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Same-Day Discharge for Atrial Fibrillation Ablation
Quick Takes
- Same-day discharge for AF ablation is feasible but may be associated with more ED utilization post-procedure.
- Patient selection, intraprocedural safety protocols, patient/family education, and early follow-up need to be optimized if same-day discharge protocols are to become commonplace.
Study Questions:
What is the safety, efficacy, and health care utilization of a same-day discharge protocol for atrial fibrillation (AF) ablation?
Methods:
This study included consecutive patients who underwent AF ablation from 2010 to 2014 at two major Canadian centers. The primary outcomes were proportion of successful same-day discharges, 30-day hospital readmission for any reason, and the composite of 30-day death, stroke/transient ischemic attack or embolism, and/or bleeding requiring hospitalization. The same-day discharge protocol incorporated standard periprocedural elements, but some details were at the discretion of the operator, such as choice of anticoagulant pre- and post-procedure.
Results:
A total of 3,054 patients met inclusion criteria. Same-day discharge was achieved in 79.2% (2,418/3,054). Hospital readmission at 30 days occurred in 7.7% of the same-day discharge group, 10.2% among those who had remained in the hospital overnight without complications (p = 0.055 for comparison with same-day discharge), and 19.5% (p < 0.001) for those who remained in the hospital with procedural complications, which had occurred in 7.7%. Complication rates from discharge to 30 days (excluding immediate procedural complications) were 0.37% for the same-day discharge group, 0.36% (p = 0.999) for those kept overnight without complications, and 2.5% (p = 0.044) for those with initial procedural complications. There were two total deaths; one was in a patient who had a stroke 24 days after same-day discharge. Pericardial effusion occurred in 58 patients (1.9%). The two most common reasons why a patient was admitted were late procedure finish and access site problem. Almost all patients received general anesthesia (98.9%), and 41.1% received low molecular weight heparin for bridging anticoagulation. In a subgroup analysis of 420 patients, there was a trend toward a high rate of emergency department (ED) visits in the same-day discharge group: the most common reason was AF/arrhythmia.
Conclusions:
Same-day discharge after AF ablation is feasible with use of a standardized protocol and not associated with higher hospital readmission or complication rates after discharge. Same-day discharge may be associated with increased ED visitation in the postoperative period.
Perspective:
This is the largest study to date on same-day discharge for AF ablation and is very timely as hospitals and electrophysiology services consider new plans of care in the era of coronavirus disease 2019 (COVID-19). Of note, this was an observational nonrandomized study in a relatively healthy population. Utilization of direct oral anticoagulants (DOACs) and cryoablation have significantly increased since the study was initiated.
Future same-day discharge protocols could build on this study. Some specifics to consider: patient selection (comorbidities), anesthesia (general vs. moderate sedation), anticoagulation (DOAC vs. warfarin, interrupted or uninterrupted), access management (ultrasound, micropuncture needle, closure device vs. figure of 8), transesophageal or intracardiac echocardiography (effusion monitoring), postoperative assessment (care team), patient/family education, and early follow-up (availability of both virtual and in-person).
Clinical Topics: Anticoagulation Management, Arrhythmias and Clinical EP, Cardiac Surgery, Pericardial Disease, Anticoagulation Management and Atrial Fibrillation, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Cardiac Surgery and Arrhythmias
Keywords: Anticoagulants, Arrhythmias, Cardiac, Atrial Fibrillation, Catheter Ablation, Cryosurgery, Electrophysiology, Embolism, Emergency Service, Hospital, Heparin, Low-Molecular-Weight, Ischemic Attack, Transient, Patient Discharge, Patient Readmission, Pericardial Effusion, Stroke, Vascular Diseases
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