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Unlock Ep Lab Capacity with Medtronic Cryoballoon Treat More Patients UNLOCK EP LAB CAPACITY WITH MEDTRONIC CRYOBALLOON TREAT MORE PATIENTS. SAVE TIME. REDUCE STRESS. University Clinical Centre Rijeka, Croatia ABLATION AS A TREATMENT FOR AF The 2016 European Society of Cardiology (ESC) serious bleeding, or cardiac arrest, or on all-cause guidelines recommend PVI with catheter ablation, mortality. However, a per-protocol analysis censoring without further substrate modification, as first- the 9.2% of ablation patients who did not get line therapy to treat patients with AF. Catheter the procedure and the 27.5% of the drug group ablation can be performed with radiofrequency (RF) who crossed over to ablation shows substantial or cryothermal energy.5 An alternative to catheter advantages to the ablation procedure: 33% relative ablation is antiarrhythmic drug therapy. reduction in the primary composite endpoint, and Results from CABANA, a large multicentre, 40% relative reduction in all-cause mortality. Both randomised controlled trial comparing catheter analyses showed a significant 17% relative reduction ablation to drug therapy for the treatment of AF, in death or cardiovascular hospitalisation associated did not demonstrate a significant difference in the with catheter ablation.6 primary composite endpoint of disabling stroke, ATRIAL FIBRILLATION: CRYOBALLOON ABLATION THE CURRENT EPIDEMIC ECONOMIC VALUE Atrial fibrillation (AF) is the most common sustained FIRE AND ICE,10 the largest multicentre, prospective, operator and volume-dependent. Cryoballoon cardiac arrhythmia, affecting 1–2% of the general randomised trial that compared the efficacy and ablation results were more consistent regardless population around the world.1,2 In Europe, there are safety of Cryoballoon ablation and RF ablation, of centre or operator experience. As a result, the over six million people diagnosed with AF,3 although met its primary safety and efficacy endpoints outcomes in less experienced centres favoured the actual number is estimated to be much higher with shorter, more consistent procedure times. cryoablation, reflecting its shorter learning curve and since so many cases remain undiagnosed. With the Secondary analyses results highlight clinically greater reproducibility.8 A single-centre study also ageing population and increasing life expectancy meaningful outcomes that are highly impactful demonstrated that RF ablation procedure durations across Europe, it is estimated that there will be to patients. Relative to RF ablation, Cryoballoon are more variable than Cryoballoon ablations. In 14-17 million people with AF in Europe by 2030.4 ablation demonstrated 21% fewer all-cause absolute terms, 28.6% of RF procedures proved to This is based on the fact that the prevalence of AF hospitalisations, 34% fewer cardiovascular be more than 30 minutes longer than the median increases with age, from 0.5% at 40–50 years of age hospitalisations (including AF hospitalisations), 50% duration, while for Cryoballoon ablation procedures, to 5–15% at 80 years of age. Given the comparable fewer direct current cardioversions and 33% fewer only 4.4% of procedures exceeded the median by demographic landscape in Croatia and the repeat ablations.7 over 30 minutes. Since a procedure with increased assumption that the prevalence of AF is similar to that Studies also demonstrate that Cryoballoon ablation variability can lead to less efficient resource planning of the rest of Europe, it is estimated that there are procedures are more reproducible and have more related to cath lab space and staffing, it can be currently 40–50 thousand patients with AF in Croatia.5 consistent outcomes compared to RF. presumed that procedure duration variability results in more resource requirements and therefore, higher Today, there are seven centres in Croatia treating For instance, a French prospective multicentre costs. Cryoballoon ablation can thus be considered atrial fibrillation patients with pulmonary vein isolation survey comparing the safety and efficacy of more resource efficient than RF ablation.9 (PVI) via catheter ablation. In 2017, there were 778 AF Cryoballoon and RF ablation demonstrated ablations performed in Croatia, 23% of which were that both techniques resulted in similar rates of performed with Cryoballoon ablation and 77% with freedom from AF (68–80% at 18 months), although point-by-point radiofrequency (RF) ablation. the Cryoballoon procedure outcomes were less CATH LAB MANAGEMENT AT UNIVERSITY CLINICAL CENTRE RIJEKA EP RESOURCES changes to the schedule can be addressed in time. To improve pathway and workflow efficiency, The cardiology department at University Clinical Knowing the schedule in advance also gives teams effective communication among ward personnel Centre (UCC) Rijeka is comprised of two cath labs, enough time to perform any additional tests required is very important. For instance, it can significantly one of which is also an EP lab. The EP team at UCC for patients undergoing AF ablation before their reduce patient changeover time and reduce idle Rijeka consists of three nurses, one radiology scheduled procedure to avoid any unnecessary time in the cath lab when the next patient is brought technician, one experienced EP specialist who is complications or delays. from the ward to the preparation room next to performing AF ablations, and two EP fellows who the cath lab where final preparations are made, at are still in training. Together, this team performs THE PATIENT PATHWAY the final stage of the preceding patient. Patient diagnostic coronarography, PCI, endovascular valve The patient admission protocol is as follows: turnover efficiency is also supported by the fact that implantation or repair, EVAR, TEVAR, LA appendage Cryoballoon ablation procedures are performed with Physical examination occlusion, device implantation and extraction, analgosedation, rather than general anesthesia. electrophysiology and catheter ablation procedures. ECG Given the diversity of the procedures performed and Routine blood tests the department resource constraints, it is essential Blood coagulation tests that procedures are managed efficiently and Blood type (in case of complications requiring according to a strict schedule. urgent blood transfusion) Transesophageal echocardiography THE GROWING DEMAND FOR AF ABLATIONS Adequate preprocedural anticoagulation The EP team at UCC Rijeka started performing therapy planning AF ablations two and a half years ago. To support access to AF ablations for the increasing number of people with AF, the hospital team hosts educational events for general practitioners and cardiologists Given this context, it is extremely important to about AF ablation therapy and the types of patients manage EP procedures efficiently and to thoughtfully who are indicated for the treatment. With growing plan the procedure schedule in advance and in THE CRYOBALLOON ABLATION awareness of the AF ablation outcomes in the local detail. Any changes in procedure durations affect medical community, and as word of mouth from the schedule, which can then cause increased idle LEARNING CURVE patients spreads, more and more patients are being time, longer cath lab occupancy time per procedure, referred to UCC Rijeka for AF ablations every year. or the need to postpone or cancel procedures The first AF ablation at UCC Rijeka was performed on To meet the growing demand for AF ablations, UCC altogether. Therefore, in addition to the need for a the 11th of April 2016 using Cryoballoon and since Rijeka has been steadily increasing the number of procedure that is effective, with a low complication then, 167 AF ablations have been performed with AF ablation procedures performed per year. The EP and repeat ablation rate, it is also very important for either cryoablation or point-by-point RF ablation. team performed 35 AF ablation procedures the first the selected method to have a predictable procedure Although both technologies are used at the hospital, year, 75 the second year, and this year the EP team duration. This helps to ensure optimal utilisation the learning curve was different for each technology. plans to perform 120 AF ablations using either RF or of hospital resources and prevents unforeseen New operators at UCC Rijeka began performing Cryoballoon ablation technologies. overtime hours for staff. To optimise cath lab time Cryoablation procedures independently after only and reduce operator idle time, block scheduling is two proctorship sessions. The straightforwardness EFFICIENT PROCEDURE MANAGEMENT used by the arrhythmologic team. Four days per of the Cryoballoon ablation procedure together Scheduling constraints coupled with the increasing week, one cath lab is reserved for the arrhythmologic with the fact that the safety of the patient was not demand for AF ablation makes it very important to team performing catheter ablation or device-related compromised even in the early learning phase helped have a simple and predictable AF ablation approach procedures. Usually two days are reserved for to save time, reduce costs, and enable an efficient to avoid long waiting lists and unplanned overtime for catheter ablation and the other two days for device- adoption process. This is supported by findings staff. Cost effectiveness is also critical in managing related procedures. Depending on the waiting list from a single-centre study in which new operators such an increase in procedures, since resources are and resource availability, both catheter ablations were able to perform PVIs successfully and with divided between several different
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