Practical Advice for Ablating Atrial Fibrillation in a Private Practice Setting:Interview with Rodney P. Horton, MD

What are the five most important factors in building a successful AF program in a private practice? Describe some of the support staff and services needed for a complete AF program. To answer the first question, one needs to understand that the physician procedural component is only one part of building an AF program. Obviously it is a critical component, and one that must be mastered. The physician aspiring to perform these procedures should have mastered a number of prerequisite skills first. These would include the transseptal puncture, mastery of three-dimensional mapping, intracardiac echocardiography, the complex anatomy of both atria. Issues that might seem mundane like sheath and guidewire management can easily lead to air emboli. Also, knowledge of the ablation system of choice, including the amount of energy delivered at different sites, is required. Each of these skills should be perfected before trying the first AF ablation. In addition to the physician procedural skills, one should employ pre-procedure imaging of the left atrium, esophagus and neighboring structures. This is useful in establishing the left atrium's (LA) size and volume, the number, size and orientation of the pulmonary veins, and the relationship of the esophagus to the posterior LA. These issues help to individualize the ablation strategy to the specific atrium. It is also necessary to rule out other co-morbidities that may not show up in other screening tests. This would include coronary artery disease (CAD), anomalous venous anatomy, aortic root aneurysms, aortic plaque, etc. The third key would be proper patient selection. This should evolve with the program's experience. The first cases should be in small atria of highly symptomatic, compliant patients. As the program grows, more complex cases can be tackled (bigger atria, persistent AF, chronic AF, significant co-morbidities). The issue of patient selection not only applies to who should be offered the service; it applies to physician education on the differences in success expectation between the spectrum of patients with AF. The fourth key would be capable and prepared supporting services. This should include a dedicated EP lab. Part-time labs don't usually have the requisite skills in EP lab basics to safely try something this complex. Sedation should be worked out in advance. I encourage the use of anesthesia staff, at least at first this is one less thing to have to worry about. Having capable cardiothoracic surgery, neurology and critical care support is also highly advisable, as it is better to be prepared for the worst.  The final key is devising a follow-up system in the office. This should include a smooth transition of care from the hospital to the office (particularly related to anticoagulation). In my opinion, smooth follow-up begins before the procedure with a realistic explanation of the issues the patient should expect to feel and experience after the procedure. Providing telephone nursing support from professionals who understand the issues can save the physician from spending all of his time fielding these post-operative questions. What are some of the benefits of creating an AF program? Also, what are some of the pitfalls that one might fall into? By creating an AF program, one provides a more complete product line. In addition, an AF program adds a certain prestige to the hospital and physician groups. While these cases make money, the reimbursement is actually poorer given the time, energy and risk than a regular ablation. As a result, several pitfalls should be avoided. The first would be to try this without adequate EP partner support. These cases take long enough that the rest of the EP practice can be neglected as a result of the cases. Also, overly optimistic expectations can sink a fledgling program; therefore, managing expectations before the first case is advisable. Furthermore, choose cases with higher success rates. If patients and referring physicians don't see early successes, future referrals will dry up. Most importantly, early complications can end the program before it has a chance to get going. The strategy should be to put safety above all other concerns. The balance between safety and efficacy is challenging, but I would much rather have a recurrence than a complication. Explain the learning curve one should expect with patient cases when beginning an AF program. The learning curve is not only steep, but very long as well. At first, the complexities of juggling so many issues are intimidating and far more involved than a conventional ablation. These include: coordination of a TEE pre-procedure to rule out an LA clot, placement of the groin sheaths (some being quite large) to avoid both a DVT and an AV fistula, intracardiac evaluation and monitoring, transseptal puncture in a part of the septum that facilitates rather than hinders the ablation, a map of the right phrenic nerve, ablation strategies that are effective yet avoid injury to the pulmonary veins or the esophagus, a system of procedural anticoagulation, and a pre-planned system for dealing with complications. As a result, competence in this procedure takes over 100 cases. Furthermore, continued education is expected as the techniques, technology and philosophy change monthly. What do you recommend to build a strong client (i.e., patient) base? Although I covered much of this topic in the first question, I also recommend communication and involvement of the referring physician. Explaining the case to clients is nice; however, using images from the case is more effective. This keeps them in the loop and gives them a feel for the complexity of the procedure. In addition, a comprehensive handout to patients can help answer the questions they don't think to ask. What is the best way to streamline follow-up of patients? Follow-up for patients after this kind of ablation can be labor-intensive. They often complain of issues not usually seen with conventional ablations. Hiring nursing staff that understand these issues is crucial. Making those nurses available by phone is a must. They serve not only to calm fears, but to triage for potentially worrisome complaints. Physicians should always be consulted when such complaints are voiced. How many ablation procedures does Texas Cardiac Arrhythmia (TCA) perform each year? In your knowledge, what percentage of cases in private practices are AF ablations, in comparison to all other ablation cases? TCA performs over 2,000 ablations per year, approximately 25% of which are AF cases. In what ways do you keep your practice thriving? What personal advice can you offer others? As the founder of TCA, developing the AF program has been the biggest growth area for our practice. By mastering all the skills needed for these endeavors, our skill with all other ablation procedures has improved. Furthermore, referrals for other complex procedures have increased. I suspect that the notoriety in building the AF program has carried over in this way.