Barriers to atrial fibrillation ablation during mitral valve surgery

Abstract

Background: Nearly 40% of patients with atrial fibrillation (AF) undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. We assessed barriers to implementation of this evidence-based practice through a survey of cardiac surgeons in 2 statewide quality collaboratives.

Methods: Adult cardiac surgeons across 2 statewide collaboratives were surveyed on their knowledge and practice regarding AF ablation. Questions concerning experience, clinical practice, case scenarios, and barriers to implementation were included.

Results: Among 66 respondents (66 of 135; 48.9%), the majority reported "very comfortable/frequently use" cryoablation (53 of 66; 80.3%) and radiofrequency (55 of 66; 83.3%). Only 12.1% (8/66) were not aware of the recommendations. Approximately one-half of the respondents reported learning AF ablation in fellowship (50.0%; 33 of 66) or attending courses (47.0%; 31 of 66). Responses to clinical scenarios demonstrated wide variability in practice patterns. One-half of the respondents reported no barriers; others cited increased cross-clamp time, excessive patient risk, and arrhythmia incidence as obstacles. Desired interventions included cardiology/electrophysiology support, protocols, pacemaker rate information, and education in the form of site visits, videos and proctors.

Conclusions: Knowledge of evidence-based recommendations and practice patterns vary widely. These data identify several barriers to implementation of concomitant AF ablation and suggest specific interventions (mentorship/support, protocols, research, and education) to overcome these barriers.

Keywords: atrial fibrillation; barriers; concomitant ablation; implementation science.

Figure 1

Surgeon Reported Mitral Valve and Atrial Fibrillation Ablation Yearly Surgical Volume

Figure 2.

A. Surgeon Reported Barriers to Implementation of Evidence-Based Concomitant Atrial Fibrillation Ablation B. Surgeon Reported Interventions To Improve Implementation of Evidence-Based Concomitant Atrial Fibrillation Ablation C. Surgeon Reported Educational Approaches to Improve Implementation of Evidence-Based Concomitant Atrial Fibrillation Ablation

Figure 3.

Surgeon reported barriers by Mitral Valve surgical volume (High=>50 Cases/year, Medium= 10–50 Cases/year, Low <10 Cases/year). Barriers were grouped by Risk (Patients too High Risk, Additional cross-clamp time, Worsens Arrhythmias), Resources (Proper Equipment, Staff/Representative, Not Comfortable), Procedural (Not Paid, Does not work, Other), and No Barriers.

Figure 4.

A. Surgeon reported preference for Cox-Maze IV by barrier vs no barrier for each case presentation. Cases included Open Atrial (mitral valve surgery) or Closed Atrial (aortic valve, coronary, or aortic surgery). Atrial fibrillation includes Persistent Atrial Fibrillation, Paroxysmal Atrial Fibrillation, or Unclear history of Atrial Fibrillation. Percent of respondents is listed along the X-axis. B. Surgeon reported preference for Pulmonary Vein Isolation by barrier vs no barrier for each case presentation. Cases included Open Atrial (mitral valve surgery) or Closed Atrial (aortic valve, coronary, or aortic surgery). Atrial fibrillation includes Persistent Atrial Fibrillation, Paroxysmal Atrial Fibrillation, or Unclear history of Atrial Fibrillation. Percent of respondents is listed along the X-axis. C. Surgeon reported preference for Left Atrial Appendage Ligation by barrier vs no barrier for each case presentation. Cases included Open Atrial (mitral valve surgery) or Closed Atrial (aortic valve, coronary, or aortic surgery). Atrial fibrillation includes Persistent Atrial Fibrillation, Paroxysmal Atrial Fibrillation, or Unclear history of Atrial Fibrillation. Percent of respondents is listed along the X-axis.

Figure 5.

Graphical abstract highlighting the results of this implementation science based survey of cardiothoracic surgeons in the VCSQI (54.3% response rate) and the MSTCV (44.9% response rate). A majority of respondents performed a moderate volume of mitral valve surgery (10–50 cases/year) with lower volume surgeons significantly more likely to report barriers to concomitant AF ablation related to patient risk or resource availability. There were 12.1% of surgeons unaware of societal guidelines while about half of respondents had formal training in AF ablation. While 46% of respondents reported no barriers, the most common barriers reported were related to patient risk and procedure safety. Finally, proposed interventions included increased support from cardiology/EP, stronger evidence, and mentorship/education including site visits and videos.