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Atrial Fibrillation Ablation and Same-Day Discharge: A Safety and Cost-Effectiveness Analysis
Introduction
Currently, 3-6 million Americans are living with atrial fibrillation (AF), the most common type of cardiac arrhythmia. Estimates project this number will increase to more than 12 million by 2030.1-3 The lifetime risk of having AF is approximately 1 in 4 (26% men and 23% women) for people older than 40 years old.4
In the first year of AF diagnosis, 1 in 3 patients will have a cardiac hospitalization, two-thirds occurring within the first 6 months.5 It is estimated that 15%-20% of thromboembolic strokes in the US are also AF related.2,3
AF treatment includes rate and rhythm control. Along with antiarrhythmic medication, catheter ablation is a common method used to treat AF. It has been demonstrated that patients who undergo ablation have a 64% decrease in AF-related hospitalizations, 65% shortened length of stay (LOS), and 52% reduction in cardioversions.6 Additionally, 1-year follow-up of patients in the A4 study demonstrated no AF reoccurrence in the ablation (89%) vs antiarrhythmic (23%) study groups.7 Decreased health care utilization and economic burden have also been observed among patients undergoing AF ablation.6,8
The care and management of postablation patients has advanced to include a same-day discharge (SDD) option.9-12 As an outpatient procedure, the average AF ablation length is a multivariable number based on comorbidities, age, provider, ablation location, and repeat ablation status. After the procedure, there is a 2- to 4-hour mandatory bed rest followed by overnight stay in a telemetry bed. SDD has the potential to reduce patient LOS, increase bed availability (and thus, enhance revenue), and increase patient satisfaction. This review examines the potential for an AF ablation SDD strategy utilizing our criteria, inclusive of medical and financial factors.
Methods
We reviewed data from 727 adult patients who underwent elective AF ablation between January 1, 2019 and December 31, 2020. This included 361 patients with paroxysmal AF and 366 with persistent AF. Institutional review board (IRB) guidelines were followed, and an IRB review was not needed based on article type and retrospective cost-effectiveness analysis.
The research team screened each chart for SDD eligibility, as outlined by our screening tool. In order for patients to be eligible for SDD, the following preoperative criteria needed to be met: (1) patient lives within 1 hour of the hospital; (2) patient admitted as an outpatient prior to procedure; (3) no history of heart failure; (4) CHA2DS2-VASc score ≤3; (5) body mass index (BMI) <35; (6) procedure length <5 hours (anesthesia and transesophageal echocardiography [TEE] included); (7) intraoperative fluid infusion <3 liters; (8) no complications during procedure; (9) case out of electrophysiology (EP) lab by 2:00 PM (for review, all cases were considered). Postop, additional criteria needed to be met to maintain eligibility for SDD: (10) postop symptom free (clean groin, no chest pain, nausea, or vomiting); (11) postop voiding; (12) ambulating and tolerating fluids by mouth; and (13) postop echo without significant pericardial effusion. Additionally, patients required an escort to accompany them home and stay overnight. SDD patients were discharged with a phone number for emergencies and received a follow-up call the next day (for review, all cases were considered).
Pre-Ablation Considerations
All patients underwent standard preoperative laboratory testing, including electrocardiogram (ECG), within 30 days. All patients also underwent COVID-19 screening as per the hospital policy in effect at the time. A complete history and physical were completed within 30 days of ablation and updated the day of the procedure. Most patients had a computed tomography angiography prior to the procedure. Patients were screened for urological issues during preprocedural assessment, and starting with the second quarter of 2020, most patients did not receive a Foley catheter.13 Patients were advised on uninterrupted, minimally interrupted, or delayed anticoagulation, per physician preference. For patients taking warfarin, the international normalized ratio (INR) was checked the morning of the procedure. Consideration was given to cancellation of procedures for INRs >3.0, per physician preference.14,15
Catheter Ablation Procedure
Patients underwent either pulmonary vein or nonpulmonary vein ablation. A total of 718 (98.8%) radiofrequency ablations and 9 (1.2%) cryoablations were performed. An attending anesthesiologist administered general anesthesia. Ultrasound-guided bilateral femoral venous access for groin punctures was established. Heparin was administered to maintain an active clotting time of 350 sec. The ablation catheters used were the ThermoCool SmartTouch SF (Biosense Webster, Inc, a Johnson & Johnson company) (majority) or Arctic Front Advance (28 mm, Medtronic), with access sheaths specific per provider. Electroanatomic mapping was performed using the Carto mapping system (Biosense Webster). Esophageal temperature was monitored with the Circa S-Cath Esophageal Temperature Probe (Circa Scientific) or a standard anesthesia probe. Intracardiac echocardiography was used for all cases. Isoproterenol and/or adenosine was administered during postablation stimulation. Closure methods included VASCADE MVP (Cardiva Medical), Perclose ProGlide (Abbott), or figure-of-8 suture.
Postablation Care, Discharge, and Follow-up
Direct oral anticoagulants or warfarin were resumed at 3 hours postprocedure or with the evening dose (uninterrupted, minimally interrupted, or delayed system). Patients remained on bed rest (2-3 hours with VASCADE MVP and Perclose ProGlide, 4 hours with figure-of-8 suture) and were monitored in the postanesthesia care unit (PACU) for 2-3 hours. A physician assistant reviewed the patient’s status, including vital signs, fluid balances, patient complaints, and groin checks. Sutures were removed 6 or more hours after end of procedure and patients remained on bed rest for an additional hour after suture removal. After closure device restrictions were complete, patients were allowed to ambulate and were monitored in a telemetry bed overnight.
Medical complications, both minor and major, were extracted from the Research Electronic Data Capture (REDCap) system. Major complications under consideration included ablation-related heart block requiring permanent pacemaker implantation, air embolus, cardiac tamponade, cerebrovascular accident, death, atrioesophageal fistula, vascular fistula or pseudoaneurysm requiring vascular surgery, heart failure, hemothorax/pneumothorax, postoperative hypotension (prolonged after anesthesia), myocardial infarction, pericardial effusion requiring drainage, phrenic nerve injury, pulmonary edema, pulmonary vein stenosis, respiratory failure requiring prolonged intubation, retroperitoneal bleed, systemic bacterial infection, transient ischemic accident, or other. Minor complications included abnormal bleeding requiring no transfusion, bacterial infection, deep vein thrombosis, fever, fistula or pseudoaneurysm with no vascular compromise, fluid overload, gout, hematoma (per MD), mild acute heart failure, pericardial effusion not requiring drainage, pericarditis (not resolved after one dose of pain medication), or other.
Fluids were monitored and diuretics were given as needed. An echo was performed prior to discharge the next day. Patients were given verbal and written discharge instructions, including an emergency contact number. Patients also received a follow-up call postdischarge.
The safety composite was any complication that occurred greater than 5 hours after the patient was documented out of the EP lab.
Statistical Analysis
Chi-squared (χ2), two proportion, and Fisher’s exact tests were used for categorical data, as appropriate, and a Student’s t-test was used for comparison of continuous variables. Logistic regression was performed for identifying additional independent variables significantly associated with SDD eligibility; factors tested in the multivariable model included age, gender, type of AF (paroxysmal vs persistent), and presence of any cardiomyopathy (hypertrophic, ischemic, nonischemic, tachycardia induced). Results with P<.05 were regarded as significant. MiniTab v17 was used for statistical analysis.
Results
Of the 727 patients who underwent AF ablation from January 1, 2019 to December 31, 2020, there were 488 males (66.4%) with a mean age of 66.14 ± 9.37 in the non-SDD eligible group and 63.59 ± 8.95 in the SDD-eligible group. The distribution of patient demographics and baseline data is shown in Table 1.
Medical records were screened to identify whether the patient met the SDD criteria. Among all elective AF ablation procedures (N = 727), 239 (32.9%) met the criteria for SDD. Reasons for ineligibility for SDD included history of heart failure, BMI >35, inpatient status, CHA2DS2-VASc score >3, zip code >1 hour, ablation time (including anesthesia setup and TEE) >300 min, intraoperative fluids >3000 mL, and complications within 5 hours postop. Table 2 illustrates the number of patients meeting the individual criteria. Note that patients may have met multiple criteria.
Age, gender, rhythm type, and presence of any cardiomyopathy were identified as independent variables that were significantly associated with SDD eligibility. (Table 3)
Safety End Point
Two patients who met the SDD criteria experienced a complication after the theoretical 5-hour postablation discharge out of the 5 postop events. One patient had a preperitoneal bleed. Vascular surgery consult was obtained, and hemoglobin monitoring and warm compresses to the area were recommended. The patient was discharged postprocedure day (POD) 2. A second patient experienced mild chest pain without respiratory involvement 2.5 hours after ablation out of room. The patient was monitored, and 8 hours after ablation, the patient reported 8/10 chest pain radiating to the jaw. The patient was hemodynamically stable and with relative hypotension. An echo revealed pericardial effusion without tamponade, which was treated with pericardiocentesis (150 cc pericardial fluid drained) and the patient was transferred to the coronary care unit. Colchicine was started POD day 1. Another 150 cc of fluid was drained before the pigtail drain was pulled POD day 2. Diffuse ST elevation consistent with pericarditis on ECG was noted POD day 3, when the patient was transferred to the telemetry floor. Patient discharge took place POD day 4.
In total, there were 5 postprocedural events, of which 3 occurred immediately to 2 hours postprocedure. Complications included hypotension/tachycardia (resolved with fluids and beta-blockers, patient discharge POD day 1), corneal abrasions (syncope, chills, initial increased white blood cells with negative cultures, patient discharge POD day 2), and hematoma (pressure hold, use of FemoStop [Abbott], patient discharge POD day 1).
Cost Analysis
The 2021 Centers for Medicare & Medicaid Services diagnosis-related group reimbursement rate for AF ablation and EP studies was $21,464.16 Two-thirds of our AF ablation patients (n = 488, 67.1%) were screened as non-SDD and required an overnight telemetry stay, and the remaining one-third (n = 239, 32.9%) were potential SDD. Increased bed availability can allow for additional EP (239 x $21,464) or cardiac procedures that require an overnight stay as well as help offset overcrowding in the emergency department and critical care settings.
Discussion
The primary finding of this study was the safe SDD criteria application to 727 patients undergoing elective AF ablation. Using conservative criteria, 239 patients qualified for SDD criteria, of which 2 (<1%) experienced postoperative complications. The 2 events occurred after the proposed 5-hour discharge. The first was a preperitoneal bleed and the second was a pericardial effusion noted on echo on POD day 2. Adherence to the SDD criteria likely would have captured the issues before patient discharge, since SDD criteria requires performance of an echo before discharge. For the other patient, a thorough discharge review of the patient’s complaints potentially would have noted the abdominal pain, as the patient stated they had experienced the pain since ablation. A strong discharge review offers an additional check for safe SDD of patients after AF ablation.
It is well known that the rate of AF increases with age and the population of adults over the age of 65 is rapidly increasing in the US. In addition, the rate of AF reoccurring after an ablation increases with age.17,18 This growing population of aging patients will increase the need for AF ablation and associated need for hospital bed availability.
As this was a retrospective analysis, patient satisfaction was not addressed. However, other recent studies support patient satisfaction with SDD. For example, one study examining SDD in patients undergoing percutaneous coronary intervention (PCI) found that 99.31% of patients surveyed were “extremely satisfied” with being discharged the same day.19
Other AF studies have also shown SDD feasibility. Creta et al11 found 1.8% met the safety end point and only 0.7% required hospitalization. Bartoletti et al9 performed a study of 1599 ablations from April 2014 to March 2017. A total of 169 (20.8%) met SDD criteria and only 2.1% required rehospitalization. Similarly, Kowalski et al20 compared the 30-day complication rate for SDD vs overnight stay in 2374 patients following AF ablation. The overall complication rate was the same for both groups at 1.26% (n = 15).
Patients are considered ready for discharge after completing bed rest, ambulating, voiding, having a dry groin or oozing resolved with minimal manual pressure, being echo negative or with minimal noncritical changes, as well as being normotensive and without major complaints. Minor complaints such as headache relieved by over-the-counter medication or positional pain are treated supportively so the patient discharge can proceed.
Postablation conditions requiring an overnight stay, resulting in ineligibility for SDD, include extended ablation time, intraprocedural complications, arrhythmias, difficulty maintaining normotension requiring vasopressors or antihypertensive mediations, or volume overload that is unresolved after diuretics in the PACU.
A multivariable logistic regression model was used to identify additional baseline demographic characteristics associated with SDD eligibility. The current SDD eligibility criteria, when correctly reviewed, can identify >99% of patients for successful SDD. Gender, age, rhythm, and history of cardiomyopathy are statistically significant for SDD eligibility. Additional variables will be considered, as needed, to improve SDD criteria.
Limitations
As a retrospective study, there are inherent limitations. The most significant limitations are the inability to consider patient preference and logistics of implementation. Patient preferences and comfort level with discharge the day of the procedure, ability to get a ride later in the day, along with the need for an overnight companion and the companions’ comfort level, are unknown.
For the facility, it is unknown if the enhanced bed capacity would be completely utilized. The cost analysis presented in this paper is based on full occupancy of the beds made available with SDD for patients who meet the criteria. Finally, labor costs are inherently interwoven with other factors and are not addressed in this paper.
Implementation
This SDD criteria was later instituted in 2021, with one provider sending home 55/155 AF ablation cases on the date of surgery. One SDD patient returned the next day with complaint of chest pain; echo was negative, colchicine was administered, and the patient was discharged the next day with complete resolution of chest pain and no additional medical regimen. A second patient also returned after overnight stay, complaining of chest, back, and bilateral arm pain; echo was negative and the patient was discharged the next day without any change to their medical regimen. As the COVID-19 pandemic continues to increase hospitalizations and decrease bed availability, multiple providers at our institution have begun utilizing this SDD criteria, with preliminary results consistent with 2021.
Conclusion
SDD after AF ablation is an emerging standard with a proven safety record. Our SDD criteria to identify patients at decreased risk for postop events met conventional cost-effectiveness in the US health care system. Findings from this retrospective analysis add to the body of knowledge of SDD after ablation. The number of patients (>99%) who met SDD criteria did not experience postprocedural complications within 5 hours and could have been safely discharged home. This is particularly meaningful given the study’s large sample size. Additionally, this analysis provides compelling support for offering SDD for all eligible patients as a safe and financially advantageous model. Future studies on SDD criteria for AF ablation are required to address clinical outcomes, cost from a societal perspective, and patient satisfaction.
Acknowledgments. We would like to thank Lewis Rubinson, MD, PhD, Kathleen Sauter, MS, Katherine Hinic, PhD, RN, and Laura Czigler, RN.
Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Sussman and Dr Mahoney report consulting and/or speaking agreements with Biosense Webster. Dr Sussman, Dr Mahoney, Dr Winters, and Dr Katz participate or have participated in trials sponsored by Medtronic and Biosense Webster. Dr Sussman also reports a consulting agreement with Biosense Webster.
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