Current Strategies for Early Ambulation and Same-Day Discharge Following Atrial Fibrillation Ablation

Atrial fibrillation (AF) is the most common cardiac arrhythmia.¹ Catheter ablation of AF has demonstrated to be an effective treatment for symptomatic patients, with a considerable superiority over standard antiarrhythmic medications.² The risks associated with catheter ablation for the treatment of AF are generally low; however, patients are typically observed overnight following the ablation procedure to monitor for complications that may manifest within the first 24 hours postprocedure (eg, access site complication, pericardial effusion, and cardiac tamponade).

The primary benefits of same-day discharge (SDD) after catheter ablation of AF include decreased length of hospital stay, improved patient satisfaction, and more optimal use of health care resources. Several studies evaluating same-day catheter ablation for AF suggest that SDD is safe and feasible, and produces significant cost savings for health care providers.^3,4

The aim of this article is to highlight the evolution of SDD after catheter ablation of AF in appropriately selected patients. Specifically, we will review the existing literature on this topic and discuss the benefits, risks, barriers, and economic implications of this approach.

Clinical Data on SDD After AF Ablation

Timing of AF Ablation Complications

Knowledge of the timing of postprocedural complications is the most important consideration in the discharge process and is historically the reason that AF ablation patients are kept overnight for monitoring. Recent publications have shown a consistent drop in major complications of AF ablation, driven by reduced vascular, stroke, and bleeding complications.⁵ The most immediate complications that would delay discharge are access site hematoma, arrhythmias, pericardial effusion, and tamponade.

Pericardial effusion, which is perhaps one of the most feared postablation complications, is accentuated due to the transseptal approach and anticoagulation administration during the procedure. However, most pericardial effusions occur during the ablation procedure and are usually discovered and treated promptly. Patients with no pericardial effusion at the end of the procedure and who are hemodynamically stable for 6 hours postablation have a very low risk of developing a pericardial effusion within 24 hours of discharge.⁶ Two studies showed that the complications affecting patients discharged on the same day were noted to occur >24 hours after ablation and would not have been detected by an overnight stay.^3,7 Deyell et al noted that the most common reason for 30-day readmission in both groups (admitted and SDD) was a recurrence of arrhythmia (47%), followed by heart failure (11%), chest pain (11%), access site hematoma (6%), digestive tract diseases (6%), and miscellaneous causes (14%). Interestingly, the composite 30-day postdischarge complication rate was not different between the SDD group and patients electively admitted without complications (Figure 1) (.37 vs .36; P=.999).⁸ Kowalski et al noted that complication rates were similar between the SDD and overnight stay (ONS) cohorts (1.26% vs 2.03%; P=.13). More importantly, none of the complications in the SDD group occurred during the first 24 hours after discharge, and therefore, could not have been prevented with an overnight stay.³ Other studies confirmed this by noting that all major complications occurred within 2-3 hours of procedure completion, which leaves little benefit to an overnight observation in the hospital.^7,9 Another study found that among 143 SDD patients, 3 (2.1%) patients returned to the hospital, of whom only 1 returned on the same day of discharge with pericarditic chest pain, which was managed conservatively. The other 2 presented >48 hours after discharge for nausea and vomiting, which was also managed conservatively.¹⁰ Pericarditic chest pain is a common reason for an ED visit or a readmission postdischarge. It was the cause for readmission in 11.3% of patients in one study.⁸ Rajendra et al discharged all patients on colchicine for 2 weeks to mitigate pericarditis.¹¹ In another study, the investigators recommended a more conservative approach by educating patients about the possibility of postprocedural pericarditic chest pain and managing it with over-the-counter analgesics.¹⁰

Unplanned Overnight Stay

All studies in this review considered a major complication to preclude SDD. In certain cases, patients assigned to SDD were subject to an unplanned overnight stay. Haegeli et al reported that in a cohort of 206 patients eligible for SDD, 11% of cases were admitted due to major complications: 1 minor stroke (0.4%), 6 cardiac tamponade requiring drainage (2.6%), minor groin bleeding requiring compression and bed rest in 10 patients (4.3%), and the remaining due to late completion of the procedure.¹² In another study, Reddy et al reported only 1 unplanned admission out of 129 cases, due to late completion of the case.⁹

SDD Protocols

The success of SDD undoubtedly relies on safe and effective SDD protocols as well as the availability of resources. These protocols are expected to consider the patient’s risk profile, the safety of vascular access, type of anesthesia used, minor and major complications, anticoagulation management, postprocedural recovery time, and postdischarge follow-up. The successful adoption of the SDD protocol in AF ablation relies on 4 different prerequisites: (1) accurate identification of patients suitable for SDD; (2) excellent procedural outcomes with low complication rates; (3) reliable stabilization of venous access site; and (4) safe discharge, adequate patient education, and appropriate follow-up.

Suitability to SDD

The timing of the procedure is the most important factor in SDD. For patients to be discharged on the same day of their procedure, it is expected that their procedure would end at a reasonable time of the day for them to safely return home. Hence, studies that have evaluated SDD thus far have restricted patients’ eligibility to first cases of the day or early morning cases.^3,4,11,12

Studies that looked at the feasibility and safety of SDD in this review were all nonrandomized, prospective, or retrospective, and included adult patients without excluding the elderly. Importantly, in most studies, the average age was not different between SDD or ONS cohorts and age was not a predictor of readmission.^8-10,13

Patients’ comorbidities also play a major role in the safety of AF ablation. In fact, a nationwide in-hospital analysis from Germany reported that advanced age with high cardiac, pulmonary, and vascular comorbidities are important risk factors leading to procedural complications and death.¹⁴ Rajendra et al applied strict eligibility criteria for SDD patients, recommending a BMI <35 and “acceptable” CHA₂DS₂-VASc score (typically less than or equal to 3), and excluding patients with labile INR, history of bleeding, congestive heart failure, pulmonary disease, and any procedure within 60 days.¹¹ Postprocedural pulmonary edema and volume overload are common obstacles to SDD, and particularly seen in patients with extensive left atrial disease or heart failure. Judicious use of postprocedural diuretics will facilitate a safe SDD.⁴

The distance needed to travel home is another crucial determinant of eligibility to SDD. Kowalski et al restricted SDD to patients living within 30 minutes from the hospital in their New York cohort and within 75 miles in their Michigan cohort (Table 1). This can be adjusted depending upon the available resources in the local region.³

Vascular Access

The most common complications of AF ablation are access site complications that, in most cases, preclude SDD.¹⁴ These adverse events are difficult to mitigate given that AF ablation is presently being done with uninterrupted anticoagulation. The use of ultrasound to guide femoral vein access has been shown to reduce vascular complications and is rapidly becoming the standard of care.¹⁵ Moreover, hemostasis strategy was not standardized among different studies, where some routinely used a figure-of-8 suture and others left it at the discretion of the operators to use manual compression or vascular closure devices.^3,4,8 It was shown that a figure-of-8 suture or vascular closure devices reduce time to hemostasis and allow patients to safely ambulate early after device deployment, which may facilitate early discharge. The AMBULATE trial showed that the use of a venous closure system when compared to manual compression resulted in significant reductions in time to ambulate, total postprocedural time, total time to hemostasis, time to discharge eligibility, and opioid use, with increased patient satisfaction and no increase in complications.^16,17

Use of Echocardiography

Other major complications of AF ablation that preclude SDD are pericardial effusions and tamponade. Most studies performed postprocedural echocardiography for prompt detection of pericardial effusions, which was repeated before discharge.^3,7,18 Other studies left the use of postprocedural echocardiography at the discretion of operators, with a low threshold to image if an effusion was clinically suspected.^8-10

Recently, to reduce fluoroscopy time and increase safety, operators have been routinely using intracardiac echocardiography (ICE) for guidance in interventional procedures.¹⁹ A recent nationwide cohort analysis of a database of Medicare patients showed that the absence of ICE is associated with a fivefold increased risk of perforation.²⁰ We believe that the routine use of ICE would also promote safer procedural outcomes and increase in the comfort level of the physician, which can facilitate SDD.

Anticoagulation Strategy

It is apparent that a strategy of performing AF ablation on patients receiving uninterrupted anticoagulation can be performed safely and minimizes the risk of thromboembolic events, obviating the need for bridging with low-molecular-weight heparin.²¹ Hence, using a standard protocol for periprocedural uninterrupted anticoagulation is vital for the success of SDD. Most studies used the standard of uninterrupted anticoagulation with warfarin or holding 1 dose of direct oral anticoagulants on the day of the procedure.^3,9,10 Moreover, recent studies have shown that the use of protamine accelerates time to groin hemostasis and effectively reduces bed rest duration without increasing the risk of thromboembolism.²²

Standardization of Procedures

To date, the studies that have looked at the feasibility and safety of SDD for AF ablation have had heterogenous procedure protocols. Most studies included patients undergoing the procedure under either general anesthesia (GA) or conscious sedation (CS).^4,6,8-10 Notably, RF ablation is a longer procedure than cryoballoon ablation; therefore, the use of GA was more common in the former.⁴ In a multivariate analysis, Deyell et al found that the use of the cryoballoon, despite it being linked to a shorter procedure time, was associated with an increased likelihood of hospital admission. According to the authors, this was probably due to the use of large bore (12 French) sheaths, which, by itself, leads to increased risk of vascular complications and the need for prolonged monitoring.⁸ Some studies included only patients undergoing the procedure under conscious sedation; whereas others included GA only.^7,11,12 Most importantly, the use of GA did not preclude SDD but did prolong recovery time.^3,11

Discharge Criteria

Most patients were monitored in the recovery area for 6-8 hours. SDD was granted to patients if certain safety criteria were met. Most importantly, patients needed to be ambulating and pain free, with stable vitals and groin access, tolerating oral intake, be suitable for resuming anticoagulation, live within a reasonable distance from the hospital, have a competent caretaker at home, and be willing to follow up within 4-12 weeks.^3,10 Most studies provided patient education and discharge instructions to SDD participants and recommended a follow-up clinic appointment within a few weeks. A phone call on postoperative day 1 or at 1-week postdischarge was part of the protocol of 5 studies.^3,6,8,11,23 In a subgroup analysis, Deyell et al found that SDD might be associated with an increase in emergency department visits with a median time of 4 days after discharge, despite having telephone access to AF clinic nurses and a robust protocol of telephone visits at 7-10 days postdischarge.⁸

Economic Impact of SDD

The total cost of AF has become a burden to the health care system.²⁴ Strategies aimed at reducing the hospital length of stay have shown to be effective in reducing health care costs. Kowalski et al³ found that the hospital cost savings ranged between $917 to $1676 for every SDD compared to an ONS (Figure 2). To note, the study only included patients undergoing cryoballoon AF ablation and the cost analysis did not account for the freed telemetry hospital bed that can potentially be used to monitor a different patient. Health care expenditure differs widely between different countries in the world. Reddy et al found that in the UK, the overall cost savings was £67,200 over a period of 13 months.⁹ In a hypothetical cost analysis, Chu et al found that the cost savings would amount to $452,400 from avoiding operating costs for 156 hospital beds, generating a revenue of $657,696 if these vacant hospital beds were to be occupied by patients admitted for chest pain evaluation.⁴

Conclusion

The future of AF ablation is exciting. Our review shows that SDD following AF ablation is safe and effective despite few logistical barriers that can be overcome with careful preprocedural planning. Moreover, the use of new ablation technologies such as pulsed field ablation hold promising prospects for SDD, as early data on this modality have shown it to reduce procedural time and enhance safety. Promoting early discharge for stable AF ablation recipients will benefit patients, caregivers, and health care systems. SDD of low-risk cases is the next step in the evolution of AF ablation. We call for a randomized controlled trial comparing SDD to hospital admission using standardized protocols, eligibility, and discharge criteria.

Find us on Twitter at @saoumania @ValayParikhMD

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Shah reports payment or honoraria from Medtronic for a lecture, as well as support from Medtronic for attending meetings and/or travel. Dr Kowalski reports consulting for Medtronic.

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