national audit of cardiac ablation 2013-14 · a registry of catheter ablation procedures was...

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33333

NATIONAL AUDIT OFCARDIAC ABLATION

2013-14

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NICOR (National Institute for Cardiovascular Outcomes Research) is aresearch partnership of clinicians, IT experts, statisticians, academicsand managers which manages six cardiovascular clinical audits and agrowing portfolio of new health technologies, including the UK TAVIregistry. NICOR analyses and disseminates information about clinicalpractice in order to drive up the quality of care and outcomes forpatients.

The British Cardiovascular Society promotes education, training andresearch in cardiovascular health and upholds clinical and professionalstandards.

The British Heart Rhythm Society (formerly Heart Rhythm UK) is anaffiliated group of the British Cardiovascular Society and theArrhythmia Alliance, and is dedicated to improving all aspects ofcardiac arrhythmia care and electrical device based therapies. Itprovides an essential link between professionals working withinpacing, devices and electrophysiology in the UK.

The Cardiac Ablation audit is commissioned by the Healthcare QualityImprovement Partnership (HQIP) as part of the National Audit ofCardiac Rhythm Management and is one of the Clinical OutcomeReview Programmes. HQIPs aim is to promote quality improvementand is led by a consortium of the Academy of Medical Royal Colleges,the Royal College of Nursing and National Voices.

The Clinical Outcome Review Programmes, which encompassesconfidential enquiries, are designed to help assess the quality ofhealthcare, and stimulate improvement in safety and effectiveness’sby systematically enabling clinicians, managers and policy makers tolearn from adverse events and adverse data.

Founded in 1826, UCL (University College London) was the firstEnglish university established after Oxford and Cambridge, the first toadmit students regardless of race, class, religion or gender, and thefirst to provide systematic teaching of law, architecture and medicine.It is among the world’s top universities, as reflected by performancein a range of international rankings and tables. UCL currently hasalmost 29,000 students from 150 countries and more than 10,000employees. Its annual income is over £900 million.

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1. Prelude

1.1 Acknowledgements

The National Cardiac Rhythm Management Ablation Audit is managed by the National Institute forCardiovascular Outcomes Research (NICOR), which is part of the National Centre for CardiovascularPrevention and Outcomes, based at University College London. Specialist clinical knowledge and leadershipis provided by the British Cardiovascular Society and British Heart Rhythm Society. The strategic directionand development of the audit is determined by the Audit Steering Group. This includes major stakeholdersin the audit, including cardiologists, the professional societies, physiologists, commissioners and patientgroup representatives.

We would especially like to thank the contribution of all NHS Trusts and the individual physiologists,clinicians and audit teams who collect data and participate in the audit. Without this input the audit couldnot continue to produce credible analysis, or to effectively monitor and assess the standard of care in theUK.

1.2 Authors

This report was produced by:Michael Griffith Lead author (co-opted by British Heart Rhythm Society)

Francis Murgatroyd BHRS Clinical Audit Lead

Nick Linker President, BHRS

David Cunningham Senior Strategist, NICOR

Morag Cunningham CRM Database Coordinator, NICOR

Anthony Bradley Project Manager, NICOR

Linda Chadburn Audit and Research Manager, NICOR

Andrew Hughes Public Health England (for the creation of the maps)

This report is available online at www.ucl.ac.uk/nicor/audits/cardiacrhythmmanagement/publicreportsand www.BHRS.com/audit

1.3 Contact Details

This report contains information on device implantation by hospitals in England and Wales. For furtherinformation or queries please contact the following:

NICOR Technical Support Help Desk Tel: 020 3108 1978 e-mail: [email protected]

Information and assistance forparticipating hospitalsMorag Cunningham – CRM AuditDatabase Coordinator

Tel: 01505 612829 e-mail: [email protected]

General EnquiriesAnthony Bradley - CRM Audit ProjectManager

Tel: 020 3108 3926 e-mail: [email protected]

Published 27 March 2015The contents of this report may not be published or used commercially without permission.

http://www.ucl.ac.uk/nicor/audits/cardiacrhythmmanagement/publicreports

http://www.bhrs.com/audit

mailto:[email protected]

mailto:[email protected]

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Contents

1. Prelude 3

1.1 Acknowledgements 3

1.2 Authors 3

1.3 Contact Details 3

2. Executive Summary 5

3. Introduction from the National Clinical Director 6

4. Aims and objectives of the audit 7

5. Methodology 7

5.1 Organisation of the audit 7

5.2 Data collection and IT 7

5.3 The future of the audit 8

6. Findings 10

6.1 Overview of ablation in the UK - National Implant Rate Trends 10

6.2 All ablation targets by year 10

6.3 Geographic rates of atrial fibrillation ablation procedures 12

6.4 Regional ablation rates – all targets 16

6.5 Regional ablation rates – AF Ablation 18

6.6 European implant rates 2013 25

6.7 Number and Type of Atrial Fibrillation Ablation procedures 27

6.8 Ablation targets per procedure by hospital 31

6.9 Data quality for key fields 34

7. Conclusions 38

8. Hospital Reports 39

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2. Executive Summary

Catheter ablation is a technique for treating (and usually curing) heart rhythm disturbances(arrhythmias), using fine, flexible electrodes threaded into the heart via veins. These are used tomake small burns that eliminate the abnormal tissue responsible for the arrhythmias. Thetechnique first appeared 25 years ago, principally for the elimination of supraventriculartachycardias (SVTs - arrhythmias caused by extra connections in the heart). More recently, it hasbecome an important treatment for symptoms in patients with arrhythmias arising from the upperchambers of the heart - chiefly atrial fibrillation (AF) and flutter, which often do not respond wellto drugs.

A registry of catheter ablation procedures was created ten years ago by the precursor of theBritish Heart Rhythm Society, and it is now jointly run by BHRS and NICOR. This is the 9th UKAblation Report, covering ablation for cardiac arrhythmias in the financial year 2013/14, and givingtrends over preceding (calendar) years. The data are based on returns from around 60 NHS andprivate centres that that undertake catheter ablation in the UK. Submission to the nationaldatabase is a mandatory requirement in specialized commissioning by NHS England, and isencouraged in Scotland, Wales and Northern Ireland.

Our principal findings are that the number of ablations performed in the UK increased significantlybetween 2007 and 2010, but has remained static since. During that period, however, thearrhythmias treated have changed, with SVTs now accounting for only 25% of cases. Two thirds ofablations are for atrial arrhythmias, and AF ablation is now the single commonestprocedure. Around half of ablation procedures (including AF ablation) are “complex”, and requiremore time than traditional procedures, as well as sophisticated 3D mapping technology, andusually general anaesthesia and overnight hospitalization. Thus the static number of ablationsoverall belies considerable changes in the actual amount of work undertaken, and consequentresource implications.

The data demonstrate that ablation is under-provided in the UK compared to our immediateWestern European neighbours, and is even below the average for “greater” Europe. This parallelsthe pattern seen with pacemakers and defibrillators. Within the UK, regional inequalities in theprovision of ablation has reduced somewhat over the last four years. However, a small number ofareas consistently have very low ablation rates while a few others are closer to that of WesternEurope. Among smaller centres, the proportion of ablations that are complex varies considerably.

This will be the last report based on the original national dataset, which was principally a registryof procedures, and has become dated. From 1/4/14, a new dataset was mandated, which moreclosely reflects modern and anticipated future practice, and information more relevant toaudit. We hope that this will in future include Patient Reported Outcome Measures to reportimprovement in symptoms over 12 months as a key measure of both appropriate patient selectionand procedure success.

Finally, it is sadly clear to the authors that the completeness and quality of data returns are highlyvariable, with some number of centres failing to report a proportion of cases altogether, and otherreturning incomplete data. It is hoped that awareness of the importance (and indeed themandatory nature) of the audit, along with the new dataset, will result in even better reports infuture.

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3. Introduction from National Clinical Director

I welcome publication of this, the 9th UK Cardiac Rhythm Management (CRM) Ablation AuditReport, covering ablation for cardiac arrhythmias in the financial year 2013/14, and trends overpreceding years.

During 2013, much work has been undertaken to redesign and improve the CRM Audit and itsrelated Cardiac Devices Audit. Such work is time consuming and it is a pleasure to recognise theimportant contributions made by those leading this work such as Francis Murgatroyd and MikeGriffith for BHRS and David Cunningham and colleagues at NICOR. Their efforts have given us abetter record of cardiac ablation procedures undertaken in the UK. Complete and accurate data,however, requires the sustained efforts of clinical physiologists, nurses and clinicians at ablationcentres. Their time is often unfunded, yet freely given, and all concerned also deserve ourrecognition and thanks.

The results show that the total number of catheter ablation procedures in the UK, which roseduring the last decade, has been fairly static since 2010. A modest increase in AF ablation hasbeen seen in parallel with a decrease in the numbers of procedures for conventionalsupraventricular tachycardias (SVTs), which now account for only 25% of all ablations. UK ablationrates remain below those reported in some other European countries, as is the case for implantedcardiac devices. Clinicians and commissioners are encouraged to follow best practice guidelines,such as those published by the National Institute for Health & Care Excellence (NICE) and be alertto any inequity in provision of these procedures.

It seems that a small number of centres are submitting incomplete data and may be omitting aproportion of their cases. For information derived from clinical audits to be of greatest value, tocommissioners, providers, professionals and patients, it is vital that data collection iscomprehensive and accurate and I would urge all to contribute to, and strengthen, this registry.

This national CRM ablation audit continues to provide an essential tool for understanding currentpractice, and how we might best plan for future improvement. As in previous years, I warmlycommend it to all who commission and deliver cardiac ablation therapy.

Huon Gray

Professor Huon GrayNational Clinical Director (Cardiac)NHS England

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4. Aims and objectives of the audit

The aim of the CRM Ablation Audit is to examine the procedure rates of all patients who undergocardiac ablation procedures in the UK.

The audit has the following objectives:

To collect data about all patients receiving interventional electrophysiology procedures for

management of cardiac rhythm disorders, in the UK.

To report activity, trends and outcomes in cardiac ablation practice in UK hospitals.

To continue to collect and develop the presentation of data from all ablation and

electrophysiology centres in the United Kingdom

To provide new analyses and outputs of the data as defined by the clinical group.

5. Methodology

5.1 Organisation of the audit

The audit is managed by the National Institute for Cardiovascular Outcomes Research (NICOR),which is part of University College London (UCL). NICOR’s mission is to provide timely and accuratedata on cardiovascular outcomes for the public, healthcare providers and the medical profession.

The audit is commissioned by the Healthcare Quality Improvement Partnership (HQIP) as part ofthe National Clinical Audit and Patient Outcomes Programme (NCAPOP).

The British Heart Rhythm Society (BHRS) provides clinical leadership through the Audit SteeringGroup, which also includes representation from a wide range of other stakeholders and is co-chaired by Dr Francis Murgatroyd and Dr Nick Linker.

5.2 Data collection and IT

Participating hospitals provide NICOR with audit data on procedure activity throughout the year.Hospitals can either enter audit data manually via a dedicated interface or upload it from existinghospital systems using commercial or locally developed software. All data uploaded is encryptedon transmission and stored in encrypted form in NICOR’s central database.

All data held by NICOR are managed in a secure environment and in compliance with UCL’sInformation Governance and Security policies. NICOR is registered under the Data Protection Actand has support under Section 251 of the National Health Service (NHS) Act 2006 to collect andstore patient identifiable data without explicit consent.

http://www.hqip.org/

http://www.hqip.org.uk/national-clinical-audits-including-ncapop/

http://www.heartrhythmuk.org.uk/

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5.3 The future of the audit

This is the last annual audit based on the “old” national dataset, which has evolved over around adecade. A new dataset has been designed after extensive stakeholder consultation (with doctors,physiologists, specialist nurses, patient representatives, government bodies, and industry), andbecame mandatory for procedures performed from 1 April 2014. This major revision will addressa number of issues:

A number of fields in the old dataset were obsolete or ambiguous

There is a need to include a number of new mapping and ablation technologies, and to“future-proof” the dataset for future developments

An increasing proportion of ablation procedures are undertaken with complex substrates,such as atrial fibrillation and ventricular tachycardia; their outcomes may be neither“binary” nor clear at the end of the procedure (see below).

More relevant clinical detail of patients and their arrhythmias is required, especiallyregarding AF ablations.

Finally, the old dataset was limited to catheter ablation procedures; the new dataset records allinvasive electrophysiologic procedures, including diagnostic EP studies, VT stimulation, andinternal cardioversion. Temporary pacing is excluded. In general, outcome measures fromprocedures are either indicators of success or of complications.

Outcomes: Success

Historically, the national ablation dataset has included a field “ablation success”. This was relevantin the early days of catheter ablation, when outcomes for conditions such as supraventriculartachycardia and typical atrial flutter were clear-cut with very low recurrence rates. Acute abolitionof the substrate for these arrhythmias could generally be assumed to predict a permanent cure.Conversely, any recurrence of these arrhythmias could be regarded as (early or late) treatmentfailure.

There has been a great increase in more complex ablation procedures such as those for atrialfibrillation and ventricular tachycardia, however, whose eventual outcomes are less binary andmay not be evident for weeks or months. Submitted “acute success” rates may therefore bearbitrary and misleading – they have therefore not been included in this report, and it isincumbent on us to seek more meaningful outcome measures.

Most ablation procedures, and especially AF ablation, are performed for the improvement ofsymptoms. It is recognized that symptoms may be greatly diminished even eliminated without 100%abolition of the causative arrhythmia. Early arrhythmia recurrence does not equate to long termfailure, and conversely late recurrence of AF is not uncommon. It follows that immediate proceduraloutcome and short-term follow up is of limited value in establishing the outcome. AF recurrence overa long term is very difficult to measure – a single ECG is of very little value, and some researchprotocols require multiple 1-week ambulatory recordings - even permanently implanted ECGrecorders have been proposed. These measures are clearly not practical for a national audit.

In future, we therefore propose to measure symptom benefit using Patient Recorded OutcomeMeasures (PROMs) – short questionnaires designed to assess disease specific symptoms and moregeneral quality of life. Patients will be asked to complete these questionnaires before and one

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year after their ablation procedure, and one or more third party providers will collect and inputthe data

NICE and NICOR have collaborated in retrospective and now prospective assessment of arrhythmiaPROMs, using simple questions, EQ5D5L, and a disease specific instrument. There is somecontroversy about whether this exercise should be extended to all ablations, but in theretrospective assessment, a significant benefit was shown for all arrhythmia substrates. However,not all patients have a positive outcome, and the reasons for this are being assessed - it is likely tobe a combination of the patients selected, the success of the procedure, and probably to a lesserextent the patient experience.

What would be the benefits be of measuring PROMs? If this exercise is funded, it may have someimmediate effect on patient selection, as patients who are truly asymptomatic will be unlikely tobenefit from an ablation. The change in PROMS will also over time allow more informed patientselection to take place, with features suggesting a large or small benefit influencing and informingthe discussion with the patient before the procedure agreed. It is also possible that the processwill identify centres with particularly good or bad PROMs. This has not, however, been the casewith the hip/knee PROMs programme, possibly because of careful selection of patients by centres,and possibly vice-versa. With hip and knee surgery in the UK, patients appear to get a veryuniform benefit, probably because they will not be offered surgery if minimally effected by theirarthritic joint. The symptomatic status of patients undergoing ablation is likely to be more varied.

Outcomes: Complications

Serious complications from catheter ablation are happily quite rare. They are also, unfortunately,hard to measure. They may occur after hospital discharge (a high proportion of ablations areperformed as day cases) and present to hospitals other than the ablation centre. Some of themost serious complications of AF ablation (pulmonary vein stenosis, phrenic palsy, atrio-oesophageal fistula) may not be evident for weeks or months after the procedure itself. Death hasbeen as an endpoint for many of the other national cardiac audits: it is “hard” and unequivocal,and amenable to validation using OPCS data. However, it is less relevant for this audit. As withcardiac device procedures, death and major adverse clinical events in the months followingablation is rare and generally unrelated, being far more frequently attributable to the underlyingdisease or comorbidity.

Reporting of complications is clearly very patchy, and indeed some cardiac software providers do notcurrently even permit retrospective entry of a complication such as pneumothorax, once theprocedure report is “closed”. A centre reporting zero complications may be failing to submit for thesetechnical reasons, or may simply be unaware of complications presenting post-discharge. For thisreason, we are again not reporting submitted complications as we do not feel these reflect reality.

The new dataset, commencing in April 2014, has asked for immediate (i.e. noticed peri-procedure)and late (3 months, or 12 months for AF ablation) to be reported. However, we recognize thateven this may be difficult, and we are therefore exploring the use of other sources to detectpossible outliers. These may include ONS data to look at death within (say) 3 months of AFablation procedures, or linkage with other national audits to detect myocardial infarction, stroke,or re-intervention.

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6. Findings

6.1 Overview of ablation in the UK – National Implant Rate Trends

Most ablation procedures target a single substrate (e.g. accessory pathway, pulmonary veins), butsome have multiple targets (e.g. pulmonary veins plus cavotricuspid isthmus for atrial fibrillationand flutter).

Table 1 illustrates the total number of ablations for each target and the total number of ablationprocedures from 2007 to 2014 and these data are shown graphically in Figure 1; highlighting alarge increase in overall ablation procedures from 2007 to 2010, but very little change thereafter.

Table 1: All Ablation Procedures and Targets by Year

Ablation Target (Substrate) 2007 2008 2009 2010 2011 2012 2013-14

1. Sinus node ablation/modification 7 18 18 19 131 57 17

2. Atrial ectopics 13 28 57 58 43 48 42

3. Ectopic atrial tachycardia 221 370 426 490 476 547 595

4. Re-entrant atrial tachycardia 111 190 222 225 262 301 284

5. Atrial flutter (common type) 1,723 2,309 3,195 3,178 3,397 3,555 3,366

6. Atrial flutter (uncommon type) 185 293 406 418 427 438 533

7. Anterograde AV nodal modification in AFib 16 39 48 44 43 56 59

8. AV nodal fast pathway in AVNRT 19 18 22 26 36 37 31

9. AV nodal slow pathway in AVNRT 1,733 2,129 2,511 2,633 2,489 2,819 2,715

10. AV nodal fast/slow pathway in AVNRT 17 58 60 61 69 63 40

11. Concealed accessory pathway 549 610 676 644 567 602 668

12. Overt accessory pathway 635 826 897 970 939 948 894

13. Ventricular extrasystoles 105 174 251 287 294 350 399

14. Ventricular tachycardia 204 329 500 576 695 629 605

15. Atrial fibrillation (unspecified) 960 1,499 1,661 1,675 1,469 1,724 2,081

16. Atrio-fascicular (Mahaim) pathway 7 10 14 20 15 12 17

17. Complete AV nodal 418 594 714 975 884 1,064 1,002

18. Atrial fibrillation - PVI 553 850 1,670 1,949 1,963 2,247 2,449

19. Atrial fibrillation - LACA 676 957 1,800 2,053 2,216 2,160 1,913

20. AVNRT (slow or fast pathway) - - - - - - 9

99. Unlisted ablation 78 162 491 532 642 503 449

Unknown ablation target 282 557 311 422 486 598 513

All ablation procedures 8,035 11,273 14,827 15,734 16,061 17,166 17,106

All ablation targets 8,512 12,020 15,950 17,255 17,543 18,758 18,681

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Some of the historic rise was due to increase in the ablation of Atrial Flutter (1,723 in 2007 to over3000) and AV Nodal Slow Pathway in AVNRT (1,733 in 2007 to 2,633 in 2010). Another increase isseen in the Atrial Fibrillation – PVI (553 in 2007 to 2,449 in 2013/14).

Concealed accessory pathway ablations remain very constant in number over this period. Overtaccessory pathway ablation remains fairly constant after 2008. Ablation procedures for ventriculararrhythmias have tripled, but from a very low base (204 peaking at 695 in 2011).

6.2 All Ablation targets by year

Figure 2 illustrates the distribution of ablation targets from 2007 to 2013. Almost 65% of ablationsare performed for atrial arrhythmias, while supraventricular tachycardias account for 25%, with AVnode ablation and ventricular arrhythmias each accounting for only 5%.

Fig 2: Distribution of Ablation Targets by Year

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

2007 2008 2009 2010 2011 2012 2013-4

Fig 1: Ablations 2007-14

Total Ablations

Targets

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6.3 Geographic variation in ablation rates (overall and for AF ablation)

The total catheter ablation rate per million population in the United Kingdom from 2010 to 2013 isillustrated in figures 3, 4, 5 and 6 respectively.

Fig 3: Total Ablation Rate 2010

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6.4: Regional ablation rates – all targets

The breakdown of the numbers of targets and rates per million population by geographic area areillustrated in table 2. These data are derived from patient postcode (>99% complete), rather thanthe location of the centre performing the procedure.

As catheter ablation comes under specialized commissioning, data are grouped by Local AreaTeam rather than Clinical Commissioning Groups or Cardiac Networks (as with prior audits).

TABLE 2: Regional ablation numbers and rates - all ablation targets

Ablation Targets Ablation Targetsper million population

Population

2007 2008 2009 2010 2011 2012 2013 2007

2008

2009

2010

2011

2012

2013

Channel Islands 168,000 11 29 21 24 24 30 39 65 173 125 143 143 179 232

England(no LATallocated)

371 257 154 348 304 356 326

Isle of Man 86,000 4 32 28 56 40 30 37 47 372 326 651 465 349 430

N Ireland 1,814,300 12 16 33 53 64 54 69 7 9 18 29 35 30 38

North Wales 687,937 53 95 150 225 171 140 165 77 138 218 327 249 204 240

Overseas 57 58 77 74 91 90 159

Q44. Cheshire,Warrington andWirral

1,221,746 103 207 328 555 444 445 548 84 169 268 454 363 364 449

Q45. Durham,Darlington andTees

1,176,033 52 200 222 269 373 415 481 44 170 189 229 317 353 409

Q46. GreaterManchester

2,715,618 710 771 677 687 801 671 361 261 284 249 253 295 247 133

Q47. Lancashire 1,460,893 198 265 306 347 433 350 437 136 181 209 238 296 240 299

Q48. Merseyside 1,187,152 27 224 384 771 462 402 451 23 189 323 649 389 339 380

Q49. Cumbria,Northumberland, Tyne and Wear

1,926,791 138 227 449 638 625 668 691 72 118 233 331 324 347 359

Q50. NorthYorkshire andHumber

1,658,665 225 186 178 443 356 217 320 136 112 107 267 215 131 193

Q51. SouthYorkshire andBassetlaw

1,456,464 163 178 182 162 182 212 240 112 122 125 111 125 146 165

Q52. WestYorkshire

2,275,387 491 312 172 258 255 416 501 216 137 76 113 112 183 220

Q53. Arden,HerefordshireandWorcestershire

1,612,080 232 230 359 377 495 763 706 144 143 223 234 307 473 438

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Q54.Birmingham andThe BlackCountry

2,419,500 280 240 292 357 590 912 931 116 99 121 148 244 377 385

Q55. DerbyshireandNottinghamshire

1,963,967 181 216 340 354 394 355 386 92 110 173 180 201 181 197

Q56. East Anglia 2,424,901 29 594 1420 939 886 1004 1194 12 245 586 387 365 414 492

Q57. Essex 1,724,950 392 282 558 539 634 613 409 227 163 323 312 368 355 237

Q58.Hertfordshireand The SouthMidlands

2,643,386 381 482 887 881 918 975 975 144 182 336 333 347 369 369

Q59.Leicestershireand Lincolnshire

1,731,350 280 368 514 520 527 589 604 162 213 297 300 304 340 349

Q60. ShropshireandStaffordshire

1,570,267 220 205 237 261 380 517 546 140 131 151 166 242 329 348

Q64. Bath,Gloucestershire,Swindon andWiltshire

1,458,129 191 229 337 359 375 451 314 131 157 231 246 257 309 215

Q65. Bristol,North Somerset,Somerset andSouthGloucestershire

1,423,539 176 203 370 212 122 176 145 124 143 260 149 86 124 102

Q66. Devon,Cornwall andIsles Of Scilly

1,668,218 178 380 503 483 434 454 430 107 228 302 290 260 272 258

Q67. Kent andMedway

1,727,665 246 676 1021 646 576 638 634 142 391 591 374 333 369 367

Q68. Surrey andSussex

2,686,340 343 1045 1085 1314 1237 1245 1319 128 389 404 489 460 463 491

Q69. ThamesValley

2,021,067 295 396 545 609 617 722 695 146 196 270 301 305 357 344

Q70. Wessex 2,684,407 320 577 557 806 882 1038 1146 119 215 207 300 329 387 427

Q71. London 8,173,941 1188 1817 2918 2734 3147 2841 2446 145 222 357 334 385 348 299

Scotland 5,254,800 650 655 116 294 102 419 355 124 125 22 56 19 80 68

South Wales 2,375,519 258 319 461 579 467 447 463 109 134 194 244 197 188 195

Wales (nonetworkallocated)

3 11 10 14 8 11 57

England (total) 53,012,456 7,410

10,767

14,995

15,869

16,449

17,445

17,236

140 203 283 299 310 329 325

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Wales (total) 3,063,456 314 425 621 818 646 598 685 102 139 203 267 211 195 224

Significant inequalities are noted. In England the mean was 325 per million in 2013, but the rangewas from 102 (Bristol) to over 490 per million (East Anglia and Surrey/Sussex).

6.5 Regional ablation rates - Atrial Fibrillation Ablation

As atrial fibrillation is now the commonest substrate for catheter ablation, this section exploresregional variation in this procedure. Table 3 and figures 7, 8, 9 and 10 illustrate the geographicdistribution of AF ablation rate per million population in 2010, 2011, 2012 and 2013 respectivelyfor the UK.

TABLE 3: Regional ablation numbers and rates – AF Ablation

AF Ablations AF Ablations per million population

Population 2007 2008 2009 2010 2011 2012 2013 2007 2008 2009 2010 2011 2012 2013

Channel Islands 168,000 2 8 4 5 5 8 8 12 48 24 30 30 48 48

England 75 60 27 75 56 81 78

Isle of Man 86,000 0 8 9 21 23 15 20 0 93 105 244 267 174 233

N Ireland 1,814,300 7 11 25 36 44 30 53 4 6 14 20 24 17 29

North Wales 687,937 10 19 51 86 79 59 70 15 28 74 125 115 86 102

Overseas 10 21 40 33 37 36 45

Q44. Cheshire,Warrington andWirral

1,221,746 19 39 98 189 172 194 234 16 32 80 155 141 159 192

Q45. Durham,Darlington and Tees

1,176,033 17 58 56 88 125 129 146 14 49 48 75 106 110 124

Q46. GreaterManchester

2,715,618 105 152 146 153 184 165 117 39 56 54 56 68 61 43

Q47. Lancashire 1,460,893 32 66 75 119 148 94 160 22 45 51 81 101 64 110

Q48. Merseyside 1,187,152 7 28 87 259 153 132 151 6 24 73 218 129 111 127

Q49. Cumbria,Northumberland,Tyne and Wear

1,926,791 39 63 126 230 220 245 253 20 33 65 119 114 127 131

Q50. North Yorkshireand Humber

1,658,665 62 69 69 138 84 87 108 37 42 42 83 51 52 65

Q51. South Yorkshireand Bassetlaw

1,456,464 8 27 32 32 46 35 40 5 19 22 22 32 24 27

Q52. West Yorkshire 2,275,387 81 66 40 80 82 130 146 36 29 18 35 36 57 64

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AF Ablations AF Ablations per million population

Q53. Arden,Herefordshire andWorcestershire

1,612,080 58 67 102 111 174 256 226 36 42 63 69 108 159 140

Q54. Birminghamand The BlackCountry

2,419,500 77 51 66 88 187 271 278 32 21 27 36 77 112 115

Q55. Derbyshire andNottinghamshire

1,963,967 53 77 82 98 92 92 106 27 39 42 50 47 47 54

Q56. East Anglia 2,424,901 11 124 395 279 285 316 316 5 51 163 115 118 130 130

Q57. Essex 1,724,950 186 147 256 228 244 233 153 108 85 148 132 141 135 89

Q58. Hertfordshireand The SouthMidlands

2,643,386 98 159 301 283 307 322 377 37 60 114 107 116 122 143

Q59. Leicestershireand Lincolnshire

1,731,350 77 101 175 141 114 181 188 44 58 101 81 66 105 109

Q60. Shropshire andStaffordshire

1,570,267 41 40 72 86 131 166 187 26 25 46 55 83 106 119

Q64. Bath,Gloucestershire,Swindon andWiltshire

1,458,129 61 79 130 137 137 179 105 42 54 89 94 94 123 72

Q65. Bristol, NorthSomerset, Somersetand SouthGloucestershire

1,423,539 42 74 151 118 54 59 58 30 52 106 83 38 41 41

Q66. Devon,Cornwall and Isles OfScilly

1,668,218 49 100 171 125 117 120 128 29 60 103 75 70 72 77

Q67. Kent andMedway

1,727,665 65 195 421 275 198 240 264 38 113 244 159 115 139 153

Q68. Surrey andSussex

2,686,340 131 343 419 457 445 525 572 49 128 156 170 166 195 213

Q69. Thames Valley 2,021,067 113 142 193 249 230 249 252 56 70 95 123 114 123 125

Q70. Wessex 2,684,407 72 124 157 249 266 334 418 27 46 58 93 99 124 156

Q71. London 8,173,941 392 555 961 894 1027 928 945 48 68 118 109 126 114 116

Scotland 5,254,800 155 171 45 69 39 81 83 29 33 9 13 7 15 16

South Wales 2,375,519 14 45 128 219 115 97 117 6 19 54 92 48 41 49

Wales 0 2 0 4 2 1 1

England (total) 53,012,456 1,971 3,006 4,808 5,181 5,278 5,763 6,006 37 57 91 98 100 109 113

Wales (total) 3,063,456 24 66 179 309 196 157 188 8 22 58 101 64 51 61

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An increase in procedure rates in most areas is seen, such that provision is more uniform over theMidlands, South-East and South, but remains low in areas such as Yorkshire, Wales, and the Bristolarea. Local rates vary from less than 30/million to over 200/million. This mirrors the totalablations per million but not precisely, and the variation in total ablations is much less than that inAF ablation.

The maps on the next 4 pages show annual AF ablation rates by region.

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Fig 7: Regional rates of AF Ablation 2010

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Fig 10: rates of AF Regional Ablation 2013

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6.6 European Ablation Rate Comparisons

Variation within Europe

Comparative estimates of catheter ablation rates are available from the “White Book”, publishedannually by the European Heart Rhythm Association. The information therein is the result of asurvey sent to national societies, and represents estimates, using methodologies (and presumablycompleteness and accuracy) that vary widely from country to country. No data are available fromsome major countries, e.g. Italy.

Estimated rates of overall ablation across Europe and ablation for atrial fibrillation for 2013 aregiven in figures 11 & 12 respectively.

Fig 11: Overall Ablation in Europe2013

All Ablations 2013

24

29

38

39

46

54

54

60

69

77

83

134

140

140

149

182

191

195

209

229

238

239

250

253

254

291

295

301

338

412

418

465

470

482

506

566

580

651

0 50 100 150 200 250 300 350 400 450 500 550 600 650 700

Azerbaijan

Malta

Macedonia

Cyprus

Armenia

Bulgaria

Georgia

Ukraine

Montenegro

Belarus

Kazakhstan

Greece

Serbia

Slovenia

Russia

Croatia

Portugal

Slovakia

Ireland

Poland

Latvia

Lithuania

Luxembourg

Spain

Iceland

UK

Austria

Estonia

Hungary

Germany

Finland

Sweden

France

Czech Republic

Norway

Switzerland

Belgium

Denmark

per million population

Euro

pean

average=-

309

26

Fig 12: AF Ablation in Europe 2013

Rates in the UK are close to the overall “greater” European average, but are at the bottom of themajor Western European economies, and have been overtaken by some newer members of theEU, such as Czech republic and Estonia. In Denmark, Belgium, and Switzerland, more than twice asmany ablations are performed per head of population.

AF Ablations 2013

0

2

3

5

7

7

7

9

15

15

17

27

29

38

40

41

44

46

51

56

60

73

83

86

94

94

100

124

129

144

179

184

196

225

241

289

0 50 100 150 200 250 300 350

Azerbaijan

Malta

Armenia

Cyprus

Bulgaria

Georgia

Belarus

Lithuania

Kazakhstan

Ukraine

Serbia

Slovakia

Latvia

Croatia

Greece

Russia

Poland

Spain

Portugal

Estonia

Luxembourg

Iceland

Slovenia

Hungary

Austria

Ireland

UK

Finland

France

Germany

Sweden

Switzerland

Czech Republic

Belgium

Norway

Denmark

per million population

Euro

pean

average=-

99

27

6.7 Number and Type of Atrial Fibrillation Ablation Procedures

Atrial fibrillation is a complex procedure and now the commonest substrate for catheter ablationand continues to grow.

The number of procedures between 2007 and 2014 are shown in Fig. 13. The current dataset wasnot designed to precisely determine whether the atrial fibrillation was paroxysmal, persistent orlong standing persistent.

The “ECG” field permitted “paroxysmal”, “persistent”, or “unknown” to be recorded and webelieve that this was generally completed with regard to the rhythm on the day of the procedure.

This will exclude some of the patients who are defined by the international definition aspersistent; i.e. patients who have had any cardioversion or more than 7 days of AF. In the periodthe proportion defined as persistent remains constant at 29-33% with no trend seen of increasingablation of more persistent AF.

It is not possible at this time to ascertain why there is such a wide variation in access to AFablation. An obvious possible explanation is that some areas are geographically distant fromablation centres. In these areas one would expect a low rate of all ablations and AF ablations. Twoother possible explanations are explored.

(1) There are centres which are doing more, or fewer, AF ablations than average in relation toreferral base because of personal bias on the part of referrers or indeed specialiststhemselves. For example, a proportion of electrophysiologists regard AF ablation as a first-line therapy for some patients, whereas most will seek a trial of at least one antiarrhythmicdrug before offering ablation. One way of measuring this would be to measure the totalnumber of AF ablation (excluding AV node ablation) divided by the AVNRT ablations. This

395 5791571 1680 1705 1678

221711221602

21822494 2496 2786

2643

544

876

10781144 1044

12501238

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

2007 2008 2009 2010 2011 2012 2013-14

Figure 13: AF ablations by type of AF and Year

Type unknown Paroxysmal Persistent

28

is based on the assumption that AVNRT referrals are relatively constant and are related tothe population served. This may be affected by an established area having already treatedthe prevalence of AVNRT, while a new centre is still finding a significant number ofuntreated cases of this “traditional” arrhythmia.

(2) Patients with both AF and atrial flutter are treated with AF ablation in some areas, andflutter ablation in others.

In order to explore these two possibilities, Table 4 shows the ratios of ablations of AF: AVNRT andAF: Flutter. These are included in the two “funnel plots”, figures 14 and 15.

Table 4: Ratios of ablations of AF: AVNRT and AF: Flutter

Code Centre Total AF AVNRT Flutter RatioAF:

AVNRT

RatioAF:

FlutterBAL Barts and the London 562 376 51 65 7.37 5.78

BAS Basildon Hospital 228 73 42 59 1.74 1.24

BHL Liverpool Heart & Chest Hospital 1081 415 189 230 2.2 1.8

BOU Royal Bournemouth Hospital 518 226 70 173 3.23 1.31

BRI Bristol Royal Infirmary 211 54 47 29 1.15 1.86

CHH Castle Hill Hospital 190 30 52 22 0.58 1.36

CHN Nottingham City Hospital 218 56 54 33 1.04 1.7

DGE Eastbourne District General Hospital 443 192 55 107 3.49 1.79

ERI Edinburgh Royal Infirmary 361 68 104 70 0.65 0.97

FRE Freeman Hospital Newcastle 755 315 120 172 2.63 1.83

GEO St Georges Hospital 188 154 7 26 22 5.92

GJH Golden Jubilee Hospital 390 122 91 88 1.34 1.39

GRL Glenfield Hospital 712 268 119 166 2.25 1.61

HAM Hammersmith Hospital 354 158 47 72 3.36 2.19

HH Harefield Hospital 406 208 77 49 2.7 4.24

KCH Kings College Hospital 279 52 56 83 0.93 0.63

LGI Leeds General Infirmary 657 179 148 139 1.21 1.29

MRI Manchester Royal Infirmary 146 61 19 44 3.21 1.39

NCR New Cross Hospital(Wolverhampton Heart Centre)

247 68 56 66 1.21 1.03

NGS Northern General Hospital Sheffield 218 35 41 33 0.85 1.06

NHB Royal Brompton Hospital 902 346 110 168 3.15 2.06

PAP Papworth Hospital 948 294 159 157 1.85 1.87

PLY Derriford Hospital 167 58 22 37 2.64 1.57

QEB Queen Elizabeth Hospital Birmingham 751 342 122 212 2.8 1.61

RAD John Radcliffe Hospital 447 182 70 91 2.6 2

RSC Royal Sussex County Hospital 359 182 43 85 4.23 2.14

SCM The James Cook University Hospital 357 106 69 69 1.54 1.54

SGH Southampton General Hospital 297 72 54 72 1.33 1

29

Code Centre Total AF AVNRT Flutter RatioAF:

AVNRT

RatioAF:

FlutterSTH St Thomas Hospital 506 213 64 98 3.33 2.17

STO University Hospital of North Staffs 176 38 29 57 1.31 0.67

UCL University College Hospital 598 276 49 156 5.63 1.77

UHW University Hospital of Wales 224 40 54 77 0.74 0.52

VIC Blackpool Victoria Hospital 332 133 58 55 2.29 2.42

WAL University Hospital Coventry 417 95 121 105 0.79 0.9

WYT Wythenshawe Hospital 667 110 101 133 1.09 0.83

30

Fig 14: Ratio of AF: AVNRT ablations 2013-14

Note: Ratio (Y-axis) is shown on a logarithmic scale. The national average value is 2.18

Fig 15: Ratio of AF: Flutter ablations 2013-14

Note: Ratio (Y-axis) is shown on a logarithmic scale. The national average value is 1.70

These graphs show that there is less variation in the ratio of AF: AVNRT and AF: flutter cases in thesix largest centres, which are all close to the national average; while in the medium-size andsmaller centres there is much more variation in the proportion of AF ablated compared to othersubstrates.

0.1

1

10

100

0 200 400 600 800 1000 1200

Total procedures

Ra

tio

of

AF

toA

VN

RT

case

s

0.1

1

10

0 200 400 600 800 1000 1200

Total procedures

Rat

ioo

fA

Fto

AV

NR

Tca

ses

31

6.8 Number of ablation substrates (‘targets’) per ablation procedure

The variation in the number of substrates per ablation procedure is represented in Table 5 by aratio of substrates treated per procedure per centre. This is broken down further in table 6 for thenumber of substrates per procedure in detail.

The true number of substrates targeted may vary less, but some centres may only be reporting theperceived “principal” substrate. This might be very common where both AF and atrial flutter aretargeted. Clearly where no substrate is reported this may be due to data quality.

Table 5: Ablation substrates (targets) per procedure

Code Centre Totalreported

procedures

All reportedablation targets

Targets(‘substrates’)per procedure

AHM BMI The Alexandra Hospital 148 158 1.07

BAS Basildon Hospital 228 228 1.00

BCH Birmingham Children’s Hospital 15 15 1.00

BHL Liverpool Heart & Chest Hospital 1081 1315 1.22

BHR Royal Berkshire Hospital 54 55 1.02

BOU Royal Bournemouth Hospital 518 579 1.12

BRC Bristol Royal Hospital forChildren

61 67 1.10

BRI Bristol Royal Infirmary 211 215 1.02

CBS Spire Southampton Hospital 86 98 1.14

CHN Nottingham City Hospital 218 218 1.00

CRO Cromwell Hospital 39 50 1.28

DGE Eastbourne District GeneralHospital

443 563 1.27

ERI Edinburgh Royal Infirmary 361 361 1.00

FRE Freeman Hospital Newcastle 755 899 1.19

FRM Frimley Park Hospital 39 39 1.00

GEO St Georges Hospital 188 208 1.11

GHB Spire Bristol Hospital 72 83 1.15

GJH Golden Jubilee Hospital 390 408 1.05

GOS Great Ormond Street Hospital 49 49 1.00

GRL Glenfield Hospital 712 840 1.18

HAM Hammersmith Hospital 354 358 1.01

HH Harefield Hospital 406 432 1.06

HSC Harley Street Clinic 423 439 1.04

KCH Kings College Hospital 279 295 1.06

LBH London Bridge Hospital 264 267 1.01

LEB Spire Leeds Hospital 52 57 1.10

LGI Leeds General Infirmary 657 711 1.08

MAI Maidstone Hospital 53 53 1.00

MOR Morriston Hospital 99 100 1.01

MRI Manchester Royal Infirmary 146 175 1.20

NCR New Cross Hospital 247 266 1.08

32

Code Centre Totalreported

procedures

All reportedablation targets

Targets(‘substrates’)per procedure

(Wolverhampton Heart Centre)

NGS Northern General HospitalSheffield

218 225 1.03

NHB Royal Brompton Hospital 902 999 1.11

NOR Norfolk & Norwich UniversityHospital

144 145 1.01

PAP Papworth Hospital 948 992 1.05

PHB BMI The Priory HospitalBirmingham

122 149 1.22

PLY Derriford Hospital 167 185 1.11

QAP Queen Alexandra Hospital 66 67 1.02

QEB Queen Elizabeth HospitalBirmingham

751 873 1.16

RAD John Radcliffe Hospital 447 553 1.24

RCH Royal Cornwall Hospital 50 50 1.00

RDE Royal Devon & Exeter Hospital 111 111 1.00

RSC Royal Sussex County Hospital 359 371 1.03

RSU Royal Surrey County Hospital 16 16 1.00

SCM The James Cook UniversityHospital

357 375 1.05

SGH Southampton General Hospital 297 315 1.06

STH St Thomas Hospital 506 550 1.09

STM St Marys Hospital Paddington 51 51 1.00

STO University Hospital of NorthStaffs

176 190 1.08

UCL University College Hospital 598 636 1.06

UHW University Hospital of Wales 224 250 1.12

VIC Blackpool Victoria Hospital 332 340 1.02

WAL University Hospital Coventry 417 460 1.10

WAT Watford General Hospital 49 49 1.00

ACH Alder Hey Hospital* 26 2 0.08

BAL Barts and the London* 562 551 0.98

CHH Castle Hill Hospital* 190 187 0.98

HHW Wellington Hospital North* 249 243 0.98

WYT Wythenshawe Hospital* 667 591 0.89

* These centres have reported less than one target per procedure and are advised to check theirdata.

33

Table 6: Number of reported substrates (targets) per procedure

Code Centre 0 1 2 3 4 5 % of cases with>1 target

ACH Alder Hey Hospital 24 2 0.0%

AHM BMI The Alexandra Hospital 6 128 12 2 9.9%

BAL Barts and the London 11 551 0.0%

BAS Basildon Hospital 228 0.0%

BCH Birmingham Children’s Hospital 15 0.0%

BHL Liverpool Heart & Chest Hospital 902 139 25 15 16.6%

BHR Royal Berkshire Hospital 53 1 1.9%

BMI BMI The Meriden Hospital 1 0.0%

BOU Royal Bournemouth Hospital 463 49 6 10.6%

BRC Bristol Royal Hospital for Children 55 6 9.8%

BRI Bristol Royal Infirmary 8 191 12 5.9%

CBS Spire Southampton Hospital 75 10 1 12.8%

CHH Castle Hill Hospital 5 183 2 1.1%

CHN Nottingham City Hospital 218 0.0%

CRO Cromwell Hospital 29 9 1 25.6%

DGE Eastbourne District General Hospital 348 75 16 3 1 21.4%

ERI Edinburgh Royal Infirmary 361 0.0%

FRE Freeman Hospital Newcastle 2 625 113 12 3 17.0%

FRM Frimley Park Hospital 39 0.0%

GEO St Georges Hospital 168 20 10.6%

GHB Spire Bristol Hospital 2 59 10 1 15.7%

GJH Golden Jubilee Hospital 2 368 20 5.2%

GOS Great Ormond Street Hospital 49 0.0%

GRL Glenfield Hospital 1 601 93 15 2 15.5%

HAM Hammersmith Hospital 350 4 1.1%

HH Harefield Hospital 1 383 18 3 1 5.4%

HHW Wellington Hospital North 13 229 7 3.0%

HSC Harley Street Clinic 3 403 15 2 4.0%

KCH Kings College Hospital 264 14 1 5.4%

LBH London Bridge Hospital 261 3 1.1%

LEB Spire Leeds Hospital 1 45 6 11.8%

LGI Leeds General Infirmary 1 605 47 4 7.8%

MAI Maidstone Hospital 53 0.0%

MOR Morriston Hospital 98 1 1.0%

MRI Manchester Royal Infirmary 122 19 5 16.4%

NCR New Cross Hospital (WolverhamptonHeart Centre)

1 226 20 8.1%

NGS Northern General Hospital Sheffield 1 209 8 3.7%

NHB Royal Brompton Hospital 3 806 86 7 10.3%

NOR Norfolk & Norwich UniversityHospital

143 1 0.7%

PAP Papworth Hospital 908 36 4 4.2%

PHB BMI The Priory Hospital Birmingham 99 20 2 1 18.9%

34

Code Centre 0 1 2 3 4 5 % of cases with>1 target

PLY Derriford Hospital 149 18 10.8%

QAP Queen Alexandra Hospital 65 1 1.5%

QEB Queen Elizabeth HospitalBirmingham

644 95 9 3 14.2%

RAD John Radcliffe Hospital 4 342 93 7 1 22.8%

RCH Royal Cornwall Hospital 50 0.0%

RDE Royal Devon & Exeter Hospital 111 0.0%

RSC Royal Sussex County Hospital 347 12 3.3%

RSU Royal Surrey County Hospital 16 0.0%

SCM The James Cook University Hospital 339 18 5.0%

SGH Southampton General Hospital 279 18 6.1%

STH St Thomas Hospital 1 461 43 1 8.7%

STM St Marys Hospital Paddington 51 0.0%

STO University Hospital of North Staffs 1 164 8 2 1 6.3%

UCL University College Hospital 24 518 50 6 9.8%

UHW University Hospital of Wales 200 22 2 10.7%

VIC Blackpool Victoria Hospital 4 317 10 1 3.4%

WAL University Hospital Coventry 3 374 34 6 9.7%

WAT Watford General Hospital 49 0.0%

WYT Wythenshawe Hospital 87 570 9 1 1.7%

Note: The minimum should be one.

Table 7 shows there has been no increase in the relative amount of ablation for chronic atrialfibrillation and much of this expansion should be in paroxysmal atrial fibrillation ablation. There iscertainly evidence that some areas have very low levels of AF ablation, which suggests manypatients who would benefit are not receiving this treatment.

35

6.9: Data quality for key fields

Table 8 provides details of the data quality of all key fields. It should be noted that data “quality” in this section refers to the proportion of key fields thathave been completed, irrespective of data correctness. This may lead to misinterpretation. For example, software in many centres returns “0” forcomplications as a default; it follows that a centre that neglects to enter its complications may appear to have 100% data quality and no complications.

Legend: greater than 90% complete 80-90% complete <80% complete

Code Centre Procedures Overall DataQuality Index

Hospital NHS DOB Sex Postcode FirstPaced

Arrhythmia Indication ProcDate

FirstOp Name

ProcedureType

AblationAttempted

Success Complics EarlyRecur

ACH Alder Hey Hospital 26 82% 100% 100% 100% 100% 100% 92% 100% 15% 100% 100% 8% 100% 92% 15% 100%

AHM BMI The Alexandra Hospital 148 90% 100% 0% 100% 100% 89% 97% 96% 99% 100% 100% 93% 89% 97% 87% 97%

BAL Barts and the London 562 92% 100% 93% 100% 100% 37% 86% 99% 91% 100% 76% 95% 100% 100% 99% 100%

BAS Basildon Hospital 228 95% 100% 99% 100% 100% 94% 100% 100% 96% 100% 100% 100% 100% 92% 42% 100%

BCH Birmingham Childrens Hospital 15 94% 100% 53% 100% 100% 60% 100% 100% 100% 100% 100% 100% 100% 100% 100% 93%

BHL Liverpool Heart & Chest Hospital 1081 98% 100% 98% 100% 100% 90% 100% 100% 99% 100% 99% 99% 87% 100% 93% 100%

BHR Royal Berkshire Hospital 54 95% 100% 100% 100% 100% 52% 100% 100% 100% 100% 100% 100% 100% 94% 100% 80%

BMI BMI The Meriden Hospital 1 93% 100% 0% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

BOU Royal Bournemouth Hospital 518 99% 100% 100% 100% 100% 92% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

BRC Bristol Royal Hospital for Children 61 90% 100% 0% 100% 100% 84% 97% 98% 98% 100% 98% 97% 98% 95% 98% 93%

BRI Bristol Royal Infirmary 211 85% 100% 99% 100% 100% 100% 98% 75% 73% 100% 100% 95% 73% 82% 56% 22%

CBS Spire Southampton Hospital 86 86% 100% 0% 100% 100% 95% 95% 95% 99% 100% 99% 100% 100% 100% 100% 1%

CHH Castle Hill Hospital 190 98% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 96% 99% 99% 82% 96%

CHN Nottingham City Hospital 218 98% 100% 100% 100% 100% 86% 100% 100% 98% 100% 100% 100% 100% 98% 94% 100%

CRO Cromwell Hospital 39 88% 100% 0% 100% 100% 92% 100% 100% 97% 100% 100% 100% 100% 97% 100% 26%

DGE Eastbourne District General Hospital 443 93% 100% 100% 100% 100% 1% 100% 100% 97% 100% 99% 100% 98% 100% 99% 100%

ERI Edinburgh Royal Infirmary 361 93% 100% 100% 100% 100% 29% 100% 100% 89% 100% 100% 100% 100% 94% 89% 100%

FRE Freeman Hospital Newcastle 755 97% 100% 99% 100% 100% 99% 99% 94% 95% 100% 89% 98% 100% 97% 93% 92%

FRM Frimley Park Hospital 39 97% 100% 100% 100% 100% 74% 97% 97% 100% 100% 100% 97% 100% 100% 97% 97%

36




FirstOp Name

ProcedureType

AblationAttempted


GEO St Georges Hospital 188 70% 100% 66% 100% 100% 1% 0% 0% 81% 100% 100% 100% 99% 97% 98% 0%

GHB Spire Bristol Hospital 72 91% 100% 21% 100% 100% 83% 94% 96% 94% 100% 99% 97% 99% 99% 96% 88%

GJH Golden Jubilee Hospital 390 98% 100% 100% 100% 100% 100% 100% 91% 99% 100% 100% 99% 99% 96% 99% 85%

GOS Great Ormond Street Hospital 49 81% 100% 10% 98% 96% 10% 43% 98% 100% 100% 100% 100% 100% 100% 100% 59%

GRL Glenfield Hospital 712 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 98% 99% 100%

HAM Hammersmith Hospital 354 40% 100% 95% 98% 2% 0% 0% 0% 0% 100% 100% 100% 0% 0% 1% 0%

HH Harefield Hospital 406 89% 100% 94% 100% 100% 100% 97% 99% 99% 100% 99% 99% 100% 48% 100% 0%

HHW Wellington Hospital North 249 89% 100% 1% 100% 100% 100% 100% 100% 100% 100% 100% 31% 100% 100% 100% 100%

HSC Harley Street Clinic 423 92% 100% 0% 100% 100% 100% 100% 100% 100% 100% 100% 83% 100% 100% 100% 100%

KCH Kings College Hospital 279 95% 100% 100% 100% 100% 100% 99% 100% 100% 100% 22% 100% 100% 100% 100% 99%

LBH London Bridge Hospital 264 94% 100% 10% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

LEB Spire Leeds Hospital 52 85% 100% 0% 100% 87% 44% 85% 85% 100% 100% 98% 98% 100% 96% 94% 90%

LGI Leeds General Infirmary 657 96% 100% 100% 100% 100% 100% 89% 93% 72% 100% 100% 100% 98% 97% 99% 99%

MAI Maidstone Hospital 53 91% 100% 100% 100% 100% 6% 100% 100% 100% 100% 100% 100% 100% 57% 98% 100%

MOR Morriston Hospital 99 90% 100% 52% 100% 97% 53% 98% 98% 100% 100% 100% 100% 99% 99% 99% 49%

MRI Manchester Royal Infirmary 146 82% 100% 95% 100% 100% 100% 78% 76% 74% 100% 79% 99% 79% 73% 77% 0%

NCR New Cross Hospital (WolverhamptonHeart Centre)

247 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

NGS Northern General Hospital Sheffield 218 91% 100% 100% 100% 100% 79% 100% 99% 100% 100% 100% 99% 100% 97% 98% 0%

NHB Royal Brompton Hospital 902 87% 100% 88% 100% 100% 86% 98% 99% 99% 100% 99% 99% 100% 38% 96% 0%

NOR Norfolk & Norwich University Hospital 144 100% 100% 99% 100% 100% 99% 100% 100% 99% 100% 100% 100% 100% 99% 99% 97%

PAP Papworth Hospital 948 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 91% 100% 55% 100%

PHB BMI The Priory Hospital Birmingham 122 85% 100% 1% 100% 100% 80% 99% 99% 98% 100% 100% 99% 99% 99% 99% 0%

PLY Derriford Hospital 167 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

QAP Queen Alexandra Hospital 66 99% 100% 100% 100% 100% 97% 98% 98% 98% 100% 98% 100% 98% 100% 98% 98%

QEB Queen Elizabeth Hospital Birmingham 751 87% 100% 18% 100% 99% 91% 99% 100% 100% 100% 100% 100% 100% 100% 100% 0%

RAD John Radcliffe Hospital 447 99% 100% 94% 100% 100% 95% 100% 100% 100% 100% 99% 94% 100% 100% 100% 100%

RCH Royal Cornwall Hospital 50 93% 100% 98% 100% 100% 98% 100% 100% 100% 100% 100% 100% 100% 98% 0% 100%

RDE Royal Devon & Exeter Hospital 111 100% 100% 100% 100% 100% 96% 100% 100% 100% 100% 100% 100% 100% 100% 99% 100%

37




FirstOp Name

ProcedureType

AblationAttempted


RSC Royal Sussex County Hospital 359 99% 100% 99% 100% 100% 99% 99% 95% 94% 100% 100% 100% 100% 100% 100% 100%

RSU Royal Surrey County Hospital 16 83% 100% 94% 100% 100% 81% 0% 0% 100% 100% 94% 100% 100% 100% 100% 69%

SCM The James Cook University Hospital 357 92% 100% 100% 100% 98% 92% 95% 100% 99% 100% 100% 100% 99% 98% 99% 0%

SGH Southampton General Hospital 297 86% 100% 49% 100% 97% 59% 97% 98% 98% 100% 100% 100% 100% 99% 99% 0%

STH St Thomas Hospital 506 93% 100% 98% 100% 100% 3% 100% 98% 98% 100% 98% 98% 99% 100% 98% 100%

STM St Marys Hospital Paddington 51 40% 100% 96% 98% 0% 0% 0% 0% 0% 100% 100% 100% 0% 0% 0% 0%

STO University Hospital of North Staffs 176 88% 100% 54% 100% 100% 97% 86% 93% 97% 100% 100% 98% 100% 95% 97% 0%

UCL University College Hospital 598 92% 100% 96% 100% 100% 71% 93% 97% 87% 100% 95% 86% 78% 97% 76% 98%

UHW University Hospital of Wales 224 96% 100% 52% 100% 100% 96% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

VIC Blackpool Victoria Hospital 332 78% 100% 91% 100% 100% 96% 73% 75% 75% 100% 100% 96% 65% 63% 40% 1%

WAL University Hospital Coventry 417 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 99% 100% 100% 100% 100%

WAT Watford General Hospital 49 93% 100% 98% 100% 100% 0% 100% 100% 92% 100% 100% 100% 100% 100% 100% 98%

WYT Wythenshawe Hospital 667 88% 100% 100% 100% 100% 100% 96% 97% 69% 100% 99% 68% 99% 92% 2% 100%

38

7. Conclusions

Ablation growth has slowed but continues to increase. The major growth seen is in atrial fibrillationablation, but with no evidence that there is a greater emphasis on more persistent/ chronic atrialfibrillation patients. There is widespread variation in ablation rates per capita, and this appears to be afunction of total local ablation numbers. However the bigger centres appear to do more atrial fibrillationablation in proportion to flutter and AVNRT ablation. The overall rates for ablation are very close toaverage for “greater” Europe but are at the lower end of the scale for the older EU members in NorthernEurope.

39

8. Individual Hospital Activity

Hospital ReportsAll ablation procedures registered in NICOR at 1/11/2014.

Q45. Durham, Darlington and Tees

The James Cook University HospitalMiddlesborough

Centre:

Town/City:

Procedures registered with NICOR for 2013‐14

Ablation Procedures

Ablation Targets reported

Atrial fibrillationAtrial flutter

Total

357

375

10669

Q45. Durham, Darlington and TeesLocal Area Team:

AVNRT 69Atrial ectopy/tachycardia 7Ventricular ectopy/tachycardia 22Complete AV nodal block 63Accessory pathway 31Other 1

40

Q46. Greater Manchester

BMI The Alexandra HospitalManchester

Centre:

Town/City:


Ablation Procedures



Total

148

158

7530

Q46. Greater ManchesterLocal Area Team:


Manchester Royal InfirmaryManchester

Centre:

Town/City:


Ablation Procedures



Total

146

175

6144



Wythenshawe HospitalManchester

Centre:

Town/City:


Ablation Procedures



Total

667

591

110133



41

Q47. Lancashire

Blackpool Victoria HospitalBlackpool

Centre:

Town/City:


Ablation Procedures



Total

332

340

13355

Q47. LancashireLocal Area Team:


Q48. Merseyside

Alder Hey HospitalLiverpool

Centre:

Town/City:


Ablation Procedures



Total

26

2

00

Q48. MerseysideLocal Area Team:


Liverpool Heart & Chest HospitalLiverpool

Centre:

Town/City:


Ablation Procedures



Total

1081

1315

415230

Q48. MerseysideLocal Area Team:


42

Q49. Cumbria, Northumberland, Tyne and Wear

Freeman Hospital NewcastleNewcastle

Centre:

Town/City:


Ablation Procedures



Total

755

899

315172

Q49. Cumbria, Northumberland, Tyne and WeLocal Area Team:


Q50. North Yorkshire and Humber

Castle Hill HospitalHull

Centre:

Town/City:


Ablation Procedures



Total

190

187

3022

Q50. North Yorkshire and HumberLocal Area Team:


43

Q51. South Yorkshire and Bassetlaw

Northern General Hospital SheffieldSheffield

Centre:

Town/City:


Ablation Procedures



Total

218

225

3533

Q51. South Yorkshire and BassetlawLocal Area Team:


Q52. West Yorkshire

Leeds General InfirmaryLeeds

Centre:

Town/City:


Ablation Procedures



Total

657

711

179139

Q52. West YorkshireLocal Area Team:


Spire Leeds HospitalLeeds

Centre:

Town/City:


Ablation Procedures



Total

52

57

179

Q52. West YorkshireLocal Area Team:


44

Q53. Arden, Herefordshire and Worcestershire

BMI The Meriden HospitalCoventry

Centre:

Town/City:


Ablation Procedures



Total

1

1

01

Q53. Arden, Herefordshire and WorcestershirLocal Area Team:


University Hospital CoventryCoventry

Centre:

Town/City:


Ablation Procedures



Total

417

460

95105

Q53. Arden, Herefordshire and WorcestershirLocal Area Team:


45

Q54. Birmingham and The Black Country

Birmingham Childrens HospitalBirmingham

Centre:

Town/City:


Ablation Procedures



Total

15

15

01

Q54. Birmingham and The Black CountryLocal Area Team:


BMI The Priory Hospital BirminghamEdgbaston

Centre:

Town/City:


Ablation Procedures



Total

122

149

8635



New Cross Hospital (Wolverhampton Heart Centre)Wolverhampton

Centre:

Town/City:


Ablation Procedures



Total

247

266

6866



46

Queen Elizabeth Hospital BirminghamBirmingham

Centre:

Town/City:


Ablation Procedures



Total

751

873

342212



Q55. Derbyshire and Nottinghamshire

Nottingham City HospitalNottingham

Centre:

Town/City:


Ablation Procedures



Total

218

218

5633

Q55. Derbyshire and NottinghamshireLocal Area Team:


47

Q56. East Anglia

Norfolk & Norwich University HospitalNorwich

Centre:

Town/City:


Ablation Procedures



Total

144

145

050

Q56. East AngliaLocal Area Team:


Papworth HospitalCambridge

Centre:

Town/City:


Ablation Procedures



Total

948

992

294157

Q56. East AngliaLocal Area Team:


Q57. Essex

Basildon HospitalBasildon

Centre:

Town/City:


Ablation Procedures



Total

228

228

7359

Q57. EssexLocal Area Team:


48

Q58. Hertfordshire and The South Midlands

Watford General HospitalWatford

Centre:

Town/City:


Ablation Procedures



Total

49

49

024

Q58. Hertfordshire and The South MidlandsLocal Area Team:


Q59. Leicestershire and Lincolnshire

Glenfield HospitalLeicester

Centre:

Town/City:


Ablation Procedures



Total

712

840

268166

Q59. Leicestershire and LincolnshireLocal Area Team:


49

Q60. Shropshire and Staffordshire

University Hospital of North StaffsStoke‐on‐Trent

Centre:

Town/City:


Ablation Procedures



Total

176

190

3857

Q60. Shropshire and StaffordshireLocal Area Team:


50

Q65. Bristol, North Somerset, Somerset and South Gloucestershire

Bristol Royal Hospital for ChildrenBristol

Centre:

Town/City:


Ablation Procedures



Total

61

67

00

Q65. Bristol, North Somerset, Somerset and SLocal Area Team:


Bristol Royal InfirmaryBristol

Centre:

Town/City:


Ablation Procedures



Total

211

215

5429



Spire Bristol HospitalBristol

Centre:

Town/City:


Ablation Procedures



Total

72

83

3523



51

Q66. Devon, Cornwall and Isles Of Scilly

Derriford HospitalPlymouth

Centre:

Town/City:


Ablation Procedures



Total

167

185

5837

Q66. Devon, Cornwall and Isles Of ScillyLocal Area Team:


Royal Cornwall HospitalTruro

Centre:

Town/City:


Ablation Procedures



Total

50

50

014



Royal Devon & Exeter HospitalExeter

Centre:

Town/City:


Ablation Procedures



Total

111

111

067



52

Q67. Kent and Medway

Maidstone HospitalMaidstone

Centre:

Town/City:


Ablation Procedures



Total

53

53

024

Q67. Kent and MedwayLocal Area Team:


53

Q68. Surrey and Sussex

Eastbourne District General HospitalEastbourne

Centre:

Town/City:


Ablation Procedures



Total

443

563

192107

Q68. Surrey and SussexLocal Area Team:


Frimley Park HospitalFrimley

Centre:

Town/City:


Ablation Procedures



Total

39

39

018



Royal Surrey County HospitalGuildford

Centre:

Town/City:


Ablation Procedures



Total

16

16

013



54

Royal Sussex County HospitalBrighton

Centre:

Town/City:


Ablation Procedures



Total

359

371

18285



Q69. Thames Valley

John Radcliffe HospitalOxford

Centre:

Town/City:


Ablation Procedures



Total

447

553

18291

Q69. Thames ValleyLocal Area Team:


Royal Berkshire HospitalReading

Centre:

Town/City:


Ablation Procedures



Total

54

55

024

Q69. Thames ValleyLocal Area Team:


55

Q70. Wessex

Queen Alexandra HospitalPortsmouth

Centre:

Town/City:


Ablation Procedures



Total

66

67

022

Q70. WessexLocal Area Team:


Royal Bournemouth HospitalBournemouth

Centre:

Town/City:


Ablation Procedures



Total

518

579

226173



Southampton General HospitalSouthampton

Centre:

Town/City:


Ablation Procedures



Total

297

315

7272



56

Spire Southampton HospitalSouthampton

Centre:

Town/City:


Ablation Procedures



Total

86

98

3029



57

Q71. London

Barts and the LondonLondon

Centre:

Town/City:


Ablation Procedures



Total

562

551

37665

Q71. LondonLocal Area Team:


Cromwell HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

39

50

2612



Great Ormond Street HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

49

49

12



58

Hammersmith HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

354

358

15872



Harefield HospitalUxbridge

Centre:

Town/City:


Ablation Procedures



Total

406

432

20849



Harley Street ClinicLondon

Centre:

Town/City:


Ablation Procedures



Total

423

439

19754



59

Kings College HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

279

295

5283



London Bridge HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

264

267

16842



Royal Brompton HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

902

999

346168



60

St Georges HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

188

208

15426



St Marys Hospital PaddingtonLondon

Centre:

Town/City:


Ablation Procedures



Total

51

51

012



St Thomas HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

506

550

21398



61

University College HospitalLondon

Centre:

Town/City:


Ablation Procedures



Total

598

636

276156



Wellington Hospital NorthLondon

Centre:

Town/City:


Ablation Procedures



Total

249

243

6980



62

Scotland

Edinburgh Royal InfirmaryEdinburgh

Centre:

Town/City:


Ablation Procedures



Total

361

361

6870

ScotlandLocal Area Team:


Golden Jubilee HospitalGlasgow

Centre:

Town/City:


Ablation Procedures



Total

390

408

12288

ScotlandLocal Area Team:


63

South Wales

Morriston HospitalSwansea

Centre:

Town/City:


Ablation Procedures



Total

99

100

016

South WalesLocal Area Team:


University Hospital of WalesCardiff

Centre:

Town/City:


Ablation Procedures



Total

224

250

4077

South WalesLocal Area Team:


64

national audit of cardiac ablation 2013-14 · a registry of catheter ablation procedures was...

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