The implementation of a comprehensive clinical protocol improves long-term success after surgical treatment of atrial fibrillation

Objective: Surgical ablation for the treatment of atrial fibrillation is now being performed routinely in centers throughout the world. After the hospital stay, patients' care is usually delivered by cardiologists who are often unfamiliar with the nuances of the procedure, as well as the management of patients' medical regimens and atrial arrhythmia recurrence. We sought to determine the effectiveness of a postdischarge protocol designed not only to capture patients' rhythm status but also to coordinate their clinical management when required for all patients undergoing surgical ablation in our institution. Methods: A unique, computer-based atrial fibrillation registry was developed to comply with the Heart Rhythm Society guidelines. An extensive follow-up program to track patients' preoperative characteristics and operative and postoperative courses was established. The required long-term clinical follow-up and interventions were based on a simple clinical algorithm-driven protocol that was developed and recommended by us to be used. All available patients were followed at each respective time point and were evaluated for protocol implementation as determined by the algorithm. Stepwise logistic regression was used to determine whether being on the protocol was a significant predictor for being in sinus rhythm at 18 and 24 months. Results: At the time of the study, we had 391 patients (multiple surgeons) in our registry with more than 2000 clinical records and follow-up rhythm status information. Overall, the return to sinus rhythm was 88%, 87%, and 84% at 6, 12, and 24 months, respectively. Significantly higher rates of sinus rhythm were documented for patients whose care was managed according to the algorithm, with a return to sinus rhythmrate of 92% versus 72%, 91% versus 62%, and 89% versus 40% at 6, 12, and 24 months, respectively. Fifty-one percent of the patients in atrial fibrillation at 12 months did not receive treatment as indicated by the algorithm, with the most common deviations being a change in antiarrhythmic drug treatment, any attempt of cardioversion, and premature placement of patients on a rate-control regimen. The odds of being in sinus rhythm at 24 months was significantly increased when a patient's care was managed according to the protocol (on protocol: odds ratio, 8.066; 95% confidence interval, 1.085-59.940; P = .041). Conclusion: This study describes a new concept in which a clinical algorithm is being used to manage patients after surgical ablation. Our findings suggest that the success rate of the surgical ablation procedure was significantly better in patients who were followed and treated according to the clinical algorithm. These findings suggest that coordination of patients' treatment with cardiologists is challenging but essential to enhance the long-term success rate of the surgical ablation procedure. (J Thorac Cardiovasc Surg 2010; 139: 1146-52)