Same-Day Discharge: An Evolving Landscape for Atrial Fibrillation Ablations

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EP LAB DIGEST. 2024;24(11):1,8-9.

Kunal Kapoor, MD MSc¹; Apoorva Sharma, MD²; Mikhael El-Chami, MD^1 
1Emory University, Cardiology Division, Department of Electrophysiology, Atlanta, Georgia; ²Emory University, Department of Medicine, Atlanta, Georgia

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia affecting millions. Its incidence is expected to rise along with the aging population, which poses substantial clinical challenges and financial burden on hospitals.¹ As hospitals grapple with these escalating costs and limited bed availability, there is a pressing need for innovative approaches to manage AF and optimize resource allocation. While same-day discharge (SDD) has been the norm after simple ablations such as typical atrial flutter and supraventricular tachycardia ablations, this has not been the case for AF ablations until more recently. This is due in part to AF ablations being typically more complex procedures that require general anesthesia, a transseptal approach, and larger sheaths for access.

At Emory University, SDD for AF ablation was gradually adopted. The approach began prior to the pandemic (2018), but became the norm during and after the pandemic. With improved physician experience and ablation technologies, AF ablation has become safer and shorter in duration. Undoubtedly, this is not only a major boon toward patient convenience, but it enhances resource allocation as well.

Several studies have demonstrated the feasibility and safety of SDD for AF ablation. In a multicenter cohort study of 3054 patients who underwent AF ablation, Deyell et al found that SDD was not associated with a higher readmission rate or with an increase in post-discharge complications.² Subsequent studies have continued to build on these standardized protocols to guide SDD. Espinosa et al implemented a nurse-coordinated standardized protocol that resulted in 91% of eligible patients being discharged the same day without major complications.³ This study design also employed a SDD coordinator as well as a smartphone-based virtual visit on postoperative days 1 and 3 to ensure patient well-being. Rajendra et al utilized a standardized protocol in a large, multicenter prospective registry of 2332 patients for both paroxysmal and persistent AF (REAL-AF SDD protocol). The study was unique in that it employed the protocol in a preprocedural visit to plan SDD, and was able to apply this approach broadly across 29 institutions. Eligibility criteria included proximity to the hospital, presence of caregiver support upon hospital discharge, and no major comorbidities (body mass index <35 preferred, no prior history of major bleeds, and ejection fraction [EF] >35%). With this approach, around 86% of patients had successful SDD. However, there was optimism that the percentage could be closer to 95% if certain timing and social factors could be optimized (earlier cases, planning for longer traveling distance, etc).⁴ 

At our institution, it is our practice to discharge all AF ablation patients (with few exceptions) on the same day of the procedure. Patients with labile vital signs, slow recovery from anesthesia, those who lack social support in the immediate postoperative setting, or patients who live a far distance from the hospital and have late procedure time are monitored overnight. We monitor patients post-procedurally for 3-4 hours using standard post-anesthesia nursing recovery protocols. We routinely perform limited bedside echocardiograms to exclude pericardial effusions. We also place a focus on early hemostasis to enhance early ambulation times. Patients with reduced EF who receive an extensive amount of saline (extensive radiofrequency ablation) are typically given a dose of diuretics and their volume status is assessed carefully prior to discharge.

For venous closure, we rely on a variety of approaches. As we are a multisite institution, the preference for venous closure varies and is provider specific. However, we typically utilize 3 approaches: Vascade MVP (Haemonetics), Perclose ProGlide (Abbott), or figure-of-8 suture. 

The Vascade system works in up to 12 French (F) sheaths and is a single-use closure device, which grants hemostasis via use of a resorbable, extravascular collagen plug. Its use gained traction following the RESPECT and AMBULATE trials, which showed shorter time to hemostasis, time to ambulation, and shorter time to discharge compared to manual compression.^5,6 

The Perclose ProGlide device, approved for use in up to 24F sheaths, employs a percutaneous suture to the access site to allow for healing. Compared to manual compression, studies have shown improved time to ambulation and reduced hospital costs through reduced laboratory and nursing time.⁷ 

In those patients who may have a hard time lying flat postprocedurally, such as due to respiratory distress or a history of back surgery, closure devices are typically preferred over the figure-of-8 suture. However, cost disparity between the closure devices and figure-of-8 suture makes the latter appealing from a system-wide cost perspective. In this approach, providers will typically utilize a nonabsorbable suture, such as a 1-0 Ethibond or 0-prolene suture. The suture is removed at the end of the patient’s flat time, which is typically 2 to 3 hours in duration. Additionally, the figure-of-8 suture is typically less time-consuming to employ and shows benefit compared to manual compression.^8,9 At the end of the designated flat time, patients are ambulated by the nursing team to evaluate ongoing hemostasis as well as monitor for pain, hemodynamic shifts, or other safety concerns.  

Following discharge, patients will routinely have a postoperative phone check within 2-3 days and a follow-up visit within 1 month with a nurse practitioner on our team. The purpose of this visit is to assess for recovery and any procedure-related complications. Within 3 months after discharge, patients will have a follow-up visit with the physician who performed the ablation. It is at this visit that discussions regarding management of AF and medication adjustments are considered. 

As SDD has become more common among EP procedures, we have noted this to extend to AF ablations as well. Across our institution, we have noted favorable results with this approach. With more standardized protocols for patient selection and procedural implementation, the systems-based approach to pre- and post-care delivery for AF ablations is a team-based intervention. However, it mutually benefits both patient satisfaction and resource utilization of the health system at large. With pulsed field ablation, the procedure is shorter in duration, more tolerated by patients (less pericarditis, less fluid use), and safer; therefore, the adoption of SDD after AF ablation is expected to increase. 

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest and report no conflicts of interest regarding the content herein. Dr El Chami reports consulting fees from Medtronic and Boston Scientific, as well as participation on a Data Safety Monitoring Board or Advisory Board for Medtronic.

References

1. Kornej J, Börschel CS, Benjamin EJ, Schnabel RB. Epidemiology of atrial fibrillation in the 21st century: novel methods and new insights. Circ Res. 2020;127(1):4-20. doi:10.1161/CIRCRESAHA.120.316340

2. Deyell MW, Leather RA, Macle L, et al. Efficacy and safety of same-day discharge for atrial fibrillation ablation. JACC Clin Electrophysiol. 2020;6(6):609-619. doi:10.1016/j.jacep.2020.02.009

3. Espinosa T, Farrus A, Venturas M, et al. Same-day discharge after atrial fibrillation ablation under a nurse-coordinated standardized protocol. Europace. 2024;26(4):euae083. doi:10.1093/europace/euae083

4. Rajendra A, Osorio J, Diaz JC, et al. Performance of the REAL-AF same-day discharge protocol in patients undergoing catheter ablation of atrial fibrillation. JACC Clin Electrophysiol. 2023;9(8 Pt 2):1515-1526. doi:10.1016/j.jacep.2023.04.014

5. Hermiller JB, Leimbach W, Gammon R, et al. A prospective, randomized, pivotal trial of a novel extravascular collagen-based closure device compared to manual compression in diagnostic and interventional patients. J Invasive Cardiol. 2015;27(3):129-136. 

6. Natale A, Mohanty S, Liu PY, et al; AMBULATE Trial Investigators. Venous vascular closure system versus manual compression following multiple access electrophysiology procedures: the AMBULATE trial. JACC Clin Electrophysiol. 2020;6(1):111-124. doi:10.1016/j.jacep.2019.08.013

7. Sekhar A, Sutton BS, Raheja P, et al. Femoral arterial closure using ProGlide® is more efficacious and cost-effective when ambulating early following cardiac catheterization. Int J Cardiol Heart Vasc. 2016;13:6-13. doi:10.1016/j.ijcha.2016.09.002 

8. Lakshmanadoss U, Wong WS, Kutinsky I, et al. Figure-of-eight suture for venous hemostasis in fully anticoagulated patients after atrial fibrillation catheter ablation. Indian Pacing Electrophysiol J. 2017 Sep-Oct;17(5):134-139. doi:10.1016/j.ipej.2017.02.003

9. Batul SA, Gopinathannair R. Femoral venous hemostasis after atrial fibrillation ablation: is figure-of-eight suture the way to go? Indian Pacing Electrophysiol J. 2017 Sep-Oct;17(5):132-133. doi:10.1016/j.ipej.2017.08.003