Feasibility and cost savings of outpatient electrophysiologic testing

[Ambulatory catheter ablation. Indications, results and risks]

The purpose of this study was to test the efficacy, feasibility, and safety of outpatient radiofrequency catheter ablation in 162 consecutive patients. There were 83 men and 79 women at a mean age of 47 + 15 years; 13 patients underwent 2 and 1 patient 3 ablation procedures. In 167 cases patients suffered from highly symptomatic paroxysmal tachycardia associated with presyncope or syncope in 74. Severe palpitations were present in 7 cases and recurrent syncope in 1 case. One patient had an asymptomatic Wolff-Parkinson-White syndrome with a shortest RR-interval during atrial fibrillation of 150 ms. The mechanism of tachycardia was found to be atrioventricular nodal reentry in 78 cases, atrioventricular reentry involving an accessory atrioventricular pathway in 56, atrial fibrillation in 16, atrial flutter of the common type in 15, ectopic atrial tachycardia in 8, and idiopathic ventricular tachycardia in 3. Catheter ablation was performed in these 176 cases at an overall success rate of 86%. In 148 cases patients could be treated on an outpatient basis and were discharged after a maximal observation time of 3 hours in 28, and 24 hours in another 120 cases. Short-term follow-up was uneventful in these patients. After 28 ablation procedures patients had to be admitted to the hospital, because of pain at the puncture sites or after pacemaker implantation in 15 cases, because of minor complications in 12, and because of pericardial tamponade in 1 case. Another severe complication occurred in 1 patient after successful ablation of right atrial tachycardia. Three days after discharge the patient suffered from pulmonary embolism originating from a thrombus at the ablation site. After hospital admission the patient recovered completely. In general, complication rate was 2.27%. This study shows that catheter ablation can be performed effectively and safety on an outpatient basis.

Outpatient radiofrequency catheter ablation

Outpatient radiofrequency catheter ablation has been shown to be safe and cost effective in the treatment of supraventricular tachycardias due to atrioventricular nodal reentrant tachycardia and atrioventricular reentry tachycardia. Complications secondary to vascular access are similar to those during outpatient cardiac catheterization procedures. Specific complications due to catheter manipulation and radiofrequency ablation include among others cardiac tamponade, AV block and proarrhythmia. Proper patient selection can help to prevent specific complications in outpatient ablations. Patients probably not suitable for outpatient procedures include the elderly as well as comorbid patients. Not all ablation procedures are suitable for the outpatient setting. Ablation procedures with an increased risk of AV block or proarrhythmia should not be performed on an outpatient basis. In order to effectively perform outpatient procedures a back up support with specially trained personnel is helpful. Radiofrequency ablations require considerable experience, therefore ablation procedures int he outpatient setting should be restricted to operators with adequate experience.

Safety, feasibility and cost of outpatient radiofrequency catheter ablation of accessory atrioventricular connections

OBJECTIVES

The purpose of this study was to evaluate prospectively the safety, feasibility and cost of performing radiofrequency catheter ablation of accessory atrioventricular (AV) connections on an outpatient basis in 137 cases.

BACKGROUND

The efficacy and low complication rate of radiofrequency ablation as performed in the hospital suggested that it might be feasible to perform it on an outpatient basis.

METHODS

In 100 cases (73%) performed between September 1, 1991 and April 20, 1992, patients met criteria for treatment as outpatients. Reasons for exclusion were age < 13 or > 70 years (4), anteroseptal location of the accessory AV connection (5 patients), obesity (> 30% of ideal body weight) (4 patients) or clinical indication for hospitalization (24 patients). Patients with only venous punctures had a recovery period of 3 h and those with arterial punctures had a recovery period of 6 h. There were 63 men and 32 women (5 patients underwent two ablation procedures > 1 month apart), with a mean age +/- SD of 36 +/- 13 years. The pathway was left-sided in 67 cases and right-sided or posteroseptal in 33.

RESULTS

The procedure was successful in 97 of 100 cases, with a mean procedure duration of 99 +/- 42 min. In 70 cases the patient was discharged the day of ablation, and in 30 cases the patient required a short (< or = 18-h) overnight stay because the procedure was completed too late in the day for recovery in the outpatient facility. The mean duration of observation was 4.8 +/- 1.5 h for outpatients and 15 +/- 1.4 h for patients who underwent overnight hospitalization. At follow-up study, two patients had a clinically significant complication; both had a femoral artery pseudoaneurysm detected > or = 1 week after the procedure and both required surgical repair. Thirty consecutive patients (22 outpatients and 8 hospitalized overnight) undergoing catheter ablation after January 1, 1992 were chosen for a cost analysis. The mean cost of the procedure was $10,183 +/- $1,082.

CONCLUSIONS

The majority of patients undergoing radiofrequency catheter ablation of an accessory AV connection can be treated safely on an outpatient basis.

The safety and economic advantages of day case electrophysiologic studies

Electrophysiologic Studies (EPS) have been performed as 'day case' procedures in selected patients at Royal Perth Hospital since April 1987. Previously, EPS had involved hospitalisation for two to ten days. During the 51 month period to June 1991, 484 EPS were performed in total. Of these, 153 (105 males and 48 females aged 46 +/- 31y) were day case procedures. Studies were baseline in 60 cases and included drug evaluation in 30. Sixty-one additional studies were performed solely to evaluate therapy. Twenty-one patients required cardioversion. One hundred and fifty one patients were discharged on the same day and two required prolonged observation. The financial cost savings to the hospital for day case EPS is estimated to be $115 per patient and to the community potentially a further $108 per patient. This study demonstrates that in selected patients undergoing elective EPS, day case management is a safe and economic alternative to hospital admission.