Same-day discharge after atrial fibrillation (AF) ablation is feasible for the majority of patients when a standardised protocol is used, findings of a multicentre cohort study, published in the Journal of the American College of Cardiology (JACC), suggest. Efficacy and safety of a same-day discharge protocol were studied by Marc Deyell (University of British Columbia, Vancouver, Canada) and colleagues; the work was supported by the Canadian Cardiovascular Society.
Writing in JACC, Deyell and colleagues note that increasing volumes of AF ablation procedures are placing demands on hospital resources. Same-day discharge has already been shown to be safe and effective for less complex ablations, such as supraventricular tachycardia and atrial flutter, the authors note; however, catheter ablation of AF is a longer and more complex procedure, requiring deep sedation or general anaesthesia and high levels of procedural anticoagulation. “These factors present challenges to early discharge after AF ablation,” they add.
The combination of increasing catheter ablation procedural volume and limited bed availability, led to the development of a same-day discharge protocol at the two major tertiary sites performing ablation in British Columbia, Canada, at that time, which formed the basis of the study. The protocol saw all patients admitted to a cardiac short stay unit three to four hours after ablation. Haemostasis was obtained through manual pressure for a minimum of 10 minutes, no sutures or vascular closure devices were routinely employed and urinary catheters were not routinely placed. Patients were transported back to the cardiac short stay unit where bedrest was maintained for up to three hours and extended if haemostasis was not obtained. Patients could remain in the recovery area for up to eight hours.
Deyell and colleagues studied all patients undergoing AF ablation from 2010 to 2014 at two major centres—St Paul’s Hospital, Vancouver, Canada and Royal Jubilee Hospital, Victoria, Canada—evaluating the proportion of successful same-day discharge, as well as safety outcomes including 30 day death, stroke/transient ischemic attack or embolism, or bleeding requiring hospitalisation.
A total of 3,054 patients underwent AF ablation from 2010 to 2014 and met inclusion criteria. The average age of patients was 60.4 years, 27.2% (830/3,054) were female, and most (62.4%, 1,907/3,054) had paroxysmal AF. Same–day discharge was achieved in 79.2% (2,418/3,054) of patients over the study period, the study team reported. In the 636 patients who required admission, Deyell et al report, the most common reasons were access site bleeding (22.8%, 145/636), late procedure finish (23.9%, 152/636), intraprocedural complications (10.1%, 64/636), and multiple concerns excluding complications (19.5%, 124/636).
The overall rate of the composite safety outcome (death, stroke/embolism and bleeding) was 0.43%, the authors report, adding that this did not include intraprocedural complications identified during the index ablation procedure admission. The highest risk of complications was observed in those with initial admission for complication, at 2.60% (p value = 0.044). The most common component of the safety outcome was bleeding (8/3,034; 0.26%), which was most common in the same-day discharge group (7/2406; 0.29%). Two deaths occurred after discharge.
Discussing the findings, Deyell et al note that same-day discharge can be achieved in >75% of patients using a standardised protocol and was not associated with an increase in post-discharge complication rates. The team state:, “This study demonstrates that the vast majority of complications are identified during or immediately after the procedure, with a composite serious complication rate of 0.43% after discharge in the entire cohort, and only 0.37% in those discharged on the same-day. The overall complication rate (immediate periprocedural and post-discharge) was 3.1% in this large cohort and is comparable to that found in other contemporary cohorts, with a notably low rate of pericardial effusion/tamponade.(16,17) Therefore, this study should provide reassurance that same-day discharge is safe for the majority of patients undergoing AF ablation.”