St Luke’s Health System
© 2025 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates.
EP LAB DIGEST. 2025;25(7):10-14.
Marcos Daccarett, MD, MSc, FACC, FAHA, FHRS, Medical Director, EP Lab, and Karen Dey, RN, BSN, Manager
EP and Cardiac Cath Labs, Boise, Idaho
When was the cardiac electrophysiology (EP) program started at your institution?
The EP lab originated in 1991 as part of our cardiac catheterization lab. It was the first EP lab to be established in the state of Idaho. A dedicated EP lab was constructed in 2004.
What drove the need to implement an EP program?
There was a growing need in Boise and the surrounding area for an EP program. Until the opening of our EP lab, patients were transferred out of state for services.
What is the size of your EP lab facility? Has it recently expanded in size, or will it soon?
We have 2 dedicated EP labs and a third lab is used as a swing room for devices. St Luke’s is in the process of expanding its current campus location and is expected to accommodate 3 to 4 EP laboratories. Our system is also expanding in the Boise Valley metro area, with plans for an additional EP lab in the west side of the Valiey. We also perform EP procedures in our Twin Falls Hospital, a St Luke’s hospital approximately 100 miles southeast of Boise.
Does your institution offer EP-related procedures in an ambulatory surgical center?
Not currently, but as the expected transition to ambulatory care progresses, St Luke’s has a mid- and long-term strategy to perform some of our procedures in this setting.
Who manages your EP laboratory, and what is the mix of credentials and experience?
Marcos Daccarett, MD, MSc, FACC, FAHA, FHRS, is our EP medical director. Khalid Sheikh, FACHE, is our system line administrator. Murali Bathina, MD, FACC, is our system line medical director. Karen Dey, RN, BSN, is the EP/cath lab manager. Electrophysiologist Milinda Marks, MD, FACC, was one of the first physicians in our EP program and has been with St Luke’s for over 30 years. Luciano Amado, MD, came to us 2 years ago from Minnesota. Justice Oranefo, MD, started here in 2024. We also have a dedicated team of anesthesia staff helping us with all general anesthesia cases.
What is the number of staff members?
Currently, we have 10 dedicated EP staff members, including a combination of registered nurses (RNs) and staff with the registered cardiac electrophysiology specialist certification. We have 1 member with over 25 years’ experience and 3 others with greater than 10 years’ experience. All our EP staff are trained in the monitor, circulator, and scrub roles.
What types of procedures are performed in your EP program?
We perform ablation procedures for all types of supraventricular and ventricular arrhythmias, including premature ventricular contractions and idiopathic and ischemic ventricular tachycardias. We also provide comprehensive catheter-based therapy for all atrial arrhythmias, including right and left atrial flutter as well as ablation of paroxysmal and persistent atrial fibrillation (AF). In February 2024, we began using pulsed field ablation (PFA) for the treatment of AF. We use the Watchman device (Boston Scientific) for left atrial appendage closure (LAAC) and have recently started offering concomitant LAAC and AF ablation.
Additional procedures include device implantation such as permanent pacemakers and leadless pacemakers, cardiac resynchronization therapy (CRT) pacemakers and defibrillators, left bundle pacing therapy devices, central sleep apnea therapy devices, and implantable loop recorders. We also perform tilt table testing.
We currently do not perform transvenous complex lead extractions at our institution. Our complex lead extractions are usually referred to tertiary academic centers. We are addressing our regional needs, with plans to potentially resume our lead extraction program at some point.
Approximately how many ablations, device implants, and LAACs are performed each week?
Per week, we perform 15 ablations, 15 pacemaker implantations, and 6 Watchman device procedures. On an annual basis, we perform approximately 700 ablations, 800 pacemaker implantations, and 300 Watchman device procedures.
What types of EP equipment are commonly used in your lab?
Our state-of-the-art system includes the LabSystem Pro EP Recording System (Boston Scientific) for hemodynamic monitoring. We use the Rhythmia Mapping System (Boston Scientific), Farapulse PFA System (Boston Scientific), and Carto Mapping System (Johnson & Johnson MedTech). We use cardiac device therapies from Boston Scientific, Medtronic, and Abbott.
Discuss your program’s use of PFA, including patient selection, challenges, and initial experience.
Before the use of PFA, we were experiencing a 2- to 3-month backlog of cases. Thanks to this new technology, our case times have decreased from 2 to 3 hours to 1 hour. Cases no longer require the use of added equipment for temperature monitoring to prevent esophageal injury. With the decreased amount of time it takes to perform these procedures, we are now able perform 6 to 7 AF cases per day. This has quickly helped us work though the backlog of cases. The ability to do concomitant procedures has broadened our patient selection by offering patients the ability to get both procedures done at the same time. Our workflows have significantly improved, reducing our procedural duration and LA time, which allows for better resource utilization from an anesthesia and EP lab scheduling perspective. It also improves the safety profile for our patients.
Discuss your use of hybrid AF ablation.
Although we have an extraordinarily strong relationship with our surgical program and actively participate in the pre- and postoperative management of atrial arrhythmias, we do not have a specific hybrid ablation program.
How is inventory managed in your EP laboratory?
St Luke’s has a robust supply chain management department. All new requested supplies go through our value analysis process using evidence-based and data-driven decisions to ensure we have access to quality products at the right price. St Luke’s has recently opened its own distribution center, which houses some of our most often used supplies. This has helped us streamline our supplies and allow for just-in-time distribution, which avoids lapses in inventory procurement.
Tell us about your device clinic.
Currently, we are the largest device clinic in the state. Over 5000 device patients are monitored here at any given time. There are 4 to 6 clinical RNs doing in-clinic checks for providers. We also have 6 dedicated device staff doing remote monitoring for most of these patients, as well as in-office checks when needed outside a provider visit. They also process all the alerts for these devices.
Discuss your approach to remote monitoring of arrhythmias, including management of data deluge from cardiac implantable electronic devices.
We follow the Heart Rhythm Society recommendation for cardiac rhythm device follow-up, with emphasis on early detection and treatment of atrial and ventricular arrhythmias. We are transitioning to Paceart, which will allow us to manage a significantly larger bandwidth and maximize resource utilization at the same time.
Tell us what a typical day is like in your EP lab.
We start our day at 6:30 AM to ready the room for the first case. We work closely with the cardiac observation unit (COU), who completes all preprocedural care. Cases usually begin at 7:30 AM, with the goal of having the patient in the room no later than 7:45 AM. We use a minimum of 3 staff in the room, plus a certified registered nurse anesthetist for all our general anesthesia cases. We are unique from most EP labs as both our RNs and technicians rotate through the scrub, circulate, and monitor roles. We start by performing all ablations with anesthesia care, and end the day with devices and any add-on urgent inpatient cases. Post procedure, our general anesthesia cases recover in the post-anesthesia care unit and all non-anesthesia cases recover in the COU or are admitted to our telemetry floor. Our operation hours are 6:30-16:30, Monday-Friday. Staff stay to complete all cases for the day but do not get called back after leaving.
Our fantastic COU unit is responsible for all loop implants, transesophageal echocardiography (TEE), and cardioversions. This helps free up our EP lab to do more EP-specific cases.
Can you describe the extent and use of vascular closure devices at your laboratory? Tell us about your approach for same-day discharge.
We intermittently utilize Perclose (Abbott) for our arterial and venous access, but in 90% of our cases, we use a figure-of-8 stitch for large vascular access. This has helped us with hemostasis times, leading to a faster turnaround time. We employed some same-day discharge strategies during the COVID-19 pandemic, but there is a considerable number of patients who have overnight observation due to clinical status and procedural start times.
Has your lab recently undergone a national accrediting inspection?
We are currently working on pursuing EP lab accreditation through the American College of Cardiology and Intersocietal Accreditation Commission. We believe accreditation plays a role in quality and outcomes.
How do you ensure timely case starts and patient turnover?
Patients arrive to the COU for preoperative care 1 to 2 hours before scheduled times. We have worked closely with our EP physician group to ensure that all preprocedural work is completed in a timely fashion so the first case of the day can start on time. This greatly improved our start times for the first case of the day. Our EP and anesthesia staff manage all patients pre- and postprocedural transport. The rest of the staff manage room turnover, including cleaning and setting up for the next case. Case turnover is one of our program’s strong suits. From the observation unit, anesthesia team, and recovery units, we have tools in place to maximize turnover times. Outliers are identified and recurrent issues are prevented using a system-based approach. Our team is involved in making the process more efficient and also providing patients with a positive experience.
How are team members scheduled for call?
Our EP staff work Monday through Friday, with no weekend or holidays. The team is required to stay until all cases for the day are completed. Any time worked after the end of a shift is paid at 1 and a half times their pay, and all staff receive 7 hours of standby pay each day to compensate for their variable schedule. Our EP lab is very busy and often runs late, which can cause some burnout and frustration. We are currently looking at process improvements to help with work-life balance while also getting our work done to improve the health of our community.
We recently worked with our physician group and scheduling experts to create more accurate case times to ensure a more precisely scheduled day, reserving after-hour time to add-on cases. We are also looking into an innovative call program that includes a team of 4-6 staff who work 1 week and 1 week off, and are still paid for 80 hours. This team would be on call 24/7 for the week they work to help with sick calls during the day and after-hour cases in the evening. It would also open the potential for work on the weekend. We currently only perform urgent or emergent pacemaker cases utilizing the cath lab’s call team on weekends. We have a similar innovative call team in the cath lab that has worked well to decrease call burden and increase staff satisfaction and work-life balance.
Do you have flexible or multiple shifts? How do you handle slow periods?
We use a combination of 8- and 9-hour shifts. Our EP lab rarely has down time, and when that happens, staff usually leave early. Other down time is filled with stocking and cleaning rooms. Staff also use this time for education.
How are vendor visits managed?
We have a great working relationship with all our vendors. Our vendors are all credentialed through symplr. We send calendar invites in Outlook for known vendor-specific cases.
What are the best features of your EP laboratory’s layout or design?
As with all EP labs, space utilization is crucial. The layout of our rooms was conceived to maximize patient flow and the mobility of our different mapping and ablation systems. This is critical, especially in our biplane room where space is tight. Our mapping systems are mobile, so we are able to utilize them in different rooms as needed.
What quality control measures are practiced?
We are currently working on a system-wide performance improvement initiative to look at venous and arterial access management. This includes streamlining policies, postoperative orders, and postprocedural care of the patient to improve patient experience and minimize complications.
What works well in your lab for onboarding new team members?
We have a detailed and well-delineated onboarding system for new staff. They only move on within the progression when they have demonstrated proficiency. We tailor the training to each new member and have no set time frame for our orientation process. We incorporate on-the-job training with the use of preceptors and peer teaching. Our physicians are helpful in mentoring and teaching staff to grow more comfortable in the lab. We also receive help from our vendors, who offer a wide range of educational topics. Most importantly, our system is dynamic and allows for changes as needed. We believe that education is a continual process that never stops.
Discuss the role of mid-level practitioners in your lab.
We have a strong group of advanced practice providers who are essential to the effective operation of the inpatient EP service. They actively participate in pre- and postoperative patient assessment. They also perform implantation and removal of cardiac monitors as well as tilt table testing.
Share a memorable case from your EP lab and how it was addressed.
We recently treated a patient with a severe adverse reaction to a neuromuscular block reversal agent. The patient abruptly became asystolic during the last phase of a LAAC device implant. We were all impressed by our quick and coordinated multidisciplinary team approach, including cardiopulmonary resuscitation and temporary transcutaneous and transvenous pacing. The patient eventually transferred out of the lab without any residual clinical issues from the event. The patient was discharged home the next day with no residual effects and discontinued anticoagulation 45 days after the implant.
Discuss your program’s approach to conduction system pacing.
We perform both left bundle and His bundle pacing. The technique is based on physician discretion and used in those with expected high ventricular pacing needs. Minimizing right ventricular pacing in cardiomyopathy is always high on our list of priorities.
Tell us about your primary approach for LAAC.
We perform only Watchman device implants in our program. Our process involves general anesthesia and TEE guidance by a member of our cardiology team. Intracardiac echocardiography (ICE) is a valuable tool, specifically 4-dimensional ICE, and we are in the process of progressively implementing it into our LAAC program. Candidacy for implants is guided by current clinical guidance. We are also involved in 2 active clinical research trials at our institution.
Discuss your program’s approach to lifestyle modification for the reduction of AF.
We have a well-established AF program that assess patients pre- and post-ablation. Lifestyle modification is crucial for the successful outcomes of our AF patients. We work closely with the Intensive Lifestyle Medicine Program within St Luke’s. We also have a close relationship with our sleep medicine colleagues to maximize the diagnosis and treatment of sleep apnea, which is a highly prevalent problem in our population.
Discuss your approach to treatment of AF in patients with heart failure.
We are very proactive, including use of early catheter-based ablation, when dealing with rhythm control in patients with an underlying cardiomyopathy given the survival benefits demonstrated in this population.
Discuss your approach to arrhythmia management in athletes.
Robyn Bryde, MD, recently joined the Hypertrophic Cardiomyopathy and Sports Cardiology Clinic at St Luke’s. She is the region’s only formally trained sports cardiologist and she also has advanced training in the management of hypertrophic cardiomyopathy. Our EP team works very closely with her in this population of patients.
How does your EP laboratory handle radiation protection for physicians and staff?
The radiation safety department at St Luke’s helps monitor radiation exposure for staff and provides education on how to decrease exposure to staff and patients. Staff also complete a yearly module on radiation safety. We try to minimize the use of fluoroscopy whenever possible by using other means such as ICE and mapping catheters. All our x-ray systems are state-of-the art and undergo preventive maintenance by both the vendor and our health technology management team. We record all radiation time and dosages in our charting and have a protocol with our radiation safety department for patient monitoring if excessive doses are used.
What are some of the dominant trends you see emerging in the practice of EP?
We believe the safety and efficiency of PFA will soon be used in the treatment of ventricular arrhythmias, making these procedures more streamlined and more frequently utilized. We also believe more advanced substrate modification techniques, including high-density mapping, will allow for a more tailored approach to persistent and permanent AF, and soon become the standard of care.
How do you use digital health and wearable technologies in your treatment strategies?
We are improving AF detection and awareness through use of wearable devices. Wearable technologies have improved early detection of AF and allowed for better treatment allocation, including anticoagulation. Along with implantable cardiac monitors, wearable devices will become the standard of care for arrhythmia detection and outcomes assessment post ablation.
Tell us about your EP program’s involvement in clinical research.
To name a few, we have participated in ADVENT, ADVANTAGE, SMILE-AF, SIMPLAAFY, and LAAOS-4.
What is considered historic about your EP program or hospital? Has your program or hospital recently experienced any “firsts”?
We were the first EP program in the state. Dr Marks was the first female electrophysiologist in the state, and the only one offering catheter ablation in pediatric patients in the state. We were the first to implant a LAAC device in Idaho, as well as the first to offer PFA in the Pacific Northwest, including during clinical trials and following FDA approval. We were also the first in the state to implant a phrenic nerve stimulator for treatment of central sleep apnea. Most recently, we were the first in the state to perform concomitant AF ablation and LAAC device implantation.
Describe your city or general regional area. How is it unique?
Boise is the capital and largest city in Idaho, known for its vibrant downtown, outdoor recreation, and extensive greenbelt trails along the Boise River. Nestled in the Treasure Valley and surrounded by mountains, if offers a mix of urban amenities and natural beauty. The city is home to Boise State University and the famous blue football turf. Boise and the surrounding Treasure Valley are consistently rated as one of the best places to live in the United States and one of the fastest growing areas in the nation. St Luke’s Health System is one of the biggest employers in the state, with hospitals located throughout Southwest and Southcentral Idaho.
What specific challenges does your hospital face given its unique geographic service area?
A significant amount of growth to the area has increased the demand for cardiac care throughout the Treasure Valley region, and led St Luke’s Health System to rapidly expand and provide this care. Our strategy at St Luke’s is to not only improve and expand care, but also maintain high-quality care and clinical outcomes.
Another challenge is the geography of the state and treating our rural patient population. Our physicians travel to outreach clinics in some of the more rural areas to provide care. This aligns with the holistic vision of St Luke’s mission to improve the health of the communities it serves by providing high-quality, patient-centered care.
Please tell our readers what you consider special about your EP lab and staff.
St Luke’s EP team has an unwavering commitment to teamwork and an incredible work ethic. They support each other like a family, always stepping up to help, problem solve, and push each other to do better. The team’s dedication to top-notch patient care and willingness to go the extra mile make a real impact on patient care every day.
