BOSTON — A novel, selective registry of high-volume electrophysiologists is helping improve treatments for atrial fibrillation by sharing data and evaluating best practices.
The Real-World Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation (REAL-AF) registry was set up in 2018 by Paul Zei, MD, PhD, director of the comprehensive atrial fibrillation program at Brigham and Women's Hospital in Boston, and three colleagues with the aim of sharing new ideas to improve patient outcomes.
It now includes 54 high-volume centers in the United States, Canada, and Europe with more than 100 operators and 7000 patients. The goal is to enroll up to 15,000 patients who have had radiofrequency ablation for paroxysmal or persistent atrial fibrillation. The registry is currently sponsored by the medical technology company Biosense Webster but is moving toward independent funding, Zei said.
"It is a new concept for a lot of people in electrophysiology, if not medicine in general," Zei said during an interview. "The idea is that you have a collection of like-minded members, in this case electrophysiologists and supporting staff, and we have the goal of achieving continuing improvements in outcomes."
Zei presented an analysis that evaluated how the registry contributed to improving outcomes here at the Heart Rhythm Society (HRS) 2024. The results were published simultaneously in the society's journal.
A Learning Network
REAL-AF is what's known as a learning health network, said Zei, which is a model that integrates data collection and research for continual improvement. Information and practice changes are fed into a feedback loop in which network participants evaluate them further.
A good example of how the registry can disseminate best practices is the embrace of high-frequency low-tidal volume ventilation among participating centers, Zei said. The technique, which has been reported to improve outcomes, was used in 35.2% of cases in the registry.
"When patients get ablation under anesthetic, the breathing from the ventilator causes the catheter to move around, so you may not deliver a quality ablation," said Zei. "We noticed that some centers were asking the anesthesiologist to take that ventilator and give a series of little breaths, and that keeps the lungs from causing the heart to move and, as a result, the catheter to move too much."
So "we disseminated that across many centers and found it improved procedure outcomes and also long-term clinical outcomes," Zei said. "Patients did well with less atrial fibrillation after 1-year follow-up."
In future, Zei plans to analyze outcomes in patients with persistent atrial fibrillation whose numbers in the registry equal those with paroxysmal disease. There's also the opportunity to further evaluate the high-frequency low-tidal volume ventilation protocol, as well as evaluate outcomes with pulsed field ablation, he said.
More Details Needed
Mervat Aboulmaaty Nabih, MD, chief of electrophysiology at Ain Shams University in Cairo, Egypt, saw the potential of the REAL-AF registry to help improve outcomes, but she said the reports were too vague.
"It doesn't account for differences in age and body type," she said during an interview. Nor did the analysis take into account other variables besides age, including gender, whether first-line ablation was used, early or later-stage atrial fibrillation, anti-arrythmia drug use, or even by center or operator.
"I hope that he gives us credible results so that this is a protocol I will follow," she said. "But I want a success rate of more than 95% to be happy."
She added the results would be more meaningful internationally if the registry included other regions of the world. "In Africa, we work in the worst conditions with the least technology and get good results, so operators can tailor what they're doing according to the facilities they have," she said. "I wish research would give us a protocol that's the least expensive."