Improved Procedural Efficiency of Atrial Fibrillation Ablation Using a Dedicated Ablation Protocol and Lean Management.

Objectives: In this study the authors hypothesized that "Lean management" within a dedicated ablation protocol could standardize the pulmonary vein isolation (PVI) procedure and improve quality.
Background: There is a large variability in safety, effectiveness, and efficiency of PVI.
Methods: This was a single-center prospective study with inclusion of all consecutive PVI procedures from 2017 to 2019. A 3-step intervention was introduced based on Lean management: step 1) simplification (CLOSE protocol); step 2) waste elimination (higher power shorter duration); and step 3) improved standardization (Lab Optimization Tool [LOT]). PVI was divided into steps that were tracked (in minutes) using LOT. Parameters were compared in 6-month intervals.
Results: Overall, 295 patients (146 patients with LOT) were analyzed. Step 1 reduced skin-to-skin procedure duration (2017: 119 ± 21 min vs. 2018: 77 ± 15 min; p < 0.001) and variance (from 2018 to 2019 p = 0.024). Step 2 reduced the radiofrequency time (2017: 38 ± 6 min vs. 2018: 20 ± 3 min; p < 0.001) and variance (from 2018 to 2019 p < 0.001). Analysis of step 3 demonstrated that only 53% of the entire procedure length (143 ± 22 min) was used for treatment (skin-to-skin time 77 ± 16 min), the remaining time being devoted for setup (42 ± 12 min, 29%); left atrial access (16 ± 7 min, 12%); respiratory gating, left atrial map, and pseudo-circle annotation (10 ± 6 min, 7%); ablation (39 ± 10 min, 27%); and bilateral block validation (10 ± 8 min, 7%).
Conclusions: Standardization of PVI using a dedicated ablation protocol and Lean management can help to reduce procedure and radiofrequency ablation duration and variance, and increase procedural efficiency without compromising safety. To improve health care utilization, increased efficiency should become an accepted goal in addition to procedural safety and effectiveness.
Competing Interests: Funding Support and Author Disclosures Dr. Berte has received a European Heart Rhythm Association grant and travel grants from Biosense Webster. Dr. Kobza has received institutional grant support from Abbott, Biotronik, Biosense Webster, Boston Scientific, and Medtronic; and has received speaking fees from Biosense Webster. Dr. Hoop is an employee of Biosense Webster. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
(Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)