BAFS: Better surgeon/EP relations may improve AF ablation outcomes
BOSTON—Implementing a hybrid approach to atrial fibrillation (AF) ablation that forms a relationship with both surgeons and electrophysiologists could help improve outcomes, but reimbursement and workflow issues will remain a constant challenge, said James R. Edgerton, MD, during a presentation at the Boston AF Symposium (BAFS) Jan. 14.
While typically epicardial ablation has been done by surgeons and endocardial transvascular approaches have been done by electrophysiologists (EPs), “the hybrid technique has several reasons why it makes sense to us,” said Edgerton, a cardiothoracic surgeon at Cardiovascular Specialty Associates of North Texas in Plano, Texas.
Surgeons are very good at making lines on the heart, he said. The smooth surface of the epicardial is designed for linear ablation, but EPs excel at what Edgerton calls “spot welding." Together, these two techniques become complementary, Edgerton offered.
"If epicardial ablation fails, it is because it fails to penetrate the endocardium. If endocardial ablation fails, it is because it fails to penetrate to the epicardium. Together these techniques complement each other," he said.
“Each ablation line that is placed in the atrium should be mapped for completeness," said Edgerton, but surgeons are not formally trained in these mapping techniques, which presents difficulty.
Another difficultly for surgeons is that pericardial attachments inhibit free movement of the mapping probe, and surgeons are not always working with the latest generation of mapping technology. On the other hand, EPs are formally trained in ablation mapping and can move freely around the endocardium.
While there is room to take unique contributions from each specialty when moving toward a hybrid approach, competition and patient referrals may get in the way of success.
Edgerton said that each surgeon should be working with a fully trained EP; however, around the country, many EPs fear surgeons as competition.
He offered that EPs may not be incentivized to refer patients to surgeons, and may be concerned with a loss of revenue and quality control because they are sending the patient to someone not formally trained in the field of ablation.
“The hybrid approach solves all of these problems,” he said. “It’s the ultimate collaboration because the EP is right there doing the procedure and does not lose control over the patients.”
However, while the hybrid approach may solve problems, it also may create them. “How do you avoid EP downtime in either an operating room or cath lab?” Edgerton asked.
He offered that a successful hybrid program must:
Additionally, one must ask whether procedures are best performed by staging them or doing them simultaneously, and there are advantages and disadvantages to both, he said.
By performing these simultaneously, “you are taking your single best shot at ablation all at once.” The patient only has a single anesthetic and probably a shorter hospital stay. However, this can lead to workflow issues and DRG reimbursement issues because if a patient is taken to both the OR and the EP during one hospital stay, only one will be paid under the reimbursement model.
Because surgeons and EPs excel at different aspects of surgery, combining these techniques with a hybrid approach may be the right plan to help improve surgical outcomes for AF patients.
“There is a potential for improved outcomes by combining the strengths of epicardial and endocardial ablation. While workflow and reimbursement challenges exist, we will need data to help understand where we are headed,” he concluded.
While typically epicardial ablation has been done by surgeons and endocardial transvascular approaches have been done by electrophysiologists (EPs), “the hybrid technique has several reasons why it makes sense to us,” said Edgerton, a cardiothoracic surgeon at Cardiovascular Specialty Associates of North Texas in Plano, Texas.
Surgeons are very good at making lines on the heart, he said. The smooth surface of the epicardial is designed for linear ablation, but EPs excel at what Edgerton calls “spot welding." Together, these two techniques become complementary, Edgerton offered.
"If epicardial ablation fails, it is because it fails to penetrate the endocardium. If endocardial ablation fails, it is because it fails to penetrate to the epicardium. Together these techniques complement each other," he said.
“Each ablation line that is placed in the atrium should be mapped for completeness," said Edgerton, but surgeons are not formally trained in these mapping techniques, which presents difficulty.
Another difficultly for surgeons is that pericardial attachments inhibit free movement of the mapping probe, and surgeons are not always working with the latest generation of mapping technology. On the other hand, EPs are formally trained in ablation mapping and can move freely around the endocardium.
While there is room to take unique contributions from each specialty when moving toward a hybrid approach, competition and patient referrals may get in the way of success.
Edgerton said that each surgeon should be working with a fully trained EP; however, around the country, many EPs fear surgeons as competition.
He offered that EPs may not be incentivized to refer patients to surgeons, and may be concerned with a loss of revenue and quality control because they are sending the patient to someone not formally trained in the field of ablation.
“The hybrid approach solves all of these problems,” he said. “It’s the ultimate collaboration because the EP is right there doing the procedure and does not lose control over the patients.”
However, while the hybrid approach may solve problems, it also may create them. “How do you avoid EP downtime in either an operating room or cath lab?” Edgerton asked.
He offered that a successful hybrid program must:
- Have predictable operative times: "Schedule your clinic. Give predictable operating times so money isn’t wasted”;
- Free up the EP lab by moving patient cases to the hybrid operating room; and
- Minimize surgical downtime.
Additionally, one must ask whether procedures are best performed by staging them or doing them simultaneously, and there are advantages and disadvantages to both, he said.
By performing these simultaneously, “you are taking your single best shot at ablation all at once.” The patient only has a single anesthetic and probably a shorter hospital stay. However, this can lead to workflow issues and DRG reimbursement issues because if a patient is taken to both the OR and the EP during one hospital stay, only one will be paid under the reimbursement model.
Because surgeons and EPs excel at different aspects of surgery, combining these techniques with a hybrid approach may be the right plan to help improve surgical outcomes for AF patients.
“There is a potential for improved outcomes by combining the strengths of epicardial and endocardial ablation. While workflow and reimbursement challenges exist, we will need data to help understand where we are headed,” he concluded.