Virtual reality-based preprocedural education increases preparedness and satisfaction of patients about the catheter ablation of atrial fibrillation

Abstract

Background:

A recent study suggested to develop and implement more interacted material for preprocedural education to decrease patients’ anxiety about the atrial fibrillation (AF) ablation. This study compared the effectiveness of using either newly developed virtual reality (VR) materials (VR group) or paper-based materials (paper group) on giving AF preprocedural education.

Methods:

This study consequentially enrolled 33 AF patients preparing for ablation from November 2019 to October 2020. After enrollment, patients were randomized as either paper (n = 22) or VR (n = 11) groups.

Results:

In comparison with the baseline stage, at the posteducation stage, the degree of improvement in patients’ self-assessed self-efficacy on AF ablation knowledge was higher among VR group patients than those in the paper group. At the posteducation stage, the patients’ satisfaction to preprocedural education and used materials were higher among the VR group than that among the paper group. In addition to meet their needs and give accurate medical information, VR group patients reported that VR materials increased the effectiveness of education, increased their preparedness for AF catheter ablation, achieved paperless purposes, and willing to recommend VR materials to others. Operators subjectively reported that the periprocedure cooperation was increased both among paper and VR group patients after preprocedural education for the details of procedure. Better preparedness of VR group patients was supported by less periprocedure pain, anxiety, and impatience than those among paper group patients.

Conclusion:

Interactive VR-based materials are superior to the paper-based materials to provide patients immerse and imagine the journey and detail knowledge of AF catheter ablation before the procedure and better prepared patients for the procedure.

1. INTRODUCTION

Longer lifespans, increased survival from cardiovascular diseases and better detection of “silent” atrial fibrillation (AF) have contributed to the worldwide epidemic of AF.¹ AF patients have an increased risk of mortality due to a five-fold increased risk of having a stroke and three-fold increase risk of heart failure.^2,3 Therefore, AF, the most common arrhythmia, has cause a large clinical, public health, and economic burden.⁴

In comparison with medication, succeed AF ablation, either using radiofrequency or cryoballoon catheter decrease the recurrence of symptomatic AF, increase 5% contractility of LV and reduce the risk of ischemic stroke 20%.^5–7 Among appropriately selected patients, a recent study reported that after 12 months of AF catheter ablation, most patients are free from arrhythmia (atrial fibrillation, atrial flutter, and atrial tachycardia).^8–10 The increasing number of patients with AF receives radiofrequency or cryoballon catheter ablation to reduce physical and psychiatric symptoms, decrease the dependence on medicine, improve heart function, and decrease the risk of stroke.

Usually, AF patients and their families suffer from psychological distress in forms of anxiety (34.9%) and depression (20.2%) that decreased their quality of life.^11–13 Significantly, AF catheter ablation relieves symptom, anxiety, depressions and improves quality of life.^14,15 Accordingly, AF catheter ablation has emerged as an effective treatment primarily for AF patients who are refractory to antiarrhythmic drugs.^1,16

In the AF catheter ablation procedure, patients should be on the table for long time to avoid movements that may interfere with the workflow. Actually, the unfamiliar room, multidiscipline procedure team, and large radiology machines may be intimidating to patients, resulting in anxiety and distress in AF catheter ablation settings. Therefore, appropriate preprocedural education is necessary to increase patient’s cooperation as well as safety and effectiveness of AF catheter ablation. Nonetheless, a recent survey from AF patient’s preparation for catheter ablation revealed that most of them feel anxiety due to only 53% of them receiving preprocedural information leaflets.¹⁷ Therefore, 55% of these patients are not satisfied with the acquired information and searching the corresponding information on the internet.^17,18 Nonetheless, the whole procedure of AF catheter ablation is relatively complicated that make it uneasy to be told clearly during preprocedure paper-based education. These results suggested that physicians’ need to provide more detailed information to patients with appropriate materials about AF ablation to improve patient experience and postprocedure satisfaction.

Virtual reality (VR) technology can deliver information via immersive, vivid, and real-time interaction with patient. Recently, VR systems have been introduced in preoperative or preprocedural patient education to minimize anxiety and improve outcome.^19–22 Especially, patients reported that visualization of the procedure during catheter ablation of AF helped them manage pain and anxiety.²¹

In comparison with the non-VR group, this study aims to evaluate the effects of newly developed interactive VR educational materials to help patients realizing the detail procedure before the AF catheter ablation. Furthermore, whether this intervention will reduce the anxiety, will make patients more comfortable during the procedure, will decrease complications, or will reduce postprocedure satisfaction were evaluated.

2. METHODS

2.1. Design

This prospective, randomized control study was conducted in a 2800-bed 6000-staff medical center and teaching hospital in this country. There were development and implementation phases within 2 years. The head-mounted display (HMD) VR materials were developed, and then the education committee implements the materials into patient’s education about the environment, devices, step-by-step cannulation, effects of catheter ablation, postprocedure self-care, and postprocedure self-monitoring knowledge.

2.2. Participants

After assessed by the cardiologic team, AF patients who met the indication of catheter ablation were invited to join this pilot study. Patients not participating in this study had no disadvantages regarding the treatment plan. The patients volunteering to be enrolled (n = 39) were invited to join the 2019 preprocedure education to increase their preparedness for AF catheter ablation. The aims of intervention are to decrease their anxiety, impatience, increase their confidence and cooperation to the procedure, and increase the degree of periprocedure cooperation. Six patients with depression and anxiety, incomplete preassessment, and postassessment were excluded from the study. Finally, a total of n = 33 patients were included in this study.

2.3. Randomization and intervention

The patients were randomly divided into either the paper or VR group. In addition to face-to-face discussion with treating physician, patients in the VR group received the preprocedure education services by healthcare assistants using the 3-minute VR head-mounted display (HMD)-based VR materials. The aims of the service are to decrease patient anxiety and encourage them to cooperate appropriately. The whole VR materials and corresponding paper-based written materials were developed by our primary care team and engineers of the VR company. The environment, equipment, facilities, team members during procedure, reason for sequential used long catheter sheath, atrial puncture needle, electrocautery catheter, frozen balloon, ring recorder with different functions, things that patients need to cooperate during procedures, the possible changes of the ECG after stepwise catheter ablation with either radiofrequency or cryoballoon, precautions after surgery and discharge, self-monitoring of potential postprocedural complications, evidence-based comparison between the medication and AF catheter ablation, and summarized knowledge for education patients about AF catheter ablation procedure (Table 1) were introduced and explained in the virtual environment (Fig. 1). Particularly, the contents of paper-based written materials were same as interacted VR materials.

Table 1.

Summarized knowledge for education patients about AF catheter ablation procedure

Know catheter equipment	[1]. Long sheath: the medical device used to dilate the blood vessel opening after piercing the blood vessel with a needle; [2]. Transseptal puncture needle: atrial fibrillation occurs in the left atrium, so to enter the left atrium from the right atrium, it is necessary to use the device to establish a channel for subsequent treatment; [3]. Radiofrequency ablation catheter: device uses to generate heat to block abnormal discharges; [4]. Frozen balloon: device uses a cryogenic gas to inject into the balloon at the front end, releasing a low-temperature gas to block the abnormal discharge lesion; [5]. Ring recorder: instant electrophysiological signals from various parts of the heart are detected by the electrode copper on the front end.
Precautions after catheter ablation procedure	[1]. After the condition is assessed by the attending physician; [2]. Return to the ward or transfer to the intensive care unit; [3]. Nursing staff will closely observe blood pressure; [4]. Heartbeat, respiration, peripheral blood circulation and pulsation, and pay attention to whether the wound has bleeding; [5]. During the removal of the catheter during the hemostasis; [6]. The affected limb remains straight and does not bend. The wound is covered with gauze and the dressing is changed every other day; [7]. During hemostasis, the toilet and urinal need to be used in bed; [8]. Postablation palpitations or chest burning sensation is a normal phenomenon and will last for 1–2 wks. Please try to keep your mood happy.
Precautions after discharge	Wound care: [1]. Three days after surgery should avoid excessive movement of the affected side joints, such as: up and down stairs, riding a bicycle, swimming, and other sports; [2]. Take a bath and keep the wound clean and dry within 7 d after ablation procedure; [3]. There is usually a slight bruise and swelling at the catheter insertion, usually within a few weeks; [4]. If the wound will be painful, hot, bruising and swelling, fever to 38°, fast heartbeat, dizziness, chest pain, and shortness of breath, please consult a doctor. General living and accommodation matters: [1]. maintain emotional stability, enjoy your body and mind, and avoid excessive stress and stressful life; [2]. keep away from irritating substances such as tobacco, alcohol, tea, and coffee; [3]. regular life and moderate exercise; [4]. be sure to confirm the medication with the medical staff; and [5]. regular outpatient tracking.
Recognize complications	Radiofrequency catheter ablation complications and recurrence rate: stroke (0.5%); complications at vascular puncture site (4%); cardiac tamponade (1.3%); gastrointestinal complications (0.5%); phrenic nerve injury (0.1%); cryoballon catheter ablation complications and recurrence rate: stroke (0.5%); complications at vascular puncture site (2%); cardiac tamponade (0.3%); gastrointestinal complications (0.3%); phrenic nerve injury (0.3%).

Summarized flowcharts of catheter ablation procedure of atrial fibrillation (as shown in Fig. 1I).

AF = atrial fibrillation.

Fig. 1.

The content of the VR materials. A, Representative images of our self-developed VR materials to educate patients about the procedure of AF catheter ablation with VR headset and controller. B, Brief review of the evidence-based information about the benefits of AF ablation. C, An user can select the area to be experience (either used devices, precautions after surgery, precautions after discharge or recognize complications). D, Introduction of the used catheters in the procedure. Introduction of the operating environment and team; the user can experience (E) the preablation preparation such as placing electrode patches and 3D external reference patches on the virtual patient’s chest wall (F). G, The selection of circular diagnostic mapping catheter to do the 3D mapping. H, The process of circumferential ablation to block the conduction of abnormal electrical discharges from the pulmonary veins after ECG return to normal, the final step is to check whether there are residual abnormal electrical discharges. AF = atrial fibrillation; VR = virtual reality.

Using the VR controller, VR group patients can experience the detailed process of disinfection, local anesthesia, insert the sheath, place the acupuncture needle in the atrium (from the right atrium to the left atrium), and go through the steps of either catheter ablation (put in a circular recorder to record cardiac electrophysiological signals, draw atrial 3D perspective using stereo positioning, perform catheter ablation to block the pulmonary vein, radiofrequency [RF] energy was delivered to create a circumferential lesion around the pulmonary vein antrum using maximum power up to 45 W [range 30–45 W], extraction of the catheter [end of procedure]) or cryocatheter ablation (place into a frozen balloon for cryocatheter ablation to block the pulmonary vein and extraction of the catheter [end of procedure]) in the 4D VR world. The VR materials ended up with immediate assessment of patients’ knowledge about the contents of the VR materials. For patients in the non-VR group, the same detailed contents of VR version were included in the written education leaflet to instruct patients about the procedure of AF catheter ablation.

2.4. Outcome measurement

Self-perceived knowledge about AF catheter ablation procedure

Basal demographic data (age, gender, with and without experience of receiving cardiac catheterization, cardiovascular risk, comorbidity, satisfaction about education and materials for AF catheter ablation) and accuracy in written knowledge test (Table 2) were collected. At baseline and posteducation stages, each patient assessed their self-efficacy (familiarity, confidence, and anxiety) about the procedure, postprocedure selfcare, and postprocedure-related knowledge (Table 2).

Table 2.

Simple short knowledge written test for user after VR experience that merged in VR materials (Fig. 1J)

Q1: Which of the following devices is not used for catheter ablation or cryo-catheter ablation of atrial fibrillation?	Choices: (A) Radiofrequency ablation catheter; (B) Frozen balloon; (C) Suction bottle; (D) Transseptal puncture needle	Answer: C
Q2: Which of the following is not a postcatheter ablation procedure precaution?	Choices: (A) After the condition is assessed by the attending physician, return to the ward or transfer to the intensive care unit; (B) You can get out of bed immediately after ablation procedure; (C) Nursing staff will closely observe blood pressure, heartbeat, respiration, peripheral blood circulation and pulsation, and pay attention to whether the wound has bleeding; (D) During the removal of the catheter during the hemostasis, the affected limb remains flat and does not bend.	Answer: B
Q3: Which of the following is not a precaution after discharge?	Choices: (A) Drinking, smoking, and living under high stress after surgery; (B) Three days after surgery, excessive movement of the affected joints should be avoided, such as going up and down stairs, riding a bicycle, swimming, etc; (C) If the wound is painful, hot, bruising and swelling, fever to 38 degrees, please go to the doctor; (D) There is usually a slight bruise and swelling at the heart catheter insertion, which is now normal and usually disappears within a few weeks.	Answer: A
Q4: Which of the following diseases is not a complication of cardiac catheterization?	Choices: (A) stroke; (B) pericardial effusion; (C) pulmonary complications; (D) Diabetes	Answer: D

VR = virtual reality.

2.5. Satisfaction to the paper or VR-based materials for procedure of AF catheter ablation

The degree of patient agreement about the statements are as follows: (1) the content of the preprocedure education materials met my needs of information; (2) the content of the preprocedure education materials provide accurate messages; (3) the materials have increased the efficiency of preprocedural education; (4) the education materials have achieved the purpose of a paperless environment; (5) the materials increase my preparedness for AF catheter ablation; and (6) I am willing to recommended the education materials to others who have preparing for the procedure was collected. Patients were asked to respond their agreements to the above statements by giving the score of strongly agree (10), somewhat agree (7.5), not somewhat agree (5), and not strongly agree (2.5). The average of scores of each statement in individual group was compared between paper and VR group patients. To provide each patient choice about paper, the HMD VR-based preprocedural material was developed.

2.6. Subjective periprocedural assessments

To realize the effects of the education materials for the periprocedure comfort and cooperation during AF catheter ablation, the degree of patient’s periprocedural pain, periprocedural anxiety, duration of using of analgesia during the procedure, patients’ impatience to the long procedure time, patients’ cooperation during the procedure were assessed by operators during the procedure. The operators are blind to whether their patients are belonging to paper or VR groups (Fig. 3).

Fig. 3.

The comparison of average degree of patients′ agreement to the self-efficacy and satisfaction-related statements. A, Self-efficacy (familiarity, confidence, not anxiety) about the procedure and post-procedure care-related knowledge and care skill of AF catheter ablation. B, Satisfaction to the education. C, Satisfaction to the paper or VR education materials about the procedure and postprocedure care-related knowledge and care skill of AF catheter ablation. *p < 0.05 vs paper group. AF = atrial fibrillation.

2.7. Statistical analysis

Data were expressed as mean standard deviation (SD). A significance level of p = 0.05 was chosen.

3. RESULTS

3.1. Patients characteristics

A total of 33 consecutive patients were prospectively enrolled randomly as paper (n = 22) and VR groups (n = 11). The distribution of age range, gender, and percentage of patients had prior experience of cardiac catheterization, percentage of AF patients with diabetes and co-morbidity (including nonfatal stroke, transient ischemic attack [TIA], heart failure [HF], percentage of under rate-control, antiarrhythmic drug, and anticoagulant drugs) were not different between paper and VR groups. The percentage of patients with hypertension was higher in paper group patients than those in the VR group, whereas the percentage of hyperlipidemia was higher in VR group patients than that in the paper group.

The final enrolled team member in each nursing team of every group had listed in Table 1. Notably, the gender distribution and mean age were similar among three groups. To test the collaborated skills of nursing students, the team member in the postintervention assessment were different from the preintervention assessment in the same group. Fore examples, nursing trainees in the scenario plus video group are randomized with other professional trainees in the scenario plus video group and the same for the scenario and control group in postintervention assessment.

3.2. VR materials better increased self-efficacy and satisfaction for the education of VR group patients

At baseline stage, the self-efficacy of paper and VR group patients was not different. In comparison with the paper group, VR materials effectively increase the VR group patient’s self-efficacy about the procedure, postprocedure self-care, and postprocedure self-monitoring-related knowledge of AF catheter ablation (Fig. 3A). Increased self-efficacy among the VR group was supported by increased familiarity, increased confidence and decreased anxiety about procedure, postprocedure self-care, and postprocedure self-monitoring-related knowledge In comparison with the VR group, the degree of patient’s agreement to the satisfaction-related statements about education (statement 1: the preprocedural education met your need; statement 2: the preprocedural education provided accurate messages) and materials (statement 1: these materials increase effectiveness of education; statement 2: these materials achieve paperless purposes; statement 4: you are willing to recommend these materials to others) were higher than those in paper group. These results indicated that the general satisfaction of VR group patients to the preprocedural education and materials were higher than those in VR group patients (Fig. 3B and C).

Fig. 2.

Flowchart of the training between non-VR and VR groups. VR = virtual reality.

3.3. VR materials better improved the preprocedure knowledge and decreased the in-procedure anxiety of VR group patients

Notably, the accurate rate of the written test of procedure, postprocedure self-care, and postprocedure self-monitoring-related knowledge about AF catheter ablation was higher among the VR group patients than those in the paper group (Fig. 4A). Significantly, using VR material in the VR group enhanced patients’ knowledge about the devices used in catheter ablation and about self-monitoring for possible procedure-related complications. Significantly, operators, who are blinding to the grouping of patients, reported that, among VR group patients, using VR materials decreases the pain, anxiety, and impatience during the AF catheter ablation (Fig. 4B). Notably, the general cooperation of VR group patients was similar to that of paper group patients.

Fig. 4.

The comparison between the subjective assessment of patients knowledge and in-procedure comfort between paper and VR groups. A, Assessment of patient knowledge by written test after receiving education. B, The operator assessed the comfort and cooperation of patients during the procedure of AF catheter ablation. AF = atrial fibrillation; VR = virtual reality.

4. DISCUSSION

The importance of periprocedural patient orientation, education, and support to facilitate recovery, reduce patient anxiety, and improve the perioperative experience are well recognized.^23,24 Therefore, booklets and videotapes are given to patients for self-study before the cardiac catheterization.²³ It had been reported that patients who acquire knowledge preprocedurally are able to cope better during the actual procedure.^23,24 Especially, the preprocedural educational video can decrease the periprocedural anxiety of patients who had undergone the cardiac catheterization procedure.²³ Therefore, in our study, we developed the AF ablation-specific paper and interactive VR materials and evaluated it effects on preprocedural education of patients.

Research has shown that 40%–60% of patients could not correctly report what their healthcare providers expected of them 10–80 minutes after they were provided with medical information. Other research demonstrated that over 60% of patients interviewed immediately after visiting their healthcare providers misunderstood the directions regarding prescribed medications.²⁵ For complex medical knowledge, patients and their families, who are with limited medical background knowledge, recall as little as half of what is discussed during a typical medical encounter.²⁶ One study found that in 66% of audiotaped cases analyzed, healthcare providers had omitted at least one piece of critical information when discussing new medical information with patients.²⁷ In limited time of medical encountering, in-hospital healthcare providers sometime may fail to give enough medical information to their patients and families.²⁸ Additionally, communication without providing complete and accurate messages can result in a negative impact on patient satisfaction and patient health outcomes.^17,18 Dissemination of written information to patients has been shown to improve patient satisfaction and positively influences perceptions of physician competence, skill, care, and concern.²⁹ In one study of patients undergoing DC cardioversion (DCCV) for AF, the receipt of written information before DCCV appeared to increase the probability of satisfaction and reduce discomfort.³⁰ In the current study, patients reported that both paper and VR educational materials met their needs, achieved accurate messaging, and increased their preparedness for the procedure.

VR technology enables more effective education at a lower cost and in less time than verbal or written methods through enhancing users’ incentive to engage.³¹ Notably, through increasing accurate messaging and decreasing the number for re-education of patients’ families, our new VR intervention module of training is much less expensive than the paper training model.

For information provision, the advancement in VR technology allows learning to occur through immersive experiences. VR provides a controlled environment in which users can navigate and interact with the virtual objects and observed their effects in real time.³² The recent study reported that VR-based education materials about the process of taking chest radiography to reduce children anxiety and increase parent satisfaction about the procedure.³³ In our study, the preprocedure VR experience significantly decrease the preprocedure anxiety, pain, and impatience of patients. These beneficial effects in our study may be attributed to familiarity and exposure to the strange environment through VR education, a finding consistent with previous investigations in adult and children undergoing anesthesia and surgery.^19,20

Patients undergoing cardiac catheterization experience several unpleasant feelings, including anxiety, fear, discomfort and distress, and anxiety being one of the most common.^33–35 Anxiety can have a negative effect on patient’s clinical outcomes such as treatment refusal and reduced tolerance to pain before, during, and after the catheterization intervention. The recent study reported that using VR as an adjunct to anesthesia in the operating room may decrease the intraoperative anesthetic requirements.³⁴ Studies show that patients become calmer when they can know more about the upcoming procedure by offering systematized information about the procedure to the patients.^23,35,36 Therefore, the use of educational sessions before admission, such as instructions about the procedure through videos, showed effective improvements in the knowledge of hospital procedures and a reduction in patients’ anxiety.³⁷ In our current study, it is interesting that the anxiety, pain, and impatience in the VR group was significantly decreased compared to the paper group.

A few limitations of the study need to be acknowledged. Our small sample size may have increased the risk of a type 2 error, limiting our ability to draw conclusions on the effect of the intervention. Due to the limitation of VR system, in this study, we used a limited number of questions to investigate knowledge retention, and we provided the answers of multiple-choice questions (MCQs) after trainees complete the baseline and posttraining written test. Although it is not easy for trainees to remember all the questions of the MCQs on the online questionnaire in limited time available to them, the possibility that they used the given answers in the follow-up cannot be ruled out. In addition, the study cannot be blinded due to intervention property; it is very likely that the trainees are more satisfied with the new technique, rather than the knowledge/skill they really gain. To avoid the bias of subjective questionnaires, our study also included subjective written and blind operators’ assessment of the periprocedural anxiety, pain, anesthesia needs, and impatience of patients.

In conclusion, both paper- and VR-based preprocedural education prepared patients for the forthcoming AF ablation. Interactive VR-based materials had provided patients to immerse and imagine the journey of AF catheter ablation before the procedure in our study. Overall, VR educational materials better decrease the preprocedural and periprocedural anxiety and smooth the procedure of AF catheter ablation.

Table 3.

Questionnaire for patients’ self-assessed self-efficacy and satisfaction survey at baseline and posteducation stages

Self-efficacy:

I am familiar with the procedure and postprocedure care-related knowledge of AF catheter ablation

I have confidence in the procedure and postprocedure care-related knowledge of AF catheter ablation

I am not feeling anxious about the procedure and postprocedure care-related knowledge of AF catheter ablation

Satisfaction to the preprocedural education:

1. The education about the procedure and postprocedure care-related knowledge of met my need

2. The education about the procedure and postprocedure care-related knowledge of AF catheter ablation provided accurate messages

Satisfaction to educational materials about the procedure and postprocedure care-related knowledge of AF catheter ablation:

1.The materials have increased the efficiency of preprocedural education

2.The materials have achieved the purpose of a paperless environment

3.The materials increase my preparedness for the AF catheter ablation

4.I am willing to recommend the education materials to others who have preparing for the procedure the degree of patient agreement to the statement were evaluated by giving score of 10 for strongly agree; 7.5 for somewhat agree; 5 for somewhat disagree; 2.5 for strongly disagree

AF = atrial fibrillation; VR = virtual reality.

Table 4.

Baseline and clinical characteristics of the study population

	Non-VR group (n = 22)	VR group (n = 11)
Distribution of age range [30–40, 40–50, 50–60, and >60 yrs]	2/4/4/12	0/1/4/6
Gender (female/male)	8/14	9/2
% of patients whose had prior experience of cardiac catheterization	2/22 (9%)	1/11(9%)
Underlying diseases
Hypertension (yes/no)	7/22(32%)	2/11 (18%)*
Diabetes (yes/no)	1/22 (5%)	1/11 (9%)
Dyslipidemia (yes/no)	3/22 (14%)	3/11(27%)*
History of nonfatal stroke (yes/no)	0	0
History of transient ischemic attack (TIA) (yes/no)	0	0
Heart failure	1/22 (5%)	0
Operation history (yes/no)	1/22 (5%)	0
Medicine
% of under heart rhythm controlling, antiarrhythmic drug and anticoagulant drugs	22/22 (100%)	11/11 (100%)

*p < 0.05 vs non-VR group.

AF = atrial fibrillation; VR = virtual reality.

ACKNOWLEDGMENTS

The authors express their gratitude to all participants in our study. This work was supported by the by grant No. V109EA-013 from the Taipei Veterans General Hospital, grant No. MOST 109-2314-B-010-032-MY3 from Ministry of Science and Technology.