In the April 2019 issue of EP Lab Digest, we outlined our same-day discharge (SDD) protocol for atrial fibrillation (AF) ablation cases. In this issue, we are pleased to present follow-up data. The study is a single site, prospective, observational study and we did not receive financial or other support from a commercial partner. We prospectively studied 148 consecutive patients (92 male, 56 female; average age 69.9 years) AF / atrial flutter (AFL) ablation requiring transseptal access. Although patients with left atrial flutter were included in the analysis, patients undergoing only cavotricuspid isthmus (CTI) ablation were excluded. Patients underwent the procedure under general anesthesia. A pre-ablation TEE was performed after intubation, vascular access was obtained via a single catheterization site (usually right femoral), and transseptal access was guided by intracardiac echocardiography (ICE). Radiofrequency (RF) ablation was then performed using a contact force catheter (THERMOCOOL SMARTTOUCH SF, Biosense Webster, Inc., a Johnson & Johnson company). Different ablation strategies were employed depending on patient characteristics, AF pattern, left atrial size, and electrophysiological findings. Patients with paroxysmal atrial fibrillation (PAF) underwent pulmonary vein (PV) isolation and CTI ablation. Patients with persistent AF and left atrial (LA) enlargement generally underwent additional ablation such as LA posterior wall ablation, septal ablation, and ablation targeting complex fractionated electrograms (CFE). Ablation was performed with the intent to convert AF to macroreentry and terminate the arrhythmia with RF energy. Atypical flutters were mapped using traditional and 3D mapping techniques. Provocative testing with isoproterenol was performed to validate endpoints. At the conclusion, pericardial effusion was excluded in the EP lab using ICE. All patients underwent sheath removal with a vascular closure device (VCD), including 144 with the Perclose ProGlide (Abbott Vascular), 3 with the VASCADE MVP (Cardiva Medical), and 1 with both the Perclose ProGlide and VASCADE MVP.
We predefined criteria for patients for potential SDD as follows: case completed before 3 pm (Criteria A), and residence within one hour of hospital (Criteria B). Both criteria had to be met for meeting the predefined endpoint. Patients without symptoms of groin site bleeding, nausea, chest pain, dyspnea, or other symptoms 4 hours post procedure were discharged. All patients received close follow-up with a telephone call the next day from our AF center coordinator. We also studied reasons for inability to achieve SDD.
Criteria A was met by 116/148 (78.4%) of patients. Of the 116 patients, Criteria B was met by 106/116 (91.4%) of patients. A total of 78/106 (67.2%) patients that met both SDD criteria were successfully discharged home same day. Additionally, 10/32 (31.3%) patients with procedures completed after 3 pm were also discharged same day. A total of 88/148 (59.5%) of unselected patients were discharged. The mean period of monitoring before discharge was 5.25 hours, with a median of 4.5 hours.
Reasons for failure to discharge included anxiety (3), vagal reactions (2), nausea (5), chest pain (2), tamponade (1), respiratory difficulty (4), lack of transportation (3), SVT (1), and patient preference (4). No patients were readmitted within 48 hours after discharge. No vascular complications occurred. The results indicate that SDD for AF ablation patients can be accomplished safely in a significant percentage of patients facilitated by use of VCD. Since this initial pilot study, we have further improved the percentage of patients being discharged.
The Importance of Vascular Access and Closure Technique
Optimal management of the catheterization site begins at the time of vessel entry. We perform ultrasound-guided access in all patients. The common femoral vein is accessed below the inguinal ligament, avoiding any side branches. Vascular ultrasound allows the puncture to avoid an overlying femoral artery; in some cases, this requires a more cranial or caudal level for puncture. The thickness of the soft tissue above the vessel wall can be assessed to determine if there is sufficient thickness to allow VCD use, since VCDs should be avoided in patients with low BMI. We perform an anterior wall puncture of the venous wall, and have gradually moved towards a two-sheath technique by reducing the number of sheaths by using different catheters sequentially (Figure 1).
Ultrasound guidance can also be useful during vessel closure. In most cases, there is sufficient bleed back through the Perclose ProGlide marker lumen that intravascular location is not in question. In some cases when the venous pressure is low or due to vessel wall apposition, this may be difficult. In these cases, ultrasound can be performed to visualize the location of the ProGlide footplate inside the vein (Figure 2).
With experience, we have reduced the number of sheaths used for these cases. This has been driven predominantly by the desire to reduce vascular complications. However, this also allows for the added benefits of improved patient comfort, increased efficiency, and reduced cost of VCDs per case. Figure 2 shows how we have gradually reduced the access sites. In 2018, we used multiple puncture sites: a 4 French (Fr) arterial sheath, two 8.5 Fr SL sheaths for double transseptal puncture, an 8 Fr short sheath for a duodecapolar catheter (coronary sinus), and a 9 Fr sheath for intracardiac echo. These sheaths were split between two or more access sites.
We then eliminated the arterial sheath and used the 9 Fr venous sheath for ICE. After transseptal puncture, the ICE catheter was removed and the duodecapolar catheter was introduced. Before the end of the case, the ICE catheter was reintroduced to exclude pericardial effusion prior to sending the patient to the recovery unit. For evaluation of hypotension during the procedure, we initially evaluate the cardiac silhouette in left anterior oblique view for evidence of pericardial effusion (static left heart border); if the hypotension is refractory to initial bolus of vasopressor agent, we perform a transthoracic echo or reintroduce the intracardiac echo. Removing the coronary sinus catheter can be problematic if we are in the process of creating an activation map. Alternatively, another sheath can be inserted at this time. Due to the infrequent occurrence of this problem, we have not had to change our current practice.
The next refinement of the technique involves a single instead of double transseptal puncture. Improvements in ablation catheter technology (primarily use of contact force catheters), improved catheter stability by use of high-frequency low tidal volume ventilation settings, improved lesion assessment by use of the VISITAG SURPOINT Module (Biosense Webster, Inc.), and availability of steerable sheaths are all advancements that have allowed for more consistent first-pass isolation of the PVs. This reduces the number of exchanges necessary to achieve and validate endpoints. We prefer to use a VCD for all patients undergoing AF/AFL ablation. Protamine is given when there is no contraindication.
There are other benefits to using VCDs beyond the now well-recognized advantages of early ambulation, avoidance of urinary catheters, reduced need for medications for back pain, avoidance of protamine and potential reactions, and reduced hospital resource utilization. Patients who have previously undergone catheter ablation or femoral cardiac catheterization often recall the 4-6 hours of bedrest, manual compression, occasional bleeding complications, and the not-infrequent occurrence of extensive limb discoloration. Careful groin management helps improve patient acceptance and satisfaction. There is also the added benefit that instead of focusing on discharging post-ablation patients every morning, our advanced practitioner team can spend the critical early hours triaging and admitting other patients.
In addition, same-day discharge has helped relieve patient anxiety related to being admitted in the hospital regarding COVID-19 transmission. It may reduce the potential risk to health care providers due to reduced interactions with patients on the floor.
Although some centers have used a “Figure of 8 suture” or a “Three-way stopcock” method for hemostasis, we do not follow or recommend these techniques. In our brief experience, we have found unreliable and imprecise compression of the venous wall puncture site, leading to risk of ecchymosis and hematoma formation. The suture also has to be removed at a later time — often the next morning — leading to further delays in ambulation.
Using this groin management protocol, we have been able to reduce the risk of vascular complications such as pseudoaneurysm, AV fistula, hematoma requiring blood transfusion, surgical intervention, infection, etc., to zero in the last approximately 400 cases.
We have a high degree of confidence that after 4-6 hours post discharge, patients who do not experience chest pain, dyspnea, or groin bleeding, and are able to ambulate and void, are safe to be discharged home. Other centers have reported an even shorter monitoring period prior to discharge home.
Close follow-up is paramount in adoption of this strategy. Our AF center coordinator calls patients the next day. If there is a concern about chest discomfort due to possible pericarditis, an echo is performed within 24 hours, and the patient is managed as an inpatient or outpatient depending upon symptom severity. We have not seen any cases of delayed cardiac tamponade requiring emergency drainage.
From a cost perspective, this strategy may prove to be favorable to institutions. In our analysis, cost attributed to overnight stay is approximately $650. The savings (approximately $1000-$2000) are reported to be higher in the AMBULATE IMPACT study, although these savings are offset partially by the added cost of VCDs. Limiting the number of VCDs used per case can be helpful from this perspective. However, we do not suggest or recommend fewer puncture sites for the sole purpose of reducing cost.
In summary, discharging patients home the same day after AF ablation is a culmination of efforts to improve many procedure and personnel related processes. We have seen reduced complications from vascular access and urinary catheters, improved patient acceptance and comfort, and reduced utilization of hospital resources and personnel time required in the care of these patients. Even in patients who are admitted for observation, these changes in our management have resulted in a much more comfortable and safer procedure. Centers that adopt this strategy will appreciate the many advantages after a short learning curve.
Disclosure: Dr. Verma has no conflicts of interest to report regarding the content herein. Outside the submitted work, he is a speaker and consultant for Abbott.
Accompanying quiz available here: https://www.eplabdigest.com/multimedia/quiz-early-ambulation-and-same-day-discharge-atrial-fibrillation-ablation
- 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.