A New Standard in Cardiac Ablation: Zero-Exchange Workflow With Arnoldas Giedrimas, MD

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EP LAB DIGEST. 2025;25(7):1,14-16.

Interview by Jodie Elrod 

In this feature interview, EP Lab Digest speaks with electrophysiologist Arnoldas Giedrimas, MD, to discuss real-world use of the FlexCath Cross™ Transseptal Solution (Medtronic) in a clinical setting, highlighting its zero-exchange workflow, efficiency, and economic benefits.

Can you describe your cardiac electrophysiology (EP) program? As a high-volume EP center known for its commitment to clinical innovation and patient care, what distinguishes your lab’s approach when it comes to adopting and optimizing procedural workflows?
Southcoast Health is located in southeastern Massachusetts. We have 3 hospitals, with the EP program based at our main cardiac hospital, Charlton Memorial Hospital. We have 3 electrophysiologists and a couple of cardiologists who perform device procedures, as well as 5 full-time advanced practice providers (APPs). We have 2 dedicated EP labs, and a third device lab that we are in the process of upgrading to a full lab. We are projected to perform about 1100 ablations this year, the majority of those being catheter ablation of atrial fibrillation (AF), as well as about 800 device procedures. So, we are quite busy clinically and we really pride ourselves in providing individualized care in the community setting. 

We have also been very active in clinical research. For example, we were the top national enrolling center for the STOP AF First trial.¹ We were also very early adopters of pulsed field ablation (PFA). We were involved in the PULSED AF pivotal trial,² in fact, enrolling the first patients in the world for that trial and being active enrollers. We then quickly adopted the technology after it gained US Food and Drug Administration (FDA) approval, and at this point, we are using it for most of our AF cases. 

I think our relatively smaller size allows us to be more nimble than some of the larger institutions. EP is going through quite a transformative time in terms of new technology and workflows, and I think our smaller size and good working relationship with administration and staff serves us well in terms of getting new equipment approved, starting up trials, and getting the workflows updated as things evolve.

Can you highlight your cardiac ablation procedural volume and some of the technologies that are used? 
At this point, AF ablations have certainly become the most common procedure. Out of the 1000 to 1100 cases, we are projecting about 800 AF ablations using primarily PFA, which is a combination of using the PulseSelect™ Pulsed Field Ablation System (Medtronic)³  and Affera™ Mapping and Ablation System with the Sphere-9 Catheter (Medtronic).

From a workflow perspective, what are some of the key challenges or inefficiencies you typically encounter during transseptal access in left-heart procedures?
For me, this was a case where I did not really know there was an inefficiency until an improvement came along. Typically, I was using a non-steerable sheath with a radiofrequency-powered needle and then performing over-the-wire exchange. With the larger sheaths for cryoablation, you sometimes have to work really hard to get the sheath across the septum. During redo ablations, the septum can be more fibrosed from prior transseptal access. Also, about 7 years ago, I adopted a fluoroless approach, and so some of the considerations were knowing how to visualize the tip of the wire and knowing where the tip of the transseptal needle was relative to the tip of the sheath. So, those were some of the challenges and considerations.

Can you speak to any recent adjustments in your transseptal approach that have contributed to shorter case durations or improved overall lab efficiency? Tell us about your use of FlexCath Cross and a zero-exchange workflow. 
We get so comfortable with doing things a certain way and sometimes we do not think twice about it. You just learn little tricks to overcome the obstacles. However, when we started using the FlexCath Cross about a year and a half ago, it was an obvious improvement. There have been significant innovations from the industry in providing us with new tools that streamline the procedures. We had tried several transseptal products, and the FlexCath Cross worked well into our existing workflows. The zero-exchange workflow is certainly a big step forward in minimizing any risk of complications. By minimizing the steps involved in getting transseptal access, it reduces the risk of air embolism. I am very meticulous about de-airing the sheath of any microbubbles. I think especially with some of the new catheter designs, which have more complex shapes, there is more possibility of air entrapment. So, I think minimizing the steps is really a step forward in terms of safety. The FlexCath Cross uses a sharp, extendable needle to gain transseptal access. It also has the ability to deliver RF at the needle tip, although the need for that is very rare.

I also find that the FlexCath Cross offers more support at the tip of the sheath, so it is a little easier to get it across the septum. Also, you do not have to worry about the spacing of the needle relative to the sheath, which is a plus for me when I am not using fluoroscopy. One of the other advantages that we found is that it works across multiple sheath sizes. So, whether we are using it with the FlexCath Contour Steerable Sheath for PulseSelect or cryoablation, or now typically an Agilis sheath for Sphere-9 Catheter with Affera, it works across multiple systems.

How do considerations around procedure time and resource utilization influence your decisions when evaluating new tools or techniques for transseptal access? Tell us also about the efficiency benefits of using the FlexCath Cross.
First and foremost, patient safety is paramount. After trying it out, I was easily convinced that there was an improvement in that regard in terms of minimizing the steps, risk of error, and embolism, I thought it was safer. The time savings with avoiding the sheath exchange is a nice plus. Whenever you can increase safety and save time, that is a win-win in the EP lab.

In your experience, how can simplifying transseptal access contribute to overall procedural value or cost-efficiency—particularly in high-throughput EP labs? Is it also possible to highlight the percentage of cost-savings per procedure by switching to FlexCath Cross?
In terms of the cost for us, we found it was essentially cost neutral compared to our previous approach of using an extra sheath with an RF transseptal needle. It was significantly less expensive than some of the other zero-exchange solutions on the market. The FlexCath Cross can be used with an existing electrocautery generator and avoids the need to purchase a separate generator. Regarding other savings, we found that by using multiple products from the same company, it can offer opportunities to offset the cost.

Are there specific areas—like equipment use, staff time, or procedure duration—where you have seen economic gains tied to modifications in your transseptal technique?
We have found that it has really created a cascading effect. It starts off with maybe just saving a few minutes on the shorter exchange time. However, when you combine that with now switching to PFA and the shorter ablation times, we are finding patients are quicker to wake up from anesthesia, we are using venous closure devices, and we are avoiding Foley catheters and arterial lines. Patients are quicker to ambulate to be discharged, and before we know it, we are doing another ablation or two that same day. So, it really has led to significant savings and improvements. 

Disclosures: Dr Giedrimas has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest, and has no conflicts of interest to report. 

The transcripts have been edited for clarity and length.

This content was published with support from Medtronic.

References

1. STOP AF First trial. Medtronic. Accessed June 2, 2025. https://www.medtronic.com/en-us/healthcare-professionals/specialties/electrophysiology/therapies-procedures/cardiac-ablation-mapping/clinical-evidence/stop-af-first-trial.html

2. PULSED AF trial. Medtronic. Accessed June 2, 2025. https://www.medtronic.com/en-us/healthcare-professionals/specialties/electrophysiology/therapies-procedures/cardiac-ablation-mapping/clinical-evidence/pulsed-af-trial.html

3. Pulsed field ablation. Medtronic. Accessed June 2, 2025. https://www.medtronic.com/en-us/healthcare-professionals/specialties/electrophysiology/therapies-procedures/cardiac-ablation-mapping/ablation-therapies/pulsed-field-ablation.html