Same-Day Discharge for EP Procedures: Update From the Baptist Heart and Vascular Institute

In previous issues of EP Lab Digest,^1,2 we described in detail our same day discharge (SDD) protocols for ablation that have helped us to safely discharge patients home on the same day. Additional experiences have been gained in the past year while extending this strategy to other EP procedures besides atrial fibrillation (AF) ablation. The COVID pandemic has facilitated a major shift in how EP and cardiac procedures are performed in the U.S. Some of these ideas were gaining traction even before the pandemic, and have certainly become more widely adopted due to the desire for efficiencies and bed space. Now, we expect that most of these practices are here to stay permanently, as they have resulted in a better patient experience and possibly improved safety.

As previously discussed, management of the access site is a critical element of the SDD process. Use of vascular ultrasound for access is universal for all our cases. We also made a concerted effort to reduce the number of puncture sites. For AF ablations, the number of sheaths has been reduced to 2 in the majority of cases. For supraventricular tachycardia (SVT) ablations, this number is usually higher (3). We try to exchange the catheters when possible, instead of adding additional sheaths. Similarly, for premature ventricular contraction (PVC) and ventricular tachycardia (VT) ablations, 3 to 4 sheaths (or less) are used. There are only rare cases where 4 sheaths may be necessary. This helps with early ambulation, decreases the number of sites punctured, and reduces the subsequent cost of vascular closure devices (VCDs). In our own institutional analysis, there is possibly a financial break-even point around 3 or 4 sheaths, beyond which use of VCD is cost negative. In most cases, there is a cost savings with the use of VCDs, early ambulation, and SDD, compared to the $1000-$2000 cost of post-procedure monitoring.

In 2020, we used VCDs in 73% of AF cases. In the later part of 2020 as well as the current year, this number is close to 100%. We used Perclose ProGlide (Abbott) in 39.2% cases and Vascade MVP (Cardiva Medical) in 33.9% cases. Currently, Vascade MVP is the only FDA-approved closure device approved for post cardiac ablations requiring 2+ access sites per limb.

We have achieved a 68% SDD rate for AF ablations. The majority of cases completed earlier in the day (ie, before 3 pm) undergo SDD; however, unsafe discharges, including late cases, are monitored overnight. Between our different operators, there is some variation in this number, which may be attributable to scheduling times, patient characteristics, and physician discretion.

For 2020, our major vascular complication rate with AF ablation was zero. This refers to vascular complications requiring surgical intervention, thrombin injection, transfusion, AV fistula, pseudoaneurysm, or prolonged hospital stay. Two patients had a groin hematoma managed conservatively. Our overall complication rate for AF ablation was less than 1% in 450 cases.

When we analyze vascular complications at our institution, we see a trending reduction in 2018 and 2019 compared to 2017 (Table 1). We initially noticed a reduction when we adopted universal use of vascular ultrasound in 2018, and a further drop in 2020 when VCD usage was increased. We feel the beneficial effect of these two techniques is additive and, combined with use of fewer sheaths, can eliminate major vascular complications, as we have demonstrated. The results are reported for 4 operators in 3 EP labs, further suggesting that the results are not operator dependent, but rather, technique dependent.

We tend to use rapid ventilation with low tidal volumes when possible. This helps increase catheter stability during ablation. Typically, patients are given muscle relaxants only after the phrenic nerve course is localized around the right superior pulmonary vein antrum by pacing maneuvers. High-power, short-duration lesions (50 watts with Ablation Index-guided lesions) using the THERMOCOOL SMARTTOUCH Surround Flow (STSF) catheter (Biosense Webster, Inc.) have helped reduce the incidence of post-ablation chest pain and pericarditis.

Similar protocols are applied to patients undergoing SVT ablations, PVC ablations, leadless implants, and uncomplicated VT ablations. Device upgrades in which relatively young leads are removed without a powered sheath also have a high probability of discharging the same day. We typically perform a chest x-ray and device interrogation prior to discharge, approximately 4 hours after conclusion of the procedure. Our device-related procedures have achieved approximately a 65% SDD rate.

There are no data to support safety in SDD for WATCHMAN device (Boston Scientific) implantation.³ In a studied published recently by Tan et al, 72 of 190 (38%) patients had SDD after a WATCHMAN device, and the remaining 118 (62%) had non-SDD. There were no statistically significant differences in the primary safety outcome through 7 days (1.4% vs 5.9%; P=.26) and 45 days post-procedure (2.8% vs 9.3%; P=.14) between the two groups. In select patients, due to concerns for COVID transmission during the pandemic, we have also performed SDD for WATCHMAN procedures, achieving a 50% SDD rate. Our WATCHMAN implant complication rate for last year was zero. As the number of COVID inpatients declines, it is prudent to provide overnight monitoring for WATCHMAN patients due to the complexity of the procedure, risk of complications, and the need for post-operative monitoring.

Besides medical complications, there are circumstances when patients are monitored overnight to observe rhythms and efficacy of ablation, etc. Additionally, patients who are elderly, frail, unstable, or have comorbidities (such as severe LV dysfunction, CHF, or ESRD on dialysis) require overnight monitoring. Patients who do not have a companion for the next 24 hours are required to be monitored. Occasionally, elderly patients suffer from urinary retention, nausea, or other symptoms requiring monitoring. Patients whose procedures are late in the day also usually require overnight monitoring. These determinations are made on a case-by-case basis.

A low complication rate is paramount to achieving a high percentage of SDD. Every institution should be monitoring complications associated with EP procedures, and if there is a higher than expected rate, we would recommend avoiding a SDD strategy until that is addressed.

Follow-up care is generally arranged with the AF coordinator and EP provider (APP or physician) at the time the procedure is scheduled. Our walk-in clinic is available to patients seeking immediate attention. “Our AF center provides our contact information to patients prior to and post ablation, to help answer all questions and concerns as quickly and efficiently as possible. This constant and direct communication greatly decreases the prevalence of ED encounters and cuts down on any unnecessary clinic visits. Patients have expressed their thankfulness for all the education provided to them regarding their procedure. Patients also have peace of mind knowing they have a direct, reachable resource to address any questions or concerns. It has allowed for more personalized care and greater access to our team,” shared Ashleigh Howard, RN, Clinical Charge Nurse and AF Clinic Coordinator.

Based on our experience, we feel that SDD is appropriate and possibly preferred for most AF ablations. Attention to safety protocols for each procedural step has translated into fewer complications for patients. It has also resulted in benefits to the institution in terms of efficiencies and cost savings. SDD is being applied to the majority of our other EP procedures as well. Programs interested in adopting SDD should carefully review their complications and results, adopt the use of VCDs, educate staff in the pre and post procedure area, and provide close follow-up and easy access to patients. Care should be taken to code procedures appropriately as outpatient/observation or inpatient status, depending on medical necessity. 

Disclosures: The authors have no conflicts of interest to report regarding the content herein. Dr. Verma reports payment/honoraria as a speaker/consultant for Abbott.   

1. Verma S. Adopting a strategy of early ambulation and same-day discharge for atrial fibrillation ablation cases. EP Lab Digest. 2019;19(5):1,10-12.

2. Verma S. Same-day discharge for AF ablation: what have we learned? EP Lab Digest. 2020;20(8):33-37.

3. Tan BE, Boppana LKT, Abdullah AS, et al. Safety and feasibility of same-day discharge after left atrial appendage closure with the WATCHMAN device. Circ Cardiovasc Interv. 2021;14:e009669. https://doi.org/10.1161/CIRCINTERVENTIONS.120.009669