A same-day discharge strategy for left atrial appendage occlusion (LAAO) could become the standard approach for this technique, according to the authors of a study published in the Journal of Invasive Cardiology, who concluded that the strategy is safe, feasible and cost-effective.
In their study Luis Augusto Palma Dallan, Steven Filby and colleagues (University Hospitals Cleveland Medical Center, Cleveland, USA) note that typically patients undergoing LAAO procedures would be kept in overnight for monitoring, but they suggest that same-day discharge has increasingly been used during the COVID-19 pandemic to improve resource use, relieve hospital occupation and reduce the possible risk of in-hospital virus transmission.
LAAO with the Watchman (Boston Scientific) device is approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with non-valvular atrial fibrillation (AF) who have an appropriate indication. Typically, operators would use transesophageal echocardiography (TEE) in conjunction with general anaesthesia for LAAO, with overnight observation following the procedure.
To date there have been very few studies comparing a same-day discharge strategy for LAAO to the conventional approach, Palma Dallan, Filby et al note, adding that their prospective single-centre study sought to compare the feasibility, outcomes and cost for same-day discharge protocol deployed during the pandemic versus the typical strategy.
The protocol developed by physicians at University Hospitals Cleveland Medical Center saw patients undergoing LAAO using conscious sedation and then discharged home after four hours of bedrest if criteria for device success were satisfied. The patient would be monitored overnight if the success criteria were not met.
The analysis includes 142 consecutive patients, 119 treated prior to the implementation of the same-day discharge protocol, and 23 who were treated in accordance with the protocol following LAAO with cardiac computed tomography (CTA)-guided preprocedural planning and intracardiac echocardiogram (ICE).
In-hospital and 45-day procedural success, adverse events, length of procedure, and length of stay were evaluated by the study team. Baseline patient characteristics including mean CHA2DS2-VASc scores and mean HAS-BLED scores were similar in both groups, the researchers report, noting that all procedures were successful.
In their paper, the researchers state that there were no significant differences between the two groups in the rates of procedural complications or in-hospital adverse events, though the mean procedure time in the same-day discharge protocol group was 11 minutes longer than in the conventional discharge group (62.1±5.9 vs. 51.1±21; p=0.01). Outcomes at 45-day follow-up were similar between the two groups, Palma Dallan et al report.
“As far as we know, this is the first prospective study comparing the safety, feasibility, and cost-effectiveness of the same-day discharge strategy with a conventional approach,” the study’s authors write. “Our study demonstrates that the majority of patients can safely be discharged from LAAO on the same day of their procedure and with lower overall cost.”
The authors add that they observed high procedural success rates in both the same-day discharge and conventional strategy groups, and note that changing to a same-day discharge strategy did not increase rates of adverse clinical events at 45-day follow-up.
“These findings are consistent with the literature and reassuring for both safety and efficacy of our new approach,” they write. “The longer procedural times noted in the same-day discharge group may be due to the learning curve in using ICE for LAAO. However, considering the improvement in efficiency and room turnaround associated with conscious sedation over general anaesthetic, these 11 minutes do not seem clinically relevant. In addition, given the large standard deviation for procedural times in the conventional group, this observed time difference may not be accurate.”
In their concluding remarks, Palma Dallan, Filby and colleagues write that a same-day discharge strategy for LAAO appears safe, feasible and could become the new standard approach for LAAO. “A protocol including CTA preprocedural planning, ICE-guided deployment, and conscious sedation reduces hospital occupation and lowers costs,” they add.