OSF Saint Francis Medical Center is a 616-bed facility located in Peoria, Illinois. In recent years, OSF Saint Francis has grown to become the fourth largest medical center in Illinois. The medical center is a major teaching affiliate of the University of Illinois College of Medicine at Peoria as well as the area’s only Level 1 Trauma Center and tertiary care provider.
Currently our electrophysiology (EP) laboratory has five technologists and four nurses; these techs and nurses assist four electrophysiologists who perform device and ablation therapy in both adult and pediatric populations.
During the summer of 2011, one of our electrophysiologists established a program for atrial fibrillation (AF) ablation, which was not performed at OSF Saint Francis at the time. Currently our laboratory performs three to four AF ablations per month. This article describes the perspective of technicians and nurses regarding the changes an EP lab must encounter in order to establish a successful atrial fibrillation ablation program.
Tip #1: It All Starts in the Clinic
Each week our clinic sees approximately 5–10 patients to be evaluated for possible AF ablation. Our physicians discuss in great detail with the patient all the risks and benefits of undergoing an ablation procedure. However, studies have shown that patients will only retain 15% of what is discussed in the initial clinic visit. Therefore, after the patient chooses to undergo AF ablation, the clinic coordinator, Jennifer Healey, RN, will spend an additional 30 minutes with the patient reinforcing the risks and benefits of an AF ablation as well as answer any other questions that may arise. It is imperative that during this clinic visit, the nurse creates realistic expectations for the patient and family. For paroxysmal AF, Jennifer will quote a success rate of approximately 75–80%, and for persistent AF, she will relay a success rate of 60–65%. In addition, all paroxysmal AF patients are told to mentally plan on two procedures with the hopes of only requiring one. Patients with persistent AF will almost always be guaranteed a second procedure.
We believe that time spent with our clinic nurse establishes a great rapport with the patient, which is greatly beneficial when moving forward throughout the ablation process.
Tip #2: Planning for the Procedure
Jennifer Healey, RN will remain in close contact with our patients for the weeks prior to their procedure. In our lab, we perform all AF ablations with an INR of 2.0–3.0. Therefore, all patients will be transitioned to Coumadin if applicable one month prior to the procedure. Jennifer will then check the INR as needed, but certainly one week as well as two days prior to the ablation date. In addition, Prilosec OTC is started in order to theoretically decrease the risk of atrio-esophageal fistula. Jennifer will also arrange for a transesophageal echocardiogram the day prior to the procedure for patients with persistent AF. Finally, AV nodal agents and blood pressure medications are held the day prior to the procedure. Jennifer strongly encourages patients to call the office if at any time they have questions about their upcoming procedure.
Tip #3: Understand the Complications of an AF Ablation
Months prior to performing AF ablation, our entire staff had several meetings to discuss the complications associated with AF ablation and what efforts needed to be instituted in order to decrease peri-procedural risk. We were all given copies of “Complications of AF Ablation,” published in the July 2011 issue of the Journal of Atrial Fibrillation.1 We felt as though this paper provided a comprehensive understanding of AF ablation complications and methods of management strategies. As a result of this article, our group implements numerous strategies to decrease peri-procedural risk (Table 1).
Tip #4: Explore Different Sedation Options
For the first 10 AF ablations that were performed in our lab, we utilized general anesthesia in order to minimize patient movement intraprocedurally. However, upon discussion with other EP laboratories (including Memorial Hospital in South Bend, IN), we found that there may be alternative sedation options, specifically dexmedetomidine (Precedex). We found dexmedetomidine provides an adequate level of moderate sedation while minimizing the total amount of fentanyl and Versed necessary for the case. Currently about 50% of our cases utilize dexmedetomidine with fentanyl and Versed given as needed by our nurses without anesthesia assistance. For patients with multiple comorbidities or significant sleep apnea, we typically request the assistance of our anesthesia colleagues, who administer propofol for moderate sedation.
Tip #5: Know Your PV Potentials!
Prior to starting our atrial fibrillation ablation program, the staff and physicians had several meetings in which we examined intracardiac electrograms with subsequent identification of pulmonary vein (PV) potentials. We found Pulmonary Vein Recordings by Macle et al2 to be an invaluable resource in learning and understanding the pathophysiology of PV potentials and ablation sites. In our lab we have created a model in which the physician rarely looks at the review screen in order to determine the “earliest” PV potential. Our EP techs Carrie Hoefling, RCES, Alice Payne, RCES, and Renee Trammell, RT RCES have become very adept at identification of PV potentials and associated ablation sites. Finally, our nurses administer adenosine and Isuprel to confirm eradication of pulmonary vein potentials at the end of the case. We feel as though a technician-led ablation strategy decreases procedure time and may lead to decreased peri-procedural risk.
Tip #6: Provide Close Post-Procedure Observation
Once our procedure has been completed, we exchange all long sheaths for short sheaths in the right femoral vein. Patients are observed in our post-procedure unit, and when the ACT returns to baseline or <180 seconds, the sheaths are withdrawn and manual pressure is held. Our post-procedure unit has been well educated regarding the risks of AF ablation, and specifically on cardiac tamponade and cerebrovascular insult that may occur during this time period.
Tip #7: Choose Your EP Lab Music Wisely
In our EP lab, we feel as though listening to music increases the concentration as well as focus required during AF ablations, which at times can be long and tedious. As a result, the music of choice during our AF procedures is a blend of hip hop music, which we stream through our Bose surround sound system. We have jokingly referred to the music montage we listen to during AF ablations as “The Club.”
Tip #8: Take Care of Your Patient After the Procedure
Approximately one week after the procedure has been completed, Jennifer will call the patient from our outpatient clinic to assess for any post-procedural complications as well as to discuss the well-being of the patient with regard to their overall experience. Patients are told to disregard any AF immediately after the procedure as we utilize a six-week blanking period to allow for immediate AF due to the inflammatory process created during the ablation procedure. Patients will then follow up in clinic three months after the procedure. If a patient has no recurrence of AF, discontinuation of Coumadin can be considered. For those with a CHA2DS2-VASc score ≥2, a three-week auto-trigger monitor is ordered, and if there is no evidence of asymptomatic AF, Coumadin therapy is replaced with aspirin.
In closing, when we were first told that we would start performing AF ablations, there was a significant amount of apprehension and uncertainty. However, the key to a successful program is understanding what the procedure entails and, most importantly, being prepared for complications if and when they occur. Participating in the procedure by directing the physician to potential PV ablation sites has allowed us to take ownership of the AF ablation. The bottom line is that communication, communication, communication will allow a new lab to successfully eradicate AF.
Acknowledgement. The electrophysiology staff would like to thank Katie Terrazas and Kim Bishop from Biosense Webster for their expertise during our AF ablations.
1. Baman T, Latchamsetty R, Oral H. Complications of Radiofrequency Catheter Ablation for Atrial Fibrillation. J Atr Fibrillation 2011;2(7).
2. Macle L, et al. Pulmonary Vein Recordings. Cardiotext Publishing, 2009.