Good afternoon. I'm Roderick Tung. I'm one of the co-chairs here with my partner, Lakash Gopinathaner. And welcome to this session about optimizing VT care in the community and private practice. And I would say we're all in practice. We're all in the community. The lines between academics and private practice have been relatively blurred, if not removed. I think we all go through the same things no matter what. We're talking about comprehensive strategies. We're going to be talking about interoperative tips and tricks, about safety, efficiency, then different optimizing workflows. So hopefully there will be a lot of time for discussion. And then we're going to talk a little bit about even the finances of VT ablation. But I think the key is that VT ablation used to be a very long endeavor, and we're changing the way we do it. And I think we have greater insights mechanistically into what we're trying to do. And obviously we have new tools and technologies. But it's really to be started with a lot of the collaboration of an ICU team. And I do think that it's important to think about VT as almost like a CCU within it. And to kick off, we're going to have Arun Sridhar from Pulse Heart Institute, Seattle, Washington, talking about collaborations for success with anesthesia, CCU, and heart failure teams. Really importantly, if you have any questions that you want to pose, just do the QR code and submit your questions. Rakesh and I will be monitoring those. And I think we have some disclosures that are airing before we get to Dr. Sridhar's talk. Thank you very much, Rob. So good morning, everyone, and thanks for the opportunity to speak today. The session focuses on optimizing VT care in community and private practices. So we're going to tailor some of the discussion on that, but most of it should be generalizable. I'll begin by discussing the importance of creating effective collaborations within the hospital as well as outside to build a successful VT program. So why is multidisciplinary collaboration so important in VT care as compared to any of the other arrhythmias that we deal with? Some of these things are kind of obvious if you've been in practice for a long time. VT patients are often extremely complex with multiple comorbidities. Risks are not limited just to the intra-procedural care. There is pre-procedural risk and there is post-procedural risk and clinic risk. So there is a lot of risk that stresses the team out, and that's important to have a good collaboration around it. Workflows are not streamlined within the procedural care as compared to AFib ablation or device implants. Most of the VT ablations are heavily individualized, and there are things that are happening in the lab which make us having to pivot into different strategies. So this makes streamlining very difficult, but still there are things that we can try to do to achieve a consistency. So VT episodes, anywhere they happen in the clinic or during the pre-procedure or post-procedure area or in the CCU, they often cause significant anxiety and stress to the patient as well as to the care team, and collaboration actually reduces this. So let's start with collaboration with the anesthesia team. Anesthesiologists are probably the most important partners for us in the VT ablation room. They are the only other physicians in the room who are consistently present in the case other than ourselves. So keeping a good anesthesia strategy is extremely important. I think one of the big recommendations would be to keep the anesthesia strategy as consistent as possible through your cases and have a strategy overarching for all your cases. But then for each patient, you should consider the patient comorbidities, the anticipated procedure duration, and the risk of VT storm during the case and titrate it based on individualized patient scenario. So a discussion with the anesthesia team just before the ablation starts is very important, but you should also have an overarching strategy for all your cases. And it's very important to also know that not all VT cases require cardiac anesthesia support. In the last few years, we've been doing VT ablation cases, and most of them are under general anesthesia. And this is very critical in community settings because if you depend on cardiac anesthesia for all your VT cases, you're going to limit access to your patients. So many of these VT ablations can be performed very safely under general anesthesia with the general team. So we'll go into some specifics about general anesthesia and MAC for these patients. Some of these things are obvious to the VT ablators here, but we'll go over some of these things and see how we can manage some of this stuff. So the advantages of general anesthesia are we have full control over the patient's airway as well as the immobility. So we can keep the patient immobile. MAPs don't move. It is easier to coordinate invasive blood pressure management and vasopressors when you have general anesthesia patient. Escalation of case is also easier when you have a patient already under general anesthesia. If you need to get new accesses or if you pivot to epicardial access, it is easier when you have a patient under general anesthesia. And more suited for prolonged cases because you don't have variation in the sedation level. There are extremely important disadvantages to general anesthesia, the biggest one being the risk of hypotension and because of the vasodilation and reduced sympathetic tone. Some of the drugs like isoflurane, sevoflurane, and propofol can also reduce inotropy and that increases the hemodynamic instability during the procedure. Deep anesthesia can also suppress VT inducibility and VT inducibility is critical. There is data to show that if you can't induce VT, the recurrence rate for VT is higher. But also if you can't induce VT, you're prolonging the procedure duration and thereby you're increasing risk of complications. And there are some patients where the risk of general anesthesia is even higher. If you look at the pain score, this is a very popular scoring system for assessing the risk of intraoperative hemodynamic decompensation. There are many factors, pulmonary disease, CHF, NYHA class, ischemic cardiomyopathy, EF, but one of the important factors is general anesthesia. General anesthesia by itself carries a score point of four and if you put somebody under general anesthesia with somebody who already has a higher score on the pain score, you are increasing the risk of hemodynamic decompensation in these patients. For MAC, MAC has several advantages. It preserves the sympathetic tone. The VT inducibility is easier in MAC compared to general anesthesia. No intubation, that leads to better recovery, quicker recovery, lower aspiration risk. It is likely easier for shorter and less painful procedures for the patients and the setup is less complex. And if you're thinking about quicker ambulation and same day discharge, MAC works much better. Sedation depth is variable, so that's a big disadvantage. So you can have variation in sedation during the case, which makes inducibility difficult at different points in your case. If the patient becomes agitated or hypotensive, then it becomes less reliable. And for some cases where we have to turn epicardial or multiple hour ablations, it's not ideal. So VT consensus document from 2019 clearly states that you need to have a plan for variable anesthesia level during the procedure. That is actually class one. They endorse MAC, at least for the idiopathic cases. But in 2023, one of the big studies, which is done by using the National Anesthesia Registry Outcomes Study, this was published in Anesthesia Journal. They showed that despite the recommendations that came in 2019, about 63% of the patients across the country still receive general anesthesia for idiopathic VT ablation. I think this can be made better with education and the outcomes and the chances of recurrence as well as prolongation. If you educate the anesthesia team, I think they would be more amenable to considering MAC. So how do you optimize that? In our practice, we start with a MAC almost all the time for our cases. The default is MAC for any ventricular case. And if the anesthesiologist thinks that the patient might do better with general anesthesia, it's a discussion that we need to have. And then we decide whether we are going to start with general anesthesia up front. But the default is start with MAC and escalate as needed during the case, depending on how the patient moves, what's the inducibility, and whether or not you continue to keep him lacerated during ablation phase. So now let's talk about collaborating with other teams outside the lab. I think the most important team that you're going to be collaborating with would be heart failure. Heart failure is the key partner outside of the lab. Inside the lab, it's anesthesia team. Outside the lab, it's heart failure team. They are the team which optimize GDMT, fluid status, and hemodynamics pre-procedure, post-procedure for you. If there is need for ischemic evaluation before the patient is taken to the lab or substrate evaluation for non-ischemic patients, they are the ones who guide you through that. And if you're anticipating mechanical circulatory support need, either during the procedure or after, heart failure is your best bet for collaboration. Sometimes things are unexpected. When you do a VT ablation, you think that things are going well, but after that you have post-ablation decompensation or fluid status changes, and you need heart failure to be aware of these things so they can help you when needed. If you look at some of the more complex, critically important problems which come up in any substantial VT program, you will always have a scenario where you're dealing with refractory VT and VT storms, and that's where you start collaborating with other programs in your hospital. We already talked about heart failure team. In our hospital, we have a shock team approach where if a patient is decompensating, the heart failure doctor, the cardiac surgeon, and the interventionist, all of them get on a shock call and decide what is the best hospital for care for this patient and transfer the patient to that particular hospital within the system. So it's a streamlined approach to dealing with shock patients. But when you have a refractory VT patient, you need to start thinking about stellate ganglion block and thoracic sympathectomy and things like that. So you need to get surgeons and anesthesiologists involved. Sometimes these things might not be available in the community, but it is still important to know whether you have these resources or you don't, and what is your bailout, and which hospital are you going to send to, and what is the partnership program you have with different hospitals. In our hospital, it happens that the neurosurgeon is the one who helps us with stellate ganglion block. It's not the anesthesia team, and we reach out to them for stellate ganglion block. We'll talk a little bit about workflow efficiency, which is very important in community or private practice settings where lab time is precious and resources are limited. So inpatient add-ons for VT ablation often take big coordination efforts between multiple teams. It leads to disruption of lab schedules and takes space from other urgent cases because of the length. So it should be reserved for the critical cases and refractory storms. As far as possible, stabilization and optimized outpatient ablation and optimizing the patient outpatient and bringing them for a planned ablation is much safer for the patient as well as less stressful for the teams and the burden on the hospital workflow. When you take discharge, not all VT patients need to stay overnight. Many of the VT, like in our hospital, about 90% of our patients go home the same day. So if you carefully select the patients, if the outpatient elective ablations, hemodynamically stable patients, and EF is not really bad, and if you only do endocardial ablations, you can consider sending the patients the same day. Obviously not suitable for patients coming in with VT storm and epicardial and pericardial access and mechanical circulatory support or patients who don't have good home support and who are very far away from the hospital. Any VT program not only needs collaborations within the hospital, we also need to have a strategy for regional collaboration. Cross-coverage is essential. No VT center can rely on a single operator or a couple of operators. We need to have good partnership between the partners and the team, and you need to build the trust because people need to take care of each other's patients when you're not there and manage your complications when you operate and leave. And the same thing needs to be done for cross-hospital collaborations. You need to develop relationships with other VT centers in the region, especially with those which have capabilities that you might not have, like sympathectomy, advanced mechanical circulatory support, or heart transplant. Identifying your quaternary referral centers and academic centers which can cater to these needs and having clear communication pathways are essential, and we need to have standardized referral packets and transfer criteria should be defined. Like up to how much can you manage in your hospital and when do you need to transfer the patient out? And that is essential both for the patient's safety as well as to maintain that relationship going forward. Communication is key. In summary, building a sustainable VT program is about collaboration at every level, externally with regional partners for high-risk transfers and internally with anesthesia, CCU, and heart failure teams. And workflows need to be streamlined to support both patient safety as well as reduce the stress on the team and team resilience. Thank you very much for your time. Thank you, Aaron. That was excellent. It's my pleasure to invite our next speaker, Samuel Omotoe from the Cleveland Clinic, who is going to talk to us about a safe, effective, and efficient approach to VT ablation. Thank you. Thank you for watching. Thank you very much for having me here. So my name is Samuel Motoi, and I'm one of the cardiac electrophysiologists at Cleveland Clinic. I'm based at one of the regional sites, the Cleveland Clinic campus in Avon. So I'll be talking about optimizing VT ablation workflow using a few case examples to demonstrate how we do this in the community outside of the main academic center at the Cleveland Clinic. And in talking about this, we do recognize that it can be a busy practice. You typically have no fellows working with you, or you have fewer EP colleagues compared to an academic center. And the procedure takes time. Frankly, somebody has to do it. But I believe that it still creates a halo effect for other EP procedures, such as other ablations and devices, highlighting other ancillary service lines and enhancing comprehensive patient care in doing so. When I was charged with developing a complex ablation program at one of these regional sites based at Fairview Hospital, I made a deliberate effort, just to what Arun identified, in curating a dedicated team of other specialists, including advanced heart failure, interventional cardiologists, cardiac surgeons, anesthesia intensivists, and vascular surgery. And by having that dedicated team, we made sure that we were able to have a meeting that discussed as a collective group all the phases of workflow for that particular patient, from pre-procedure planning to post-procedure and discharge. And in doing so, for the pre-procedure planning, we still use this famous tool to kind of screen and know what the patient's protoplasm is. In fact, we make sure that this gets documented in the clinical notes in the office or in the hospital so that we can have a sense of what their protoplasm is and guide us about how to approach it. And so we discuss the cases as a team before the procedure date and the possible approach. The patient gets seen by EP, obviously, and by advanced heart failure and all the other members of the team. When we have that, almost like a tumor board setting, when we have that discussion, we kind of review all the images and EKGs and all the investigations that have been done in the past and discuss approaches. Once we've done that, when the patient arrives for the procedure or if they are in-house, we typically encourage the patient to arrive two hours before the procedure. We held ourselves accountable to starting early. We typically do our VT procedures first thing or first case for that day, huddle at 715, and get anesthesia to kind of see the patient and get things going. We typically place all needed access up front in the EP lab, diagnostic catheters. If mechanical circulatory support is needed, that is placed as well. And whichever approach we want to use, we typically get at least more than one access, whether it's rhetoric or transeptal or epicardial access. If we are to get epicardial mapping done, we typically do this first before we go transeptal to preclude any systemic hyponatization that could, you know, confound things with pericardial or epicardial bleeding. And then for VT ablation workflow, then we define the substrate. We do, you know, the typical functional substrate mapping that Rod Tonk has demonstrated in their paper and identify all the, you know, clinical substrate, define the scar size, and then either do a substrate ablation and or map during VT. I have a few cases here to kind of demonstrate these. This is case one where we have a pain as a score, which is kind of moderate of 13, you know, in ischemic cardiomyotic patients. We did not use any mechanical circulatory support for this because patient could not tolerate any VT to be for induction. So we kind of used, you know, mapped out the substrate and develop the, define the substrate this way. And then afterwards, we started doing substrate ablation, and as you can see here, you know, as we continue to ablate the substrate, it ended up becoming a, you know, almost like a consolidation of, you know, homogenization of the scar. The VT was not, no VT was indistinguishable after this when we're done with this particular case. This second case is one where we did both VT mapping and substrate ablation in a patient with very poor protoplasm with pain as a score of 31 and, you know, ischemic cardiomyopathy. We did use mechanical circulatory support for this because I think the EF was 10, large ventricle, very scarred, even though we're able to do the same workflow and do clinical targets and successful VT ablation with termination. We obviously recognize that this is not, you know, the end all for this particular patient, so we still ended up doing additional substrate targets and extensive ablation until we're able to have non-inducibility and homogenize all the scar. For this third case, it was a moderate, low end of the pain as a score, it's a young patient with non-ischemic cardiomyopathy. We did not use any mechanical circulatory support for this. We're able to go to the same workflow after the discussion, and we did both endocardial and epicardial mapping for this particular patient, even though, again, we're able to ablate the clinical VT in the anterior anterolateral endocardial location, we still ended up doing some additional substrate ablation on the epicardial adjacent juxtaposed epicardial location for this patient. And afterwards, there was no reinduction for this particular patient. So we typically, we define our endpoints by elimination of all the substrates, ablation of all clinical VTs that we have, and confirm there's no capture at high outputs at critical sites, and we then remap after ablation to confirm elimination of all the targets. We will still do some program electrical stimulation, but we typically defer this in patients that are very sick or high-risk patients, because we found that this may not add any additional value if not putting the patient at more risk of non-clinical VTs. Once we're done, and once we're done, we win off all the mechanical support if used. Sometimes this can take hours, but we take our time to make sure that the interventional cardiologist that's managing the impeller or, you know, and the impeller team, or any mechanical circulatory support that was used is properly managed. Sometimes it may be removed in the intensive care unit, but intensive is because they are part of the team. They are aware that a patient may be coming in with the such support in place. We secure hemostasis. We do use some interpericardial steroid injection if we get pericardial access, and then we resume all the antiarrhythmic therapy short-term. We use the direct oral anticoagulation therapy for about a month after the ablation because we found that this helped prevent stroke better than aspirin, as described by Lacaretti and his colleagues. We get advanced heart failure team involved to reassess, just like Aaron mentioned earlier on, to reassess the patient and assist with volume management before they get discharged. So in summary, we believe that optimal VT ablation can be safe and achievable outside academic centers as more expertise gets filtered, in quotes, into regional and community setups. We do believe that multidisciplinary approach is paramount in building and sustaining an efficient VT ablation program in a community practice, and the complexity of what can be done may be dependent on local factors, and continuous enrichment of such expertise and availability of multidisciplinary support is paramount. If there's anything you did not hear me say here is that, you know, is the word fast. You know, there's a difference between being fast and being efficient, and I'm sure that as we get into the discussion that this is one of the most important things we need to mention, that the right thing still needs to be done, and we believe that if it's done collaboratively that it can still be a good outcome for the patients and the hospital system. Thank you very much. Great. Our next talk is by Jayashree Pillaresetti from the Cardiology Clinic of San Antonio, and she's going to talk about the non-operative components of VT management, which includes the device clinic, titration of antiarrhythmics, and when to admit to the hospital. Good afternoon, everyone. I'm Jayashree Pillaresetti, and I'm going to talk about non-operative care of VT patients in the clinic. So imagine a 60-year-old male with a history of ischemic cardiomyopathy, and in a year of 30% he calls you about his ICD going off. So what do you do next? You tell him to go to the ER, or do you have him come into the device clinic for evaluation? That's correct. If the patient is stable and they only received one shock, then you would ask them to come into the clinic. So the questions to ask are, well, is this the first shock? Is this the only shock? Is this an appropriate shock? And does the patient have other symptoms? Is he in acute heart failure? Does he have any acute ischemic event? Are his electrolytes normal? These need to be addressed. Also is the VT monomorphic or is it polymorphic? Because that gives an idea about the etiology. If a patient, however, has more than three VTs within a 24-hour period, then it is a VT storm and you have to admit the patient. So the incidence of ICT therapies in secondary prevention patients is about 15% within their first year and about 5% in primary prevention cases. Patients may present with a variety of symptoms, and that depends upon, you know, it could be from their VT or VF, so they could pass out or they may be lightheaded. They could be volume overloaded and present with shortness of breath, or it could be with chest pain because they're having an acute MI, or it could be from the shock itself when they call you and say they've been shocked, or it could be a combination of the above. So start with obtaining a good history about the onset and duration and frequency of symptoms. Look at their comorbidities. You have to go over their medication list. And then interrogate the device to look at the arrhythmia burden and the morphologies. It is good to have far-field EGMs so that you can assess the morphology of the VT that would help you later on. And if possible, get labs to check electrolytes, troponin, BNP, and drug screening, if appropriate. And these help in identifying the underlying pathology, so, you know, is this ischemia that's causing this VT? Is it a structural heart disease? Is it any of the genetic syndromes? Is it a congenital heart disease? It could be inflammatory, infective, or infiltrative diseases, or is it electrolyte abnormalities or some new medications that they have been placed on? So what do you do with him? This is a guy with structural heart disease and a monomorphic VT. Would you give him antiarrhythmics? Would you start him on antiarrhythmic drug therapy, or would you take him for ablation? Another scenario is if they're already on antiarrhythmic drug therapy, then would you increase the dose? Would you change the medication, or would you add a new drug? So, we'll go over a few trials to discuss this concept. So one of the original trials was VANISH trial that compared patients with ischemic cardiomyopathy who had VT into either taking them for an ablation or escalating antiarrhythmic drug therapy. These patients were already on antiarrhythmic therapy at baseline. And they noted that the composite primary endpoint of death, VT storm, and appropriate ICD shock was better, was reduced with catheter ablation as opposed to antiarrhythmic drug therapy. And the difference was primarily driven by the VT storm events. They did look at subgroups, and they noted that patients who were on amiodarone escalated drug therapy meant an increase in amiodarone dose or an addition of myxilatine, and ablation benefit was noted in these patients, meaning patients who were already on amiodarone, and if it was amiodarone refractory VT, then catheter ablation helped. Whereas patients who were in the Sotilol group, escalation of drug therapy meant initiation of amiodarone, and ablation did not help in these, did not show significant benefit in these patients in terms of the primary outcome. They looked at other endpoints, and they looked at shock-treated VT burden, appropriate shock burden. These were all better in patients in the ablation group as opposed to antiarrhythmic group. And again, this difference was more prominently noted or significant in patients who were already taking amiodarone. The VANISH-II trial is in the same patient population of ischemic cardiomyopathies, but this is now tested about using catheter ablation as a first-line approach. So this is antiarrhythmic drug therapy or VT ablation as a first-line approach. And it did show that catheter ablation is better in terms of the composite endpoint of all-cause death, VT storm, appropriate ICD shock, or sustained VT below the ICD detection rate requiring treatment. The difference was not huge, but it was a significant difference, and the difference was primarily driven by a treated sustained VT below the ICD detection limit. Another study, the SURVIVE VT study, looked at substrate ablation versus antiarrhythmic drug therapy. Again, catheter ablation was a first-line treatment. These patients were not on prior antiarrhythmic medications. And the composite primary endpoint of cardiovascular mortality, ICD shocks, heart failure hospitalization, and drug-related adverse effects, the endpoint was better with catheter ablation. The difference in this study was driven more so by treatment-related adverse effects with antiarrhythmic drug medications rather than the other components. Other secondary endpoints, like reducing incessant VT, VT storm was better with catheter ablation as did cardiovascular hospitalizations, including hospitalization for VT that was better with catheter ablation. So these are all studies on ischemic cardiomyopathy patients. Non-ischemic cardiomyopathy patients tell a different story. These are most often polymorphic or pleomorphic. The substrate is intramural. They're less hemodynamically tolerated, they're difficulty-induced, and they're much faster compared to post-infarction patients. So while all the trials, they do show reduction in appropriate therapies with catheter ablation, none of them show a benefit in terms of mortality with catheter ablation. So we really have to assess the risks and benefits of the procedure with every patient and individualize it. One of the studies from a hospital discharge database showed a complication rate of 8% with ablation. Again, this is minor complications and major combined, and mortality was 1%. The other speakers talked about the pain ESD score as well, and this is something that you can use to determine whether patients need other mechanical circulator support devices when you send them for ablation, and whether or not they're good candidates for ablation. So if you choose to give antiarrhythmic therapy, however, what are our choices? Again, we are limited to amiodarone, mixletein, and sotalol primarily, beta blockers to help heart failure patients. The other new medications that could be used are dofetilide and ranolazine. We do not have a lot of data, but dofetilide was tested in a small study where they looked at incidence of VT and VF and ICD therapies in patients before and after initiation of dofetilide, and the burden was significantly reduced. They also used it to compare patients who were on other antiarrhythmics, and then dofetilide was used, and the arrhythmia burden was reduced. Ranolazine is a medication that is similar to amiodarone in terms of blocking sodium channels and potassium channel, and ranolazine showed improvement in the VT burden when used in CRTD patients, so mostly patients with heart failure, not so much in patients who were recipients of ICD. It was also better in reducing VT events when it was used as a standalone drug than when used along with other antiarrhythmic agents. So when do you hold antiarrhythmic agents prior to ablation? You need to hold them at least five half-lives before the VT ablation. That helps in induction of the VT during the procedure. For amiodarone, it has to be at least two weeks. If amiodarone is not held, then the end point of VT non-inducibility after substrate ablation is much easier, and after ablation, if you stop amiodarone, there is a higher recurrence rate. So I like the study done by DBSC where they looked at amiodarone on and off pre-ablation for eight weeks. In the on group, they were on amiodarone, and these patients, they required more aggressive stimulation of VT induction during the lab, and these patients had fewer LAWAs and late potentials as compared to patients who were taken off amiodarone. What about post-ablation? Can you discontinue antiarrhythmics? There is one study that showed that yes, after successful VT ablation defined by all the goals that you saw in the previous speaker slide, yes, amiodarone can be discontinued without an unacceptable increase in VT recurrence. So with the data dilute with devices, we do now have third-party companies that help with remote monitoring and can help report to the physicians when patients need immediate attention. You do have to have standardized alert parameters, though, for red day alerts, what you would call a yellow alert, and what you would not want to be disturbed every day about. And careful attention to these alert managements can help minimize false positive alerts. We also have to look into optimizing ICD programming to minimize the burden of ICD therapy, minimize RV pacing to prevent cardiomyopathies, merit RIT settings, high rate thresholds, and prolonged settings to reduce ICD therapies that has been shown to reduce mortality in ICD therapies without increasing syncope. And use SVT and VT discriminators to reduce inappropriate therapies. So in summary, yes, ICD shocks are a common presentation. You need to identify the underlying cause and treat accordingly. Device programming needs to be done to reduce ICD therapies burden. And ablation, while it is preferred over antiarrhythmic drug therapy, you still have to have individual risk-benefit assessment prior to sending for a first-time ablation. And if they are in a VT storm, then you would directly admit them. Thank you. Thank you, Jayshree. Our next speaker is Dr. Gopi Nirdamudi from Prisma Health System in South Carolina. Dr. Nirdamudi is going to talk to us about the finances, optimizing practice finances, billing and coding for VT ablations. Thank you. Thanks to Rakesh and Rod for this invitation. So my talk is structured in a way to start out with talking about a little bit fundamentals of billing and coding and typically how are payments made. I think it's important to understand the context of what we do and how third parties and so on see us. And then we'll go a little bit into the details of VT billing from a physician standpoint more than from a facility standpoint. So basics of billing and coding, this is very basic. So the whole idea of billing and coding is you take your clinical documentation, which essentially you're documenting what you are doing to that patient, whether it may be procedural-based or just even clinical management-based. Those are then converted into standardized codes, and we'll talk a little bit about those codes. And then ultimately you submit these standardized codes for claims. And when you talk about coding, for most of us, we're not trained. We don't learn these in medical school. We learn these as we go. I wish I had known all these early on in my career. Over time I've learned these. But we have CPT codes, which are current procedural terminology. These represent the procedures and services that we perform as providers. These are categorized by the AMA. Then you have the ICD-10 codes. There's clinical modification codes. There's also procedural-based codes that explain, essentially, the reason behind why you're providing those medical services. Then there's the HCPCS codes. Again, these are not something that we are familiar with. It's more on the system-based. But they actually bundle your CPT codes with additional codes, such as supplies and equipment. And these are managed by CMS. So ICD-10 codes, actually, any takers on who actually came or where they are housed? Which organization? This is surprising to me. AMA? CDC. So what CDC has to do with ICD-10 codes, but CDC is actually the one with which ICD-10 codes reside. So when you're talking about codes and you take billing, they have professional billing component to it. There's facility billing. When we're talking about professional billing, obviously, we're talking about our practice, whether you're employed at a group practice or a private practice. It's really our time, provider time and expertise. And then we bundle these into either CPT codes or ICD-10 codes, depending on hospitalization and so on. And the facility side, it's either the hospital side or the ASC side. Hospital side, remember, there's hospital outpatient, call it HOPT, outpatient departments in the hospital. This includes the equipment, the space, the supplies. And then, I'm not sure why this is advancing. APCs and DRGs. So APCs are on the ambulatory side. This is the ambulatory payment classification, where hospitals bill for the ambulatory or the outpatient side. Most of our AP work is on that side, because these are all outpatient-based. And there's also DRGs for the inpatient. That's the diagnosis-related group or grouping. And it's important to understand where the payment comes from. So Medicare, when you're looking at Medicare payments, there's the provider side. That's the PFS, the physician fee schedule. That's what pays physician for their services. And this is standardized across the country. And we'll talk a little bit about the geographic location and so on. And there's the outpatient side. That's the facility side, the outpatient prospective payment system. And there's the inpatient side, inpatient prospective payment system. Again, these are on the hospital side. That's how Medicare does the billing for our services. And I think some of the things you always hear, but probably don't really understand when you look at Medicare, when they pay a physician or provider for services, it's broken down into several components. We look at the work RVU, which is what we get. But there's actually a total RVU on which Medicare actually pays. Because we have to have facilities, we have malpractice, geographic locations have variations. If you're doing it in New York City versus somewhere rural where the costs are lower. So Medicare actually takes into account and actually comes up with a formula, or plugs it into a formula and says we're going to pay a certain rate if you do this procedure, based on what the malpractice patterns are in that particular region. And finally, it takes that entire sum and multiplies it by a conversion factor. You hear this term all the time, what is a conversion factor and so on. That's based on budget neutrality for Medicare. So when CMS is looking at annually budgets and what they want to spend, somewhere they have to cut. And that's where physicians have taken the brunt of it, is that budget neutrality, policy changes, the macro, which is essentially looking at value-based care and how is value-based care impacting. So value-based care has an impact on the conversion factor. It actually drops the conversion factor because of what's being bundled into it. So that's the basics of billing, coding, and how Medicare sees payments, and how do they use, how do they calculate for a particular service. I'm going to spend a little time now looking at VT. Obviously, I'm comparing it here with AF because, you know, AF has become the darling and the love of all of EP, pays the bill. So everybody compares everything with AF. But they're very similar procedures in terms of billing, except that VT actually allows you to add some other code. So when you look at the basics of VT ablation, inherent, that means the procedure itself, Medicare sees this as these are inherent to the procedure itself. And in the past, even though they could be billed separately, now that certain services are certain types of things that we do, our bundle, for example, mapping and what chamber you're pacing and so on. So the standard for VT ablation 93654 code is all these things. Again, I'm not sure why this is advancing. But add-on codes for VT include a transeptal catheterization, doing a transeptal access. Because traditionally speaking, we did retrograde aortic, almost all of us probably today. If it's amenable, we'll do transeptal. So that's an add-on code. And ICE has also not been bundled yet. I think the good thing about VT ablation is it's still a small proportion of what we do that probably unlikely they'll target that. So you can still bill for ICE. If you look at AF ablation, essentially everything you do is now bundled. That's why it's just one payment for a basic AF ablation. So a big difference there between VT ablation and AF ablation that you can still do transeptal catheterization. That's considered separate. And ICE, which is considered separate. So when you start looking at these codes, sorry, I'm not sure if you can actually see all of these. But you have your standard 93654. One of the things I've learned, and I've been doing this for a long time, and I still learn every day. The 93655 code that we use sometimes for AF ablation, that's a MUE code. It essentially means medically unnecessary edit. It's what Medicare uses. So you can bill that for your ablations, whether for AF or VT, up to two times. So Medicare allows up to two times to bill that code provided you're actually doing the work. You can't just bill for it and say, I did it. Most likely than not, when you're dealing with non-ischemic or ischemic VT, you are going to be dealing with more than one VT. We all know that. The mechanisms may be different, or even though they may be the same mechanisms, there's two separate VTs or three separate VTs. If you're targeting them, you can actually bill for it. Similarly, like we talked about, there's also drug infusion probably. So if you combine all of them for VT, you have your basic 93654 if you attempt a VT ablation and you bill for that. That's about 18.1 RVUs. There's the 93655 add-on code. You can bill up to two times. That's five and a half times two. That's 11. Then you have the 93622 code, your transeptal and ICE. That's ICE and that's transeptal. And then finally you have a drug infusion. Similarly for AF, assuming you're doing all of the work, this is a max value that I looked at. You have your basic AF ablation with PV isolation. If you add on anything, whether it be linear ablation or you do something different, different focus or so on, or if you do a flutter line and so on, that's another additional 11 RVUs. And then if you give a drug infusion, that's .99. So if you take the max value of a basic VT ablation compared to an AF ablation where you can bill for the services that you provide, there's a 22% difference in VT versus AF. I think, again, people don't realize, I think we're very quick to discount VT saying, oh, it doesn't, or AF is better. Yes. Is it possible that you may be able to do more AFs than VTs? Yeah, it depends on what you're targeting, what kind of procedure you're talking about. Are you talking about a redo-redo case? Are you talking about your first time VT ablation where most of us today, with the technology that we have, can be relatively straightforward, I believe. It's also important to understand on the facility side, again, we tend to think just about our codes, but what does the system see on its side when you do these? An outpatient payment for an ablation, especially these are considered a level three VT and AF, is around $24,500. And if you do it inpatient with major comorbid conditions or complication, the MCC code, it's around $28,000. But this is, again, something people don't realize. When you do inpatient without an MCC code, that means, let's assume somebody comes in with an SVT, single episode, somehow ER admits them, and you decide to ablate, that actually pays lower than what you would get paid as an outpatient for the same procedure. This is one of the reasons why it's important to understand the economics of what we do. For routine things, for example, somebody comes with a pneumonia and you find that they have a single episode, an SVT, ablating them in the hospital, keeping them longer, actually is detrimental to your practice and to your organization. Or similarly, if you do an AF ablation, especially if it goes into a DRG, you could potentially, you know, my lab staff, my ex-lab staff are laughing because one of our providers always believes that anybody who has anything in their hospital has to be taken care of. I think that's a bad way to look at it if you're looking at it from, obviously patient care comes first, but if it's non-urgent, it's just an elective thing they can do a few days later and they can come back, actually it's better for your system from an economic perspective. Some of the considerations, remember, I think we tend to bucket all VT together and think about it as being complex and it takes five hours or six hours and so on and so forth. That is not the case in most of the stuff that we do today. Substrate ablation has become a big part of what we do. We definitely have better mapping and technologies. I'm sure PFA will probably have a place in this and significantly reduce our time for these procedures. And again, you cannot discount ultimately we're here to take care of a patient. And if you look at all the data, VT recurrence rates reduced by 60%, ICD shocks reduced by 50%, mortality reduced by 25%, hospitalizations overall reduced by 40%, and cost long-term reduced by 20%. So at the end of the day, regardless of it, if we have to take care of these patients, ablating and as a strategy up front is actually incredibly beneficial in the long-term if you look at even cost reduction of recurrence of hospitalizations and so on and so forth. So hopefully I convinced everybody to start VT ablations and not just AF ablations. Thank you. Gopi, since you're up there, I'm going to ask a quick question. You talked about the distinct mechanisms and you can build up to two additional. So would that just be exactly how many morphologies of VT you have? Do they have to be in specific areas? Do they have to be discrete from the target area? How specific and granular does that get? Yeah, it's not entirely clear. It depends on your coding people when they look at it and some will accept your codes if you clearly document that it has to be distinct from the initial arrhythmia that you targeted. It could be in the vicinity, but it depends on how you describe it. If you describe it that you just changed the exit site and so on and you're ablating the same arrhythmia and say that's a different ablation, that won't count. But it's pretty loose. I think what they're more interested in is making sure that you don't do more than two codes. That's what triggers usually a review if you build more than two of those. So if you see a different mechanism or if you think you're targeting the substrate and now you're doing pace mapping, if it's different, obviously when we ablate we see something different. It depends on how you describe it. Is that a change in exit site or is it something different? Right, I mean those are subtleties that our coders don't have. They're subtleties that the payers don't really understand. Nobody resets for mechanism anyway, so mechanism is actually the wrong thing to say. It's like a different site. But I mean if you have VT6 and VT7, by definition, and there's a lot of shared isthmuses, but we've never seen one that shared seven VTs. Sometimes we've seen two or three. But it would seem to me that we would all benefit from just going ahead and billing that 5-5 code. I think so too. Honestly, I was never aware of it for a long time. Well, I would admit that I've never done it. No, I think the majority of us have not done it because we've never thought through this. Pete Weiss has and everyone has little tricks and that's why I think it's important that we get together and talk about those. I was going to ask a quick question to follow up on that, Gopi. So for like where you now get Epicardial access or, you know, one of the things that I've done in the past was to try and do multiplier codes of 20, you know, times 22. 22 modifiers? Yeah, 22. Is that something that's still practically flagged? Yeah, again, a lot of this is flagged by your own coders. I don't think within reasonable limits Medicare or anybody cares as long as you're providing the care and documenting. So really it's your coders understanding how you're coding. A lot of times it's at the local level. It's not really at the CMS level. I would say most of this is at the local level. So 22 modifier usually increases the payment for complexity by maybe 20%, but then, you know, University of Chicago, they said we never get paid for 22 modifiers. Don't even bother. So I think it's important to have those conversations with the coder. I do agree that Epicardial is a problem still. You know, some people, John Miller is billing for pericardiosynthesis. We're billing a 9361, which is actually intraoperative epicardial mapping. And at University of Chicago, they said, well, that's fine because it's a minimally invasive intraoperative. But then other places say, well, that's purely surgical. But it actually says for slow conduction zones, which is what we do. So I think it's highly variable, but even with epicardial, it's not clear what's happening. Epicardial is actually bundled into your VTE technically. So some people bill for pericardiosynthesis. So again, it depends on how you document. Saying that you're withdrawing fluid periodically for hemodynamic purposes probably covers the pericardiosynthesis site. So there are different ways to, again, it's documenting what you're doing probably. But epicardial typically is bundled if I'm not mistaken. That's why there's no specific code for epicardial access. Same thing if you do retrograde aortic. As long as the anesthesiologist doesn't get an art line and say, I'm going to do the monitoring, you can actually bill for blood pressure monitoring for retrograde access if you do aortic access. I mean, it's small numbers, all these. But they add up at the end of the day. If you do these and that's your practice over a year, it's not trivial. Anybody from the audience have any questions? Please come forward to the microphone. When making a VT program, in the panel's opinion, how many epicardial cases per year would you need to be a reasonable center? Why don't we start with you, Rakesh? I would say... Or do you even need to have to do epicardial to be a VT program? That might be another question. Like, can you do all the VTs but just not do epi? I mean, doesn't... I think it is perfectly reasonable to have a VT program where you don't do the epicardials because you're still taking care of a large majority of your community. Can you speak in the... I think it is perfectly reasonable to have a VT program where you don't do epicardials but choose to do everything else because you're still taking care of the majority of the community. And that's what is important because if you reduce the volume that needs to go to the universities, you're already doing a favor on the community. So, and if epicardials is a barrier that you don't want to cross and you want to reserve that for university programs, I think, by all means, that's... I feel it's reasonable. What do you guys think about the percentage of epicardial cases that you see? Has it changed over time? Has it gotten lower, higher? What do you think? I mean, I think it's probably about the same. Probably 10-15% of the time will go epicardial to the point that Arun said. The other thing is that I believe that, you know, when developing a VT program, it starts from when we're fellows, right? You know, you want to get your hands wet and get well-trained so that you can be well-armed because I think that that's where, you know, when I use in my slide that, you know, whatever expertise goes to the community starts from the academic program, right? Because the more well-trained a person is then when they go out there and they can then curate what they can handle with fewer operators around them than not. And I think it also has to do with how many re-do's your center gets. Because if you have re-do's and three-do's, the epicardial will be over 50%. And I agree, first time, I think most places are less than 50%. So I think that will really depend on the case composition. You know, another question that came up from the audience is how much MCS are you using? And then we can even go down the row. How much impeller using balloon pump versus ECMO versus none? Yeah, so for MCS, once we determine that that's going to be part of the workflow and we discuss it, we use impeller for all our cases because one, we found that, you know, it's way better than balloon pump. We don't even consider balloon pump anymore. You know, occasionally we may use ECMO, but once we get to that level of ECMO, then we have to involve vascular surgery, peripheral interventional cardiologists, then we just send them to Pasquale at main campus to take care of it for us. But we just use impeller CP, and now they have the expandable impeller that, you know, is knife-wrench that can be used. And so that's even more manageable. Dr. Sridhar? I think a lot of... How much MCS in your practice? Very little, actually. So like less than 10 percent. So I think a lot of patients can safely be obliterated if you have a good anesthesia strategy and if you... For many of my patients with less than EF, EF less than 25 percent, I just do them on MAC and I don't put them on general anesthesia and use minimal sedation. You can get away with it. I think you don't really need to put impeller on every patient. It just increases the workflow by an enormous amount. What about you, Rajesh? I'm sort of the same as Aaron. I used to do a lot of impeller cases, but I think more and more we are doing more MAC and then, you know, keeping that sympathetic tone and then try to maintain the patient that way. I think part of it is, you know, figuring out the impeller weaning process and, you know, the training that's involved in the ICU, all that kind of stuff. And then the outcomes were not, you know, super different, so I think that also played a role in that. So I think we are doing more and more with MAC and substrate based ablation. Yeah, I think we can probably count on one hand of how many impellers we've put in in the last four years in Phoenix. It's probably less than five. And we're typically using dopamine, which we like because it's beta before alpha, but the reflex of anesthesiologists is always to immediately give something that's alpha. And that even includes epi, right? So you don't get to alpha doses. That's why we like dopa. And everyone says, well, we don't like dopa because we were taught not to use dopa because it's arrhythmogenic. And we said, that's great. Fantastic. We can't wait to see some more VTs. So that's that. And then another little trick that we've found is atropine. There's a lot of patients that get some vaguely mediated stuff with intubation, et cetera. And then during VT, we were looking at the sinus rates during VT. And if you see that we always say V greater than A, but look at the A. It's usually a Brady A. And if you think about a patient that has a terminal rhythm that you're dying from and the sinus doesn't respond to that, we're not talking someone with VA conduction. Why is the sinus node suppressed? And that's because we actually think there's a massive vagal response to VT. And Margarita Pujol-Lopez published that in Jack. So we actually give atropine when someone's a little hypotensive, and it often functions as a presser. And we'll just give one of atropine. I wouldn't give more than one because that can cause urinary retention. But glyco would be fine, too. Some vagalytic. And I think we are beyond our time for the session. We thank all the speakers for their excellent presentations, and thank you. We'll close the session.

ventricular tachycardia

VT ablation

multidisciplinary collaboration

anesthesia strategies

heart failure teams

workflow efficiency

mechanical circulatory support

ICD programming

antiarrhythmic drug therapy

financial aspects