In this interview, we speak with Marshall Winner, MD, about the Atrial Fibrillation (AFib) Center of Excellence at TriHealth Heart Institute in Cincinnati, Ohio.
When was the AFib Center of Excellence at TriHealth Heart Institute created? How many AFib patients are treated at the center?
We started our program 4 years ago in 2017. We see approximately 10 new patients per week, in addition to the patients that are already part of the program. The program as a whole has grown over the years, but the number of new patients that we see is fairly stable.
What is the goal of an AFib Center of Excellence?
The goal for our center of excellence is to identify patients early in the course of their disease and provide comprehensive treatment for their atrial fibrillation. We want to see these patients soon after their diagnosis, and treat all the different facets of their AFib, whether or not that includes catheter ablation, surgical ablation, or lifestyle modification (sleep apnea, weight loss, or exercise).
Why is a team-based approach important?
Because AFib is associated with many different common comorbidities such as hypertension, obesity, and sleep apnea, no one person can treat AFib by themselves. Management of AFib requires help from other specialties.
In terms of directly treating the AFib, the things that we do now for rate and rhythm control are getting much more complex, including medication, implanted devices, catheter-based ablation, surgical ablation, and hybrid ablation, depending on what the patient may need.
Other components to treating AFib include stroke prevention and left atrial appendage (LAA) management. There are multiple different medications in terms of anticoagulation that can be used. There are also percutaneous-based and surgical approaches to close the appendage. So for one disease, there are many treatment options that are all important, and that all need to be individualized for each patient.
Can you tell me about the different specialties that are involved in care at the AFib center?
Electrophysiology is the “hub” of the wheel, but we also work closely with our sleep apnea physicians and CT surgeons. A lot of times, if surgical intervention in the form of an epicardial ablation or left atrial appendage clip is going to be necessary, we’ll have the patient meet with both the surgeon and physician at the same visit to discuss those options. Our general cardiologists are also involved in the center, but more so in follow-up of patients that don’t require specialized care from an electrophysiologist.
We are also working on developing a program for exercise and weight loss, and have a pilot program started. It’s at a local health club that is part of our health system, and offers patients a free membership to the gym for 12 weeks. The supervised exercise program is 2 nights per week and can be individualized to include classes on nutrition and wellness. We are using it for patients with atrial fibrillation who probably do not need or qualify for traditional cardiac rehabilitation, but would still certainly benefit from an supervised exercise and education program. I believe having other people involved as well as a defined time and location brings structure and accountability to the program.
How do you best identify at-risk patients who would benefit from this model of care?
My personal belief is that all AFib patients would benefit from it. When we see patients at their initial evaluation, we make sure that all comorbidities are being addressed. We have a thorough discussion regarding options for rhythm control, such as ablation, and we evaluate whether non-pharmacologic treatments such as the WATCHMAN device (Boston Scientific) for stroke prevention can be utilized. Again, we can always refer back to the general cardiologists for long-term management. The patient does not need to continue to see us indefinitely, but I think pretty much everybody with atrial fibrillation would benefit from this.
How do you ensure timely access to care? What is the treatment pathway for patients presenting to urgent care, ED, or primary care physicians?
This is one of the areas where we are currently struggling to get more people in to be seen — everyone’s schedule is very busy in the clinic. So we set aside one afternoon a week for new patient referrals for the AFib clinic. Therefore, if somebody with AFib comes into the ER or is referred in by a primary care physician, we schedule them during that time. We do see some new patient referrals from our general cardiology partners as well. However, a lot of these patients come from the ER and directly from primary care to EP. Again, it’s really modeled on seeing those newly diagnosed atrial fibrillation patients. We are not currently seeing them all the next day after their emergency room visit, and we’re certainly still seeing new atrial fibrillation patients in our regular practice and offering them all those similar treatment options. But the goal is to have dedicated clinic time every week for new atrial fibrillation referrals.
Can you tell me about the development of team-based pathways and standardized protocols for the AFib Center?
Where we have been most successful is our partnership with our surgeons. Surgical ablation for AFib, including the Maze procedure, the convergent procedure, and the left atrial appendage clip, has all really come into maturity over the last 10 years. We partner with our surgeons to decide which patients are better suited for a surgical procedure, a more traditional catheter-based approach, or left atrial appendage closure.
Our coordinator for the WATCHMAN program has also been tremendously helpful. We’re working on getting a dedicated coordinator for the general AFib program as well.
How did you ensure support and buy-in from stakeholders?
Buy-in is incredibly important. We’ve done well because we have good collegiality amongst our EP physicians and we’re all happy to use this model to set aside dedicated clinic time. There are 4 main EP doctors that staff the clinic, and we participate on a rotating basis. Buy-in from surgery is also important, because these procedures are different than standard open-heart surgeries and require a commitment on the part of the surgeon. Our surgeons have to be interested in keeping their volumes up and focused on a particular skill set. Finally, it’s important to have buy-in from administration. It may sound simple to hold one afternoon open a week for new AFib patient referrals; however, it can be a challenge if everybody is busy. Therefore, it’s important to enlist the help of your office manager, hospital administrators, and schedulers. It takes a team.
How has the pandemic also impacted treatment and management of AFib?
Great question. In March and some of April 2020, we slowed way down, as did everyone else. We did fewer procedures and saw fewer patients. Many of those patients were seen over Zoom. But since that time, we’ve been able to successfully reopen our program. By May 2020, we were again performing AFib ablations and WATCHMAN implants. One of the major changes we made during this time is that we shifted all of our ablations and LAAC implants to same-day discharge. I would estimate more than 90% of those patients now go home same day. The patients like it and have done very well. We still offer some telehealth visits, but the majority of visits are back to being in person. Like probably most other programs around the country, we’ve successfully reopened in-person visits and are pretty much back to normal, obviously with the exception of masks and distancing and extra hygiene.
But I think the one area that affected us long term is implementing a same-day discharge approach. We have probably done close to 100 WATCHMAN implants utilizing same-day discharge, and they have all done remarkably well. Often patients will ask us beforehand what the procedure and recovery will be like for them. When we tell them that they will be able to go home later that same day, I think they are a little less nervous. It’s kind of a game changer for a lot of them. We’ve been coming up on a year of same-day discharges, and it’s working well.
Does a more personalized approach to AFib improve care for patients?
Absolutely. There are so many treatment options, but the options can be confusing because none of them are black and white, so I would say a personalized approach is mandatory. I think we see it most dramatically on our end in patients that would be eligible for or benefit from some kind of procedure such as LAAC, or they just had a recurrent GI bleed and we have something we can offer them, or they’ve been symptomatic with their AFib and have had a declining ejection fraction for years in some cases, but they’re only being managed with minimal rate control and anticoagulation. At the same time, you cannot take a blanket statement and assume that every patient with AFib should be ablated, because that’s not true. So a personalized approach is absolutely important.
Have you seen reductions in factors such as AFib-related admissions, ER visits, or cardiovascular events?
We have not yet tracked hard outcomes of cardiovascular events. However, I can tell you that of the patients in our program, we do see reduced hospitalizations and patients tend to do better. We also work with our ER doctors to get people out of the emergency room with an outpatient pathway towards treatment rather than needing to be frequently admitted for the AFib-related events.
What suggestions do you have for building a comprehensive AFib center of excellence?
Start with your relationships among the physicians, including the EPs and surgeons. Identify early on what resources and commitments that you will need from administration, and work to get those. And don’t forget perseverance. We tried to get this going a few times before we were really successful. So even if you try once and things don’t seem to be perfect, try twice, try three times. You’ll get there.
Disclosures: Dr. Winner has no conflicts of interest to report regarding the content herein.