A Multidisciplinary Approach to Surgical Treatment of Atrial Fibrillation: Allied Health Professionals as Stakeholders for the First Robotic-Enhanced Hybrid Ablation Program

T. Wilcox, S. Scalish, A. Koenigs, S. Schena, M. Gasparri
Medical College of Wisconsin, Milwaukee, Wisconsin

Purpose: Atrial fibrillation (AF) affects over 33 million worldwide, posing risks of stroke, cardiac failure and dementia.1 Surgical innovations like Robotic-Enhanced Hybrid Ablation (RE-HA)2 offer less-invasive solutions. Successful implementation hinges on multidisciplinary collaboration, careful patient selection, resource assessment, and industry alliances. We aim to outline program initiation, core objectives, and outcomes.

Methods: Following consultation with stakeholders, champions from surgery, electrophysiology, cardiology imaging and cardiac anesthesia were selected for the purpose of creating a RE-HA program. Core members included advanced practice providers (APPs) coordinators and a registered nurse (RN) navigator. RE-HA consists of sequential epicardial ablation, left atrial appendage occlusion (LAAO), and endocardial lesion-set completion.[2] Program growth was evaluated before and after initiation of such team-approach by number of referrals/case volume. Multidisciplinary approach from referral to long-term follow-up allowed prospective post-procedural data collection in an institutional database. Review of electronic medical records also allowed to establish proper discontinuation of both class I/III anti-arrhythmic drugs (AAD) and oral anticoagulation (OAC). Rhythm follow-up was performed through either Holter monitor or interrogation of any pre-implanted pacing device at 3 and 12-months. Furthermore, successful LAAO was determined through either cardiac-CT scan or transesophageal echocardiography (TEE).

Results: Between November 2019 and March 2024, 123 patients (66 ± 9 years, 67.5% male, BMI 33.6 ± 6.9 kg/m2, CHA2-DS2-VASc 2.9±1.5, HASBLED 2.9±1.3) underwent RE-HA. Seven patients had a prior sternotomy. When assessing program’s growth from its inception to date, there was a progressive increase in referred patients and surgical volume, with 5 patient referrals in the first year and 83 at the end of 2023 (Figure). This corresponded to a 59% increase since instituting our APP-guided pathways in 2021 and introducing an RN navigator in 2022. No operative mortalities have been observed thus far (Table). At imaging follow-up, LAAO by CT-scan or TEE was confirmed in 97.3% of patients. Within the surgical cohort, 85 patients have successfully entered long-term rhythm follow-up with an observed 71.1% freedom from AF at 1 year. Class I/III AAD were discontinued for 61% of patients, while 72% of eligible patients did not necessitate further OAC

Conclusion: AHP can be the foundation of a RE-HA program where multidisciplinary approach is paramount. Its creation and implementation through crucial interfacing roles between professionals and patients favors outcomes in-line with other minimally-invasive approaches to AF. This model helps effectively addressing more patients by improving symptomology, promoting adherence-to-treatment and minimizing complications.

Identify the source of the funding for this research project: NA