Same-Day Discharge After Catheter Ablation of Atrial Fibrillation in Traditional Nonambulatory and Freestanding Ambulatory Settings

It is estimated that nearly 60 million people worldwide and as many as 6 million in the United States suffer from atrial fibrillation (AF), with the numbers projected to double by 2035.^1,2 The contemporary approach to management of AF has focused on rhythm control strategies, particularly catheter ablation, given the improved outcomes associated with maintenance of sinus rhythm using this technique.³ Although at least as many as 30% of patients with AF meet indications for catheter ablation, an estimate from the Global Physical Activity Alliance Exercise and Reporting suggests that only 4% of patients receive catheter ablation therapy.^4,5 Recently, catheter ablation as a first-line strategy has been shown to be more effective than antiarrhythmic therapy in preventing AF recurrence, and it is expected that this will lead to an increased early adoption of AF ablation.⁶

In many regards, the periprocedural management of patients who receive catheter ablation for AF is similar to those undergoing ambulatory surgery. But historically, postprocedural care following AF ablation has included an overnight hospital stay (ONS). Recently, there has been a growing interest in same-day discharge (SDD) of patients who undergo AF ablation, and some centers have even expanded it to a completely ambulatory setting. Herein, we briefly examine the safety, feasibility, and benefits associated with SDD after catheter ablation of AF in traditional nonambulatory as well as freestanding ambulatory settings.

SDD After Catheter Ablation of AF in a Traditional Setting

For several years, SDD following AF ablation has been considered a routine practice across many high-volume centers, including ours.⁷ However, with the recent challenges (eg, reassignment of hospital beds and personnel) associated with the COVID-19 pandemic, there has been a renewed interest in the SDD strategy.^8,9 A number of recent studies^7-10 have closely examined this approach and found that SDD after AF ablation appears safe and feasible in the vast majority of patients, particularly when guided by a prespecified protocol.^7,11 A multicenter study inclusive of our own experience previously evaluated the outcomes of SDD vs ONS following cryoballoon ablation of AF in 2374 consecutive patients (SDD = 1119 vs ONS = 1180).⁷ All procedures were performed on uninterrupted oral anticoagulation under general anesthesia and included the use of intracardiac echocardiography. Postprocedurally, all patients were monitored for acute indications of groin complication or pericardial effusion/tamponade, and if either were suspected, further testing was utilized for triaging purposes. The occurrence of either complication nullified a SDD strategy. Of note, each facility utilized a standardized protocol that consisted of a checklist criteria prior to considering the SDD strategy. Table 1 depicts the SDD protocol from our own facility. In brief, this multicenter comparative study found no difference in the 30-day adverse event (AE) rates between SDD (1.26%) vs ONS (2.03%), respectively (P=.14).⁷ The most common complication was groin hematoma (SDD = .67% vs ONS = .93%; P=.57). There were 3 cases of pericardial effusion in ONS with zero 30-day mortality. An economic sensitivity analysis demonstrated that when 50% of every 100 patients treated were discharged the same day, annual hospital cost savings varied between $45,825 and $83,813 based on geographical locations (Figure 1). Specifically, hospital cost savings per patient were $917, $1437, and $1676 for the East Coast, Midwest, and West Coast hospitals, respectively.

These findings are consistent with other reports and experiences that have shown that most major complications following AF ablation occur either intraprocedurally or within the initial 6 hours of the procedure.¹⁰ Deyell et al, who evaluated the efficacy and safety of a SDD protocol for AF ablation, noted that this could be achieved in ~80% of patients.¹¹ Moreover, they found that the 30-day hospital readmission rate was 7.7% with SDD vs 10.2% with ONS (P=.05) in those without complications, and 19.5% (P<.001) in those with procedural complications. AEs from the time of discharge to 30 days following procedure were 0.37% with SDD vs 0.36% with ONS without complications (P=.99) and 2.5% (P=.04) with initial procedural complications. Chu et al also investigated SDD after catheter ablation of AF and found that this could have been implemented in up to 80% of patients if avoidable barriers had been addressed, including logistical/nonclinical barriers (43%), prolonged postprocedure recovery (42%), and minor procedural complications (15%).¹² Along these lines, a large meta-analyses evaluating the outcomes of AF ablation in 11,660 patients (SDD = 5982 vs ONS = 5678) from 10 observational studies¹³ and a study of 6660 propensity-matched AF ablations (SDD = 1660 vs ONS = 4940) derived from health insurance claims¹⁴ similarly found comparable safety associated with SDD as compared to ONS.

Catheter Ablation of AF in a Freestanding Ambulatory Setting

While catheter ablation of AF has traditionally been performed in the hospital setting, the initial experience with AF ablations performed within an ambulatory surgical center (ASC) was recently reported.¹⁵ This not only has the potential to yield a much higher level of efficiency, but considerably greater overall savings for the health care system. Although cardiovascular implantable electronic devices have been successfully implanted for many years in ASCs across the United States and reimbursed accordingly, this has not been the case with catheter ablation procedures. However, the COVID-19 pandemic temporarily incentivized the Centers for Medicare & Medicaid Services to expand certain allowable procedures to ASCs. This, in turn, led to AF ablations being performed in select patients within ASCs in certain parts of the country, including Texas, Arizona, and Alaska.

Zagrodzky et al investigated the outcomes of cryoballoon ablation of AF in 26 consecutive patients, including 13 ablated patients in a freestanding ASC (71 ± 8 years, 69% with paroxysmal AF) vs 13 matched patients in the hospital setting.¹⁵ The ASC consisted of an outpatient facility with a cardiac fluoroscopy suite and a dedicated cardiac catheterization team that routinely performs heart catheterization, percutaneous coronary intervention, and stenting. It is located 1 mile away from a tertiary center with cardiothoracic surgery services and an existing transfer agreement between the 2 facilities. The ASC is also supported by anesthesiologists and equipped with a Prucka CardioLab recording system (GE Healthcare), Bloom electrophysiology stimulator (Fisher Medical), and intracardiac echocardiography, but not 3D mapping. Briefly, no  acute AEs were encountered in either group, but 1 ASC-treated patient later presented with a minor groin hematoma without bleeding/pseudoaneurysm and was managed conservatively. While the procedural durations were similar between the 2 groups, the length of stay was significantly shorter in the ASC (5.4 ± 1.5 h) vs in the hospital setting (13.0 ± 13.0 h), P<.01 (Figure 2).

It should be highlighted that this is not the only available experience with catheter ablation within the ASC setting. In the last 2 years, catheter ablation of AF along with other types of ablations have been successfully performed at a number of ASCs across the United States. Still, several questions remain. For instance, what should be the qualifying criteria for ASCs? Should there be any requirements for association or proximity to hospitals, emergency departments, or cardiac surgery? What should be required of the operators and their experiences? Most importantly, what types of ablations might be considered suitable? It seems that simple ablations (ie, atrioventricular node or supraventricular tachycardia) would likely be an appropriate starting point. But owing to its high level of safety and the lack of need for 3D mapping, one may also argue that cryoballoon ablation of AF in select patients could represent a suitable procedure to be transitioned to the ambulatory setting. As this procedure has become increasingly safe and facile with its roles and indications gradually expanding, its eventual transition to an ASC seems inevitable. The significantly shorter lengths of stay and lower costs to the health care system associated with such an approach will not only yield marked reductions in resource utilization and increased cost savings, but could also drastically improve global access for patients in need of catheter ablation therapy. 

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors have no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr Aryana reports research grant, consulting, and speaker honoraria from Medtronic.

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