Same-day CIED implantation and discharge: Is it possible? The E-MOTION trial (Early MObilization after pacemaker implantaTION)

Outcomes of an expedited same-day discharge protocol following cardiac implantable electronic device (CIED) implantation

BACKGROUND

With increasing constraints on healthcare resources, greater attention is being focused on improved resource utilization. Prior studies have demonstrated safety of same-day discharge following CIED implantation but are limited by vague protocols with long observation periods. In this study, we evaluate the safety of an expedited 2 hour same-day discharge protocol following CIED implantation.

METHODS

Patients undergoing CIED implantation at three centers between 2015 and 2021 were included. Procedural, demographic, and adverse event data were abstracted from the electronic health record. Patients were divided into same-day discharge (SDD) and delayed discharge (DD) cohorts. The primary outcome was complications including lead malfunction requiring revision, pneumothorax, hemothorax, lead dislodgement, lead perforation with tamponade, and mortality within 30 days of procedure. Outcomes were compared between the two cohorts using the χ2 test.

RESULTS

A total of 4543 CIED implantation procedures were included with 1557 patients (34%) in the SDD cohort. SDD patients were comparatively younger, were more likely to be male, and had fewer comorbidities than DD patients. Among SDD patients, the mean time to post-operative chest X-ray was 2.6 h. SDD had lower rates of complications (1.3% vs 2.1%, p = 0.0487) and acute care utilization post-discharge (9.6% vs 14.0%, p < 0.0001). There was no difference in the 90-day infection rate between the cohorts.

CONCLUSIONS

An expedited 2 hour same-day discharge protocol is safe and effective with low rates of complications, infection, and post-operative acute care utilization.

Outcomes of a 24/7 service for urgent permanent pacemaker implantation

INTRODUCTION AND OBJECTIVES

Most of the complications associated with acute and symptomatic bradyarrhythmia (ASB) occur in the time from diagnosis to permanent pacemaker implantation (PPI). We aimed to evaluate the outcomes of an urgent 24/7 PPI service (PPI-24/7) for patients with ASB.

METHODS

A total of 664 patients undergoing first-time PPI for ASB were prospectively assessed during 2 periods of identical length (18 months): 341 patients who underwent the procedure during working hours only (PPI-WH), and 323 patients who underwent the procedure after the implementation of the PPI-24/7 service. The primary safety endpoint was established as the cumulative 180-day incidence of complications related to the index arrhythmia and device implant. The primary efficacy endpoint was determined as the average number of hospital stays per patient.

RESULTS

The PPI-24/7 period was associated with a significant shortening of the time from diagnosis to implantation (median [interquartile range]): 3hours [2-6] vs 16 [5-21]). The cumulative incidence of patients with complications at 180 days was lower in the PPI-24/7 period: 9% vs 17% (adjusted odds ratio, 0.5; P=.002), due to a significant reduction in preimplant complications: 2.5% vs 12% (P <.001). The average number of hospital stays was reduced by 2 per patient in the PPI-24/7 period (nonparametric P <.001). PPI-24/7 implants performed outside working hours (n=178) were safe, with a 180-day cumulative incidence in procedure-related complications of 3.9%.

CONCLUSIONS

Among patients with ASB, PPI-24/7 was associated with a significant reduction in patient morbidity and efficient hospital resource use.

Telehealth of cardiac devices for CVD treatment

This review covers currently available cardiac implantable electronic devices (CIEDs) as well as updated progress in real-time monitoring techniques for CIEDs. A variety of implantable and wearable devices that can diagnose and monitor patients with cardiovascular diseases are summarized, and various working mechanisms and principles of monitoring techniques for Telehealth and mHealth are discussed. In addition, future research directions are presented based on the rapidly evolving research landscape including Artificial Intelligence (AI).

Role of routine investigations post cardiac devices implants in detecting peri-procedural complications: A retrospective analysis from a tertiary UK center

BACKGROUND

Peri-procedural complications associated with cardiac implantable electronic devices are not uncommon. European Society of Cardiology guidelines recommend device checks of all devices within 72 h of implant. European Heart Rhythm Association expert practical guide on Cardiac implantable electronic devices (CIEDs) recommend that a chest x-ray (CXR) should be performed within 24 h to rule out pneumothorax and document lead positions. First, the rate of peri-procedural complications associated with CIED implants at our center, as well as patient and/or procedural-related factors that are associated with higher rates of complications, is analyzed. Second, the yield of the guideline-recommended measures in the early detection of peri-procedural complications is examined.

MATERIALS AND METHODS

Consecutive de novo transvenous device implants at our center in 2019 were retrospectively analyzed. Patients' demographics, types and indications for device therapy, procedural reports, device checks, and CXRs were obtained from the hospital electronic records.

RESULTS

A total of 578 patients (Age 74 ± 16 years, 68% male) were included. All patients had routine post-procedure CXRs and device checks. There were 16 (2.8%) complications; 7 (1.2%) pneumothoraxes, 6 (1%) pericardial effusions, and 3 (0.5%) lead displacements. Procedure time correlated significantly with complications; in uncomplicated cases it was 99 ± 43 min versus 127 ± 50 min in procedures associated with complications (p = .02).

CONCLUSIONS

Routine post CIED implantation CXRs can detect early peri-procedural complications, while repeat post mobilization device checks has low yield of detection of complications. The only statistically significant predictor of peri-procedural complications is the duration of the procedure; longer procedures were associated with higher rates of complications.

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.

Safety of same-day discharge versus overnight stay strategy following cardiac device implantations: a high-volume single-centre experience

BACKGROUND

The strategy of cardiac implantable electronic device (CIED) implantations performed as day-case admissions has gained a wider acceptance overtime; however, data on safety are still limited. This study aims to investigate the safety of a same-day discharge protocol introduced in our hospital for the postprocedural management of patients undergoing CIED implantation.

METHODS

Α prospective, non-interventional, non-randomised study performed in a single high-volume implanting centre for a 16-month period (March 2020 to June 2021). At total of 821 of 965 (85.1%) patients scheduled for elective CIED implantation were considered to be eligible for inclusion in the Short-stay Device Management Protocol. These patients were compared with a historical group of 932 patients, meeting the same inclusion criteria.

RESULTS

Procedure was successful in 812 patients (98.9%), committed to same-day discharge versus 921 of 932 patients (98.8%) admitted for overnight stay (p = 0.87). Overall, 90-day complication rate was comparable in both groups (4.14% vs 4.07%, p = 0.95), as was major (1.46% vs. 1.82%, p = 0.55) and minor (2.67% vs. 2.25%, p = 0.64) complication rates. The composite early post-procedural complication rates and late post-procedural complication rates were comparable among groups (0.97 vs 1.18%, p = 0.70 and 0.73% vs 0.64%, p = 0.83, respectively). Six hundred sixty-seven patients (84%) preferred the same-day discharge strategy. Finally, a reduction of 792 bed-days was recorded, resulting in possible financial Health System benefits.

CONCLUSIONS

Same-day discharge is feasible and safe in the majority of patients referred for CIED implantation. Additionally, same-day discharge is preferred by patients and may reduce procedure-related costs due to significant bed-day reductions.

Adverse clinical events during the first 24 h of bedrest following cardiac electronic device implantation: a prospective observational study

AIMS

To describe the incidence and impact of adverse clinical events (ACEs) during first 24 h of bedrest of patients after cardiac implantable electronic device (CIED) implantation.

METHODS AND RESULTS

We conducted a prospective observational study of patients aged over 18 years undergoing elective placement of permanent bicameral pacemaker (PM), cardiac resynchronization therapy (CRT) PM, CRT defibrillator, or implantable cardioverter-defibrillator. Patients were maintained on bedrest post-operatively for 24 h and delirium, post-operative urinary retention, severe post-operative pain, pressure ulcer, and sleep disturbance were recorded using standardized assessments. Of 90 patients, 66 (73.3%) were male and average age was 76 ± 10 years. The median time to first mobilization was 23 (21-24) h. The adverse clinical events occurred in 48/90, with severe pain (38/90), sleep disturbance (12/90), delirium (9/90), and urinary retention requiring urinary catheterization (8/90) most frequent. Patients receiving implantable cardioverter-defibrillator or CRT defibrillator experienced ACEs significantly more frequently than those receiving PM. Adverse clinical event was associated with prolonged hospital stay [odds ratio (OR) 2.5; 95% confidence interval (CI) 1.16-6.17]. Patients with delirium were more dependent for daily living activities on admission (OR 8.0; 95% CI 1.55-41.3).

CONCLUSION

Adverse clinical events frequently occur post-insertion of a CIED and impact patient clinical course and experience. The progressive increase in ageing and frailty of CIED implant candidates requires special nursing attention to improve patients' satisfaction and to prevent increased healthcare resource use.

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.

SCAI expert consensus update on best practices in the cardiac catheterization laboratory: This statement was endorsed by the American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Rhythm Society (HRS) in April 2021

The current document commissioned by the Society for Cardiovascular Angiography and Interventions (SCAI) and endorsed by the American College of Cardiology, the American Heart Association, and Heart Rhythm Society represents a comprehensive update to the 2012 and 2016 consensus documents on patient-centered best practices in the cardiac catheterization laboratory. Comprising updates to staffing and credentialing, as well as evidence-based updates to the pre-, intra-, and post-procedural logistics, clinical standards and patient flow, the document also includes an expanded section on CCL governance, administration, and approach to quality metrics. This update also acknowledges the collaboration with various specialties, including discussion of the heart team approach to management, and working with electrophysiology colleagues in particular. It is hoped that this document will be utilized by hospitals, health systems, as well as regulatory bodies involved in assuring and maintaining quality, safety, efficiency, and cost-effectiveness of patient throughput in this high volume area.

A survey on patient preferences towards CIED implantation

Background

Cardiac implantable electronic device (CIED) implantation is increasingly performed worldwide with improving safety. Outpatient CIED implantation has similar complication rates compared to those implants which are hospitalized. Here, we analyze patient preferences on discharge timing after CIED implantation.

Objective

To identify and understand the factors contributing to patient preferences towards same-day or next-day discharge after CIED implantation.

Methods

One hundred and two patients undergoing new CIED implants were included in the study at two separate hospitals in CT (CT group) and FL (FL group) from 2018-2019. A 7-question survey was administered to the patients after the procedure. Survey responses and demographic data were statistically analyzed.

Results

Seventy-four percent of CT group and 58% of the FL group responded with a 10 score (0-10) that they were ready to be discharged home the same day (p=0.09). Both groups reported a low number of patients feeling safer by having a remote monitor provided at the time of discharge (44% CT group, 28% FL group; p=0.123). The mean distance of patients living from the hospital in CT group (21.6 miles) was significantly lower than that for the FL group (35.5 miles); p=0.01. Hypertension (86% vs 52%; p=0.0002) and Diabetes mellitus (44% vs 21%; p=0.013) were more prevalent in the FL group compared to the CT group.

Conclusion

Despite the influence of local practices, the majority of patients preferred same-day discharge after CIED implantation. Improved patient education regarding the ability of remote monitors to provide real-time response to acute events is needed.

Very early discharge after cardiac implantable electronic device implantations: is this the future?

PURPOSE

To limit the ever-increasing healthcare costs, strategies to minimize hospitalization length are warranted. In this perspective, early discharge (the same day or after < 24 h) post-cardiac implantable electronic device (CIED) implantation might represent a useful strategy; nevertheless, it is imperative first to understand the timing of (potentially lethal) complications and evaluate whether this is not only an effective but also a safe clinical decision.

METHODS

A retrospective cohort analysis of all patients undergoing new CIED implantation from Jan 2008 to Dec 2014 was conducted. Patient demographics, comorbidities, and timing of complications post CIED implantation were evaluated, and the timing of complications was divided into intra-operative, 0-6 h (h), 6 to 24 h, and > 24 h post-implant. One-year post-implant follow-up (FU) was performed in our CIED clinic.

RESULTS

A total of 1868 patients (68% men, average age 70 years, 85% hypertension, 39% diabetes, 57% coronary artery disease, and average left ventricular ejection fraction (LVEF) 41%) received 703 (38%) pacemaker, 448 (24%) implantable cardioverter-defibrillator (ICD), 639 (34%) cardiac resynchronization therapy (CRT) devices, and 78 (4.2%) cardiac contractility modulation. A total of 199 (11%) patients experienced 214 complications. Most (75%) occurred > 24 h post-implantation (with a median of 7 days). At univariate analysis, complications occurred more often in patients with a lower LVEF, on anticoagulation/antiplatelet therapy, and undergoing ICD/CRT-D implantation (p < 0.05 for all).

CONCLUSION

Most complications occur > 24 h after first time CIED implantation. Therefore, it might not be optimal to discharge patients in ≤ 24 h, unless extensive ambulatory monitoring for complications is available.