Arrhythmia

Standardised procedures needed to reduce variations in complications after AF ablation


Researchers have called for standardised processes to be implemented in centres performing atrial fibrillation ablation after finding patient complications varied threefold across Australian and New Zealand hospitals.

A study published in the Journal of the American Heart Association found the overall risk of patient complications within 30 days of catheter ablation to treat AF was 5.5%. Of the 46 hospitals surveyed, six had rates of adverse outcomes that were significant above the national average for the procedure.

Across the board, about one in 18 patients experienced complications. Three-quarters of the complications were deemed potentially reducible or avoidable.

“The rate of complications is highly variable, suggesting that clinically meaningful differences may exist in procedural quality and after-care practices,” said the study authors, led by Dr Linh Ngo from the University of Queensland.

“Concerted clinical and policy efforts are needed to better inform patients, to improve care practices, and to standardise outcomes across ablation centres,” they wrote.

The study assessed reported outcomes from 25,237 patients from 2012 to 2017, as the complex procedure became more commonplace in line with clinical guidelines.

The complication rate from hospitals ranged from zero to more than 21%. The study did not find a correlation between the risk-standardised complication rate and the number of ablations performed each year, with all centres performing  at least 25 procedures during the six-year study period, .

However the incidence of complications was highly dependent on the ablation centre, the researchers noted.

Three quarters of all complications were attributable to bleeding (3.31%), pericardial effusion (0.74%) and infection (o.44%) – complications that can be reduced or avoided with established interventions such as vascular ultrasound, intracardiac echocardiography, or prophylactic antibiotics.

Stroke/transient ischemic attack (0.24%), cardiorespiratory failure and shock (0.19%), and death (0.08%) occurred less frequently.

The study authors said the variation in outcomes was unsurprising given the rapid take-up of the procedure and the wide range of techniques, equipment and resources available.

They pointed to previous research that revealed variation in outcomes for the management of other atrial fibrillation treatments, as well as different cardiac procedures, such as the implantation of defibrillators or pacemakers.

And since the analysis did not find a correlation between complications and the number of ablations performed annually, this suggested procedural quality may be more important.

“Although we could not clearly identify the mechanisms behind the observed variation, there are strategies proven to be effective in reducing procedural complications and therefore should be implemented at all hospital performing AF ablation,” the authors wrote.

“For example, the use of vascular ultrasound could significantly reduce the risk of injury to the blood vessel used for inserting the ablation catheter. Similarly, the use of a small ultrasound catheter (intracardiac echocardiography) could help the doctors to have better visualisation of the heart structure to avoid causing inadvertent injury to the heart while performing the procedure.

“More broadly, clinical audits and safety checklists, which have been shown to be effective in reducing adverse events in general, should also be considered for routine implementation,” Dr Ngo and colleagues suggested.

“Collectively, these findings call for concerted clinical and policy intervention to inform patients, improve procedural safety and standardise care among hospitals,” they concluded.

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