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Team-Based Approach to Atrial Fibrillation Ablation: Experience From the Heart Rhythm Clinic of Western Australia
In this article, we speak with Professor Rukshen Weerasooriya, BMedSc (hons), MBBS, FRACP, FCSANZ, GAICD, from the Heart Rhythm Clinic of Western Australia (WA), a private secondary, tertiary, and quaternary service for arrhythmia patients in Perth. The main clinical and research focus is atrial fibrillation (AF) intervention, including catheter and surgical ablation.
When was the clinic established?
I established the clinic in September 2003 after my fellowship at the Hôpital Cardiologique du Haut-Lévêque in Bordeaux-Pessac, France. During my fellowship, I was fortunate to train under four exceptionally gifted, kind, and generous teachers: Professors Michel Haïssaguerre, Pierre Jaïs, Méleze Hocini, and Dipen Shah. Other fellows at the time were instrumental as well, including Professors Laurent Macle (Montreal), Christophe Scavee (Brussels), Prash Sanders (Adelaide), and Hsu Li-Fern (Singapore). From 2001 to 2003, there was palpable excitement every day in the cath lab, and the team in Bordeaux was constantly innovating and publishing new findings. It was clear that AF ablation was destined to continue to evolve and grow. The Heart Rhythm Clinic of WA was established as one of the first highly specialized private arrhythmia clinics of its kind in Australia. The clinic is now located within Hollywood Private Hospital, which is the largest hospital precinct and largest private hospital in Western Australia.
What is the prevalence of AF in your region? How many AF ablation procedures does the Heart Rhythm Clinic of WA perform annually?
As with all populations in industrialized countries, we have seen an increased prevalence of AF in Western Australia. In fact, between 1995 to 2010, incident AF as a principal diagnosis increased annually by 1.2 percent.1 As a single-operator practice, we are limited in the total number of AF ablations that we can perform, but as of early December 2021, we have performed 314 AF ablation procedures thus far.
Tell us about staff structure and different specialties that are involved in care at the AF clinic.
Our clinic has 2 full-time front desk patient care managers (Alyssa Marshall and Marlies Garnham) who act as the first point of contact for our patients. Alyssa and Marlies are highly experienced and have a deep understanding of the patient journey. They manage all patient appointments, tests, and procedural bookings. Aruni Weerasooriya is our dedicated EP technician; she is assisted in the cath lab by Dr. Wei Chua. We work with 4 anesthetists who have an excellent understanding of the workflow of AF ablation as well as of the risks and potential complications, such as cardiac tamponade, stroke, and esophageal injury. The cath lab team at Hollywood Private Hospital has been performing AF ablations since 2003.
Describe your comprehensive approach to the management of atrial fibrillation, including use of team-based care pathways and standardized protocols for AF.
We have adopted a comprehensive approach to AF management at the Heart Rhythm Clinic of WA. The key pillars are: (1) Universal access to cardiac rehabilitation; (2) Investigation for sleep apnea, with active management of diagnosed obstructive sleep apnea; (3) Aggressive management of blood pressure in patients with hypertension; and (4) Weight management, including referral to endocrinology or bariatric surgery for advanced treatment in some cases.
What is the treatment pathway for patients presenting to urgent care, ED, or primary care physicians? How do you ensure timely access to care?
We receive most of our referrals from family physicians, as patients with newly diagnosed AF in Australia are generally not admitted to the hospital from the emergency department. We see new AF patients within 2 weeks via a dedicated fast-track clinic.
What are the considerations for a successful team-based approach to AF ablation?
Catheter ablation of AF is a highly complex and risk-laden procedure. The key to a safe, effective, and successful AF ablation program is having the collective effort of a dedicated team. During fellowship, I was taught to consider AF ablation as a form of “closed open-heart” surgery. Successful AF ablation should improve quality of life in patients. Important considerations should be made in terms of case selection, informed consent, management of risk, and use of checklists, protocols, and contingency planning in case of complications.
Informed consent is critical. At the time of consultation, we provide patients with comprehensive education, including an informational booklet that thoroughly describes the procedure as well as links to patient-centric websites. Following the procedure, all patients are provided with a folder containing printouts of three-dimensional mapping images from their procedure, a complete printed procedure report, and a USB flash drive with cardiac mapping videos from their procedure. All patients are offered comprehensive cardiac rehabilitation and participate in a post-discharge counseling session with the ward nurse, who outlines expectations during the recovery period. Our protocol dictates that patients receive standard written post-procedure instructions.
A high level of skill and knowledge is required of all team members. We achieve this with regular educational sessions for the team. Continuing education for staff is important, because AF ablation procedures are highly dependent on advanced technologies that constantly improve and evolve. A sophisticated level of expertise for all team members means that anyone in the lab has the knowledge to observe if something is not right, and that each team member feels comfortable communicating feedback to the EP before, during, and after a case. We are fortunate to not have much staff turnover on our team, so many members of our team have been working together for well over 10 years. In addition, several of the anesthetists are friends from medical school and provide tailored ventilation regimens when ablating tricky areas. Jet ventilation is too expensive for use in AF ablation procedures in Australia, so we use a simpler version by intermittently altering the ventilation rate and judicious use of prolonged apneas.
Video 1. Prof. Rukshen Weerasooriya leads a timeout during an atrial fibrillation ablation at Hollywood Private Hospital.
Tell us more about your approach to risk management and surgical timeout.
Dr. Atul Gawande’s The Checklist Manifesto really helped me crystalize my thinking around risk management.2 We have adopted many of these processes in our workflow, particularly with regard to the use of checklists and closed-loop communication during procedures. Gawande’s other works are also helpful for anyone interested in process improvement and team dynamics during complex procedures such as AF ablation.3,4 We routinely perform a timeout before each AF ablation procedure. This includes the following:
- Identification of patient, history, allergies, and clinical information;
- Identification of team members and roles;
- Pre-specification of the leading individual in case of tamponade or other serious complication;
- Left atrial anatomical discussion, including location of the esophagus, left atrial appendage morphology, septal morphology, anomalous veins, left atrial pouches;
- Anticoagulation plan;
- Ablation plan and strategy.
What research is the clinic involved in?
We are proud to have been involved in some important clinical studies, including ADVICE, STAR AF II, TOUCH AF, DECAAF II, and most recently, OCEAN and STAR AF III. The technological landscape in EP has changed dramatically in the past 20 years, so we try to stay engaged in clinical research to both contribute knowledge and keep ourselves appraised of the latest developments. This has been very beneficial to our program and our patients.
Tell us about your collaborations with other EPs.
I maintain close contact with the team in Bordeaux and try to visit at least once per year. I am also a visiting scientist at the LIRYC - Electrophysiology and Heart Modeling Institute in Bordeaux-Pessac, and appreciate the opportunity to interact with the scientists and clinicians there on cutting-edge research projects. I also visit Montreal Heart Institute and Cliniques Universitaires Saint-Luc in Brussels from time to time to gain new perspectives. We also host several distinguished overseas EP colleagues in our lab.
Why is a team-based approach to AF ablation important? What are the key components to a successful heart rhythm clinic?
A team-based approach helps keep patients calm, procedures running more smoothly, and complication rates low. A successful AF ablation program requires a dedicated team that works well together. Knowledge and education are key, and participation in clinical research greatly assists the entire team in remaining curious and knowledgeable. Tools and techniques for AF ablation will continue to be improved and optimized over time, so that more patients can be safely and effectively treated. The Heart Rhythm Clinic of WA will continue to actively contribute towards this goal. I am fortunate to be surrounded by a great team as well as some of the giants in this field.
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Disclosures: Prof. Weerasooriya has no conflicts of interest to report regarding the content herein.
References
1. Briffa T, Hung J, Knuiman N, et al. Trends in incidence and prevalence of hospitalization for atrial fibrillation and associated mortality in Western Australia, 1995-2010. Int J Cardiol. 2016;208:19-25. doi: 10.1016/j.ijcard.2016.01.196
2. Gawande A. The Checklist Manifesto: How to Get Things Right. Picador; 2010.
3. Gawande A. Better: A Surgeon’s Notes on Performance. Picador; 2007.
4. Gawande A. Complications: A Surgeon’s Notes on an Imperfect Science. Picador; 2002.
