A Team Approach: How the New York University School of Medicine is Making AF Management a Routine Procedure

Larry A. Chinitz, MD, and Electrophysiology Lab Staff
Larry A. Chinitz, MD, and Electrophysiology Lab Staff
The NYU approach to AF management goes far beyond techniques in the EP lab. Using various resources and processes, AF management is accomplished using the basic laboratory, clinical lab, and extensive patient follow-up. This Bench to Bedside approach was developed over the course of 4 or 5 years. Today, the EP team takes over the patient s case completely for a 1- to 2-month period, even if the patient also sees a general cardiologist. Taking such a complete view of each case helps to ensure that the ablation procedure has been successful, and that the lengthier, equally critical process of atrial remodeling is well under way. Dr. Larry A. Chinitz, Associate Professor of Medicine and Director, Cardiac Electrophysiology commented, Clearly, comprehensive treatment of AF is expensive. The average AF case can occupy lab resources for up to 6 hours. After the procedure patients require a great deal of care; they have questions and issues which arise at all hours, and need to be answered by professionals. Nurse Practitioners are needed to manage patient support groups with knowledgeable, sensible advice. NYU has invested in this process in order to stay on the cutting edge of science, and to continue moving closer to a cure. At NYU, each member of the electrophysiology team plays a critical role, and is responsible for voicing opinions whenever necessary. From attending physicians, to fellows, to nurses and lab technicians, the specialized skills of each member are an integral part of every procedure. Managing the care of AF patients outside the lab is the primary responsibility of Aileen Ferrick, NP. She creates support groups, develops teaching tools, and plays an active role in the care of the patient from the moment they decide to pursue catheter ablation until long after the procedure has been completed. Ferrick comments, Most of the patients treated by NYU are young, and very tuned in to what s happening in their bodies. They need someone to call with questions, who can provide both reassurance and knowledgeable advice concerning activity and medication. The nurses and technicians in the lab ensure that physicians are dealing with the most current and accurate information possible, conducting a TEE immediately prior to the procedure, monitoring vital signs and pressure readings, and ensuring that anticoagulation levels are appropriate. By maintaining proper patient sedation, nurses become a constant link between the patient and the physician. Most importantly, they are aware of the possible complications and their causes, so that any situation which may arise can be dealt with quickly and safely. Attending physicians and Fellows each play an integral role in the management of AF patients and cases. There are two physicians present in every AF case at NYU. Whether it is an attending or a fellow, the person reading the ECG monitors is just as important as the person handling the catheters. Time and patience are critical for all physicians in the EP lab. Every aspect of the procedure must be executed with meticulous attention to detail, and monitors must be watched for even the most subtle changes. NYU is a high-volume EP lab, so it s important to understand any potential pitfalls and be watchful of them. Together, the EP team helps ensure that nothing is overlooked. The NYU team s successful approach to catheter-based AF management incorporates a combination of science, clinical knowledge, and industry support. As a research institution, NYU has the resources to allow physicians to share time between the science laboratory and the EP lab. Working with transgenic mice, the scientists at NYU are studying how hearts can become predestined for developmental abnormalities which, when combined with later environmental influences, become arrhythmias. Each week, the physicians at NYU participate in multiple clinical and basic science conferences, keeping them up to date on new theories and discoveries in the scientific and the clinical lab. The lessons learned in scientific study do not always translate directly to the EP lab, but can offer insight during cases or patient assessment. The current ablation strategy at NYU is anatomically focused, and is also the result of many years development and discovery. Protocols continue to change every 1 to 2 months, the result of new product introductions, scientific advances, and patient follow-up information. The NYU team begins by performing RF ablation to isolate all four pulmonary veins. Then, one right atrial linear lesion is made for atrial flutter, a process developed after numerous cases and research indicated that atrial flutter could be a contributing factor toward atrial fibrillation. In some cases, a linear lesion between the left inferior pulmonary vein and the mitral valve annulus is added, further eliminating the chances for AF to reoccur. By blocking multiple pathways, NYU achieves encouraging success rates and less frequent reoccurrence of AF. Clinical methods and expertise are often supported by the products, knowledge, and financial support of industry companies like St. Jude Medical. They facilitate interaction between physicians, both in the EP lab and by supporting major educational conferences. Also, Field Clinical Engineers from St. Jude Medical form a traveling network that runs throughout the EP community, offering troubleshooting advice and sharing expertise gained in labs across the country. Another important factor in the management of AF is the patients themselves. AF therapy takes place both in the EP lab and through the subsequent remodeling of the heart, so success often depends as much on the patient as the clinicians. Typically, NYU encounters patients who have been referred due to an evolving case of AF. Each patient is given the most current, accurate data available, so that they can offer informed consent. For many patients, drug therapy offers little or no alleviation of symptoms, said Dr. Chinitz. They don t like the sense of palpitation, and so they pursue a catheter-based solution. If the patient appears to be a good candidate, without structural damage, we try to empower him or her to make their own decision. Neil Bernstein, Arrhythmia Service Attending Physician, said AF ablation is not a first-line therapy. The procedure is constantly evolving, and the risks are significant. We like for the patient to have failed medication and other standard therapies before attempting a catheter-based solution. Having informed patients is also important during the follow-up period. They have a better understanding of their condition, and can offer more focused, detailed accounts of any sensations or occurrences they experience. Dr. Chinitz adds, Treatment of AF is both an in-lab and a post-discharge process, during which patients require a great deal of care. It s not a one-shot deal. Our goal is not just to destroy the sources of AF today, but to help the patient s heart remodel and return to normal over time. There is no one secret to success for the NYU EP team. Every case requires the perfect balance of science, technology and people. The clinicians in the lab must be as methodical and patient as possible, to ensure that all possible sources of AF have been eliminated. Armed with the best possible knowledge and tools in each case, they are constantly working to surpass the standard 70% success rate. Companies like St. Jude Medical play an important role in our cases, said Dr. Chinitz. We need the best, newest catheter technology, along with proven products like guiding introducers and transseptal needles. Our techniques in the lab and the technology that industry develops challenge each other to be better. This constant improvement means that we are continuously moving closer to a cure. The most important element, of course, is the people in the lab. It is imperative to be surrounded by people you know and trust. Each member of the team has independent thoughts and opinions everyone speaks their mind, and the patient benefits from that. Mutual respect makes our team stronger and more effective.