Design of an Outpatient Atrial Fibrillation of Excellence: Current experience with the deliver of pre and post procedure care
Credits:Authors: Kevin Kreighbaum, RN, BSN; Loren Berenbom, MD
Institution: Center for Excellence in Atrial Fibrillation, The Bloch Heart Rhythm Center, Mid America Cardiology at the University of Kansas Hospital, Kansas City, KS 66221
Director, Outpatient EP services, The Bloch Heart Rhythm Center, Mid America
Cardiology at the Univeristy of Kansas Hospital, Kansas City, KS 66221.
doi : 10.4022/jafib.v1i1.405
of patients with atrial fibrillation (AF) continues to expand and emerges to be
the most common arrhythmia we deal with. Referrals to centers performing
catheter based ablation procedures for AF also continue to grow as catheter
ablation becomes an increasingly accepted therapeutic approach. In this
article we will describe the infrastructure we have developed to manage our
atrial fibrillation ablation population at the Richard and Annette Bloch Heart Rhythm Center at the University of Kansas Hospital. Our goal is to provide
a “nuts and bolts” overview from the allied health professional perspective.
For concise reviews of AF management we recommend the ACC/AHA/EFC 2006 guidelines
and the HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation
of atrial fibrillation 1,2.
The Bloch Heart Rhythm Center at the University of Kansas Hospital provides electrophysiology
services, including patient medical management, implantable cardiac devices and
complex ablation techniques, to 35 cardiologists at the University, as well as
a regional referral area extending several hundred miles. Patients for complex
ablation procedures come from even greater distances. We have five
electrophysiologists, Loren Berenbom, MD, Raghuveer Dendi, MD, Martin Emert,
MD, Dhanunjaya Lakkireddy, MD, and Rhea Pimentel, MD. Not all our
electrophysiologists perform ablation procedures, although all are involved in
patient selection, as well as post-procedure management. We feel it is
important to maintain a high degree of proficiency in A-Fib ablation and
believe that operators should perform a minimum of 50 cases per year, and
ideally 100 cases per year to develop and maintain excellence in this
technically demanding procedure. Again, we would like to highlight that there
is no consensus on what the magic number is.
allied health staff consists of nurse practitioners, registered nurses,
exercise specialists, medical technicians, ECG, Holter and event recorder staff
at our main campus and at various outreach sites. The Bloch Heart Rhythm Center provides comprehensive care for electrophysiology patients including
medical management, implant devices and complex ablation techniques.
initiated a catheter based AF ablation program in 2005. Volume increased
substantially with the addition of Dr. Dhanunjaya Lakkireddy in July 2006 and
has continued to increase. Currently we perform approximately 20 cases
monthly. The logistics of evaluating these patients, completing appropriate pre-procedure
diagnostic testing, and orchestrating post-procedure follow-up is complex. As
our population grows, the complexity of organization continues to grow as well.
Although all of our staff is expected to be familiar with this patient
population, we quickly learned identification of “AF Champions” was necessary to
our ongoing success as a regional referral center. We also identified the need
to partner with our surgical colleagues to offer an integrated program which
includes surgical as well as medical and catheter based options. Ultimately,
the Center for Excellence in Atrial Fibrillation was developed.
The outpatient portion of the Center needs a strong outpatient allied
professional team consisting of RNs, EP technicians, EKG and holter technicians
along with administrative staff. (Figure-2)
Flow chart of organization of Center for Excellence in Atrial Fibrillation
Figure 1: Flow chart of organization of Center for Excellence in Atrial Fibrillation
The outpatient wing of the Center. From Left to Right – Diane Parker (RN);
Dustin Baker (Tech); Jamie Salmons (RN); Lori Garnett (Tech); Kevin Kreighbaum
(RN); Justin Conley (Tech); Jean Ann Thompson (Tech), Marie Hauser (Tech),
Carrie Uecker (RN); Katherine Lee (Tech). Absent from the picture – Debbie Mc
Morris (RN), Jeanine Swope (RN); Shawn Beggs (RN); Andrea Behne (RN); Debbie
Pelke (RN); Courtney Jeffery (PA).
As part of
ongoing training, our outpatient staff has the opportunity to observe in the EP
lab to ensure familiarity with the procedure itself. The staff also has the
opportunity to attend relevant meetings such as the Boston Atrial Fibrillation
Symposium and the Heart Rhythm Society Scientific Sessions.
established basic pathways but remain flexible. No two AF patients are the
same. It is important to customize our approach to accommodate patient needs.
Our basic pathway continues to evolve over time.
management is facilitated by our electronic medical record. Outside records
are scanned into this system so that all pertinent information is immediately
available to anyone on our staff who requires access to it.
scheduling appointments, we attempt to obtain all relevant outside records,
including office notes, echocardiograms, stress tests, and laboratory work.
Previous catheterization data, results of electrophysiology studies and
implanted device information are also obtained. Our business office reviews
insurance information for compatibility. Once pertinent records are obtained,
patients are scheduled at our main campus or one of our outreach sites to see
an electrophysiologist to discuss treatment options. All appropriate options
are discussed with the patient and family in detail. Additional patient
education is carried out by Allied Health staff and includes both print and
ablation is a determined to be a viable option, a detailed discussion of procedures,
possible outcomes and complications, is outlined in detail verbally and again reinforced
with written and web-based materials. If patients have not had an Echo Doppler
completed within the past twelve months, we will update the study or request
one from the referring physician if they provide echo services.
obtain a 64-slice cardiac CT to assess the left atrium and pulmonary vein anatomy
for proper planning of the procedure. Also these segmented images are used for
integration into our EP lab three dimensional mapping systems. Insurance
reimbursements for these critical tests continue to be an issue and we try to
deal with these one on one. Ruling out prior PV stenosis is important
especially for people who had prior attempts at AF ablation. More than a few
times we caught structural anomalies like intracavitary (right atrial) coronary
artery, tortuous and elongated left atrial appendageal clots usually not
visualized by TEE with the help of these preablation CTs. The importance of
post ablation CTs could not be stressed less.
management is an area of particular concern. INR’s are obtained weekly for at
least one month prior to the procedure. Coumadin is typically held for two
days before ablation. For patients in atrial fibrillation in the days prior to
the procedure, a Lovenox bridge is utilized. (1 mg/kg subcutaneously every 12 hours
with the last dose administered 12-18 hours prior to the procedure.) Although,
in the recent months, we are slowly moving towards ablation while INRs are
therapeutic between 2 and 3. There is increasing evidence that AF ablation can
be safely performed on therapeutic INRs minimizing the risk of periprocedural
echocardiograms are obtained on the day prior to the procedure, or on the day
of the procedure, if anticoagulation has been interrupted in the presence of
atrial fibrillation. Most patients do not require a TEE. This is an area
where particularly close communication between the physician performing the
A-Fib ablation procedure and the nurse orchestrating pre-procedure care is
pre-procedure labs, besides PT/INR include CBC, BMP and magnesium. These are
typically obtained 7-14 days prior to procedure to allow adequate time to address
any abnormalities. If a woman of childbearing potential is scheduled for
ablation, a beta HCG is obtained within three days of the procedure. Membrane active
antiarrhythmic medications are typically held for 48 hours before ablation. Amiodarone
is typically held for at least six weeks prior to ablation. Patients are
admitted on the morning of their procedure and most procedures are done on an
outpatient basis, although all of our patients remain in the hospital
discharged on Lovenox 0.5mg/kg q 12 hours until their INR is greater than or
equal 2.0. PT/INR is monitored every 2-3 days early post-procedure. Most patients
are on membrane active antiarrhythmic drugs pre-procedure and most continue on
these drugs for at least 8-12 weeks post-procedure.
rhythm monitoring requires a robust infrastructure. We do ambulatory recording
on our patients for at least three months post-procedure. We typically use a
“heart card” type device and request that patients make recordings whenever
they are symptomatic, and at least twice a week on a random basis. Rhythm strips
are reviewed by staff on a daily basis. Significant abnormalities are brought
to the attention of one of our Electrophysiologists, or ARNP for further
guidance and management. Otherwise, recordings are reviewed by a physician at
the end of each month. We continue to evaluate new technologies to enhance
contacted by phone by the EP lab staff, 2-4 days post-procedure and by the
office staff at 1 and 2 weeks post-procedure. The staff inquires about potential
post-procedure complications, including palpitation, lightheadedness,
catheterization site status, chest pain, shortness of breath, dysphagia and
overall sense of well being.
recommended at one month with the patient’s primary provider and at two months
with the ablating electrophysiologist. Not infrequently patient concerns lead
to additional APRN visits. At two months, if the patient is doing well,
membrane active drugs are discontinued. In those patients who have had
recurrence of arrhythmia in the first two months membrane active drugs are
continued. Heart rhythm monitoring is continued for another 4weeks off of the
antiarrhythmic drug. In the absence of any recurrences we discontinue the heart
rhythm monitoring but continue monthly EKGs either at the primary care
physician or the cardiologists office. In the event of symptoms we tend to
extend the heart rhythm monitoring.
follow-up visit with one of our electrophysiologists is scheduled at 3-4 months
post-procedure. A follow-up CT is typically obtained at 4-6 months although we
are considering eliminating this as a routine, given very low incidence of
significant pulmonary vein stenosis.
The six month
follow-up visit is generally the first time that we will entertain the
possibility of discontinuing Coumadin in appropriate patients (CHADS score 0-1
and no evidence of AF recurrence). In conjunction with this decision, an
additional 30 days of heart rhythm monitoring is typically completed. We take a
conservative approach to anticoagulation and favor maintaining it if there is any
question as to possible recurrence of arrhythmia.
post ablation left atrial tachycardia is complex. Majority of these are
reentry tachycardias that subside by the end of 8 weeks post ablation.
Certainly, a small percentage (5%) of these patients have persistent atrial
tachycardias that need repeat intervention. We generally take an aggressive
approach to terminating any sustained arrhythmias within 24-48 hours by moving
quickly to DC cardioversion. If these patients have not been on a membrane
active antiarrhythmic drug, one is initiated in the hospital in association
with cardioversion. We try to delay repeat ablation until at least three
months, preferring up to six months, after the initial procedure.
Many of these
patients are very knowledgeable about atrial fibrillation and have actively researched
their condition. These patients often have many questions which we begin to
address by phone even before they are seen for their initial evaluation. Much
of what they have read and heard is accurate and helpful, but occasionally they
have some misperceptions that we work hard to correct. Both pre and post-
procedure patients often have significant anxiety. They require extensive
counseling and reassurance. Prompt access to a well informed RN, APRN, or
physician is the key to managing these patients in a constructive way.
A well trained,
well educated, focused staff supported by their physician partners, enhances
our ability to effectively manage patients pre and post -procedure. Excellent
counseling skills as well as technical expertise, is necessary to maintain
patients’ confidence through what can be an emotional and physical roller
coaster ride for these patients. The guiding bodies like HRS should proactively
consider releasing some position statements in attempt to create uniform
We greatly appreciate Dr. Dhanunjaya Lakkireddy’s (Director, Center for Excellence
in Atrial Fibrillation, The Bloch Heart Rhythm Center) input to this article.
1.ACC/AHA/ESC 2006 guidelines for the management of patients with
atrial fibrillation--executive summary: a report of the American College of
Cardiology/American Heart Association Task Force on Practice Guidelines and the
European Society of Cardiology Committee for Practice Guidelines (Writing
Committee to Revise the 2001 Guidelines for the Management of Patients With
Atrial Fibrillation). J Am
Coll Cardiol.2006 Aug 15; 48 (4):854-906.
2.HRS/EHRA/ECAS expert Consensus Statement on catheter and surgical
ablation of atrial fibrillation: recommendations for personnel, policy,
procedures and follow-up. A report of the Heart Rhythm Society (HRS) Task Force
on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2007
Epub 2007 Apr 30. Review.