Lessons Learned Establishing a Hybrid Atrial Fibrillation Ablation Service

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EP LAB DIGEST. 2024;24(9):16-17.

Rukshen Weerasooriya, MBBS (WA), BMEDSC (HONS), FRACP, FCSANZ, GAICD
Heart Rhythm Clinic, Hollywood Private Hospital, Ramsay Health Care, The University of Western Australia, Nedlands, Western Australia

Background 
Hollywood Private Hospital is the largest private hospital campus in Australia; it is also one of the highest volume and longest established atrial fibrillation (AF) ablation providers ‘down under.’ The cardiothoracic (CT) surgical service was established in 2021 and has been well supported by the local cardiology community, resulting in the completion of 1000 cases with excellent safety and quality metrics. Having CT surgery onsite has also allowed for the development of a hybrid ablation program, now designated as a training center of excellence for Convergent ablation. We now collaborate with AtriCure to deliver the EPiC Convergent Skills Building training program for centers commencing Convergent hybrid ablation in Australia, New Zealand, and Asia. In this article, we discuss our experience establishing a hybrid ablation service for the treatment of AF, including ideal patients for the procedure, best practices, and troubleshooting.

Why Hybrid?
Catheter ablation of paroxysmal AF in a structurally normal heart is generally straightforward and now recommended earlier in the natural history than ever before. The latest guidelines list AF ablation as a class Ia indication for patients with symptomatic paroxysmal AF.1 In some instances, catheter ablation of paroxysmal AF is being performed as a first-line treatment, including at our center. 

Catheter ablation of persistent AF remains somewhat challenging, and catheter ablation of long-standing persistent AF is associated with low success rates despite numerous efforts to better define non-pulmonary vein targets. 

The CONVERGE study demonstrated the benefit of the thoracoscopic hybrid approach in a randomized control trial.2 This approach had already been widely applied in North America and Europe, but not in Australia, New Zealand, or any Asian country. We were keen to offer this treatment strategy, as part of a mix of available interventions, to our local patients. 

Our initial exposure to hybrid ablation was in March 2006. Our motivation to start Convergent procedures was due to the fact that, after 12 very active years of catheter ablation of AF, we had a cohort of failed pulmonary vein isolation cases. In some cases, patients enrolled in the STAR AF II and DECAAF II trials at our center remained in persistent AF following multiple ablation attempts. A hybrid ablation offered a ‘bailout’ rhythm control solution to these highly symptomatic patients.

Keys to Establishing a Hybrid AF Ablation Service
1. Establish an excellent working relationship between the cardiac electrophysiology (EP) and CT teams. These 2 groups typically do not often work together except for emergency open-heart repair in cases of cardiac tamponade or other emergencies in the EP laboratory. 

2. Create formal training. AtriCure mandated vigorous assessment of the operators and center, as well as face-to-face training with EP and CT at 2 high-volume centers in the United States and a lifelike simulation laboratory at the Columbia School of Medicine alongside highly experienced proctors. This diligent training was a key factor in our success.

3. Implement a whole hospital approach. Presenting the concept at grand rounds and educating colleagues in the operating rooms (ORs), intensive care unit, emergency department, cardiac catheterization laboratory, cardiology, cardiology rehabilitation, and CT wards was important to take everyone on the journey with us. We found that this level of buy-in resulted in a smooth start to the program and a high level of pride.

4. Develop patient education. We developed patient education materials for our center that explain to patients that part 2 is performed 3 months following part 1. It is critical that patients make an informed decision regarding hybrid AF treatment. 

5. Get ahead of pericarditis. We learned that pericarditis is a bigger issue following surgical hybrid compared to catheter ablation. We worked with the cardiac anesthetists to develop a standard 4-week protocol with pre-treatment commencing in the OR, and have found that pain following surgery is now a minor issue.

6. Keep it simple to start. We saved the more difficult cases, such as patients with a larger left atrium or long-standing persistent AF, for later in our experience. We completed 20 fairly simple PAF cases before tackling the more difficult cases.

7. Provide pre- and post-procedure rehabilitation. We are fortunate to have an excellent cardiac rehabilitation service, and all patients interact with the service before and after procedures. Management of cardiac risk factors, weight reduction, cardiorespiratory fitness, and sleep apnea are all important aspects of this service.

Summary 
Looking back on 3 years, the introduction of a hybrid ablation service at our center has been extremely satisfying. Professionally, working in a heart team model with CT surgeons is beneficial as we gain different perspectives from each other. Our hospital management celebrates that we are able to provide the most advanced AF treatments to patients. Finally, with the availability of hybrid ablation, we are much less likely to decline ablation to patients. 
 
Disclosure: Dr Weerasooriya has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest and report no conflicts of interest regarding the content herein. 

References

1. Tzeis S, Gerstenfeld EP, Kalman J, et al. European Heart Rhythm Association/Heart Rhythm Society/Asia Pacific Heart Rhythm Society/Latin American Heart Rhythm Society expert consensus statement on catheter and surgical ablation of atrial fibrillation. Europace. 2024;26(4):euae043. doi:10.1093/europace/euae043

2. DeLurgio DB, Crossen KJ, Gill J, et al. Hybrid convergent procedure for the treatment of persistent and long-standing persistent atrial fibrillation: results of CONVERGE clinical trial. Circ Arrhythm Electrophysiol. 2020;13:e009288. doi:10.1161/CIRCEP.120.009288