Aims There are conflicting data as to the impact of procedural volume on outcomes with specific reference to the incidence of major complications after catheter ablation for atrial fibrillation. Questions regarding minimum volume requirements and whether these should be per centre or per operator remain unclear. Studies have reported divergent results. We performed a systematic review and meta-analysis of studies reporting the relationship between either operator or hospital atrial fibrillation (AF) ablation volumes and incidence of complications. Methods and results Databases were searched for studies describing the relationship between operator or hospital AF ablation volumes and incidence of complications which were published prior to 12 June 2020. Of 1593 articles identified, 14 (315 120 patients) were included in the meta-analysis. Almost two-thirds of the procedures were performed in low-volume centres. Both hospital volume of ≥50 and ≥100 procedures/year were associated with a significantly lower incidence of complications compared to <50/year (4.2% vs. 5.5%, OR = 0.58, 95% CI 0.50–0.66, P < 0.001) or <100/year (5.5% vs. 6.2%, OR = 0.62, 95% CI 0.53–0.73, P < 0.001), respectively. Hospitals performing ≥50 procedures/year demonstrated significantly lower mortality compared with those performing <50 procedures/year (0.16% vs. 0.55%, OR = 0.33, 95% CI 0.26–0.43, P < 0.001). A similar relationship existed between proceduralist volume of <50/year and incidence of complications [3.75% vs. 12.73%, P < 0.001; OR = 0.27 (0.23–0.32)]. Conclusion There is an inverse relationship between both hospital and proceduralist AF ablation volume and the incidence of complications. Implementation of minimum hospital and operator AF ablation volume standards should be considered in the context of a broader strategy to identify AF ablation Centers of Excellence.

Goals 1. Ensure that critical resources are used efficiently, namely staff and personal protective equipment (PPE). 2. Provide guidance for the appropriate use of EP and CIED services during the pandemic. 3. Minimise adverse patient outcomes during the pandemic period where resources are limited. 4. Minimise exposure of patients and health care workers. Key Considerations 1. Mandatory training of staff on use of PPE. 2. Tailoring of the current document to local demand for EP and CIED services, local outbreak patterns, local hospital recommendations, hospital PPE supply chain, and hospital contingency plans and/or crisis capacity status. 3. Encourage patient specific risk assessment and sound clinical judgment, weighing the risk vs. benefits of delaying intervention versus risk of patient and staff infection with COVID-19, and use of precious PPE resources. 4. Realignment of the delivery of EP and CIED services with a switch to telehealth and remote monitoring, where feasible. 5. Division of physicians and allied health professionals into separate teams, with minimal in-person interaction between team members 6. Where feasible, segregation of labs and equipment for use in patients with suspected or confirmed COVID-19. 7. Temporary deferment of non-critical ambulatory monitoring services to minimise direct patient contact. 8. Rapid completion of inpatient EP and CIED procedures which cannot be deferred for 1-3 months. 9. Temporary deferment of non-urgent elective EP and CIED procedures. 10. Outpatient procedures limited to only those deemed urgent or deemed ''semi-urgent" where risks of prolonged deferment are unacceptably high. 11. Individual patient screening for COVID-19 exposure risk as per local hospital recommendations, and appropriate use of PPE. Keywords COVID-19 Cardiac electrophysiology Cardiac implantable electronic devices Personal protective equipment Congenital heart disease e58 S. Kumar et al.

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