Integrated Approach to Treating Atrial Fibrillation

A Closer Look Within Two Progressive AF Programs: Vanderbilt Heart and Vascular Institute and Sentara Heart Hospital

In this interview, we speak with electrophysiologists and cardiovascular surgeons from two heart centers that have evolved their atrial fibrillation (AF) programs from silos of AF expertise to highly integrated AF teams delivering a new standard for comprehensive AF care.    

First we will hear from the EP/CV surgeon team at the rapidly expanding AF Clinic at the Vanderbilt Heart and Vascular Institute in Nashville, Tennessee: 

What is the size of your EP lab facility and number of staff members? 

Dr. Patrick Whalen: We will have three labs and a hybrid lab in a couple of months. Currently there are two EP labs, with a third lab that is used as a hybrid lab and for overflow EP cases. 

Approximately how many AF patients are you typically seeing per month in the AF center?

Dr. Christopher R. Ellis: It’s difficult to estimate since we are actually over capacity in our AF clinics, so a lot of the AF consults and patients spill over into our other clinics. We do have half days twice a week, which totals eight clinics, with typically 10 patients each clinic. Therefore, I would imagine we see somewhere between 80 and 100 patients per month. 

Whalen: Yes, the AF patients are seen by general cardiologists, by our EP partners that don’t do AF ablation, and by the AF operators. There are four of us who have AF clinic, so essentially two full days a week are dedicated to the AF clinic; the patients who have more complex needs get referred into the AF clinic selectively for left atrial appendage (LAA) management, complex ablation, and hybrid ablation. To put a number on how many patients are seen for AF or in the AF group is a bit of a hard thing to quantify. However, we probably do about 450 AF ablations a year. 

How many CV surgeons are involved with the AF center, and are there any shared staff supporting this?   

Dr. Steven Hoff: There are two surgeons that have been actively involved in arrhythmia surgery for years. Aside from myself is my partner Dr. Michael Petracek, who has been an active arrhythmia surgeon for 25 years and has an extensive history in predominately concomitant ablation with mitral valve surgery. I primarily staff the AF clinic. We see patients one afternoon a week.  Drs. Whalen and Ellis alternate participating in that clinic. We have a nurse practitioner that works in that clinic with us, in addition to other roles in the EP service.

Describe the range of AF procedures being offered to patients at your institution.

Ellis: It runs the entire spectrum, from echo-guided and straight cardioversions, pacemaker implants, and AV node ablations, to RF catheter ablations for paroxysmal AF and some persistent AF, cryoballoon ablations for paroxysmal AF, and hybrid AF ablations for longstanding persistent AF or for AF patients in which we want to manage the LAA by surgical ligation. For patients that have failed prior catheter ablation attempts, we’ll perform hybrid AF ablation. Some patients will have standalone surgical maze or standalone thorascopic ablation by Dr. Hoff. We’re starting our LAA ligation program and becoming involved in the AMPLATZER^™ cardiac plug study (St. Jude Medical), and we’re also starting to use the LARIAT^® suture delivery device (SentreHEART, Inc.). 

Hoff: On the surgery side, we’re busiest right now with the hybrid AF practice, but we also do quite a bit of concomitant ablation at the time of coronary surgery or valve surgery. We’ve also started doing hybrid ablation for ventricular tachycardia as well. We’ve been involved with the AF program for about four years now, and we have multiple companies and devices that we work with. We started out predominately using a simultaneous ablation procedure, where we perform a minimally invasive epicardial surgical ablation followed by an endocardial ablation in the same setting of the hybrid OR. More recently we’ve been involved in staged applications for that particular procedure as well as some additional techniques.

Next, we will hear from the multispecialty AF team from Sentara Heart Hospital in Norfolk, Virginia: 

What is the size of your EP lab facility and number of staff members? 

Dr. Jonathan Philpott, Director of the Sentara Atrial Fibrillation Surgery Program: Right now we have one hybrid-qualified surgeon and four concomitant ablation-qualified surgeons. We will have all surgeons fully certified in the upcoming month and all will be ablation qualified. 

Dr. Robert C. Bernstein, Electrophysiologist from Sentara Cardiology Specialists: We currently have three labs and a hybrid OR; a fourth lab will be built next year. There are five interventional EPs and four device-implanting physicians.

How many cardiovascular surgeons are involved in AF care, and are there any shared staff supporting this?

Bernstein: One is actively engaged in center and program development, three are involved in lead work, and all the surgeons perform some variation of concomitant AF surgery.

Our surgeon is involved in ventricular tachycardia (VT) ablations, device complication management, extractions, hybrid and Cox procedures, as well as participates in and supports new technologies and consultations.

Describe the range of AF procedures offered to patients at Sentara.

Philpott: We offer the full spectrum of procedures, including endocardial ablation, repeat endocardial ablation, hybrid ablation using the AtriCure system and following the DEEP protocol lesion set, which mimics the Cox Maze lesion pattern, concomitant Cox Maze IV, and standalone Cox Maze IV.

Bernstein: Yes, we offer endocardial-based radiofrequency, laser, and cryoballoon ablations. We also offer hybrid as single and split procedures, as well as Cox 4 standalone and as concomitant treatment.

In this next section, we’ll highlight some of the key aspects of how these collaborative AF teams work together to provide a wider range of treatment options, how the teams collaborate on treatment options, and the impact of their collaboration on patient outcomes and referral volumes.    

How is your AF team working together to provide more comprehensive treatment options?

Whalen: I think the best example of that is how the AF clinic runs. The AF clinic is staffed by an AF ablationist (an electrophysiologist), a cardiac surgeon who does arrhythmia surgery, and a nurse practitioner. It works in close conjunction with our device clinic, because so many of these patients have either implantable loop recorders or pacing devices. When patients come in, they are seen by both an electrophysiologist and a surgeon, and together we come up with a comprehensive plan. Because the spectrum is so wide, this may be as simple as coumadin for chronic AF all the way to combined endocardial and epicardial ablation for surgery and catheter approaches. The clinic is the constant and it’s able to meet all the needs of the patients. 

Hoff: The practice here in cardiology and cardiac surgery is extremely converged, and that was the brainchild of our former chairman. It started back when Dr. Douglas Vaughan was the chair of cardiovascular medicine and Dr. John Byrne had just been recruited to be the chairman of cardiac surgery. They formed the Vanderbilt Heart and Vascular Institute (VHVI), and developed a framework for a tremendously collegial and converged practice across cardiology and cardiac surgery and its subspecialties. John used to describe himself and the cardiac surgeons — and the cardiologists as well — as all cardiologists, just with different tools. So that is the sort of background that we have for the practice itself.  So within that context, when I got recruited to come here six years ago, one of the things that I was interested in doing was expanding my interest in arrhythmia surgery; I met the electrophysiologist here, who had like-minded ideas about setting up a collaborative center for AF, which we did at that point with the enthusiastic support of the leadership at VHVI. So it started out with this idea that we’re going to learn each other’s procedures, learn each other’s workflows, understand the language that each other speaks, and be able to collaboratively work for the betterment of the patients and not so much worry about who’s going to steal what case from somebody else. The embodiment of that effort, the center for atrial fibrillation, came about a year later when we started a multi-disciplinary AF clinic. We offered a kind of “one-stop shopping” where patients and their doctors could sit in the same room and talk about treatment options. We went out into the community and talked about our approach for treating atrial fibrillation — usually a surgeon and electrophysiologist would split the talk — and patients could really see how we worked together for their betterment. It became a wildly successful concept.

Bernstein: Patients without a clearly defined path now have the advantage of seeing an EP physician and an arrhythmia surgeon in consultation, and we work together on the best approach for each individual patient. Everything is very patient focused and collaborative. Two heads are always better than one. I feel this improves quality outcomes for our patients and ensures they get the AF management that is most appropriate for them. Patients cannot believe that not only do their physicians communicate about their care, but that we often end up recommending a third option that may not have been entertained originally. It is a very selfless collaborative.

Philpott: The real difference is the change in persistent and longstanding persistent AF management (non PAF). For PAF, endocardial ablation remains the standard of care for trigger suppression. However, when that fails, or when more than trigger suppression is needed, the team is moving toward earlier consideration of much more robust lesion sets like the hybrid ablation. For those patients who are felt to be extremely difficult and high risk for hybrid ablation, our standalone Cox Maze IV platform has proven to be a viable and highly celebrated option with proven excellent outcomes, great safety, and a highly satisfied group of patients. This armamentarium of options for all aspects of AF has been a major advance here in Norfolk. It’s a much smarter way of thinking about AF, and it gives patients much more accurate treatment. 

How is that the same or different from a typical EP program or even your own program three years ago?

Ellis: We now have a lot closer of a relationship with cardiac surgery, and after our experience in the last three years doing hybrid cases, we know who is a good patient for that procedure and we are more quickly able to triage them into the right treatment category. 

Whalen: Because we work so closely with our surgeons, it’s not uncommon for someone to be referred in for surgery and for our surgeon to say to a patient “you know, catheter ablation would work just fine for you.” Dr. Hoff has a better understanding of what we do, and we have a better understanding of how he approaches things. We refer to him as our “senior EP fellow in training”!

Discuss the changing provider model in healthcare today, and if you see this impacting how AF treatments are approached.

Hoff: That’s a great question. With healthcare reform as it stands, a lot of what is going to happen will be value based and not thinking in the short term. It’s really going to be long-term, if not lifelong, concepts of care, and so it fits well into our center’s approach when we think about the primary indication that we have for the hybrid ablation procedures that we’ve done who have had non-paroxysmal AF. The strengths of one (procedure) are the weaknesses of the other, and vice versa. So, we reasoned that if we could put them together, perhaps we would have a better chance of curing these patients long term, and this is precisely what we’ve seen. So I think in the model of healthcare reform, where you’re talking about the value-based procedures and long-term impacts in patient care, this procedure (hybrid) may be very valuable in potentially offering patients a lifetime off of antiarrhythmics and anticoagulation without the attendant risks that go along with a lifetime of AF.  

Philpott: AF has been severely limited by teams focusing on solving the problem entirely within their own specialty. This has been a mistake. Non-PAF is a difficult disease to tackle. The only way to truly get great results is to bring all of the talents into one team where everyone working together can focus their strengths to channel therapies that are not possible alone. The truth is that patients want this. They want to go to an institution where they are given a report that says for their type of AF, age, and LA size, of the four different treatment options their 1-, 3-, and 5-year success rates are A, B, and C; also, their complication rates and recovery times are D, E, and F. That is good medicine and equipoise in the treatment. The team approach also then allows performance improvement activity to drill down into AF subtypes or patient demographics to see what therapy works best for each patient. 

Bernstein: Coming together as a larger entity also allows more focus in deciding capital expenditures and identifying cost savings and efficiencies in the system.

How do you see the multi-specialty AF center approach benefiting the hospital, patients, and EP/cardiac surgery service lines?    

Hoff: Certainly what we’ve seen when we talk to other groups about integrated care is that there is plenty of work for everybody, and nobody should be afraid about it negatively impacting one another. In fact, what we’ve seen is that it has ramped up the volume for both surgery and EP. From a hospital standpoint, the reimbursement for these procedures tends to be really good and the complication rates are very low, so the risk/benefit ratio is quite positive, and this is just one of many ways that these sorts of collaborative programs can build reputations for the institution in the local marketplace. So we’ve used efforts like this to go out and market not only disease-based methods of care, but also a way of marketing the institution. In that way I think we seem to be very valuable not only to the individual practitioners involved, but to the hospital and the institution in general.

What is the feedback from patients on the AF center approach? Do you find that they are seeking out your program for this reason?  

Ellis: Our program is getting a lot more self-referrals than it would have years ago, largely because of our efforts to communicate in the community and educate patients, and partly because of outcomes. One of the things that I think benefits us in terms of having a robust hybrid ablation program is that it takes chronic AF ablation cases off my schedule. Honestly, that helps us electrophysiologists, because if you get really good at streamlining your paroxysmal AF cases, it’s going to improve your outcome. You know that you’re in for a long day when you have two chronic AF ablations on your calendar. Whether it’s a same-day or split or staged hybrid ablation, if you know that you could get two-thirds of that work done operatively while you’re working on a paroxysmal case, and then come back in and finish up a hybrid case, it makes life a lot easier as an AF ablator. Personally, I would not want to fill my calendar with chronic AF ablation cases. However, when we do hybrid cases, we’re getting really good outcomes documented by loop recorders. Patients are not having strokes when they have their appendage ligated or when they’re coming off anticoagulants. For the most part, they’re probably the most enjoyable people to see back, because as a whole, that group is doing really well. 

Whalen: I think patients really like being able to make one visit to see both of the physicians who were involved in their care in the same room, having the discussion together about what their options are. They have communication between their doctors that their care is important to them, and that we’re really thinking about every option.  

Philpott: As we get better at tackling it, we are seeing our volumes increasing in an exponential fashion. Secondly, as the news of our outcomes has gotten out, we have begun to get referrals from outside our region. Our ultimate goal is to become a national referral center for complex AF. 

Do you see a benefit in forming a network of like-minded, integrated AF centers coming together in the future?    

Hoff: I think it will only help strengthen that sort of informal situation that already exists and would create a lot of advantages, including the ability to put together clinical trials and learn from each other about what they do best, thereby improving our own program. I believe many programs would find a tremendous benefit from this effort.

Ellis: Looking at the study that we’re involved in with AtriCure (DEEP AF), there are a few centers around the world — but not many in the U.S. — that are efficient at this. We would need to be training other centers on how to approach this and get off the ground, and eventually you would have a network of centers that have internally created a program. Our program was in its infancy when I started here, and I think it took an interested and motivated surgeon, as well as EPs that wanted to think outside the box a little too. We had to work outside our comfort zone, and still do in terms of the hybrid OR room that we use. It’s not our normal EP lab, and there are limitations to this. 

Whalen: One of the biggest challenges is that the surgical skills required to do this are not necessarily widespread.  You need to have a surgeon with a skillset that is of a certain caliber, and you need someone with a personality that can take criticism, because at the end of their surgery, someone else will be going in after them and saying “well, you missed a spot here and there — this is what we found when we looked.” You also need to have electrophysiologists willing to give up control over the patients and be willing to lean on the surgeons’ tools. Essentially, you need to have the sandbox skills to coexist in the same environment. I think that in the end it’s in everybody’s best interest, and most importantly in the patient’s best interest. 

Are integrated AF programs on the leading edge of what payers and patients are looking for?    

Ellis: I would hope so, because as we’ve created this vision and it’s evolved over these last three or four years, our outcomes have improved as a whole. You have to look pretty deep to tell if it’s cost-effective medicine or not, I don’t know the answer to that. But in terms of quality outcomes, safety, stroke prevention, and quality of life for patients, it’s certainly heading in the right direction. If you’re going to take dabigatran for 20 years at a 2% annual rate of bleed, how does that compare to the success of a single hybrid AF surgery with appendage ligation and a loop recorder? This is what payers care about — cost-effectiveness and quality. However, quality in medicine is very hard to define, and it’s difficult to properly incentivize quality. 

Bernstein: This approach provides a platform to streamline the evaluation, treatment, and follow-up process and gives a better experience to our patients — including accessibility of physicians, clinic space, imaging, labs/OR, midlevels, noninvasive monitoring, and device clinic — all under one roof. Patients have a single contact for all of their questions. Also, quality initiatives, research, marketing, and outreach education can be carried out in more uniform and efficient manner.

Philpott: The team approach for AF was really only the beginning. It opened the door for collaboration on a whole host of initiatives such as laser lead extraction, thorascopic LV lead implants, standalone LAA closure therapies (both endovascular and minimally invasive surgical with neurology joining the team), and hybrid VT ablation. Tomorrow morning we have a hybrid VT ablation that we will perform in our hybrid EP OR. The patient has been ablated multiple times in the past, including an epicardial catheter-based ablation, which have all failed. We will perform simultaneous epicardial and endocardial mapping and ablation, followed by CABG. This kind of option for the patient was never an option several years ago, but is possible now due to the collaborative work we put together for treating patients with AF. These are the kinds of unanticipated rewards that the team approach for AF has resulted in.  

Disclosures: Dr. Ellis reports consultancy with TYRX, GLG, and Navigant; expert testimony for London Amburn, Navigant; honoraria from TYRX, OppenheimerFunds, Wells Fargo; payment for development of educational presentations including service on speakers’ bureaus from Boehringer Ingelheim; stock/stock options with Johnson and Johnson, Bristol-Myers Squibb, Dexcom; travel/accommodations expenses covered or reimbursed by TYRX, Boehringer Ingelheim; and grants/grants pending to his institution from Boehringer Ingelheim. Dr. Hoff reports having travel/accommodations expenses covered or reimbursed by AtriCure. Dr. Whalen has no conflict of interests to report. Dr. Philpott reports money to his institution as a consultant, FDA testimony/consultant, grants/grants pending (development of integrated AF DB development to track surgical and catheter-based follow-up for AF), payment for development of educational presentations including service on speakers’ bureaus (Maze Certification Courses), and travel/accommodations expenses covered or reimbursed (consulting or certification courses) for AtriCure. Dr. Bernstein has no conflict of interests to report.