Q&A: Importance of advanced EP training to deliver effective, durable AF ablation
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Key takeaways:
- Advanced electrophysiology fellowship training is essential for operators conducting AF ablations.
- Complete mapping and assessment of the pulmonary veins is necessary to ensure effective, durable ablation.
Atrial fibrillation is a complex disease with ever-increasing treatment options, such as ablation, and advanced electrophysiology fellowship training is key to improving long-term outcomes, according to a new consensus statement.
To emphasize the importance of advanced electrophysiology (EP) training among operators performing pulmonary vein isolation for AF ablation, the Heart Rhythm Society issued a policy statement, highlighting training goals and the complex, individualized considerations necessary for safe and effective ablation.
“As newer technologies have become increasingly available to treat a wider spectrum of patients with AF, the Heart Rhythm Society (the preeminent voice of heart rhythm physicians, scientists and allied professionals) would like to emphasize and reaffirm the foundational principles that are appropriate to the performance of AF ablation contained within these documents,” Kenneth A. Ellenbogen, MD, FHRS, the Martha M. and Harold W. Kimmerling chair in cardiology, the Pauley Heart Center’s director of clinical cardiac electrophysiology and pacing at the Medical College of Virginia (MCV) and director of clinical cardiac electrophysiology and pacing at Virginia Commonwealth University’s MCV campus, and colleagues wrote.
Healio spoke with Ellenbogen, the president of HRS and a co-author of the consensus statement, about the importance of high-quality EP training and “complete and careful electrophysiology study” in achieving accurate, durable AF ablation.
Healio: What is the goal of this consensus statement?
Ellenbogen: The goal of the consensus statement is to provide optimal care to patients with AF. We want to make certain that patient outcomes and safety are optimal, and ensure that only physicians trained in electrophysiology perform these procedures. Training in electrophysiology requires 4 years in medical school and 8 years of additional very rigorous training. The training involves substantial expertise in performing cardiac ablation procedures, of which AF is the most common.
Healio: Has the rise of catheter ablation also been met with a rise in interest in advanced EP fellowship training? How has it impacted training?
Ellenbogen: Yes, there is an increase in interest in electrophysiology training and EP fellowship training programs. In the past, it was not uncommon for 25% of electrophysiology training fellowship slots to go unfilled.
Healio: What are your biggest takeaways from this consensus statement?
Ellenbogen: Our society will strongly advocate on behalf of our patients and providers. We must be certain that patients receive the best possible care. This means that they have these complex procedures performed by the most expert and highly trained individuals. We wish to advocate on behalf of our physicians who have been rigorously and completely trained in all aspects of performing this complex procedure.
Healio: Can you summarize some of the key targets and barriers to complete pulmonary vein isolation during ablation procedures?
Ellenbogen: It requires patience and training to do a thorough, complete and comprehensive procedure. The targets can be anywhere in the right or left atrium. There are many potential targets for mapping and ablation and the electrophysiologist must decide which areas need to be ablated and which do not. They must make many complex decisions that they learn during training to analyze and decide what are the safest and most effective way to deliver lesions.
Healio: What is the current state of concomitant catheter AF ablation and percutaneous left atrial appendage closure/occlusion?
Ellenbogen: This was recently approved as a combined procedure for reimbursement by CMS. We are beginning to do the combined procedure in appropriately selected patients. This requires more physician time and more physician expertise as well as more planning. My personal experience and that of others is that in the right patient, it is a wonderful opportunity for them to have one combined procedure rather than two separate procedures.
Healio: What are some of the key points to an individualized approach to catheter ablation for AF?
Ellenbogen: The most important key takeaway or take-home point for other physicians and health care providers/professionals is that patients with AF often may have other cardiac arrhythmias that also need to be treated. These arrhythmias include atrial flutter, atrial tachycardia and [atrioventricular] nodal reentry. It is absolutely critical that the electrophysiologist does a complete and careful electrophysiology study to diagnose these arrhythmias and, at the same ablation procedure, cure them as well. It is also equally important to perform careful mapping of the pulmonary veins at baseline and then after the procedure is performed to confirm the ablation has been successful and that there are not additional areas that need to be ablated or that there are no areas that were missed by the ablation procedure.
Reference:
For more information:
Kenneth A. Ellenbogen, MD, FHRS, can be reached at 1200 E. Marshall St., Richmond, VA 23219.
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