The Feasibility of Same-Day Discharge After Atrial Fibrillation Ablation: A Community Hospital Experience
© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of EP Lab Digest or HMP Global, their employees, and affiliates.
EP LAB DIGEST. 2024;24(12):19-21.
Carson Florkowski, BS1; William Conroy, BS2; Weihai Zhan, PhD, MS, BMed3; Imdad Ahmed, MD, MBA, CPE, FHRS, FACC4
1Medical Student, University of Illinois College of Medicine, Rockford, Illinois; 2Medical Student, University of Illinois College of Medicine, Rockford, Illinois; 3Director of Student Research, University of Illinois College of Medicine, Rockford, Illinois; 4Director Arrhythmia Center, Mercy Health System, University Illinois College of Medicine, Rockford, Illinois
Catheter ablation has demonstrated major advancements within the past 20 years and become the most common treatment for paroxysmal and persistent atrial fibrillation (AF). With technological improvements and greater experience, the periprocedural complication rate of AF ablation has significantly decreased.1 Outpatient procedures are becoming more common in electrophysiology. The safety and effectiveness of same-day discharge (SDD) AF ablations has been well established in tertiary care centers.2,3 Traditionally, patients who undergo AF ablation in community hospitals are monitored in the hospital overnight. However, during the COVID-19 pandemic, community hospitals implemented various restrictions on overnight stays, making SDD after AF ablation an option for many patients.
The primary goal of this study was to assess the safety of SDD after AF ablation in a community hospital setting.
Methods
This retrospective study included 543 patients who underwent radiofrequency (RF) catheter ablation from January 2020 to December 2023 at 2 community hospitals.
Statistical Analysis
Wilcoxon rank-sum tests for continuous variables (due to non-normality) and chi-square tests (Fisher’s exact test when chi-square tests are inappropriate) for categorical variables were used to examine if the adverse outcome differed by SDD. Logistic regression models were used to determine if SDD was associated with an unfavorable outcome.
Ablation Procedure
Venous access is obtained with the help of ultrasound. For all AF ablations, 1 access via the right femoral vein and 2 access via the left femoral vein are obtained. A long J-wire is inserted via each venous access. A Vizigo sheath (Johnson & Johnson MedTech) is inserted via the right femoral vein. Eight French (F) and 9F venous sheaths are inserted into the left femoral vein. All ablation procedures are performed utilizing a RF energy source; the Carto mapping system and 4-mm SmartTouch irrigation catheters (Johnson & Johnson MedTech) are used. After completing the ablation procedure, 3 J-wires are inserted via 3 sheaths. Three 8F short sheaths are then inserted individually over each J-wire. Dilators and wires are removed, and the sheaths are properly flushed.
Vascade MVP (Haemonetics) catheters are inserted through each 8F sheath. Each Vascade MVP Disc is then deployed within the vessel and the introducer sheath is removed over the Vascade MVP catheter. After the introducer sheath is removed, the Vascade MVP Disc is positioned against the intimal aspect of the venotomy, providing both temporary hemostasis and protection from intravascular placement of the Collagen Patch. The Vascade MVP Clip is applied at skin level to maintain the position of the disc. After confirming the position of the Collagen Patch by ultrasound, the Black Sleeve is unlocked and retracted to expose the Collagen Patch to the tissue tract. The system is left in place for a brief dwell period to allow the patch to swell, after which the Disc is collapsed and the Vascade MVP Catheter is removed from the vein leaving the resorbable, extravascular, hemostatic Collagen Patch at the venotomy site providing hemostasis.4 Gentle pressure is applied for 2-3 minutes.
Patients who did not receive a Vascade closure device had a figure-of-8 suture at both groins. The figure-of-8 sutures were either removed after 4 hours, or patients were discharged home with a figure-of-8 suture, which was removed the next day in clinic as per the discretion of the physician.
All patients had 2 hours of bed rest, after which they were ambulated and a discharge decision was made.
SDD Criteria
All patients were admitted to a cardiac short-stay unit for 4 hours after the procedure. Standard nursing post-anesthesia recovery protocols were used. After 2 hours of bed rest, all patients were ambulated. If ambulation was well tolerated with no access site bleeding and vital signs were stable, patients were discharged from the hospital into the care of a family member or support person. Oral anticoagulation was resumed as scheduled for that day.
Written education material and discharge instructions were provided to the patient. The decision to admit a patient for overnight monitoring was made if they had any of the following criteria: more than a 1-hour drive, inadequate support at home, patient’s preference to stay overnight, or any complications post procedure requiring overnight monitoring. All SDD patients received a follow-up phone call the next day. All patients had a 30-day clinic follow-up.
Outcome of Interest
Groin complications that were assessed included groin bleeding, hematoma, and pain requiring emergency department (ED) or urgent care visits within 30 days from the index procedure. Major bleeding, groin complications, acute coronary syndrome, pleural effusion, pericardial effusion, heart failure, respiratory failure, pericarditis, pulmonary embolism, cerebrovascular accident, ventricular tachycardia, death, and ED or urgent care visits were assessed within 30 days of hospital discharge for any reason.
Results
The percentage of patients discharged on the same day of the procedure was 50.8% (n=543). The overall rate of postoperative adverse outcomes was 4.1%. The adverse outcome rate was 3.8% for patients with non-SDD, while the rate was 4.4% for patients with SDD (P=0.72). Controlling for significant covariates, no significant difference in adverse outcome rates was demonstrated between SDD and non-SDD (adjusted odds ratio [OR] = 0.96; 95% confidence interval [CI], 0.39-2.33).
The 101 Vascade patients had no groin complications, while the 442 non-Vascade patients had 3 groin complications. These complications included a femoral pseudoaneurysm, hematoma, and general groin pain. In the Vascade group, there was no report of groin pain and readmission due to groin-related complications within 30 days of discharge.
Table 1 shows all major postprocedural complications that occurred within 30 days of hospital discharge. Table 2 shows characteristics by adverse events.
Discussion
The findings of this study have the potential to make significant improvement in patient satisfaction without sacrificing safety or effectiveness of catheter ablation in the treatment of AF in a community hospital.5 Utilizing a SDD strategy showed no significant difference in adverse events compared to the previous standard of care involving an overnight stay.
SDD after AF ablation has been the standard of care in a large tertiary care hospital. This strategy is novel for a community hospital.
During the pandemic, there was an increased demand for hospital beds across the country, especially in community hospitals, and it soon became desirable to send patients home as soon as it was deemed safe. This shift in postoperative disposition created the question of whether this new approach was equal to, or superior to, the former standard of care.
Based on the results of this study, it was shown that in this population, patients who were sent home showed no significant increase in adverse events compared to patients who stayed overnight following their ablation. It allows the patient to undergo their recovery and healing process in the comfort of their own home.
Use of the Vascade device demonstrated fewer groin complications compared to the non-Vascade group. It also appeared to be beneficial in early ambulation post-ablation, which improved patient satisfaction through decreased recovery time and earlier discharge.
Conclusion
Implementing SDD as the standard of care following uncomplicated catheter ablation may greatly improve patient satisfaction and may help in allocation of hospital resources. This finding is important for a small community hospital with fewer inpatient beds to perform AF ablations, allowing safe SDD without an increase in complications.
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. Dr Ahmed reports payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from Biosense Webster and Abbott.
References
1. Rashedi S, Tavolinejad H, Kazemian S, et al. Efficacy and safety of same-day discharge after atrial fibrillation ablation: a systematic review and meta-analysis. Clin Cardiol. 2022;45(2):162-172. doi:10.1002/clc.23778
2. Dixit S. Feasibility of same day discharge in atrial fibrillation patients undergoing catheter ablation. JACC Clin Electrophysiol. 2020;6(6):620-622. doi:10.1016/j.jacep.2020.03.008
3. Kowalski M, Parikh V, Salcido JR, et al. Same-day discharge after cryoballoon ablation of atrial fibrillation: a multicenter experience. J Cardiovasc Electrophysiol. 2021;32(2):183-190.
4. VASCADE® MVP Venous Vascular Closure System (VVCS). Instructions for use. Model 800-612C. Cardiva Medical, Inc. Accessed October 30, 2024. https://www.accessdata.fda.gov/cdrh_docs/pdf12/P120016S024C.pdf
5. Field ME, Gold MR, Rahman M, et al. Healthcare utilization and cost in patients with atrial fibrillation and heart failure undergoing catheter ablation. J Cardiovasc Electrophysiol. 2020;31(12):3166-3175. doi:10.1111/jce.14774
