Skip to main content
SpringerLink
Log in

Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry

Journal of Interventional Cardiac Electrophysiology Aims and scope Submit manuscript

Cite this article

Abstract

Background

The Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) is a multicenter prospective registry of atrial fibrillation (AF) ablation. We sought to describe the baseline workflows of REAL-AF operators.

Methods

REAL-AF enrolls high volume minimum fluoroscopy radiofrequency ablators. A 150 item questionnaire was administered to participating operators. Responses were analyzed using standard methods.

Results

Forty-two respondents had a mean 178.2 ± 89.2 yearly AF ablations, with 42.4 ± 11.9% being paroxysmal (PAF). Most operators performed ablation with uninterrupted or minimally interrupted anticoagulation (66.7% and 28.6%). Left atrial appendage (LAA) thrombus was most commonly ruled out with transesophageal echocardiography (33.3% and 42.9% for PAF and persistent AF). Consistent with registry design, radiofrequency energy (92.1% ± 18.8% of cases) and zero fluoroscopy ablation (73.8% goal 0 fluoroscopy) were common. The majority of operators relied on index-guided ablation (90.5%); Mean Visitag surpoint targets were higher anteriorly vs posteriorly (508.3 ± 49.8 vs 392.3 ± 37.0, p < 0.01), but power was similar. There was considerable heterogeneity related to gaps in current knowledge, such as lesion delivery targets and sites of extra-pulmonary vein ablation (most common was the posterior wall followed by the roof). Peri-procedural risk factor management of obesity, hypertension, and sleep apnea was common. There was a mean of 3.0 ± 1.2 follow-up visits at 12 months.

Conclusions

REAL-AF operators were high volume low fluoroscopy “real world” operators with good follow-up and adherence to known best-practices. There was disagreement related to knowledge gaps in guidelines.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7

Similar content being viewed by others

References

  1. Holmqvist F, Kesek M, Englund A, Blomström-Lundqvist C, Karlsson LO, Kennebäck G, …Insulander P. A decade of catheter ablation of cardiac arrhythmias in Sweden: ablation practices and outcomes. Eur Heart J. 2019; 40(10), 820–830. https://doi.org/10.1093/eurheartj/ehy709.

  2. Hosseini SM, Rozen G, Saleh A, Vaid J, Biton Y, Moazzami K, …Ruskin JN. Catheter Ablation for Cardiac Arrhythmias: Utilization and In-Hospital Complications, 2000 to 2013. JACC Clin Electrophysiol. (2017); 3(11), 1240–1248. https://doi.org/10.1016/j.jacep.2017.05.005.

  3. Cappato R, Calkins H, Chen S.-A, Davies W, Iesaka Y, Kalman J, …Biganzoli E. Updated worldwide survey on the methods, efficacy, and safety of catheter ablation for human atrial fibrillation. Circ Arrhythm Electrophysiol. (2010);3(1), 32–38. https://doi.org/10.1161/CIRCEP.109.859116.

  4. Tripathi B, Arora S, Kumar V, Abdelrahman M, Lahewala S, Dave M, …Deshmukh A. Temporal trends of in-hospital complications associated with catheter ablation of atrial fibrillation in the United States: An update from Nationwide Inpatient Sample database (2011-2014). J Cardiovasc Electrophysiol. 2018;29(5):715–724. https://doi.org/10.1111/jce.13471.

  5. Varley AL, Kreidieh O, Godfrey BE, Whitmire C, Thorington S, D’Souza B, …Osorio J (2021) A prospective multi-site registry of real-world experience of catheter ablation for treatment of symptomatic paroxysmal and persistent atrial fibrillation (Real-AF): design and objectives. J Interv Card Electrophysiol. https://doi.org/10.1007/s10840-021-01031-w.

  6. Calkins H, Hindricks G, Cappato R, Kim Y.-H, Saad EB, Aguinaga L, …Yamane T. 2017 HRS/EHRA/ECAS/APHRS/SOLAECE expert consensus statement on catheter and surgical ablation of atrial fibrillation. Heart Rhythm. 2017;14(10):e275–e444. https://doi.org/10.1016/j.hrthm.2017.05.012.

  7. Middeldorp ME, Pathak RK, Meredith M, Mehta AB, Elliott AD, Mahajan R, …Sanders P. PREVEntion and regReSsive Effect of weight-loss and risk factor modification on Atrial Fibrillation: the REVERSE-AF study. EP Europace. 2018;20(12):1929–1935. https://doi.org/10.1093/europace/euy117.

  8. Pathak RK, Middeldorp ME, Meredith M, Mehta AB, Mahajan R, Wong CX, … Sanders P. Long-Term Effect of Goal-Directed Weight Management in an Atrial Fibrillation Cohort. J Am Coll Cardiol. 2015;65(20):2159–2169. https://doi.org/10.1016/j.jacc.2015.03.002.

  9. Pathak RK, Evans M, Middeldorp ME, Mahajan R, Mehta AB, Meredith M, … Sanders P. Cost-Effectiveness and Clinical Effectiveness of the Risk Factor Management Clinic in Atrial Fibrillation. JACC Clin Electrophysiol. , 3(5), 436–447. 2017. https://doi.org/10.1016/j.jacep.2016.12.015.

  10. Di Biase L, Burkhardt JD, Santangeli P, Mohanty P, Sanchez JE, Horton R, … Natale A. Periprocedural Stroke and Bleeding Complications in Patients Undergoing Catheter Ablation of Atrial Fibrillation With Different Anticoagulation Management: Results From the Role of Coumadin in Preventing Thromboembolism in Atrial Fibrillation (AF) Patients Undergoing Catheter Ablation (COMPARE) Randomized Trial. Circulation. 2014; 129(25):2638–2644. https://doi.org/10.1161/CIRCULATIONAHA.113.006426.

  11. El Haddad M, Taghji P, Phlips T, Wolf M, Demolder A, Choudhury R, … Duytschaever M. Determinants of Acute and Late Pulmonary Vein Reconnection in Contact Force–Guided Pulmonary Vein Isolation: Identifying the Weakest Link in the Ablation Chain. Circ Arrhythm Electrophysiol. 2017;10(4). https://doi.org/10.1161/CIRCEP.116.004867.

  12. Duytschaever M, Vijgen J, De Potter T, Scherr D, Van Herendael H, Knecht S, … Gupta D. Standardized pulmonary vein isolation workflow to enclose veins with contiguous lesions: the multicentre VISTAX trial. EP Europace. 2020;22(11):1645–1652. https://doi.org/10.1093/europace/euaa157.

  13. Chinitz J, Michaud G, Stephenson K. Impedance-guided Radiofrequency Ablation: Using Impedance to Improve Ablation Outcomes. J Innov Cardiac Rhythm Manage. 2017;8(10):2868–73. https://doi.org/10.19102/icrm.2017.081003.

    Article  Google Scholar 

  14. Naniwadekar A, Dukkipati SR. High-power short-duration ablation of atrial fibrillation: A contemporary review. Pacing Clin Electrophysiol. 2021;44(3):528–40. https://doi.org/10.1111/pace.14167.

    Article  PubMed  Google Scholar 

  15. Kaneshiro T, Kamioka M, Hijioka N, Yamada S, Yokokawa T, Misaka T, … Takeishi Y. Characteristics of Esophageal Injury in Ablation of Atrial Fibrillation Using a High-Power Short-Duration Setting. Circ Arrhythm Electrophysiol. 2020; 13(10). https://doi.org/10.1161/CIRCEP.120.008602.

  16. Leung LWM, Akhtar Z, Sheppard MN, Louis-Auguste J, Hayat J, Gallagher MM. Preventing esophageal complications from atrial fibrillation ablation: A review. Heart Rhythm O2. 2021;2(6):651–64. https://doi.org/10.1016/j.hroo.2021.09.004.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Valderrábano M, Peterson LE, Swarup V, Schurmann PA, Makkar A, Doshi RN, … Kleiman NS. Effect of Catheter Ablation With Vein of Marshall Ethanol Infusion vs Catheter Ablation Alone on Persistent Atrial Fibrillation: The VENUS Randomized Clinical Trial. JAMA. 2020;324(16):1620. https://doi.org/10.1001/jama.2020.16195.

  18. Romero J, Patel K, Briceno D, Lakkireddy D, Gabr M, Diaz JC, … Di Biase L. Cavotricuspid isthmus line in patients undergoing catheter ablation of atrial fibrillation with or without history of typical atrial flutter: A meta‐analysis. J Cardiovasc Electrophysiol. 2020; 31(8):1987–1995. https://doi.org/10.1111/jce.14614.

  19. Verma A, Jiang C, Betts TR, Chen J, Deisenhofer I, Mantovan R, … Sanders P. Approaches to Catheter Ablation for Persistent Atrial Fibrillation. N Engl J Med. 2015;372(19):1812–1822. https://doi.org/10.1056/NEJMoa1408288.

  20. Romero J, Gabr M, Alviz I, Briceno D, Diaz JC, Rodriguez D, … Di Biase L. Focal impulse and rotor modulation guided ablation versus pulmonary vein isolation for atrial fibrillation: A meta‐analysis of head‐to‐head comparative studies. J Cardiovasc Electrophysiol. 2021;32(7):1822–1832. https://doi.org/10.1111/jce.15036.

  21. Romero J, Di Biase L, Mohanty S, Trivedi C, Patel K, Parides M, … Natale A. Long-Term Outcomes of Left Atrial Appendage Electrical Isolation in Patients With Nonparoxysmal Atrial Fibrillation: A Propensity Score-Matched Analysis. Circ Arrhythm Electrophysiol. 2020;13(11). https://doi.org/10.1161/CIRCEP.120.008390.

  22. Presented by Dr. David J. Wilber at the American Heart Association Virtual Annual Scientific Sessions (AHA 2021), November 14, 2021. (n.d.).

  23. Osorio J. Gains in Paroxysmal Atrial Fibrillation Ablation Using a Standardized Workflow to Optimize Contact Force Technologies. J Atr Fibrillation. 2018;11(4):2097. https://doi.org/10.4022/jafib.2097.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Skjold-Ødegaard B, Søreide K. Standardization in surgery: friend or foe? Br J Surg. 2020;107(9):1094–6. https://doi.org/10.1002/bjs.11573.

    Article  PubMed  Google Scholar 

  25. Loring Z, Holmes DN, Matsouaka RA, Curtis AB, Day JD, Desai N, … Piccini JP. Procedural Patterns and Safety of Atrial Fibrillation Ablation: Findings From Get With The Guidelines-Atrial Fibrillation. Circulation. Arrhythm Electrophysiol. 2020;13(9):e007944. https://doi.org/10.1161/CIRCEP.119.007944.

  26. Sommer P, Bertagnolli L, Kircher S, Arya A, Bollmann A, Richter S, … Hindricks G. Safety profile of near-zero fluoroscopy atrial fibrillation ablation with non-fluoroscopic catheter visualization: experience from 1000 consecutive procedures. Europace. 2018;20(12):1952–1958. https://doi.org/10.1093/europace/eux378.

  27. Bayoumy K, Gaber M, Elshafeey A, Mhaimeed O, Dineen EH, Marvel FA, … Elshazly MB. Smart wearable devices in cardiovascular care: where we are and how to move forward. Nat Rev Cardiol. 2021. https://doi.org/10.1038/s41569-021-00522-7.

  28. Steinberg BA, Piccini JP. Screening for Atrial Fibrillation With a Wearable Device. JAMA. 2018;320(2):139. https://doi.org/10.1001/jama.2018.8513.

    Article  PubMed  Google Scholar 

Download references

Funding

The REAL-AF Registry is an investigator initiated study which is sponsored by Heart Rhythm Clinical and Research Solutions and funded by Biosense-Webster. There was no funding provided for the specific analysis presented here.

Author information

Authors and Affiliations

  1. Brigham And Women’s Hospital, Harvard Medical School, 44 Washington Street, Boston, MA, 02115, USA

    Omar Kreidieh, Jorge Romero & Paul C. Zei

  2. Heart Rhythm Clinical and Research Solutions, Birmingham, AL, USA

    Allyson L. Varley, Brigham E. Godfrey, Gunther Schrappe & Linda Justice

  3. Division of Cardiology, Queen’s Medical Center, Honolulu, HI, USA

    David Singh

  4. Allegheny General Hospital, Pittsburgh, PA, USA

    Josh Silverstein & Amit Thosani

  5. Division of Cardiology, University of Colorado Anschutz Medical Campus, Denver, CO, USA

    Paul Varosy

  6. Michigan Heart and Vascular Institute, St Mary Mercy Hospital, Livonia, MI, USA

    Shrinivas Hebsur

  7. Arrhythmia Institute at Grandview Health, Birmingham, AL, USA

    Jose Osorio

Authors
  1. Omar Kreidieh
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Allyson L. Varley
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jorge Romero
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. David Singh
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Josh Silverstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Amit Thosani
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Paul Varosy
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Shrinivas Hebsur
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Brigham E. Godfrey
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Gunther Schrappe
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Linda Justice
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Paul C. Zei
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Jose Osorio
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Omar Kreidieh.

Ethics declarations

Ethical/IRB approval

The Brookwood Baptist Health System Institutional Review Board (IRB) originally granted a waiver of informed consent and authorization for analysis and publication of data from the REAL-AF registry on April 5, 2016. Due to subsequent closure of this IRB, the project was transferred to and approved by the Western Institutional Review Board (WIRB) on October 31, 2018. The current analysis utilizes physician surveys on practice patterns and does not include direct patient data.

Disclosures

Joshua Silverstein – Consulting and Honoraria Biosense Webster, Medtronic.

J Osorio is a paid consultant for Biosense Webster, Inc., Galaxy Medical, Medtronic and Boston Scientific Allyson Varley- employed by HRCRS/REAL-AF.

The REAL-AF Registry is sponsored by Heart Rhythm Clinical and Research Solutions and funded by Biosense-Webster. There was no funding provided for the analysis presented here.

No other conflicts of interest to disclose.

Additional information

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (PDF 250 kb)

Rights and permissions

Reprints and Permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Kreidieh, O., Varley, A.L., Romero, J. et al. Practice Patterns of Operators Participating in the Real-World Experience of Catheter Ablation for Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) Registry. J Interv Card Electrophysiol 65, 429–440 (2022). https://doi.org/10.1007/s10840-022-01205-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s10840-022-01205-0

Keywords

search

Navigation