’s not so trivial a distinction to call it a safety alert instead of a recall. Studies have shown that people respond differently depending on what words you use. The Heart Rhythm Society has been working to get the FDA to change the language. A recall implies patients can bring it in, EPs can take it out and the problem is fixed. We know it’s much different than that. We have found that in almost all cases continuing to monitor the patient for an actual failure, even in an identified at-risk situation, is less risky to the patient than changing the device. : How has newer imaging technology helped in the EP lab? n Natale: Intracardiac echo imaging (ICE) has been important in reducing the risk of perforation. Obviously, the cost of ICE has been a deterrent for many labs and it is a choice people have to make in terms of how much they care about increasing safety or otherwise taking the risk. We also use 3D CT and MRI reconstruction. There is some retrospective data showing that these might increase success, but they don’t reduce the complication rate. : What is a typical per-case disposable cost for an atrial fibrillation procedure? n Natale: Usually, I use the Thermocool catheter and the Lasso circular mapping catheter. I use robotic navigation in some instances, but there are some in my group who use robotic almost routinely. So, the official cost of the robotic sheath is close to $3,000. We get it for $1,600 because we use many of them. Then you have to use the ablation catheter and the Lasso on top of that. So, the robotic sheath becomes an extra cost. cardiovascularbusiness.com cardiovascular business 7 http://www.CardiovascularBusiness.com

Table of Contents Feed for the Digital Edition of Cardiovascular Business - January/February 2009

Cardiovascular Business - January/February 2009 Contents First Word Electrophysiology Roundtable Forum: A Candid Conversation about Profits, Procedures and Patients Heart Failure Care Gets Boost from Technology Emerging Technologies in Peripheral Vascular Interventions Stent vs. Graft: Choosing the Best Path for the Diabetic Patient with Multivessel Disease Cardiology Groups and Hospitals Strive to ‘Connect’ Seamlessly CT Beyond 64 Slices Clinical Study Digest: Kidney Disease & PCI; Women and Valve Disease Compact Echo Systems Come Up Big in Cardiac Care News & Views Reader Resources The ACC Corner

Cardiovascular Business - January/February 2009

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