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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.
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.
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.
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.
Concomitant atrial fibrillation ablation during mitral valve surgery remains underutilized despite societal class I recommendations based on level A evidence. Implementation science establishes strategies to increase the integration of effective, evidence-based interventions into clinical practice.
See Commentaries on pages 659 and 660.
Despite the multisocietal class I recommendation, approximately 40% of patients with preoperative atrial fibrillation (AF) undergoing mitral valve surgery do not undergo concomitant ablation.
The 2016 Cardiothoracic Surgical Trials Network randomized trial demonstrated concomitant surgical ablation during mitral valve operations improved freedom from AF at 1 year without any significant effect on mortality or morbidity.
Risk-adjusted analysis supported the safety of concomitant ablation and found that the additional procedure is not associated with increased Society of Thoracic Surgeons (STS) major morbidity or mortality.
These results were validated in an analysis of national STS data demonstrating lower risk-adjusted operative mortality in patients with preoperative AF undergoing concomitant ablation during mitral valve surgery.
Implementation science involves the active application of theoretical frameworks to identify the best methods for promoting best practices. One such established framework, Translating Evidence into Practice, involves 4 steps: (1) summarizing the evidence, (2) measuring current performance, (3) identifying barriers to implementation and dissemination, and (4) maximizing the proportion of patients who receive the recommended intervention.
As steps 1 and 2 have been extensively reported, the objective of this study was to identify barriers to implementation of concomitant AF ablation. Using the Consolidated Framework for Implementation Research, we designed and administered a survey of all adult cardiac surgeons in the Virginia Cardiac Services Quality Initiative (VCSQI) and the Michigan Society of Thoracic and Cardiovascular Surgeons (MSTCVS) Quality Collaborative.
The survey sought to gather information on practice environment, perceived capability, skill, and consequences (Appendix E1). We hypothesized that specific barriers exist that could be ameliorated through education and quality improvement initiatives.
Survey Development and Administration
The study was exempted from review by the University of Virginia's Institutional Review Board with waiver of consent for voluntary participation in the anonymous survey (Protocol 22445). The survey was developed and piloted by the investigators and administered using the Qualtrics survey tool (Qualtrics XM, Seattle, Wash). Questions were based on previous studies of concomitant AF ablation and the scientific approach to implementation science using the Translating Evidence into Practice and Consolidated Framework for Implementation Research frameworks.
The survey and background data were introduced at a quarterly quality meeting and then distributed via email to all adult cardiac surgeons in the VCSQI and MSTCVS quality collaboratives in July 2020. Surgeons who did not complete the survey initially were contacted at least 3 times via email to optimize response rate. After completion of the survey period in August 2020, incomplete surveys (n = 3) were excluded from analysis.
Continuous variables are presented as mean ± standard deviation or median and interquartile range as appropriate based on normality of distribution, and categorical variables are presented as number and percentage of the total. For subgroup analysis, mitral valve surgical volume was stratified as high (≥50 cases/year), medium (10-50 cases/year), or 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. All analyses were performed and figures created with GraphPad Prism version 8.0.1 (GraphPad Software, La Jolla, Calif).
Baseline Characteristics of Respondents
The overall response rate was 48.9% (66 of 135), with similar rates in the VCSQI (54.3%; 31 of 57) and the MSTCVS (44.9%; 35 of 78). Responses were captured from 12 of 19 centers (63.1%) in the VCSQI and from 19 of 33 centers (57.6%) in the MSTCVS. Of all respondents, 45.5% have been in practice for >20 years, with 19.7% having less than 5 years of clinical practice. One-half (33 of 66) of respondents had a broad adult cardiac surgery practice, with 24.2% (16 of 66) reporting a majority subspecialty focus on valvular surgery and 16.7% (11 of 66) reporting a mixed adult cardiac/general thoracic/vascular/congenital practice. Most respondents (71.2%; 47 of 66) reported centralizing mitral valve operations to one partner in their practice, and 19 of those 47 respondents (40.3%) are the mitral valve surgeons in these groups. Mitral valve and AF ablation volume varied across respondents (Figure 1). Thirteen respondents (19.6%) reported using a minimally invasive or robotic approach in more than one-half of their cases, whereas the majority of respondents (59.0%) reported using a standard open approach. Only 40.9% of respondents (27 of 66) reported performing standalone AF ablation procedures in their practice. Finally, 39.3% of respondents (26 of 66) reported that the referring cardiologist rarely (<10%) or never discussed concomitant ablation, whereas only 10.6% (7 of 66) reported that the referring doctor almost always (>90%) discussed concomitant ablation.
One-half of respondents (33 of 66) reported learning AF ablation during their fellowship, whereas 46.9% (31 of 66) reported attending a course on AF ablation (responses were not exclusive). The majority of respondents reported being “very comfortable/frequently use” cryoablation (80.3%; 53 of 66) and bipolar radiofrequency (83.3%; 55 of 66). Similarly, all but 1 respondent reported having access to AF ablation equipment/resources (98.5%) and a company representative (98.5%) at their hospital. However, 12.1% of respondents (8 of 66) of respondents did not know the 2017 STS and Heart Rhythm Society expert consensus class I recommendations regarding concomitant surgical ablation for AF at the time of mitral valve surgery. Despite this knowledge gap, 66.7% of respondents (44 of 66) reported being more likely to perform concomitant AF ablation based on these recommendations.
Surgeon-Reported Clinical Decision Making
The survey presented general clinical scenarios to capture surgeon-reported clinical decision making related to concomitant AF ablation and left atrial appendage ligation (LAAL). The first set of questions related to use of the Cox-Maze IV lesion during open atrial (mitral valve) or closed atrial (coronary or aortic valve) surgery in patients with persistent, paroxysmal, or no preoperative AF (Table 1). The next question set focused on the use of left-sided lesions and pulmonary vein isolation only during open atrial or closed atrial surgery in patients with persistent, paroxysmal, or no preoperative AF (Table 2). Finally, the last set of questions focused on the use of LAAL during open atrial or closed atrial surgery in patients with persistent, paroxysmal, or no preoperative AF (Table 3).
Barriers and Interventions to Improve Implementation
When asked about barriers to implementation of evidenced-based practices, more than one-half (53.7%) of respondents reported barriers (Figure 2). These included a number of operative factors, such as additional cross-clamp time (22.7%), concerns over patient risk (12.9%), and an increased risk of arrhythmias (3.0%). A limited number of respondents (4.6%) reported a lack of financial incentive. Inadequate education (3.0%) or access to equipment/resources (3.0%) were not commonly reported. Importantly, only 1 respondent did not think that sufficient evidence exists to support concomitant AF ablation. When stratified by mitral valve surgical volume, the majority of high-volume (≥50 cases/year) and medium-volume (10-50 cases/year) surgeons reported no barriers (Figure 3). A significantly higher proportion of low-volume (<10 cases/year) mitral valve surgeons reported risk (includes patients too high risk, additional cross-clamp time, worsens arrhythmias) as a barrier to concomitant ablation (P = .023).
When stratifying surgeon preference for the use of Cox Maze IV (CM-IV), pulmonary vein isolation (PVI), and LAAL, we demonstrate that surgeons who report no barriers are more likely to answer “always” or “usually” for performance of a concomitant AF procedure (P = .014). Specifically, in patients with persistent AF, surgeons with no barriers reported “always” performing concomitant CM-IV in 67% of closed atrial and 78% of open atrial operations, compared with 31% and 27%, respectively, for surgeons who reported barriers (Figure 4, A). Surgeon preference for PVI was not significantly different by barrier status (Figure 4, B). Finally, a majority of surgeons reported that they would perform LAAL for patients with persistent or paroxysmal AF, with a significantly higher proportion of “always” from surgeons reporting no barriers (Figure 4, C).
Respondents identified a number of interventions to overcome these barriers, with the most frequent answer being “more support from cardiology/electrophysiology” (Figure 2, B). Other write-in responses reported a desire for “systematic protocols,” “more data on permanent pacemaker rate,” “more support from surgical community when detrimental outcome,” and “improved minimally invasive approaches.” Additional responses included need for mentorship, education, and financial incentive. Finally, when asked specifically about optimal approaches to improve education, the 3 most common suggestions were site visits (25.7%), educational videos (24.2%), and on-site proctors (24.2%) (Figure 2, C).
These survey results from 2 large statewide quality collaboratives provide qualitative and quantitative data highlighting the variability in practice patterns and knowledge of evidence-based recommendations about concomitant AF treatment. A majority of respondents had formal training in AF ablation during fellowship or postgraduate courses, with most surgeons reporting they felt comfortable using the devices and had adequate access to resources. Although almost one-half of respondents reported no barriers to implementation of these evidence-based recommendations, several modifiable barriers were identified, including patient selection, education, arrhythmia data, and financial incentives. Second-order analysis identified low mitral valve surgical volume as associated with higher rates of risk and resource-related barriers to implementation of concomitant AF ablation. In addition, surgeons who reported no barriers were significantly more likely to report the performance of CM-IV and LAAL in patients with AF. Suggestions for interventions included more support from cardiology/electrophysiology, systematic protocols, mentorship, research, financial support, and education. Specifically, respondents reported the most-needed educational resources include site visits, surgical videos, and onsite proctoring (Figure 5).
Since the 2015 publication of the Cardiothoracic Surgical Trials Network trial supporting the routine use of concomitant AF ablation during mitral valve surgery, there have been a number of consensus statements from the STS, American College of Cardiology, American Association for Thoracic Surgery, Heart Rhythm Society, Asia Pacific Heart Rhythm Society, Latin American Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society supporting this practice. Despite the unanimous support from professional societies, there have been limited plans for support or implementation of these recommendations.
One of the major findings from the present survey was that surgeons would like more support from electrophysiology and cardiology colleagues who refer the patients. Although this may be perceived support, survey respondents wanted a more collaborative environment in which complications like arrhythmias and permanent pacemaker placement would be managed with a team approach. The formal societal recommendations are important, but these data suggest that continued education is needed even within the cardiology community. Similarly, the survey identified a major need for surgical mentorship from surgeons experienced in AF ablation. One strategy for overcoming these obstacles would be institution-wide or collaborative-wide standardized protocols to determine who undergoes concomitant AF ablation during mitral valve surgery and the approach used. Standardized protocols have been successful in other quality improvement efforts, such as in blood transfusion.
These protocols need to be combined with educational initiatives, including video-based learning, funded courses, mentored site visits, and adequate resources, to ensure that surgeons are supported in the care of these complex patients. Most importantly, these protocols need a buy-in from cardiology and electrophysiology colleagues to provide optimal multidisciplinary care.
Another approach to increase the implementation of evidence-based concomitant AF ablation would be through quality reporting and tracking. This method has proven successful across many interventions, because “what gets tracked gets fixed.”
Before implementing quality reporting, more data are needed regarding the effectiveness of PVI versus biatrial maze to drive the metrics. The STS Adult Cardiac Surgery Database has been a major driver of quality improvement over the years and serves as an example of positive change through quality reporting.
Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals. The MITI Investigators. Myocardiol Infarction Triage and Intervention.
Increasing reimbursements for AF ablation may increase the implementation of evidence-based recommendations as surgeons perform additional procedures and take on additional risk. In addition, we demonstrated a strong association between surgeon volume and perceived risk as a barrier. By appropriately incentivizing the performance of evidence-based concomitant AF ablation, surgeons with perceived barriers may have increased implementation.
Finally, a recurring theme throughout the survey results was concern over applying the current level of evidence to a complex patient population. Multiple prospective studies have demonstrated the safety and efficacy of AF ablation during mitral valve surgery; however, these populations had strict exclusion criteria.
It is also important to consider the patient's perspective and their opinion about the trade-off between decreasing AF versus a increased risk of permanent pacemaker placement. Furthermore, survey respondents suggested that additional data are needed on rates of heart block and other arrhythmias regarding higher rates of postoperative permanent pacemaker placement.
To address these specific barriers highlighted in this study, we have developed several projects to increase the evidence-based use of concomitant AF ablation. First, we are developing a protocol with inclusion and exclusion criteria for patients undergoing mitral valve surgery with preoperative AF to support concomitant ablation. This protocol will include multidisciplinary discussion of these complex patients preoperatively to provide the best treatment plan for the patient. The protocol will be evaluated and adopted by the VCSQI and MSTCVS to reduce variability. Next, we will create “how to” videos for robotic and open AF ablation lesion sets and develop a mentorship program to support surgeons with less experience and increase the adoption of this practice. This mentorship will be critical for the low-volume mitral valve surgeons who report risk as a major barrier to implementation. Finally, working with our cardiology/electrophysiology colleagues and existing databases of patients who have undergone surgical AF ablation, we will explore the long-term rates of arrhythmia and pacemaker placement to provide scientific evidence pertaining to this barrier.
This study has several important limitations, including the response rate of only 48.9%, which compares favorably to other email surveys among practicing surgeons, including the recent publication from JAMA Surgery with a 15% response rate.
Additionally, the responses might not adequately reflect all surgeons in the VCSQI and MSTCVS quality collaboratives, as highlighted by 70% of respondents reporting centralizing mitral valve operations and 40% of those being the mitral valve surgeon in their practice. Therefore, we might not be capturing responses from surgeons who have other barriers to performing concomitant ablation. Additionally, these responses reflect surgeons' perception of their practice patterns, and we are unable to confirm this with clinical data owing to the anonymous nature of the survey.
This effect likely highlights the “ideal” practice with bias in favor of more recommendation adherence. Furthermore, this analysis does not account for various quality improvement initiatives regarding concomitant AF ablation in the collaboratives or the hospital-specific protocols. Also, the study does not delineate what is meant by “concern for more arrhythmias” and whether most surgeons are concerned about the higher pacemaker rate. Finally, we were unable to differentiate concerns related to cardiopulmonary bypass time versus cross-clamp time in our survey, because we specifically asked about cross-clamp time.
In conclusion, knowledge of evidence-based recommendations and practice patterns varies widely across respondents. These survey data identify several barriers to the implementation of recommendations and provide specific interventions to overcome these barriers, including mentorship/support, systematic protocols, peer-to-peer education, and additional research.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Appendix E1. Material
The Online Data Supplement shows the survey eliciting surgeons' knowledge, availability, and practice patterns around the use of concomitant atrial fibrillation ablation. The survey captures details about time in practice, training experiences, case type and volume, knowledge of guidelines, availability of equipment and support for ablation, practice patterns, and barriers to implementation, as well as their thoughts on how best to overcome these barriers.
Resource utilization in treatment of acute myocardial infarction: staff-model health maintenance organization versus fee-for-service hospitals. The MITI Investigators. Myocardiol Infarction Triage and Intervention.
This study was funded by the Cardiothoracic Surgical Trials Network Grant for Implementation Science (Grant UM1HL088925, to J.H.M.). The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the National Heart, Lung and Blood Institute, the National Institutes of Health, or the US Department of Health and Human Services.
Presented at the AATS Surgical Treatment for Arrhythmias and Rhythm Disorders: A Virtual Learning Experience, October 30, 2020.
I wish to thank authors of this important multicentral study dealing with barriers to atrial fibrillation (AF) ablation during mitral surgery.1 The authors mention that nearly 40% of patients with AF undergoing mitral valve surgery do not receive concomitant ablation despite societal guidelines. Badhwar and colleagues2 reported in 2017 that surgical ablation during mitral surgery was performed in only 68.4% of patients with AF in the United States. Nine years earlier, Gammie and colleagues3 published that a surgical AF ablation was done just in 52% (6415 of 12,235) of mitral valve surgeries in patients with AF.
Contemporary trials in cardiovascular medicine focus on studying new treatments or techniques for existing diseases that impact public health. There is often a clear progression of knowledge from bench research to phase I clinical trials (translation to humans; T1), then phase II and III trials (translation to patients; T2), and finally phase IV trials (translation to clinical practice; T3). However, significant gaps exist in our understanding of how research findings are disseminated and implemented in common practice among physicians, patients, health care systems, and populations (translation to real world settings; T4).