Feasibility and safety of same-day home discharge after radiofrequency catheter ablation

Same-day discharge strategy in a heart rhythm management clinic: The patient-reported experience

BACKGROUND

Same-day discharge (SDD) has been adopted for interventional cardiology procedures, however, data on patient experience are scarce.

AIMS

To investigate patient-reported experience after various SDD electrophysiology procedures.

METHODS

Consecutive patients undergoing electrophysiology procedures, who fulfilled pre-defined eligibility criteria for SDD, completed the questionnaire before discharge. Procedures suitable for SDD included non/minimally-invasive (e.g. electric cardioversions, tilt tests) and invasive procedures (e.g. cardiac device replacements, catheter ablations). The questionnaire assessed patient experience before and during the procedure, satisfaction with the provided information and understanding of the discharge instructions.

RESULTS

The questionnaire was completed by 501 patients (57.5% men). Invasive procedures accounted for 56.7% of SDD procedures. Most patients (88.9%) described SDD as a good or quite good experience, while 95.3% would not hesitate to undergo a second SDD procedure if necessary. A direct interview with a healthcare team member was the preferred method of obtaining information. At discharge, a considerable number of patients were unsure about the provided instructions, including those related to anticoagulation. Patient-reported satisfaction did not differ between invasive and non/minimally-invasive procedures (P=0.06). However, after an invasive procedure, patients had a better understanding of discharge instructions (59.5% vs 41.9%; P<0.001). Most patients who underwent a procedure under general anaesthesia reported a good or quite good experience (87.7% vs 84.2% of sedation patients; P=0.16).

CONCLUSION

SDD was generally a positive experience for patients undergoing invasive or non/minimally-invasive procedures. However, discharge instructions and patient understanding require improvement.

Management of anesthesia for procedures in the cardiac electrophysiology laboratory

The complexity of cardiac electrophysiology procedures has increased significantly during the past 3 decades. Anesthesia requirements of these procedures can differ on the basis of patient- and procedure-specific factors. This manuscript outlines various anesthesia strategies for cardiac implantable electronic devices and electrophysiology procedures, including preprocedural, procedural, and postprocedural management. A team-based approach with collaboration between cardiac electrophysiologists and anesthesiologists is required with careful preprocedural and intraprocedural planning. Given the recent advances in electrophysiology, there is a need for specialized cardiac electrophysiology anesthesia care to improve the efficacy and safety of the procedures.

Safety and efficacy of same-day discharge for premature ventricular complex ablations

AIMS

Patients undergoing catheter ablation (CA) of ventricular arrhythmias (VAs) are generally observed overnight in the hospital given the concern for complications. To evaluate the efficacy and safety of same-day discharge (SDD) of patients undergoing elective CA of premature ventricular complexes (PVCs).

METHODS AND RESULTS

A retrospective evaluation of all patients undergoing elective VA ablation at Ascension St Vincent Hospital from 1 January 2018 to 31 December 2019 was undertaken. Of those, the patients undergoing PVC ablation were divided into SDD and non-SDD. Patients underwent SDD at the discretion of the operator. The primary safety outcome was the 30-day incidence of complications and death. The primary efficacy outcome was procedural success. Among 188 patients who underwent VA ablation, 98 (52.1%) were PVC ablations, and of those, 55 (56.1%) were SDD. There was no difference in age, gender, comorbidities, or ejection fraction between the two groups. Patients that were non-SDD were more likely to be on chronic anticoagulation (P = 0.03), have ablation in the LV (P = 0.04), have retrograde access (P = 0.03), and receive heparin during the procedure (P = 0.01). There were no complications in the SDD group compared with one (2.3%) in the non-SDD group. There was no difference in primary efficacy between the two groups with a 90.9% acute success in the SDD and 88.4% in the non-SDD (P = 0.68).

CONCLUSION

Same-day discharge for CA of PVCs is feasible and could lower healthcare resource utilization without compromising outcomes in this unique population.

Micro-Costing Analysis for the Treatment of Atrial Fibrillation: An Economic Evaluation of the First Italian Experience of Same-Day Discharge Protocol for Cryoballoon Atrial Fibrillation Ablation

Background: Atrial fibrillation (AF) is the most common cardiac arrhythmia, and its prevalence is expected to increase further due to the aging population, increasing prevalence of risk factors, improving detection methods, and broadening of catheter ablation indications. Along with limited healthcare resources and bed availability, these reasons led to the development of a same-day discharge (SDD) protocol. The aim of this study was to evaluate the health and economic impact of a routine adoption of same-day discharge after cryoballoon AF ablation. Methods: Consecutive patients with symptomatic and drug-refractory AF scheduled for first-time AF ablation were screened, and if deemed suitable, the SDD protocol was proposed and, if accepted, enrolled in the protocol. Results: A total of 324 patients were screened, and 118 were considered eligible for the SDD pathway. Fifty-two patients accepted the SDD pathway and were included in this study. The analysis showed that the variation in resource consumption associated with cryoablation in SDD is equal to EUR 739.85/patient. The analysis showed that the main cost driver for ordinary hospitalization was represented by the hospital stay, which was calculated to be 36% of the total cost. In total, there was a cost reduction of EUR 38.472 thanks to optimized AF patient management from the standard recovery setting to SDD. Conclusions: SDD after cryoballoon ablation of AF is feasible in selected patients with a standardized protocol.

Safety of same-day discharge without anticoagulation for left-sided radiofrequency catheter ablations in pediatrics

BACKGROUND

For left-sided radiofrequency catheter ablation (LCA) in pediatrics, significant practice variability exists regarding anticoagulation and discharge practices. Given the lack of data in pediatric patients, the risks and benefits of these practices are not well defined.

OBJECTIVE

The purpose of this study was to evaluate the safety of same-day discharge and use of aspirin (ASA) in pediatric patients following LCA.

METHODS

We performed a retrospective cohort study of pediatric patients who underwent LCA from 2010 to 2020 at our institution. Discharge timing and ASA usage were based on operator preference. The primary outcome was incidence of postablation anticoagulation complications reported within 1 month of the procedure.

RESULTS

Three hundred seventy-six patients underwent LCA and met inclusion criteria. Median [25th, 75th percentiles] age was 13.9 [10.5, 16.2] years; 18 (4.7%) had a history of structural heart disease. The most common substrates for ablation were Wolff-Parkinson-White syndrome (183 patients [48.7%]), concealed accessory pathway (159 patients [42.3%]), and ectopic atrial tachycardia (10 patients [2.7%]). Three hundred thirty-eight patients (89.9%) were discharged on the day of LCA. Seventy-six patients (20.2%) were prescribed ASA at discharge. Of those who underwent follow-up (273 patients [72.6%]), 7 (2.7%) reported an anticoagulation complication (5 with hematoma, 2 with headache). One of these patients was prescribed ASA; none required readmission. There was no correlation between anticoagulation complications and same-day discharge or with ASA usage.

CONCLUSION

Given the rare incidence of anticoagulation complications in pediatric patients undergoing LCAs, same-day discharge from the electrophysiology laboratory without anticoagulation should be considered.

Same-day discharge after atrial fibrillation ablation

Background

Atrial fibrillation (AF) catheter ablation has become an increasingly effective and safe strategy for the management of AF. With increased safety of catheter ablation, same-day discharge (SDD) is a potential way to minimize health care resource utilization and improve patient experience.

Objective

To evaluate the safety and patient satisfaction of SDD after contemporary AF ablation.

Methods

Consecutive patient undergoing AF ablation at our institution between 1/2020 and 10/2021 were enrolled in registry for clinical, quality, procedural and outcomes data. Patients were considered for SDD per physician discretion and patients' preference based upon clinical evaluation. Adjudicated ninety-day major complications, thirty-day adverse events, and thirty-day re-admissions were collected in a prospective registry for all patients.

Results

A total of 2142 consecutive patients underwent elective AF ablation during the study period. After excluding cases with missing data, 1830 patients were included in the analysis. Of those, 350 (19 %) patients were discharged the same day (SDD group) and 1480 (81 %) stayed overnight. Patients in the SDD group compared to overnight stay group were younger, more likely to be male, White patients, lower CHA2DS2-VASc score and to be on lower rates of warfarin as an anticoagulation strategy. After propensity score matching, SDD was associated with lower rate of major complications and higher patient satisfaction. The majority of life-treating complications occurred interprocedurally or within 6 h of procedure termination.

Conclusion

The present study demonstrated that SDD after contemporary AF ablation is feasible, safe and associated with higher patient satisfaction using a proposed SDD pathway and criteria.

Effectiveness and Safety of an Outpatient Program for Percutaneous Left Atrial Appendage Occlusion

BACKGROUND

Left atrial appendage occlusion (LAAO) is a safe and effective alternative to oral anticoagulation for thromboprophylaxis in patients with nonvalvular atrial fibrillation. Technological development in devices and imaging techniques, as well as accumulated experience, have increased procedural success rates and decreased complications. Same-day discharge protocols have been proposed in the field of structural heart disease, but this approach has not been studied in detail for the LAAO procedure.

AIM

The aim of this study is to assess the safety and efficacy of an outpatient program for LAAO when compared to the conventional treatment approach.

METHODS

We present a retrospective, non-randomized single-center study of 262 consecutive patients undergoing LAAO. Patients were divided into two groups, the first (n = 131) followed a conventional protocol (CP), and the second (n = 131) an outpatient protocol (OP). The primary composite endpoint comprised MACCE (death, stroke, and bleeding), cardiac tamponade, vascular complication, or attendance in the emergency department after hospital discharge at 30 days.

RESULTS

The overall success rate was 99.6%, with a periprocedural complication rate of 2.29%. With regards to the CP versus OP group, there were no differences between incidences of the primary composite endpoint (6.1% PC vs. 3.0% PA, p = 0.24), or after an analysis, with propensity score matching. No differences were observed in the individual endpoints. There was a decrease in hospital length of stay in the same-day discharge group (p < 0.01).

CONCLUSIONS

A same-day discharge LAAO program is safe, effective, and feasible when compared to the conventional strategy. Moreover, it reduces hospital length of stay, which might have clinical and economic benefits.

Length of hospital stay for elective electrophysiological procedures: a survey from the European Heart Rhythm Association

AIMS

Electrophysiological (EP) operations that have traditionally involved long hospital lengths of stay (LOS) are now being undertaken as day case procedures. The coronavirus disease-19 pandemic served as an impetus for many centres to shorten LOS for EP procedures. This survey explores LOS for elective EP procedures in the modern era.

METHODS AND RESULTS

An online survey consisting of 27 multiple-choice questions was completed by 245 respondents from 35 countries. With respect to de novo cardiac implantable electronic device (CIED) implantations, day case procedures were reported for 79.5% of implantable loop recorders, 13.3% of pacemakers (PMs), 10.4% of implantable cardioverter defibrillators (ICDs), and 10.2% of cardiac resynchronization therapy (CRT) devices. With respect to CIED generator replacements, day case procedures were reported for 61.7% of PMs, 49.2% of ICDs, and 48.2% of CRT devices. With regard to ablations, day case procedures were reported for 5.7% of atrial fibrillation (AF) ablations, 10.7% of left-sided ablations, and 17.5% of right-sided ablations. A LOS ≥ 2 days for CIED implantation was reported for 47.7% of PM, 54.5% of ICDs, and 56.9% of CRT devices and for 54.5% of AF ablations, 42.2% of right-sided ablations, and 46.1% of left-sided ablations. Reimbursement (43-56%) and bed availability (20-47%) were reported to have no consistent impact on the organization of elective procedures.

CONCLUSION

There is a wide variation in the LOS for elective EP procedures. The LOS for some procedures appears disproportionate to their complexity. Neither reimbursement nor bed availability consistently influenced LOS.

Patient perspectives on same-day discharge following catheter ablation for atrial fibrillation: results from a patient survey as part of the monocentric FAST AFA trial

AIMS

Same-day discharge (SDD) following catheter ablation (CA) of atrial fibrillation (AF) was already introduced in selected facilities in Europe, but a widespread implementation has not yet succeeded. Data on patients' perspectives are lacking. Therefore, we conducted a survey to address patients' beliefs towards SDD and identify variables that are associated with their evaluation.

METHODS AND RESULTS

As part of the prospective, monocentric FAST AFA trial, patients aged ≥20 years undergoing left atrial CA for AF were asked to participate in the survey consisting of a study-specific questionnaire, the AF knowledge scale, and pre-defined patient-reported outcome measures. The study cohort was stratified based on SDD willingness, and a logistic regression analysis was used to identify predictors for patients' valuation. Between 26 July 2021 and 01 July 2022, 256 of 376 screened patients consented to study participation of whom 248 (mean age 61.8 years, 33.9% female) completed the SDD survey. Of them, 50.0% were willing to have SDD concepts integrated into their clinical course with increased patient comfort (27.5%), shorter waiting times (14.6%), and a cost-efficient treatment (14.0%) being imaginable benefits. In contrast, expressed concerns included uncertainties with occurring complaints (50.6%), the insufficient recognition (47.8%), and treatment (48.9%) of complications. European Heart Rhythm Association class at baseline and inpatient treatments within the preceding year were predictors for SDD willingness whereas comorbidity burden or AF knowledge were not.

CONCLUSION

We provide a detailed survey expressing patients' beliefs towards SDD following left atrial CA. Our findings may facilitate adequate patient selection to improve the future implementation of SDD programs in suitable cohorts.

Same-day discharge for left atrial appendage occlusion procedure: A systematic review and meta-analysis

INTRODUCTION

Most patients undergoing a left atrial appendage occlusion (LAAO) procedure are admitted for overnight observation. A same-day discharge strategy offers the opportunity to improve resource utilization without compromising patient safety. We compared the patient safety outcomes and post-discharge complications between same-day discharge versus hospital admission (HA) (>1 day) in patients undergoing LAAO procedure.

METHODS

A systematic search of MEDLINE and Embase was conducted. Outcomes of interest included peri-procedural complications, re-admissions, discharge complications including major bleeding and vascular complications, ischemic stroke, all-cause mortality, and peri-device leak >5 mm. Mantel-Haenszel risk ratios (RRs) with 95% CIs were calculated.

RESULTS

A total of seven observational studies met the inclusion criteria. There was no statistically significant difference between same-day discharge versus HA regarding readmission (RR: 0.61; 95% confidence interval [CI]: [0.29-1.31]; p = .21), ischemic stroke after discharge (RR: 1.16; 95% CI: [0.49-2.73]), peri-device leak >5 mm (RR: 1.27; 95% CI: [0.42-3.85], and all-cause mortality (RR: 0.60; 95% CI: [0.36-1.02]). The same-day discharge study group had significantly lower major bleeding or vascular complications (RR: 0.71; 95% CI: [0.54-0.94]).

CONCLUSIONS

This meta-analysis of seven observational studies showed no significant difference in patient safety outcomes and post-discharge complications between same-day discharge versus HA. These findings provide a solid basis to perform a randomized control trial to eliminate any potential confounders.

Safety and feasibility of same-day discharge for catheter ablation of atrial fibrillation: a systematic review and meta-analysis

PURPOSE

Most centers performing catheter ablation (CA) of atrial fibrillation (AF) admit the patients for an overnight hospital stay to monitor for post-procedure complications, but the clinical benefits of this overnight hospital admission policy have not been carefully investigated. We hypothesized that same-day discharge strategy is safe and feasible in patients with AF undergoing CA.

METHODS

A systematic review of studies comparing the safety of same-day discharge vs hospital admission for AF patients undergoing CA was conducted in PubMed/MEDLINE, Embase, Scopus, and Web of Science. No randomized controlled trials met the inclusion criteria; therefore, observational cohort studies were included. Mantel-Haenszel risk ratios were calculated and I² statistics were reported for heterogeneity assessment.

RESULTS

A total of 8 observational studies with 10,102 patients were included. There were no statistically significant differences between same-day discharge vs hospital admission in all studied outcomes including post-discharge 30-day hospital visits (RR: 0.90; 95% CI: 0.40-2.02; p = 0.81), post-discharge vascular/bleeding complications (RR: 0.93; 95% CI: 0.46-1.88; p = 0.85), post-discharge stroke/transient ischemic attack/thromboembolism (RR: 0.70; 95% CI: 0.23-2.20; p = 0.55), and post-discharge recurrent arrhythmias (RR: 0.81; 95% CI: 0.60-1.09; p = 0.1).

CONCLUSION

In carefully selected AF patients undergoing CA, same-day discharge strategy is feasible and safe. There are no significant differences in post-discharge 30-day hospital visits, post-discharge vascular complications, and other safety outcomes. Randomized trials are needed to validate these hypothesis-generating findings.

Efficacy and safety of same-day discharge after atrial fibrillation ablation compared with post-procedural overnight stay: a systematic review and meta-analysis

AIMS

Catheter ablation for atrial fibrillation (AF) has historically required inpatient admission post-procedure, but same-day discharge (SDD) has recently been reported. We aimed to assess the efficacy and safety of SDD compared with overnight stay (OS) post-ablation.

METHODS AND RESULTS

We performed a systematic search of the PubMed database. Random-effects meta-analysis was performed to assess the efficacy (successful SDD) and safety (24 h complications, 30-day complications, 30-day re-admissions, and 30-day mortality) of a SDD AF ablation strategy. Fourteen non-randomized observational studies met criteria for inclusion, encompassing 26488 patients undergoing AF ablation, of whom 9766 were SDD. The mean age of participants was 61.9 years, and 67.9% were male. Around 61.7% underwent ablation for paroxysmal AF. The pooled success rate of SDD was 83.2% [95% confidence intervals (CIs): 61.5-97.0%, I2 100%]. The risk of bias was severe for all effect estimates due to confounding, as most cohorts were retrospectively identified without appropriately matched comparators. There was no significant difference in 30-day complications [odds ratio (OR): 0.95, 95% CI: 0.65-1.40, I2 53%] or 30-day re-admission (OR 0.96, 95% CI: 0.49-1.89, I2 82%) between groups. There were insufficient data for meta-analysis of 24 h complications and 30-day mortality. Where reported, no re-admissions occurred due to 24 h complications after SDD. Two deaths (0.04%) were reported in both SDD and OS groups.

CONCLUSION

Same-day discharge after AF ablation appears to be an effective and safe strategy in selected patients. However, the available evidence is of low quality, and more robust prospective studies comparing SDD to OS are needed.

Safety and feasibility of same-day discharge following catheter ablation of atrial fibrillation: what is known and what needs to be explored?

Catheter ablation of atrial fibrillation (AF) is the most effective rhythm control strategy and its role in the treatment of AF patients has been strengthened by recent guidelines. An increasing AF prevalence and the resulting demands on interventional electrophysiology call for improved resource allocation through both technical innovations and streamlined workflows and patient pathways. Same-day discharge is already established in the context of other electrophysiological interventions; however, its broad implementation in the practice of AF ablation is pending for several reasons, despite the fact that the body of evidence is growing and the majority of reports propagate early discharge to be feasible and safe under certain conditions. This review article is intended to provide an overview of the existing data, classify these into the specific study context, and to show limitations and open questions.

Same Day versus Overnight Discharge in Patients Undergoing Ablation for Atrial Fibrillation (SODA) Study

Patients undergoing catheter ablation for atrial fibrillation (AF) are routinely admitted for observation overnight in the hospital. With the rising incidence of AF among the population, increased volumes of procedures are placing increased demands on hospital resources. The purpose of this study was to evaluate the efficacy and safety of same day discharge in patients undergoing ablation for AF when compared to patients admitted for overnight observation. We performed a retrospective analysis using a multicenter cohort among patients who were discharged home after elective pulmonary vein isolation (PVI) ablation for AF. In our analysis, we found no statistically significant difference between patients discharged on the day of their procedure when compared to patients admitted for overnight observation in terms of 90-day readmission, major adverse cardiovascular events and death. This study shows that same day discharge after AF ablation is a feasible option. Future studies are needed to elicit the appropriate protocol to use.

Impact of Coronavirus Disease 2019 on Cardiac Arrhythmia Care: Experience of a Spanish Tertiary Hospital During the Health Crisis Triggered by the First Wave of the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has resulted in a deep restructuring of cardiovascular care, especially in the setting of cardiac arrhythmia units, which are characterized by a wide variety of clinical and interventional activities. We describe the experience of a large university hospital deeply hit during the COVID-19 health crisis (first outbreak of the pandemic), focusing on the exceptional measures implemented and their impact in terms of outcomes. We performed a retrospective study comparing the human and structural resources and the activity of a cardiac arrhythmia unit in a Spanish tertiary hospital for two consecutive periods: from January 12, 2020, to March 8, 2020 (“pre-COVID stage”), and from March 9, 2020, to May 2, 2020 (“COVID stage”). Data were contextualized within the number of confirmed COVID-19 cases in the region of Madrid. The measures implemented were promotion of non–face-to-face consultations, selection of urgent procedures, design of a “COVID-free” circuit for outpatient interventions, and protocolization for patients with COVID-19. A total of 3,526 consultations and 362 procedures were performed. During the COVID stage, the number of consultations remained stable, and the electrophysiology rooms’ activity decreased by 55.2% with a relative increase in the number of urgent-hospitalized cases attended (11.8% COVID-19-positive patients). The electrophysiology rooms’ activity returned to “normal” in the last week of the COVID stage, with no contagion being detected among patients or professionals. In conclusion, the measures implemented allowed us to respond safely and efficiently to the health care needs of patients with arrhythmias during the COVID-19 crisis and may be useful for other institutions facing similar situations.

Evaluating outcomes of same-day discharge after catheter ablation for atrial fibrillation in a real-world cohort

Background

As same-day discharge (SDD) after catheter ablation (CA) for atrial fibrillation (AF) is increasingly utilized, it is important to further investigate this approach.

Objective

To investigate the safety and efficacy of SDD after CA for AF in a large nationwide administrative sample.

Methods

The IBM MarketScan Commercial Claims and Encounters database was used to identify adult patients under 65 years undergoing CA for AF (2016-2020). Eligible patients were indexed to date of first CA and classified into SDD or overnight stay (ONS) groups based on length of service. A 1:3 propensity score matching was used to create comparable SDD:ONS samples. Study outcomes were CA-related complications within 30 days after index procedure and AF recurrence within 1 year. Cox proportional hazards models were estimated for outcome comparison.

Results

In the postmatch 30-day cohort, there were 1610 SDD and 4637 ONS patients with mean age 56.1 (± 7.6) years. There was no significant difference in composite 30-day postprocedural complication rate between SDD and ONS groups (2.7% vs 2.8%, respectively; P = .884). The most common complications were cerebrovascular events (0.7% vs 0.7%; P = .948), vascular access events (0.6% vs 0.6%; P = .935), and pericardial complications (0.6% vs 0.5%; P = .921). Further, no significant difference in composite AF recurrence rate at 1 year was observed among SDD and ONS groups (10.2% vs 8.8%; hazard ratio = 1.167; 95% confidence interval 0.935-1.455; P = .172).

Conclusion

In a large, propensity-matched, real-world sample, SDD appears to be safe and have similar outcomes compared with overnight observation following CA for AF.

Same-day discharge after catheter ablation in patients with atrial fibrillation in a large nationwide administrative claims database

BACKGROUND

Catheter ablation (CA) is a common treatment for atrial fibrillation (AF). This study evaluated outcomes of same day discharge (SDD) versus overnight stay (ONS) among AF patients undergoing outpatient CA.

METHODS

The Optum SES Clinformatics Extended Data Mart database was used to identify patients ≥18 years of age undergoing outpatient CA for AF (2016-2020). Eligible patients were indexed to the date of first CA and classified into SDD and ONS groups based on the length of service. A 1:3 propensity score matching was used to create comparable SDD:ONS samples. The primary safety outcome was CA-related complications within 30 days of index procedure. The primary efficacy outcome was AF recurrence within 1 year. Cox proportional hazards models were estimated for outcome comparison.

RESULTS

In the postmatch 30-day cohort for safety evaluation, there were 6600 patients (1660 [25.2%] SDD; 4940 [74.8%] ONS), with a mean age of 66.6 years. There was no significant difference in the 30-day composite rate of postablation complications (4.7% [78/1660] vs. 3.8% [187/4940]; p = 0.100) and 1-year composite rate of AF recurrence (14.3% [142/996] vs. 14.5% [430/2972]; p = 0.705) between the SDD and ONS groups.

CONCLUSION

This study demonstrated that SDD following CA to treat patients with AF is safe, with low rates of postablation complications and AF recurrence, which were comparable to rates in patients with an ONS after CA.

Utilization and perception of same-day discharge in electrophysiological procedures and device implantations: an EHRA survey

The aim of this European Heart Rhythm Association (EHRA) survey was to assess the utilization of same-day discharge (SDD) in electrophysiology (EP). An online-based questionnaire was shared with the EHRA community between 12 and 30 June 2020 and recorded institutional information, complication assessment, recent experiences, and opinions regarding possible advantages or concerns with SDD. In total, 218 responses from 49 countries provided information on current SDD management. Overall, SDD was implemented in 77.5%, whereas this proportion was significantly higher in tertiary and high-volume centres (83.8% and 85.3%, both P < 0.01). The concept of SDD was most commonly used following implantations of cardiac event recorders (97%), diagnostic EP procedures (72.2%), and implantations of pacemakers with one or two intracardiac leads (50%), while the lowest SDD utilization was observed after catheter ablations of left atrial or ventricular arrhythmias. Within SDD-experienced centres, ∼90% respondents stated that this discharge concept is recommendable or highly recommendable and reported that rates of increased rehospitalization and complication rates were low. Most respondents assumed a better utilization of hospital resources (78.2%), better cost effectiveness (77.3%), and an improved patients' comfort but were concerned about possible impairment of detection (72.5%) and management (78.7%) of late complications. In conclusion, >75% of respondents already implement SDD following EP interventions with a large heterogeneity with regard to specific procedures. Further research is needed to confirm or disprove existing and expected benefits and obstacles.

Safety and Feasibility of Same-Day Discharge After Left Atrial Appendage Closure With the WATCHMAN Device

Background:

As the use of left atrial appendage closure (LAAC) becomes more widespread, improvements in resource utilization and cost-effectiveness are necessary. Currently, there are limited data on same-day discharge (SDD) after LAAC. We aimed to evaluate the safety and feasibility of SDD versus non-SDD in patients with nonvalvular atrial fibrillation who underwent LAAC.

Methods:

We retrospectively studied 211 patients who underwent the WATCHMAN procedure in a tertiary hospital (June 2016 to June 2019). The primary safety outcome was the composite of stroke, systemic embolism, major bleeding requiring transfusion, vascular complications requiring endovascular intervention, or death through 7 days (periprocedural) and 45 days post-procedure. The secondary outcomes were the individual components of the primary outcome and all-cause readmission. We compared the clinical outcomes of patients who had SDD and non-SDD post-procedure.

Results:

Patients with procedure-related complications on the day of LAAC and patients who were admitted for acute clinical events before LAAC were excluded. One hundred ninety patients were included in the final analysis. Seventy-two of 190 (38%) patients had SDD, and 118 of 190 (62%) had non-SDD. There were no statistically significant differences in the primary safety outcome through 7 days (1.4% versus 5.9%; P=0.26) and 45 days post-procedure (2.8% versus 9.3%; P=0.14) between the two groups. The secondary outcomes were similar in both groups. No patients had device-related thrombus on transesophageal echocardiography at 45 days. Only 1 patient from the non-SDD group had clinically significant peri-device flow (>5 mm) at 45 days.

Conclusions:

In a selected cohort of patients who underwent successful elective LAAC with WATCHMAN without same-day procedure-related complications, the primary safety outcome and secondary outcomes through 7 and 45 days post-procedure were similar in the SDD and non-SDD groups. Our findings are hypothesis generating and warrant further investigation in prospective trials.

Prospective implementation of a same-day discharge protocol for catheter ablation of paroxysmal atrial fibrillation

PURPOSE

Overnight stays associated with catheter ablation (CA) for paroxysmal atrial fibrillation (PAF) account for a significant proportion of treatment cost. Same-day discharge (SDD) after CA may be attractive to both patients and hospitals, especially in light of current restrictions on overnight stays due to COVID-19. This study reports on the selection criteria, protocol, and safety of SDD after CA of PAF.

METHODS

Patients undergoing CA for PAF were evaluated to assess the risk of groin, respiratory, cardiac, or bleeding complications. SDD eligibility criteria were stable anticoagulation with no bleeding history, systolic heart failure, respiratory conditions, or interventional procedures within 60 days, and recommended BMI < 35. Patient proximity to the hospital was also considered. Anesthesia with propofol was used, and ablations were performed with a contact force catheter. Patients rested for 6 h post-procedure and then ambulated over 1-2 h. Discharge followed if they were stable without evidence of complications. A nurse called all patients the following morning to elicit evidence of complications.

RESULTS

Of 44 planned SDD procedures between April 2017 and June 2018, 41 resulted in SDD after 7.2 ± 1.0 h, 2 patients stayed overnight for observation, and one by choice. Average age was 59 ± 10 years with CHA₂DS₂-VASc of 1.6 ± 1.1. No SDD-related complications occurred, and no return visits resulted from the follow-up calls.

CONCLUSION

Appropriate low-risk patients identified by well-defined clinical criteria can be safely discharged the same day after CA for PAF. Evaluation in a larger population across different centers is required for generalizability of this SDD protocol.

Safety and cost-effectiveness of same-day complex left atrial ablation

Background

Catheter ablation for complex left-atrial arrhythmia is increasing worldwide with many centres admitting patients overnight. Same-day procedures using conscious sedation carry significant benefits to patients/healthcare providers but data are limited. We evaluated the safety and cost-effectiveness of same-day complex left-atrial arrhythmia ablation.

Method

Multi-centre retrospective cohort study of all consecutive complex elective left-atrial ablation procedures performed between January 2011 and December 2019. Data were collected on planned same-day discharge versus overnight stay, baseline parameters, procedure details/success, ablation technology, post-operative complications, unplanned overnight admissions/outcomes at 4-months and mortality up to April 2020. A cost analysis of potential savings was also performed.

Results

A total of 967 consecutive patients underwent complex left-ablation using radiofrequency (point-by-point ablation aided by 3D-mapping or PVAC catheter ablation with fluoroscopic screening) or cryoballoon-ablation (mean age: 60.9 ± 11.6 years, range 23-83 yrs., 572 [59%] females). The majority of patients had isolation of pulmonary veins alone (n = 846, 87%) and most using conscious-sedation alone (n = 921, 95%). Of the total cohort, 414 (43%) had planned same-day procedure with 35 (8%) admitted overnight due to major (n = 5) or minor (n = 30) complications. Overall acute procedural success-rate was 96% (n = 932). Complications in planned overnight-stay/same-day cohorts were low. At 4-month follow-up there were 62 (6.4%) readmissions (femoral haematomas, palpitation, other reasons); there were 3 deaths at mean follow-up of 42.0 ± 27.6 months, none related to the procedure. Overnight stay costs £350; the same-day ablation policy over this period would have saved £310,450.

Conclusions

Same-day complex left-atrial catheter ablation using conscious sedation is safe and cost-effective with significant benefits for patients and healthcare providers. This is especially important in the current financial climate and Covid-19 pandemic.

•

We have previously reported same-day standard catheter ablation is safe, feasible and cost-effective. Data on same-day complex left-atrial ablation are limited.

•

Our multi-centre cohort study of 967 consecutive elective complex left-atrial ablation procedures between January 2011 and December 2019 revealed same-day ablations using conscious sedation were safe and associated with very few complications and could have significant benefits to patients and cost-savings for healthcare providers worldwide.

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Same-day complex left-atrial ablation procedures can be performed safely without the need for overnight-stay. This has major implications for both patients and healthcare providers, especially given the current financial challenges and Covid-19 pandemic.

Safety, Feasibility and Economic Impact of Same-Day Discharge Following Atrial Fibrillation Ablation

BACKGROUND

The widely accepted model for atrial fibrillation (AF) ablation involves overnight hospital stay post-procedure. Day case AF ablation has been carried out at Royal Papworth Hospital (RPH) since early 2017. We evaluated the feasibility, safety and efficacy of day case AF ablation at RPH.

METHOD

This was a retrospective, single-centre study of consecutive AF ablations at RPH between March 2017 and April 2018. Demographic, procedural and outcome data were analysed.

RESULTS

Over the study period, 452 AF ablations were performed in 448 patients. One hundred and twenty-nine (129) (28.5%) were planned day cases; of these 128 were discharged on the same day. Two hundred and eighty-three (283) procedures resulted in at least one night admission. There was no significant difference in age or sex between the groups. Of note, day case procedures were significantly shorter, more likely to commence in the morning and less likely to require general anaesthetic than overnight stays. Patients listed as day cases also had less far to travel. The overall complication rate was 3.3%, with no significant difference between groups. Follow-up data was available for 448 cases (99.1%). Procedural success rates were comparable between groups. The overall cost saving attributable to providing AF ablation as a day case was £67,200 over the 13-month period.

CONCLUSIONS

Day case AF ablation is efficacious and associated with a low event rate, even without strict standardisation of patient selection or procedural protocols, in a high-volume centre. Substantial reduction in health care expenditure can be achieved with more widespread implementation of outpatient AF ablation.

Safety of Same Day Discharge after Atrial Fibrillation Ablation

INTRODUCTION

It is routine practice to observe patients (pts) overnight in the hospital after atrial fibrillation (AF) ablation. We report single center experience comparing the rate of complications prior to and after implementing a strategy of same day discharge (SDD) following AF ablation.

OBJECTIVE

To assess the safety of SDD after AF ablation.

METHODS

We reviewed the charts of consecutive pts who underwent AF ablation between Jan 2005 to Dec 2015. Patients who were electively admitted to undergo AF ablation or left atrial flutter ablation (AFL) were included. Patients undergoing only right atrial flutter ablation and in-patients were excluded. In Sept 2012 SDD strategy was implemented. Complication rates were collected up to 3 months post ablation. Major complications were defined as death, pericardial tamponade, CVA, hematoma requiring intervention, pulmonary vein stenosis, diaphragmatic paralysis or atrioesophageal fistula formation. Minor complications were defined as hematoma not requiring intervention and procedure related readmissions. Comparisons were made using an intention to treat analysis.

RESULTS

Group A (between Jan 2005 to Feb 2010) included 145 patients (87 males; 60.2 yrs mean age; 103 paroxysmal AF) who were observed overnight. Group B (between Mar 2010 to Dec 2015) included 426 patients (298 males; 62.3 yrs mean age; 247 paroxysmal AF) undergoing ablation following implementation of the SDD strategy. Patients in Group B were contacted by phone next day. In Group B, 51/426 (12%) pts were not discharged same day due to non-ablation related medical care (15/50 pts), ablation related complications (17/50 pts), pt preference (14/50 pts) and late cases (5/50 pts). Rate of total complications was more frequent in Group A (Group A 11.7% vs Group B 4.4%; p 0.026). Major complications happened in 2 pts in Group A and 6 pts in Group B. None of the major complications in Group B happened within 24 hrs of discharge. Only one pt in Group B had pericardial effusion drained 10 days post procedure. Most common minor complication in Group A was hematoma not requiring intervention and Group B was procedure related readmissions.

CONCLUSIONS

Our data suggest that SDD after AF or AFL ablation can be safely implemented in majority of pts with similar outcomes as pts observed overnight.

Feasibility and safety of same day subcutaneous defibrillator implantation and send home (DASH) strategy

PURPOSE

To assess the feasibility and safety of same-day discharge after S-ICD implantation by implementing a specific analgesia protocol and phone follow-up.

METHODS

Consecutive patients presenting for outpatient S-ICD implantation were enrolled between 1/1/2018 and 4/30/2019. An analgesia protocol included pre-operative acetaminophen and oxycodone, intraoperative local bupivacaine, and limited use of oxycodone-acetaminophen at discharge. The primary outcome was successful same-day discharge. Numerical Pain Rating Scale (NPRS) on postoperative day (POD) 1, 3, 14, and 30 and any unplanned health care visits during the 1-month follow-up period were assessed.

RESULTS

Out of 53 potentially eligible S-ICD patients, 49 patients (92.5%) were enrolled and successfully discharged on the same day. Mean age of these 49 patients was 47 ± 14 years. There were no acute procedural complications. Severe pain (NPRS ≥ 8) on POD 0, 1, and 3 was present in 14.3%, 14.3%, and 8.2% of patients, respectively. The total in-hospital stay was 534 ± 80 min. Four unplanned visits (8%) due to cardiac or device-related issues occurred during 1-month follow-up, including 2 patients with heart failure exacerbation, one patient with an incisional infection, and one patient with inappropriate shocks.

CONCLUSIONS

With the appropriate institutional protocol including specific analgesics and phone follow-up, same-day discharge after outpatient S-ICD implantation is feasible and appears safe for most patients.. Device-related pain can be severe in the first 3 days post-implantation and can be successfully treated with limited supply of narcotic medications.

Day-case percutaneous left atrial appendage occlusion-Safety and efficacy

OBJECTIVES

We evaluated the safety and efficacy of percutaneous left atrial appendage (LAA) occlusion performed as a day case procedure.

BACKGROUND

LAA occlusion has been shown to be safe and effective for stroke prevention in patients with atrial fibrillation. It has not been shown if the procedure can safely be performed on a day-case basis.

METHODS

Retrospective analysis was made of 117 LAA occlusion procedures in a single large teaching hospital in the UK. Procedural success, procedural complications, length of stay, and readmission data were examined.

RESULTS

Successful deployment of a device was possible in all but one patient (whose appendage was too large). Major in-hospital complications occurred in 1.7% of patients (both femoral vascular). Same-day discharge was made in 66% of patients overall. Since January 2016, only 3 of 59 patients (5%) have remained in hospital overnight following LAAO. Echocardiography 2-4 hr postprocedure was undertaken prior to discharge. One patient was readmitted within 7 days but this readmission would not have been prevented by overnight stay.

CONCLUSIONS

LAA occlusion can be safely performed as a day case procedure with acceptable complication rates and no increment of complications related to the lack of routine overnight stay.

Pulmonary embolism as a complication of an electrophysiological study: a case report

BACKGROUND

Electrophysiological studies have become an established practice in the evaluation and treatment of arrhythmias. Symptomatic pulmonary embolism as a result of deep vein thrombosis arising from multiple venous sheath femoral vein catheterization is an uncommon complication associated with it. We report the case of a 33-year-old woman who developed pulmonary embolism after an electrophysiological study, which was successfully treated at a cardiac hospital in Bangladesh.

CASE PRESENTATION

A 33-year-old Bangladeshi woman with hypertension and diabetes had initially presented with recurrent episodes of paroxysmal atrial fibrillation that manifested as palpitations for 2 years. Her atrial fibrillation was drug-refractory and could not be attributed to a treatable etiology. She had undergone an electrophysiological study at a different hospital, where right femoral venous catheterization was performed followed by the insertion of three venous sheaths. However, tachyarrhythmia could not be induced and a procedure to isolate the pulmonary vein was postponed because all the veins could not be isolated. Forty-eight hours later, she presented to our hospital with shortness of breath, chest heaviness, palpitations, and recurrent episodes of syncope. She had normal coronary arteries and no other risk factors for venous thromboembolism. She was hemodynamically stable on examination. There was echocardiographic evidence of pulmonary hypertension and right ventricular dilatation and dysfunction. A computed tomography pulmonary angiogram confirmed pulmonary embolus in the descending branch of her left pulmonary artery, extending up to the segmental arteries. Subsequently, a duplex ultrasound confirmed acute deep vein thrombosis affecting her right ilio-femoral segment. She was successfully managed with subcutaneous enoxaparin and oral warfarin (target international normalized ratio 2.5-3).

CONCLUSIONS

Pulmonary embolism is a rare but serious complication that may occur in patients who undergo electrophysiological studies. Multiple venous sheaths inserted into the femoral vein and catheter-induced endothelial injury, further compounded by prolonged procedural time, may be responsible for the increased thrombogenicity leading to deep vein thrombosis and subsequent pulmonary embolism. An adequate observation time after the procedure and clinical alertness are necessary for rapid diagnosis and treatment.