Watch Dr. Elias Zias host a roundtable discussion, with Drs. Okum, O'Keefe and Philpott, that reviews the AATS guidelines for the concomitant treatment of atrial fibrillation during cardiac surgery.
For the hearing impaired members of the AFibSurgeons.org community, we have provided a written transcript below:
Dr. Zias: Hello, I am Elias Zias. I am a cardiac surgeon at NYU-Langone in New York City. Thank you for joining us in this AATS Mini Theater presentation. Myself along with three colleagues will try to present some of the information to help you bridge the gap to concomitant treatment of atrial fibrillation in cardiac surgery.
I will be joined by Dr. Eric Okum and Cathryn O'Keefe, both from TriHealth System in Cincinnati, Ohio, and Dr. Jonathan Philpott from Sentara Heart Hospital in Norfolk, Virginia. We are going to review some of the evidence and society guidelines for concomitant treatment of atrial fibrillation, review some of the current adoption levels, and go through some case studies and see how we can adapt treating atrial fibrillation in all our concomitant surgeries. We are going to review establishing an expectation for treatment of atrial fibrillation through training, measuring the adoption by operator to benchmark performance, and essentially talking of how we can integrate atrial fibrillation treatment to a group practice through a quality scoring system.
To just review all the evidence that all of you already know, since 2017, there is a consensus statement on catheter surgical ablation of atrial fibrillation that makes it a class I recommendation to treat concomitant AF in pretty much every surgery that we do, specifically and most importantly in mitral surgery, CABG, and aortic valve surgery. In a very recent publication, 2019, of Dr. McCarthy and his group from Chicago at the Journal of Thoracic and Cardiovascular Surgery, it was shown that only 38% of patients with concomitant AF in mitral valve surgery had their atrial fibrillation treated. At the same time, and this is where we have to make an effort to significantly improve adoption of treating atrial fibrillation, only 16% of non-mitral valve surgery had concomitant treatment of surgical ablation. With this, I would like to invite Dr. Okum and Dr. O’Keefe to go through our first case study.
Dr. Okum: Welcome to AATS mini theater online. I’m Dr. Jeff Okum. I’m a cardiac surgeon in Cincinnati, Ohio. I’m joined with my younger, but not so much younger, partner Dr. Kathryn O’Keefe, and we’d like to talk to you about things that we have done at TriHealth in terms of integration – integrating concomitant ablation over the last, probably, decade at this point. Our program is a one hospital program. We currently have five partners. Four of them focus on cardiac surgery, and one is on thoracic. Our history of atrial fibrillation surgery goes back many years. We happen to be geography in a very close place with AtriCure in industry, and we – our group has participated in many ablation technology researches and concomitant clinical trials. As a result, the senior partners have adopted concomitant ablation early, and this has been continued throughout our last decade and expanded into hiring – expanded as we’ve hired younger surgeons.
We basically feel that all patients that have any documented atrial fibrillation, whether it’s paroxysmal, persistent, or long-standing persistent – long-standing persistent should undergo ablation at the time of. We looked at our own data and over 90% of patients with atrial fibrillation as a diagnosis at the time of surgery have some form of ablation. We also have done many things as a group together to develop some non-atriotomy techniques, and we also standardize lesion sets, so we feel that this is a great addition to concomitant procedures without very little morbidity and mortality and easy reproducibility.
How do we do this? Our program roughly has about 500 cardiac cases a year. Of those cases, about 70 to 80 are concomitant procedures, and that includes the smattering of mitral, CABG, aortic valve and combination procedures. We’re also a hybrid ablation – hybrid atrial fibrillation ablation procedure program, and we do 20 to 30 stand-alone cases a year. We discuss all of our cases weekly, and treatments are standardized, including our lesion sets. We all tend when we’re doing left atrium atriotomy surgery, we all do full Cox IV Mazes, and in patients that have CABGs, aortic valves, or concomitant procedures, combining the two, we do a non-atriotomy lesion set, which includes a roof and floor lesion with epicardial cryo as well as a right atrial lesion set with cryo.
Over the years, this has progressed into that our referring physicians actually expect that any patient with atrial fibrillation will be ablated regardless of their duration of atrial fibrillation, and frankly, this has expanded into increasing our left atrial appendage management for non-atrial fibrillation cases as well. Most of the surgeons are clipping the majority of their patients with concomitant CABG or aortic valve surgery. What I’d like to do is turn it over to my partner to discuss how she was brought up in this environment where we all expect that concomitant ablation is standard care, and we are doing greater than 90% of those, so her perspective as a young trainee progressing into a mid-level surgeon on how she has grown her practice into this type of a program.
Dr. O’Keefe: Thank you. Appreciate the opportunity to be here. Thank you, Dr. Zias, also. My experience has an early career surgeon is probably like a lot of early career surgeons where I had great training, but I really wasn’t confident or comfortable doing a full Cox IV Maze or any kind of concomitant Maze procedure in the operating room, and there was this expectation in our practice that every patient with AFib was going to be treated, so we had to set up a way for me to be comfortable. In fact, early on, I dreaded doing these cases. I did not like doing them at all, so thankfully, I had a mentor in my partner Dr. Okum, and I had a lot of support in the practice to have them come in and scrub with me.
For the first probably year that I did concomitant cases, every case, they would book out time to come in and scrub with me, either stand across the table or stand next to me until I was confident with the lesion set and really had a quality outcome, and that really helped me not just be confident that I was providing a good Maze, but it really helped the referring doctors be confident that my work was acceptable and appropriate for the patient, so it helped build that referring relationship that I needed early on, and now – right now I feel that adding it – adding a Maze procedure to the bypass time takes maybe another 30 minutes or so, do not feel like it increases the amount of cross clamp or bypass time unnecessarily. I think out – to the early career surgeons out there, it takes commitment, but it also takes a mentor in your practice that can help you do that.
Dr. Philpott: Thank you very much, Dr. Zias. I am joined here by my colleague Lauren Gillis who’s a nurse practitioner, and the director of what we’ve created, which is a post-surgical ablation surveillance clinic, and I’d like to take you through that now and the impetus of how it got started and how we feel that this is absolutely critical for surgeons to improve their technique, primarily by learning what their outcomes are. The other thing that it does is it dramatically improves some of the post-op management, post-Maze, which we felt was falling through the cracks, but I’d like to start with this slide right here. This is from Damiano’s group, and it clearly shows that at about 10 years, there’s about a 20% survival improvement for patients that got a successful Maze procedure, and I think that this data is just incredibly paramount. This is a call to arms for us. We have to get better with our Maze procedures, and the concomitant intervention rate that we have right now, the percentage of patients that are actually getting in ablation who are coming to the operating room is just staggeringly low for our society.
This is something that we have to get better at, and I’ve been trying to perfect atrial fibrillation surgery now for about 15 years. We have attempted standardizing lesion sets and so forth, but it was a little bit of a puzzle because it stood out very uniquely as compared to other types of surgery that we did. It finally came to me that the major element that’s missing in Maze surgery is just the routine of follow-up that you would get with any other type of surgery to let you know how you did. For example, if you were doing coronary bypass grafting, and you had a couple of deaths, the way the data is now tracked in databases, you would immediately realize because of the reports coming back to you that there was a problem and that you would need to tune up your technique. This is also true for transplant surgery and SRTR as well as with VADs and just about everything else that we do, but with atrial fibrillation surgery, unfortunately, it’s just this black box, and it has caused a great deal of confusion with learning how to do the surgery.
Many people that are trying to learn how to get good with their Mazes simply just don’t know if what they’re doing works or not, and inwardly, a lot – although many times they won’t actually vocalize it, they’re concerned that they’re just trying to do this, but they’re not really 100% certain it’s going to work, so when we got really involved in a lot of the national trials, we started to get feedback on how I was doing. It was at that point that I realized that surgeons just simply aren’t going to get better unless they can continually see their results and see how they track with other surgeons, particularly other surgeons in their groups, so when we set this clinic up, that was probably the number one thing we wanted to go after.
We wanted to follow every single patient that got any ablation in the operating room and then have that patient go through an exact set of follow-up that would be for life. The other two hats I wear are transplant and aortic surgery, and we do the same thing like Dr. Okum suggested there for our aortic patients. We follow them for life. Lauren is also the director of that clinic as well, so it was a natural fit to bring her into here where we could do a lifelong surveillance clinic and begin to generate data like I just showed you from Damiano, not at one year or three years or five years but 10 years, 15 years, 20-year data. By the time I’m retiring, that’s what I would love to see coming out of this.
Now, the other part that we needed to improve on was the post-op management, and that included AADs, anti-coagulation, but interestingly, also the left atrial appendage management. Not all appendage closures are 100% correct, and we needed to identify those to make the decision some people could stay on anti-coagulation or, hopefully, who could come off. Let’s go through these one by one. The post-op anti-arrhythmic drugs actually is how I finally got the administration to back bringing Lauren into this. Of all things we were seeing a patient in the aneurysm clinic who we’d also performed a Maze procedure on and the Maze worked, but of all things, nobody shut the amiodarone off, and as time went by, this poor patient actually developed a rare complication with long-term amiodarone, which is they became blind. As they came out of the clinic, it just was fortunate luck that we had a high-level administrator who was there, and they were aghast at this, and that was the impetus to get this going.
These drugs are toxic. They have terrible side effects. Many of them do, so being able to transition the patient appropriately off of their anti-arrhythmic with a successful Maze is a key goal that we also all need to pay attention to. Anti-coagulation is the same thing. How many patients have you seen that have had a successful Maze, they haven’t had any atrial fibrillation for three or five years, and yet everybody’s terrified about taking off the anti-coagulation. Anti-coagulation has its own set of risks. Getting it off safely should be a goal of one of these clinics.
Now, the left atrial appendage management we had to go through a little bit a journey on. We started with TEEs on these patients, all of them, and the patients hated it, and it was difficult to set up, but we have an advanced imaging center here, and luckily, with the watchmen, they’ve set up a protocol that, apparently, is used all throughout the country called triple flash imaging. With this you can get very sensitive, high accurate images of the atrial appendage to determine how well it’s excluded or not, so we’ve moved to that. The patients are tremendously happy with this change. Now, I’m going to turn it over to Lauren here just a little bit, but we see them for a total of five major points throughout the year and not annual. Yeah, just speak to this quickly.
Lauren: This is our schedule of visits. They come in for the one-week and the three-week. They’re pretty much your post-op checks. We also see them about seven to ten days after discharge, but we do get the EKG there, pretty basic visits. The real meat and potatoes is the three-month where we start putting on the Zio Patch for seven days, and as long as that comes back negative, we can get rid of those anti-arrhythmics. Then the same thing repeats for six months and then yearly. We’ll put the Zio Patch on, and then at six months is where we can talk about getting that blood thinner off. That’s usually about the time we order the CAT scan. I should point out on these slide that we don’t order that CTA every single time. I’m just getting one scan, and so that repeats every year for life. I’ll the patient, this program has been well-received by them. They, in a lot of cases, look forward to getting these monitors on because they want to know did the procedure work? Is their AFib gone? More importantly, they want off of these medications, so that six-month visit is very important, and they’re very happy for the most part to be off of it, so we’ve had great success with that so far.
Dr. Philpott: We do this in collaboration with our EP physicians, so Lauren is in a multi-disciplinary clinic where she works in between both groups, and if there’s a question or if an event monitor comes back and we’re not sure, or if we have a failure, we immediately bring in the EP physician who is in charge of that patient. If for some strange reason there wasn’t one assigned, we get him assigned, so it’s very collaborative. This is multi-disciplinary. This just shows you once we get through that first year, then we do track them for life. Now, the clinic’s relatively new, so we’ve got six-month data to show you right now. In June, we’ll begin getting our one-year data, so we’ll have that to show.
This first slide shows you what the initial clinic volume was up to about December. We’re typically adding about five to eight patients per month as it builds, and it will continue to build as we go forward, so these clinic volumes are going to increase significantly as we roll forward with the surgical program alone. The clinic financially is black. Lauren can bill for what she needs to bill for, so this is not a red program, so to speak. If you want to look at a quality program that actually generates a little bit of money, this is something that most administrators when they see the performer begin to warm to, so to speak.
I’m going to start with this. This is the first slide for success at six months. This is for my group, seven surgeons, about 1300 pumps per year. Again, interestingly, this surprised us. We thought it was going to look a little different. We thought the paroxysmal patients were going to be at a hundred, but at six months, everybody was doing really well. Now, this slide, though, begins to show you a little bit of the problem or the challenge that we had. CIR stands for concomitant intervention rate, and again, this is the rate of patients that are coming into the OR with AFib that are actually getting something done. Look, we’ve got a huge opportunity here. We were about at 57%. With COVID now, we’ve actually fallen way down here. We’re back down into about 23, so we’ve got to bump that back up, but our success rates are good. Our intervention rates are lacking. Nobody knew any of this data until we could actually show them.
When you look at the surgeons across the group, as you would expect, there’s actually a significant degree of variability. Some of the younger surgeons are quite scared of the operation. Some of the older surgeons do it quite frequently, but what I want to focus your attention on are these two sets. Bar G here, which is one surgeon at 53% on the concomitant intervention rate, so a little better than the average, but still a ways to go, and then this surgeon, 20% concomitant intervention rate. Let’s go to success for each one of these. Keep your eye on bar A there. This surgeon has a hundred percent success rate, and he’s only intervening at about 20% of the time. Once they start to see this data, and they realize that the procedure’s working, they’re going to start to increase the amount of concomitant intervention that they do.
Let’s go back to this surgeon. He’s the fallout. He’s at 66%. He’s not with the rest of the pack here. This is the surgeon that we had to go to and say hey, listen, there’s something that’s a little off here. We need to go look at your technique. Are you doing all the lines correctly? Are your Maze procedures full? The beauty of the data is you don’t have to really browbeat these surgeons. They’re cardiac surgeons. They want to be excellent at what they do. As soon as they see this data, they start their own – almost all of them, they start their own performance improvement projects to try to get better, which is the beauty of it.
I’d like to say that the CIR kept on going up above 80%, but the best we’ve been able to get to is about 75%. It does vary a little bit. Every now and then, we’ll have an off month. You can see down at 28 or 27%, but what I’m hopeful for is as the surgeons continue to see this data, that they’re bothered by these numbers that are low down here, and we keep it up at about the 70% range, which is where we were in December. Again, we’ve just recently fallen off a little bit with COVID, but again, we’re releasing this data quarterly to the guys, and as they get it, we’re more mindful of it as a group. We’re also trying to get it into our operations committee meetings, which also go monthly, so that everybody, the entire team, can see this data and try to get behind it.
Now, a couple words about left atrial appendage management. If there was ever a proof of concept, this kind of clinic is key to why you should be looking at this. Not all of the appendages were successfully excluded, and being able to identify that when you’re having that discussion with the patient about whether or not you’re going to come off anti-coagulation really is critically important. Interestingly, the clips have worked beautifully. It’s the stapler that we’re having issues with, and right now, we’ve got about a 40% pouch rate with the stapler. Now, again, that’s one or two surgeons that have been championing the stapler, but as they get this data back, they’re moving away from the stapler. It still is a conundrum when you have a patch here – or a pouch, a residual pouch in the left atrium, the left atrial appendage, about whether or not you can safely take that patient off anti-coagulation. It’s a big debate. We do it with our electrophysiologists. Right now, we are leaving them on anti-coagulation if they still have a stump.
Here are our future goals, but really, I think, at this point we’re onto something. This process that we’re doing, I think, needs to become standard for every serious program out there. They’re just not going to be able to get better until they see what their results are. That’s how they’re going to know that they have a problem. It beautifully bridges the multi-disciplinary hurdle by allowing you to work with the electrophysiologists. They love this. They initially were very much into letting us go off to look at the post-surgical side of this, but now they’re warming to what we want to do in phase two, which is to wrap all patients, EP included, into this exact surveillance program. It’s then that we’re really going to be able to generate some powerful data about what is truly effective at a three or five or longer window, and what’s cost-effective for quality care with patients with atrial fibrillation.
Dr. Zias: I’m going to give you a perspective of how you can integrate pretty much everything that was said, information – how you can quantify this information of who treats atrial fibrillation and who doesn’t in academic setting that involves more than one site, meaning there are two hospitals within NYU Langone that perform cardiac surgery. We are over ten surgeons, so how do you go ahead and bring this change of obviously following the guidelines, do the best that we can for our patients, but at the same time give quarterly feedback back to the surgeons and to the administration to show them the quality that you are offering the patients by treating concomitant AFib?
Going to the next slide, I will go through our approach here at NYU Langone. What we have done is we have – one of our surgeons have come up with a way to essentially grade – not grade, but review every procedure we do and give feedback back to the surgeons with a specific formula, which I will review with you. We have applied this formula with essentially called the surgical efficiency and quality index with other procedures. For example, if we wanted to increase adoption of more tubular grafts within our practice, what we did is we essentially review every surgeon’s data. We came up with a number for the SEQI, and presented at our quality – our quarterly quality meetings, and we view the results.
We have seen that every time we try to advocate performing more arterial grafts, for example, this tool, the SEQI is a very powerful tool because essentially gives every surgeon some information, not necessarily of how many arterial grafts they do but – and I’m picking up that example because we’ve used that as our pilot study – but essentially how an intervention such as treating AF or doing more than one arterial graft affects the patient, affects the hospital, and bringing that information back to all the surgeons. As we all know, there’s not much really that you need to tell the surgeons. Everybody is fairly competitive, and everybody doesn’t want to be at the bottom of the pack, and everybody’s trying to do their best, obviously, for their patients.
When we came in trying to figure a way to increase adoption of concomitant AFib with other surgeries, we essentially started tracking the patients before coming to the operating room with electronic medical record. We use EPIC here. Essentially, every patient who comes in who has pre-operative AFib is identified. We have developed smart phrases that our APPs, our assistants when they do the history and physical and when we see patients to specifically ask to identify patients who have atrial fibrillation. Once we capture the atrial fibrillation in the chart, that automatically pulls a consult to our EP colleagues. The moment the patient comes to the hospital, an EP consult is generated, even if the surgeon does not want one, which obviously, all of us want EP involved because they can only help with the management of these sometimes complex patients.
Doing surgery, we capture the intervention done, essentially the lesion set, and I agree with what was said up until now that in most cases, the minimum lesion that we would like to see is a box lesion with the left atrial appendage managed at the same time. We have then all that information in the electronic medical record, and then we follow these patients, obviously, at 30 days and then through our colleagues with EP for many years to come. We’ve started this program I say in the last six months, and essentially, if we review the next slide, you can see some of the metrics that we use to incorporate into the surgical efficient quality index.
In other words, it’s not just a measure if the patient gets treatment for AFib or not, but it’s a measure as well of how this patient does in the sense of everything else that happens to him in the hospital, and then we tabulate all the results for all the surgeons, and we present it in our quality meeting. We have seen that when we present data to surgeons, as I mentioned before, everybody wants to be part of the treatment arm, and even though we don’t have results, I can tell you as I mentioned the example of a second arterial graft, before we introduced this method, this SEQI, in seeing how many arterial grafts we’re doing, let’s say year to year, we had an improvement from 10% use second arterial graft to about 70% adoption rate. It’s a very powerful tool.
I think that, somehow, we should come together really as societies and make treatment of atrial fibrillation as a quality measure as it is for using, for example, the left internal mammary artery. I appreciate one of the graphs that was present by Dr. Philpott who remind me essentially of the graph that you see with use of the left internal mammary artery versus using veins and the improvement that you see in patient survival at 10 or 20 years. I will pretty much finish my presentation here, and I want to thank Dr. Okum, Dr. O’Keefe, Dr. Philpott, and his associate for giving us this excellent review and showing us how they implement treating atrial fibrillation concomitant surgery and, most importantly, the amazing results that they have shared with us. Thank you so much.