Dr. Jonthan Philpott and NP Lauren Gillis discuss how to establish an AFib Surveillance Program. They review their early findings from this initiative including impact on surgeons and patients.
For the hearing impaired members of the AFibSurgeons.org community, we have provided a written transcript below:
Jonathan 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 left 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 annually. Yeah, just speak to this quickly.
Lauren Gillis: 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 where 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. 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.
Jonathan 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 at about a 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 you 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.