Logistics for Same-Day Discharge Following Atrial Fibrillation Ablation and Cardiac Implantable Electronic Device Implantation: Single-Center Experience From Munson Health Care

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EP LAB DIGEST. 2024;24(2):1,18,22.

For many years, it was standard of care to observe patients overnight following relatively more complex ablations and CIED implantation. In recent years, many centers evolved to offer same-day discharge (SDD) following such procedures. We offer a review of our single-center workflow for SDD following ablation for atrial fibrillation (AF) and cardiac implantable electronic device (CIED) implantations.

AF Ablation

Recent trials have shown efficacy of AF ablation in reducing AF burden, decreasing the progression of paroxysmal to persistent AF and—in certain patient populations—contributing to mortality benefit.^1-3 With increasing AF incidence,⁴ ablation will continue to be important among rhythm control management options. SDD offers an opportunity to meet growing clinical demand in the face of relatively fixed inpatient resources and can also offer the possibility of higher patient satisfaction.

The primary concern when offering SDD following ablation is timely identification and management of acute complications. Examples include vascular access bleeding, pericardial effusion, stroke, and reactions to sedation.

Patients arrive the morning of the planned AF ablation. A single prep and recovery room is assigned for the pre- and postprocedural time frame, providing the patients and care partners with a predictable and private environment throughout the process. Patients are monitored on telemetry before and after the case.

Transesophageal echocardiography is scheduled at the discretion of the operator, and if needed, is performed in the cardiac electrophysiology (EP) laboratory immediately preceding the ablation. With regard to the preoperative management of oral anticoagulation, available data show the use of uninterrupted oral anticoagulation is not associated with increased bleeding risk and suggest an association with decreased silent cerebral ischemic events.⁵ We have chosen to standardize our approach as a group and our default is to instruct patients to continue oral anticoagulation without interruption.

Femoral venous access is obtained with ultrasound guidance. We prefer this method to minimize risk of vascular access complications, particularly in the setting of continued oral anticoagulation. Intracardiac echocardiography (ICE) images are obtained to identify any pre-existing pericardial fluid. The ablation procedure is then performed, typically without the use of fluoroscopy or with minimal fluoroscopy. Briefly, as a group we prefer radiofrequency ablation and typically use higher power levels over shorter duration radiofrequency applications, as detailed in previously published data.⁶ We have recently implemented use of very high power, short duration lesions⁷ in anatomically appropriate locations, at the discretion of the operator (90 watts, 4 seconds, QDOT Micro Catheter, Biosense Webster, Inc).

We use heparin during the ablation as guided by serial activated coagulation time measurements. At the end of the ablation, ICE imaging is used to rule out a new pericardial effusion that would have developed during the procedure. Intravenous protamine is then given to reverse the heparin.

Vascular access closure is then completed using either a figure-of-8 stitch or a commercially available extravascular absorbable closure device (Vascade MVP System, Haemonetics). The choice of closure method is at the discretion of the operator. If a figure-of-8 stitch is used, the patient is observed in recovery with 3 hours of bed rest, followed by ambulation and 1 additional hour of observation. If the closure device is used, the patient is observed in recovery with 2 hours of bed rest, followed by ambulation and 1 additional hour of observation.

Serial neurologic assessments are completed during the recovery time to assess for stroke or adverse reactions to sedation. After the post-operative monitoring period, patients are discharged home in the company of their care partner. A health care team member contacts the patient the following day. Post-operative clinic follow-up is then arranged.

CIED Implant

SDD following CIED implant has become a more widely accepted alternative to the historical standard of overnight observation. That said, the practice is a relatively recent development and data to guide decision-making are still growing. While data support the safety of same-day CIED implant discharge,⁸ there are currently no society-driven guidelines or consensus statements to serve as a reference when developing an institution-specific protocol. Therefore, specific operational processes may vary.

Our patients who are planned for outpatient CIED implant arrive the morning of the procedure. Preprocedural anticoagulation is managed at the discretion of the implanting physician and the strategy is routinely decided upon in advance. Any medications that require suspension will have been identified in the preprocedural clinic visit. Labs are typically drawn prior to the day of the procedure, although lab draw immediately on arrival is an available option. Antibiotic prophylaxis with cefazolin or vancomycin is prescribed according to our protocol, which was developed with our clinical pharmacy colleagues.

CIED implantation is then performed per routine procedural workflow, with the use of an absorbable antibiotic envelope and agents to aid in hemostasis at the discretion of the operator. At the end of the case, fluoroscopic images of the CIED system are taken in right and left anterior oblique views to serve as a reference when obtaining post-implant posterior-anterior (PA)/lateral chest X-ray.

The patient returns to their post-operative room, where recovery and telemetry monitoring is continued. We ensure the PA/lateral chest X-ray is performed, viewed, and interpreted before consideration of discharge. The new CIED system is interrogated shortly before discharge to document stable lead parameters.

Post-implant observation serves to identify acute complications including pocket hematoma, pneumothorax, acute pericardial effusion, or lead dislodgement. A retrospective analysis found that most acute post-CIED complications are found within 6 hours or more than 24 hours after implant.⁹ We have found that a monitoring period of 4 hours offers a reasonable balance of post-operative monitoring, identification of acute complications, and for patients to travel earlier in the day.

Patients are contacted by a health team member the following day. Remote device data are pulled on post-operative day 1 and are reviewed by the implanting physician to confirm stable lead parameters and presenting rhythm. In-person device clinic enrollment and CIED site check is scheduled for 3-4 weeks following CIED implant.

The above workflow pertains to transvenous CIED systems. We do offer SDD for patients undergoing leadless pacemaker and subcutaneous implantable cardioverter-defibrillator implantation procedures.

Following leadless pacemaker implantation, the femoral vein is closed using either a figure-of-8 stich followed by a 4-hour bed rest time, or a commercially available percutaneous closure system (Perclose, Abbott) followed by a 2-hour bed rest time. Chest X-ray and device interrogation are performed in a similar manner as described.

Of note, our patient population who present for symptomatic high-degree atrioventricular block generally do so through the inpatient setting. In this clinical scenario, patients are often discharged the following day, which allows for a longer monitoring period in the setting of new ventricular pacing dependence.

Conclusions

We present our workflow for SDD following AF ablation and CIED implantation. We have found it to be safe and easy to implement. While SDD has evolved to become our default process, decision-making individualized to the patient, close assessment and reassessment of postprocedural data, and preserved access to overnight observation remain critical to its success. 

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

References

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