Successful Same-Day Discharge After Atrial Fibrillation Ablation: An Institutional Experience

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EP LAB DIGEST. 2025;25(2):1,11-13.

Osama T Niazi, DO¹, and Hend Bcharah, BS^2
1Cardiac electrophysiologist, Director of the Cardiac Electrophysiology Laboratory, Dignity Health East Valley, Chandler, Arizona; ²AT Still University-School of Osteopathic Medicine Arizona, Mesa, Arizona

Atrial fibrillation (AF) is one of the most common cardiac arrhythmias that significantly impacts quality of life while increasing the risk of stroke, heart failure, and sudden cardiac death, among other complications.¹ Treatment with catheter or surgical ablation is considered in the setting of symptomatic AF or when antiarrhythmic drugs have been ineffective, contraindicated, not tolerated, or not preferred by the patient.1 Traditionally, patients undergoing an AF ablation require an overnight stay at the hospital to monitor for any potential postoperative complications, such as vascular injury, pericardial tamponade, and phrenic and vagal nerve paralysis.² However, extended hospital stays not only add discomfort and anxiety for patients, but also increase costs and resource utilization for health care institutions.³ 

In recent years, advancements in procedural technologies and postoperative care have revolutionized the periprocedural management of AF ablation. At Dignity Health, through adapting cutting-edge technologies and strategizing our patient selection and education approaches, we have allowed most of our patients to return home on the same day as their procedure, improving patient satisfaction while maintaining high standards of care.

This article provides an in-depth look at the updates to our same-day discharge (SDD) protocol. We outline the eligibility criteria that help identify suitable candidates for SDD, detail our advanced vascular access and closure techniques, and highlight the importance of patient education in ensuring successful outcomes. Additionally, we discuss potential challenges and share our insights into future directions for further improving patient care and outcomes in AF ablation. 

Eligibility

A key factor in facilitating SDD is setting clear expectations with patients about the preprocedural and postprocedural process. At our facility, we thoroughly discuss the procedure and emphasize the goal of discharging patients the same day. This approach not only reassures the patients on SDD, but also clarifies what they can expect throughout their care. While there are no strict eligibility criteria for SDD after AF ablation, several clinical factors can make certain patients more suitable candidates. Key preoperative parameters such as younger age, left ventricular ejection fraction (>35%), fewer comorbidities, and a CHA₂DS₂-VASc score of less than 2 have all been linked with reduced likelihood of perioperative complications and provide reassurance on the patient’s recovery.⁴ Also considered is the availability and adequacy of the patient’s home support as well as their proximity and access to a health care facility should any emergencies occur. Postoperatively, in the setting of an uncomplicated procedure, patients are then monitored for 4 to 6 hours to decide on SDD. Key factors in determining discharge eligibility include hemodynamic stability, ability to ambulate, and the absence of significant complications, such as bleeding or arrhythmias. Procedures are ideally scheduled in the early morning to allow sufficient time for postoperative observation. Ultimately, the decision to consider a patient for SDD is guided by the provider’s clinical judgment and the patient’s wishes, considering the patient’s overall health status and anticipated postoperative recovery.  

Workflow: Techniques for Vascular Access and Closure

In our experience, the use of ultrasound-guided femoral access (Figure 1) and vascular closure devices (VCDs) have significantly mitigated access

site complications and have shown to have downstream effect on facilitating quicker discharge. Real-time visualization of the femoral vein significantly reduces the risk of arterial punctures and other vascular complications, particularly when using larger sheaths in ablation procedures. The ULTRA-FAST trial, amongst other studies, has demonstrated the advantage of ultrasound guidance in offering shorter puncture times, higher first-pass success rates, and fewer additional puncture attempts compared to conventional methods.⁵ It has also been associated with shorter patient ambulation time (2.0 ± 0.1 hours) compared to conventional methods (2.2 ± 0.6 hours), thus bringing patients closer to discharge earlier.⁶ The UNIVERSAL trial further demonstrated that ultrasound-guided femoral access, when combined with VCDs, results in significantly reduced risk of bleeding and vascular complications when compared to standard access techniques.⁷

The recent implementation of pulsed field ablation (PFA) technology at Dignity Health (Figure 2) has significantly reduced procedure times, enhancing both efficiency and patient outcomes. PFA is a novel, nonthermal ablation technique that uses high-voltage electrical pulses to create irreversible electroporation, disrupting myocardial cell membranes while sparing surrounding tissue.⁸ Studies have demonstrated PFA’s outstanding efficacy and safety in achieving pulmonary vein isolation with a 0% risk of esophageal injury and phrenic nerve damage compared to the 40%-60% risk of esophageal injury and the 4.2% incidence of phrenic nerve injury associated with cryoablation (CA) and radiofrequency ablation (RFA).^9,10 However, recent meta-analysis of 1199 patients showed no significant difference in periprocedural complications or arrhythmia recurrence when comparing PFA to CA and RFA.¹¹ PFA procedures have a median duration of approximately 61 minutes, significantly shorter than traditional methods like RFA (median 171 minutes) and CA (median 84 minutes).¹² The reduction in procedure time also decreases the duration of anesthesia, thereby reducing potential anesthesia-related complications that could delay SDD.

VCDs also play a critical role in facilitating SDD. By utilizing devices such as Vascade MVP (Haemonetics) and Perclose (Abbott), the time to hemostasis, ambulation, and discharge is significantly reduced compared to traditional methods like manual compression or figure-of-8 sutures. While manual compression is still applied immediately after sheath removal to ensure complete hemostasis, the use of VCDs has drastically shortened the time to achieve hemostasis to approximately 1 minute, compared to 10 minutes with manual compression alone.¹³ Due to the faster hemostasis, postoperative ambulation can be achieved earlier, which in our experience, is typically within 2 hours after the ablation procedure compared to the 4 to 6 hours required with traditional methods. This quicker recovery not only improves patient comfort, but also optimizes the medical team’s workflow while maintaining patient safety.

Patients are monitored for a total of 4 hours to ensure hemodynamic stability, assess mental status, and evaluate ambulatory effort, while also monitoring for any immediate complications such as bleeding, pericardial effusions, or arrhythmias. At our institution, a 1-2-4 rule is followed, which stands for resting for 1 hour, ambulating within 2 hours, and aiming for discharge by 4 hours if all criteria are met. These timed benchmarks guide the monitoring process and help assess patient readiness for SDD. From our experience, a stable postoperative course, particularly when adhering to the 1-2-4 rule, has been one of the strongest predictors of SDD at our institution.

Patient Education

Establishing expectations for patients regarding their clinical course is imperative to SDD. Before discharge, patients are provided with detailed

instructions on postoperative care, including how to monitor for signs of potential complications that require immediate medical attention, such as chest pain, shortness of breath, or increased swelling, pain, or bleeding at the access site. Additionally, patients receive guidance on managing their anticoagulation therapy, which is tailored based on their CHA₂DS₂-VASc score and other relevant risk factors. All patients are scheduled for a follow-up appointment at the electrophysiology (EP) clinic 7 to 10 days after their ablation procedure, and again 3 months later, to assess their recovery and discuss the continuation of anticoagulation therapy.

Challenges and Future Directions

While VCDs offer significant benefits in reducing time to ambulation and enabling SSD, they also present certain challenges that must be considered. The primary concern is the potential for device failure or incorrect application, which can result in vascular injury, bleeding, or hematoma formation. Patient-specific factors, such as vascular anatomy, bleeding risk, and peripheral vascular disease, can also compromise the safety and efficacy of these devices. However, our experience with reduced postoperative complications, shorter recovery times, and increased patient satisfaction have consistently outweighed the risks and challenges associated with the use of VCDs.

Dignity Health is committed to remaining at the forefront of advancements in EP to further enhance patient care and outcomes. The recent implementation of PFA has been a key step in this direction, allowing for shorter procedure times, reducing the risk of complications, and, most importantly, optimizing patient outcomes.

Conclusion

The advancements in technology and procedural techniques at Dignity Health, particularly with the integration of ultrasound-guided vascular access, VCDs, and PFA, have optimized the safety and success of AF ablation procedures. These innovations have facilitated SDD, offering patients a more comfortable recovery with fewer complications while also optimizing resource utilization within the health care system. Establishing expectations also plays a vital role in facilitating SDD with patients and their families. Although challenges remain, particularly regarding the potential risks of VCDs, our experience has demonstrated that the benefits—such as reduced procedure times, quicker recovery, and higher patient satisfaction—outweigh these concerns. As we continue to adopt and refine cutting-edge technologies, our commitment to improving patient care remains at the forefront, and we look forward to further advancements in the field of EP that will continue to enhance patient outcomes.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. They report no conflicts of interest regarding the content herein. 

References

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