Same-Day Discharge Following Atrial Fibrillation Catheter Ablation: The Perfect Blend?

Laura Ueberham; Andreas Bollmann


Europace. 2019;21(3):363-365. 

Procedure numbers of atrial fibrillation (AF) catheter ablation are increasing worldwide and forecasts indicate an exponential growth of health-care expenditure and use of resources.[1] AF catheter ablations are mostly performed in an inpatient setting with at least one overnight stay following the procedure. To ensure an optimal, high-quality care in a timely manner for the increasing numbers of patients, a shift from inpatient care to hospital ambulatory medicine should be considered for selected patients and procedures to cope with advanced demands, especially in the internal medicine sector.[2]

In this issue of EP-Europace, Opel et al.[3] report on a high-throughput AF catheter ablation service at a local non-cardiac centre hospital with a protocol for discharge on the day of the procedure.

Same-day discharge following elective procedures in cardiology has been already attempted for higher-risk elective percutaneous coronary intervention and implantation of pacemakers and implantable cardioverter-defibrillators.[4,5] However, data about the feasibility of same-day discharge following AF catheter ablation are sparse.[6] Therefore, this thought-provoking study addresses an interesting question comparing a local hospital with an ambulatory AF catheter ablation service to matched patients treated at the regional cardiac centre.

The study included a total of 276 patients who underwent catheter ablation at the local hospital with a same-day discharge approach, matched 1:1 to standard care cases at the regional cardiac centre. The presented setting at the local hospital is easy and straight forward: the procedure has been performed by an experienced electrophysiologist with expertise in cryoablation. Of note, staff without any experience in electrophysiology or AF catheter ablation were trained within 2 days to take care for the patients. Patients were discharged 4 h after sheath removal. However, the service at the local hospital was provided for patients with symptomatic paroxysmal AF or early persistent AF, suitable for cryoablation only and thus limits the general applicability of the results.

The overall complication rate of the high-throughput ablation service was 5.4% and comparable to that at the regional cardiac centre (6.3%). Phrenic nerve palsy (1.8% local hospital and 2.5% regional cardiac centre) and vascular complications (1.4% local hospital and 1.1% regional cardiac centre) occurred most frequently, whereas cardiac tamponade (0.7% local hospital and 0.4% regional cardiac centre) was rare and no stroke was recognized. Outcomes at 3 months were comparable as well, with 91% vs. 80% of patients in sinus rhythm at the local hospital and the regional cardiac centre, respectively.

However, there are several limitations in the study design that make a comparison of the high-throughput and the traditional service at the regional cardiac centre complicated. Due to the small sample size, statements about complication rates have to be interpreted with caution. Besides, the study cohort was non-randomized but matched to regional cardiac centre cases, while the matching approach remains elusive as is illustrated by differences in baseline characteristics such as hypertension (significantly fewer patients with hypertension in the local hospital group) or oral anticoagulation (significantly fewer patients on warfarin in the local hospital group).

No transoesophageal echocardiogram (TOE) had been performed at the local centre. Although the value of TOE before AF catheter ablation is currently under debate,[7,8] the authors report a 37% rate of TOE before AF catheter ablation at the regional cardiac centre with 'operators preference' as the main reason. For a straight comparison, it would have been preferable to perform TOE based on the same criteria at the local and at the regional cardiac centre, even though no stroke occurred in the studied patient population. Furthermore, there is no discernible reason, why TOE should not be provided at the high-throughput local non-cardiac centre in selective cases. For instance, a study by Haegeli et al.[6] reported about an outpatient setting of AF catheter ablation, with same-day discharge, where TOE was performed, if the patient had persistent AF or was without sufficient anticoagulation before the procedure.

In addition to that, Opel et al. report about a significant shortening of the procedure time that made activated clotting time (ACT) checks impracticable. The current expert consensus statement recommends to adjust the ACT (a circumstance that requires measurement) to achieve and maintain an ACT of at least 300 s.[9] Furthermore, there are several factors with influence on ACT levels, not easy to predict beforehand.[10,11] The authors thus took a risk without any evidence, what has to be highlighted and has nothing directly to do with the high-throughput local hospital approach.

Although observed complication rates were reported to be similar between both approaches, there was no structured follow-up in the high-throughput ablation service that allowed for systematic complication screening. The authors report about a final transthoracic echocardiogram to exclude pericardial effusion, but discharge home was nurse-led, and there was no final exam by a doctor. It would have been preferable to cover the same time interval for complication occurrence as in the regional cardiac centre, but in an ambulatory fashion. As the patient at the regional cardiac centre stayed at least one night to the following day, complications occurring during this time span had been recognized to a higher probability, than in the same-day discharge group.

Importantly, overall complication rate at the local hospital was 5.4% and 1.4% were not discharged home the same day, meaning by implication that 4% of patients with complications were discharged home. Opel et al.[3] report on one patient with bleeding at the vascular access site, presenting at the emergency department the day after the procedure and patients with arteriovenous fistula and pseudoaneurysms. In the case of complications at the vascular access site, bed rest with re-application of a pressure dressing until the final diagnosis is made via Doppler sonography, can prevent severe bleeding.[12] It should therefore be considered, whether an ambulatory 1-day post-procedure check up should be introduced, to ensure patients well-being and to check the groins.

In addition to that, two patients experienced cardiac tamponade and were transferred to the regional cardiac centre following drain insertion. Even though the complications could be managed successfully, it has to be mentioned that there are situation with complicated or insufficient drainage. In cases like that, every minute counts and the transferral to another institution that can handle the complication might take too long. In our series of 21 141 AF catheter ablations, 12 of 196 patients with pericardial effusion following ablation had to undergo surgical repair and two patients died.[13]

Of note, the procedural time at the local hospital was one third shorter than at the regional centre and fluoroscopy time was even halved, although the regional cardiac centre ablation protocol was identical to the local hospital protocol (besides TOE and day of discharge). Compared with the FIRE and ICE trial, with a procedural time of 124.4 ± 39.0 min and a fluoroscopy time of 21.7 ± 13.9 min in the cryoballoon group,[14] the local hospital results by Opel et al.[3] were remarkably efficient. The authors provided several explanations for that, not only supporting the high-throughput local hospital protocol, but also leading to questions concerning the daily practice at the regional cardiac centre.

Lastly, it has to be compromised, whether the high-throughput same-day discharge AF catheter ablation service should be performed at a local hospital without cardiac surgery support at all. Representing an elective procedure, patient safety should be as high as possible and procedural risks should be extremely low. Although there is a trend towards increasing numbers of ablation performing centers,[15,16] evidence about higher complication rates in low-volume centres is growing.[13,17,18] Why should we thus promote the implementation of even more ablation centres? In our opinion, the proposed efficient protocol for same-day discharge should be considered for regional, high-volume hospital centres to face increasing procedure numbers. Furthermore, the regional centre would provide a plan B infrastructure for patients with complex atrial arrhythmias during electrophysiological study aside from paroxysmal AF.

As was expected, the high-throughput local hospital AF catheter ablation approach saved costs and was even less time-consuming and more efficient, probably due to a smaller, defined team and repetitive tasks.

The authors can be congratulated for having successfully implemented this innovative study. This is an interesting and promising approach that shows increase in efficiency in a short time. The same setting as in the local hospital should therefore be considered for the regional cardiac centre for the perfect blend of time efficiency and safety. Importantly, as in this study, this should be done by experienced electrophysiologists who not only can successfully isolate the pulmonary veins but recognize and manage procedural complications.