In the United States, there are roughly 2.7 million Americans living with atrial fibrillation (AF).1 Treatment for AF includes medical treatment, cardioversion, heart ablation, and/or any combination of treatments. The most important goal in treating AF is the prevention of stroke due to the increased risk.2 WakeMed Health & Hospitals started its atrial fibrillation ablation program in 2009. Our electrophysiologists perform radiofrequency (RF) ablation using the CARTO (Biosense Webster, Inc., a Johnson & Johnson company) and EnSite Velocity (St. Jude Medical) three-dimensional mapping systems.
In 2013, electrophysiologist Pavlo Netrebko, MD, FACC created the Convergent procedure program at WakeMed Health & Hospitals. This multidisciplinary approach is performed in the electrophysiology (EP) lab with a surgical and electrophysiology team, including a cardiothoracic surgeon and electrophysiologist. The Convergent procedure was developed by integrating the cardiothoracic surgeon’s anatomical approach to AF with the electrophysiologist’s physiological approach.3 This article highlights one of the first Convergent procedures performed at WakeMed Health & Hospitals, and discusses the initial challenges faced when implementing this program.
A 70-year-old male patient presented with a history of coronary artery disease post stent placement to the right coronary artery and left anterior descending artery. He was first diagnosed with AF in 2006 after waking up with an irregular heartbeat and shortness of breath. After failed medication management, the patient had his first pulmonary vein isolation (PVI) ablation in 2008, and a subsequent PVI ablation in 2009. The patient was placed on dofetilide in 2009, and experienced infrequent dysrhythmia episodes, including one requiring cardioversion. His CHADS2 score was greater than 2, and he was placed on rivaroxaban. The patient also had a history of sleep apnea requiring CPAP therapy, and a hiatal hernia repair with a Nissen fundoplication. Given his extensive seven-year history of AF with more than one ablation, the patient was considered a good candidate for the Convergent procedure. Because of the patient’s prior history of upper abdominal surgery, the Convergent procedural team would consist of a general surgeon, cardiothoracic surgeon, and the electrophysiologist.
The general surgeon started the Convergent procedure by performing a diagnostic laparoscopy with lysis of adhesions. The cardiothoracic surgeon followed using an ablation catheter (AtriCure) to perform a modified MAZE procedure with laparoscopic exposure and pericardioscopic assistance. A total of 24 lesions were applied to the left atrium. Isolation of the PV potentials was achieved by placing anterior and inferior lesions on both the right and left pulmonary veins. A total of 36 minutes of ablation time was used during this portion of the procedure.
The electrophysiologist followed using a venous access approach to perform the endocardial ablation. A contact map was created showing the atrial septum, proximal portion of the coronary sinus, tricuspid isthmus, and part of the right atrium. RF ablation was delivered to the site of the usual slow pathway location, resulting in conducted rapid junctional beats. A total of three lesions were delivered. A contact map was then created of the left atrium. It was noted that all veins were isolated except for the left superior pulmonary vein. RF ablation was delivered to the superior aspect of the left superior pulmonary vein, leading to vein isolation. RF ablation was also delivered along the left lateral mitral isthmus and medial aspect of the mitral annulus. Lesions were created connecting the septal portion of the mitral isthmus to the right superior pulmonary vein.
Following the ablation, the electrophysiologist performed an aggressive isoproterenol challenge and aggressive burst pacing, noting that there were no inducible left atrial flutters. Exit block was confirmed in all four pulmonary veins; however, the patient showed evidence of AV nodal reentry tachycardia. The ablation catheter was moved to the right side, and RF ablation was delivered, creating complete cavotricuspid isthmus block. An area of slow AV node pathway was mapped and additional RF was delivered, resulting in multiple conducted junctional beats. The arrhythmia became non-inducible with loss of slow AV node pathway function.
The patient was extubated and transferred to the Cardiovascular Surgery Intensive Care Unit. While in recovery following the Convergent procedure, the patient developed a distended abdomen, fever, and pain at the abdominal insertion site. The patient was noted to be anemic and received a blood transfusion three days after the Convergent procedure. An abdominal CT scan was obtained, showing a hematoma and mild hemoperitoneum. After five days, the patient’s symptoms improved, and he was discharged home on day six. Discharge medications included dofetilide, rivaroxaban, colchicine, and pantoprazole.
WakeMed Health & Hospitals is a three-hospital, 919-bed private not-for-profit health system. The Invasive Cardiology Department consists of eight cardiac catheterization procedure rooms (three are both coronary and peripheral functional). The EP lab consists of three procedure rooms and an inventory supply room.
At WakeMed Health & Hospitals, we are proud to offer this procedure for patients with longstanding atrial fibrillation. “The Convergent procedure has provided relief for many patients with advanced disease who do not experience relief with conventional ablation,” explains Dr. Netrebko.
This case described here is a great example of the multidisciplinary approach and teamwork that is involved with the Convergent procedure. “We work together on both the inside and outside of the heart using RF ablation to address all causes of atrial fibrillation. Through this combined approach, we are able to address all circuits responsible for atrial fibrillation and ensure completeness of ablation before we finish the procedure,” said Dr. Netrebko.
There are multiple challenges when creating an ablation program than involves anesthesia, cardiothoracic surgery, and electrophysiology. One of the first issues that we had to address was physician scheduling. The Convergent procedure has to be scheduled with all modalities and physician offices. Prior to the implementation of EPIC in 2014, a conference call was required between offices and departments to help reduce time and frustration when scheduling these procedures. Another issue that occurred at the program’s beginning was the variation in physician orders. A different set of orders was initially used for each physician on the multidisciplinary team. As our program evolved, the performing cardiothoracic surgeon, electrophysiologist, and anesthesiologist created one order set that would be used for all Convergent procedure patients.
As the OR and EP staff collaborated in this hybrid setting, issues arose related to team member roles and responsibilities. To address these issues, multiple practice runs were conducted in the EP lab before our first procedure. We practiced every possible scenario imaginable. Each task within the procedure room was assigned an individual role. This helped to ensure that all things were completed and done correctly. In the beginning, we had to learn to work together and appreciate the strengths that each modality brought to this procedure. The two collective teams met frequently during the months leading up to the start of the Convergent program, and continued to meet afterward. When we sat down together to discuss our differences in practice and why certain actions are taken, we found that judgement and blame stopped, and the trust and teamwork began.
A successful Convergent procedure program is about blending different modalities and building a team, and recognizing that everyone offers a different talent. Creating trust and having respect for each discipline takes time, but it is imperative in order to provide exceptional patient care. Having the ability to collectively meet prior to our first Convergent procedure, practicing together before the first procedure, and working toward becoming a team helped to build our confidence and create respect for one another. The end result is a well-run team delivering exceptional patient care.
- What is Atrial Fibrillation (AFib or AF)? American Heart Association. Published October 18, 2016. Available online at http://bit.ly/1yjanPC. Accessed November 21, 2016.
- Davis LL. (2014). Preventing Stroke in Patients with Atrial Fibrillation. Dimens Crit Care Nurs. 2014;33(2):96-102.
- Kiser AC, Mounsey JP, Landers MD. The Convergent Procedure is a Collaborative Atrial Fibrillation Treatment. Innovations in Cardiac Rhythm Management. 2011;2:289-293.