Response to “Catheter Ablation: Evolution and Efficiencies”

Catheter ablation has become more efficient over time with the evolution of technology, but can come at a cost to efficiency and safety if not performed proficiently. We highlight efficiency in a single lab setting in a resource-constrained environment using the LEAN/Six Sigma principles of simplification, waste elimination, and standardization. JCE -- Letter to the Editor Response to “Catheter Ablation: Evolution and Efficiencies” William K. Chan MD 1,2, Juan G. Acosta-Vélez MD 1,2, Umjeet S. Jolly MD 1 Author Affiliations: Heart Rhythm Program, Waterloo Regional Health Network, Kitchener, Ontario, Canada Department of Medicine, McMaster University Corresponding Author: William K. Chan, MD FRCPC, DRCPSC Cardiologist, Cardiac Electrophysiologist Heart Rhythm Program, Waterloo Regional Health Network Kitchener, Ontario Tel: (519) 749-6578 ext. 1500 Fax: (519) 749-6589 E-mail: [email protected]

Catheter ablation has become more efficient over time with the evolution of technology, but can come at a cost to efficiency and safety if not performed proficiently. We highlight efficiency in a single lab setting in a resource-constrained environment using the LEAN/Six Sigma principles of simplification, waste elimination, and standardization.

We would like to acknowledge Jane Hammond and Georg Klein for their support in the preparation of this manuscript. Funding: All costs associated with production of this work were unsponsored. Disclosures: U.J and W.C. have received honorariums from Johnson & Johnson MedTech. No personal payments or other disclosures were reported. WORD COUNT: 498 We read with interest the article by Kalluri and Knight 1 . In Canada, efficiency is the driving force behind change as wait times are notoriously long for atrial fibrillation catheter ablation depending on where you live and your socioeconomic status 2 . There is increased demand for catheter ablation given the evidence for early rhythm control, yet patients often transition from paroxysmal to persistent atrial fibrillation while waiting on average 218 days for their procedure, resulting in significant morbidity and healthcare costs 3 . The Canadian government recognizes this problem and has recently mandated an increase in catheter ablation volumes to address the atrial fibrillation pandemic. Yet the question remains: how do we accomplish this task with finite resources and limited lab time? The above article accurately highlights the many intra-procedural strategies to improve efficiency. This is particularly conducive to anatomically-based pulmonary vein isolation (PVI) for atrial fibrillation, which has a stepwise and regimented approach. Once the procedure itself has been optimized, many principles borrowed from the automotive industry, such as LEAN and Six Sigma can be applied – simplification, waste elimination, and standardization 4 . At our institution, the same and less catheter equipment are used by all operators to simplify the procedure. Intra-cardiac echocardiography is essential to avoid fluoroscopy, create a shell of the left atrium without dedicated imaging, and replace invasive arterial monitoring. Recently, single-shot catheters using pulsed field ablation disruptively transformed our prior practice with point-by-point, radiofrequency ablation – removing bilateral femoral vein access, excess mapping and pacing catheters, double transeptal access, and adenosine administration 5 . Finally, dedicating a single day per week to ablating lower risk patients with paroxysmal atrial fibrillation enabled us to follow a standardized procedural workflow with early ambulation and same day discharge – termed “high efficiency, electrophysiology” or “HEEP” days (Figure 1). Overall, the LEAN and Six Sigma model integrates well in our environment of 3 high volume operators (>50 complex ablations per year) where experience yields not only higher procedural success, but also lower rates of complications 6 . This shows with our 1-year recurrence rates of <20% with only half of these patients requiring repeat ablation (unpublished data). Major complications including vascular injury, stroke, and cardiac perforation remain low at 1% in line with existing quality standards. Ultimately, we agree that in the pursuit of efficiency, safety and effectiveness must never be compromised. Remarkably, this has all been done in only one electrophysiology lab. A single-lab setting forced us to maximize and dedicate all our resources into this valuable space by building a culture of collaboration with nursing, anesthesia, and administrative staff. In the end, these “HEEP” days offload other days to focus on sicker patients and more complex procedures. With the efficiencies gained to date since the opening of our lab in 2021, we have been able to increase our daily PVI procedures from 2 to 6 in order to more timely serve a catchment area of $1 million people – many of which who live in rural areas with limited access to care. FIGURE 1: Average times for each measured step of a PVI procedure comparing radiofrequency ablation vs. pulsed field ablation. Abbreviations: RF – radiofrequency, VP – VARIPULSE™, PVI – pulmonary vein isolation

1. Kalluri AG, Knight BP. Catheter Ablation: Evolution and Efficiencies. J Cardiovasc Electrophysiol . Published online August 18, 2025. doi:10.1111/jce.700592. Hamlin J, Cox J, Hamilton L, et al. Regional Disparities in Atrial Fibrillation Management: An IMPACT-AF Substudy. CJC Open . 2024;6(10):1162-1169. doi:10.1016/j.cjco.2024.06.0103. Qeska D, Singh SM, Qiu F, et al. Variation and clinical consequences of wait-times for atrial fibrillation ablation: population level study in Ontario, Canada. Europace . 2023;25(5):euad074. doi:10.1093/europace/euad0744. Berte B, Kobza R, Toggweiler S, et al. Improved Procedural Efficiency of Atrial Fibrillation Ablation Using a Dedicated Ablation Protocol and Lean Management. JACC Clin Electrophysiol . 2021;7(3):321-332. doi:10.1016/j.jacep.2020.08.0235. A simplified, fluoroless workflow for atrial fibrillation pulsed field electroporation - Chan - 2025 - Journal of Arrhythmia - Wiley Online Library. Accessed October 6, 2025. https://onlinelibrary.wiley.com/doi/10.1002/joa3.700576. Sairaku A, Yoshida Y, Nakano Y, et al. Who is the operator, that is the question: a multicentre study of catheter ablation of atrial fibrillation. Europace . 2016;18(9):1352-1356. doi:10.1093/europace/euv424 Supplementary Material File (image1.emf) - Download - 3.06 MB Information & Authors Information Version history Peer review timeline Published Journal of Cardiovascular Electrophysiology Version of Record18 Oct 2025Published Copyright This work is licensed under a Non Exclusive No Reuse License. Collection

Authors Metrics & Citations Metrics Article Usage 214views 186downloads Citations Download citation William K. Chan, Juan G. Acosta-Vélez, Umjeet Jolly. Response to “Catheter Ablation: Evolution and Efficiencies”. Authorea. 10 October 2025. DOI: https://doi.org/10.22541/au.176009594.45765505/v1 DOI: https://doi.org/10.22541/au.176009594.45765505/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.