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Vol. 74. Issue 5.
Pages 466-468 (May 2021)
Vol. 74. Issue 5.
Pages 466-468 (May 2021)
Scientific letter
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Outpatient ablation for atrial fibrillation
Ablación ambulatoria de fibrilación auricular
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Javier Jiménez-Candila,b,
Corresponding author
jimenezcandil@secardiologia.es

Corresponding author:
, Jendri Pereza,b, Jesús Hernándeza,b, José Luis Moríñigoa,b, Manuel Sánchez Garcíaa,b, Pedro L. Sáncheza,b
a Servicio de Cardiología, Hospital Universitario de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, Spain
b Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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Table 1. Comparison of epidemiological, clinical, and procedural characteristics according to the strategy used
Full Text
To the Editor,

Catheter ablation is very effective for symptom control in atrial fibrillation (AF).1 Because of the high volume of procedures performed, strategies are required to optimize allocated resources. In this letter we present the results of the first day-case program for AF catheter ablation in Spain.

We prospectively analyzed all elective AF catheter ablation procedures performed over 2 consecutive years, using a conventional strategy (n=100), from April 1, 2018 to March 31, 2019, and using an early-discharge strategy (n=123), from April 1, 2019 to March 31, 2020.

The patient flowchart for each strategy is shown in figure 1. Patients who were receiving oral anticoagulant treatment (n=182, of whom 11 were taking acenocoumarol) omitted it on the morning of the procedure. Independently of the treatment discharge strategy, the catheter ablation itself was carried out using the same method, following current recommendations. Conscious sedation with dexmedetomidine was given as a continuous infusion2 and a figure-of-eight suture was used for hemostasis.3 In the conventional strategy, patients were admitted to hospital following the procedure. In the early-discharge strategy, they were discharged before 8 pm on the same day, provided there were no complications; if complications occurred, per protocol, they were admitted. Patients who had early discharge were contacted at 48 hours and 10 days after the procedure.

Figure 1.

Flow chart of patients. CT-angio, computed tomography angiography; DH, day hospital; DOAC, direct-acting oral anticoagulants; ECG, electrocardiogram; PVs, pulmonary veins.

(0.17MB).

The primary efficacy objective was to determine the proportion of patients in the early-discharge strategy who were discharged on the same day having spent less than 12 hours in hospital. The primary safety objective was to determine the need for emergency department care in the 10 days after discharge (ED-10), presumably related to the procedure. The secondary objective was to perform an economic analysis comparing the 2 strategies. The estimated saving was calculated as the mean difference in cost per procedure in day-hospital care, days of hospital stay, and ED-10. The prices used were taken from the public prices for health care services from 3 public health boards in Spain.

Continuous variables with normal distribution are described as mean±standard deviation, and categorical variables as absolute number and percentage. Comparison of categorical variables was performed with the chi-square test. Comparison of 2 continuous variables with normal distribution was performed with Student t test. Logarithmic ranges were used to compare the ED-10 cumulative incidence. A P value<.05 was considered statistically significant.

Table 1 shows the patient characteristics, immediate outcomes, and procedural complications, which were similar for the 2 strategies. In the early-discharge strategy, in 111 (90%) of 123 procedures, the patient was discharged within 12 hours of arrival at the hospital; the remaining 12 patients (10%) were admitted to hospital. The reasons for admission were: immediate complications (n=8), vagal response on mobilization (n=2), Brugada type 1 pattern after administration of oral flecainide (n=1), and observation due to a history of contrast allergy (n=1). The frequency of early discharge was similar in cryoablation (n=69; 88%) and radiofrequency ablation (n=42; 93%); (P=.5).

Table 1.

Comparison of epidemiological, clinical, and procedural characteristics according to the strategy used

Variable  Conventional strategy (n=100)  Early discharge (n=123)  P 
Age, y  59±10  59±10  .8 
Women  29  25  .5 
Type of AF      .2 
Paroxysmal  55  47   
Permanent  45  53   
CHA2DS2-VASc  1.2±0.1  1.1±0.1  .5 
Previous long-term oral anticoagulation  82  81  .9 
Hypertension  37  44  .3 
Diabetes  34  37  .6 
Obesity  30  33  .7 
History of heart failure  17  10  .1 
LVEF, %  57±58±.06 
LVEF ≤ 45%  10  .9 
Left atrial area, mm2  27±10  28±.8 
Chronic kidney disease  4.3  .6 
Energy used      .8 
Cryoablation  62  63   
Radiofrequency  38  37   
Previous AF ablation  12  18  .2 
Ablation of CTI during procedure  18  16  .5 
Ablation of substrates outside the PVs  10  12  .7 
Duration of procedure, min  132±42  129±45  .6 
Isolation of all PVs  100  97.5  .8 
Acute complications  5.7  .8 
Small hematoma   
Femoral pseudoaneurysm   
Non-Q wave AMI   
Pericarditis   
Time procedure ended      .5 
Before 12 noon   
12 noon-1 pm  64  62   
1-2 pm  21  19   
2-3 pm  11  12   
After 3 pm   
Hospital stays  1±0.3  0.1±0.6  <.001 
Attended emergency department within 10 days of discharge  12  13.8  .7 
AF/atrial flutter   
Pericarditis   
Small hematoma   
Urticaria   
Epistaxis   
Dizziness   
Gastroparesis   
Bronchopneumonia   
Mean cost per patient, €     
Sanidad de Castilla y León health board, 2013  496 (467-525)  125 (75-125)  <.001 
Servicio Murciano de Salud health board, 2019  775 (732-819)  230 (156-304)  <.001 
Osakidetza health board, 2019  1372 (1303-1440)  474 (353-594)  <.001 

AF, atrial fibrillation; AMI, acute myocardial infarction; CTI, cavotricuscpid isthmus; LVEF, left ventricular ejection fraction; PVs, pulmonary veins.

Values are expressed as percentage, mean±standard deviation or mean (95% confidence interval).

The incidence of ED-10 was 12% in the conventional strategy vs 13.8% in the early-discharge group (P=.7). Table 1 shows the reasons for ED-10. All of these patients were discharged within 8 hours. In the early-discharge group, only one ED-10 occurred, the day after discharge. The mean cost per procedure was lower in the early-discharge strategy (table 1).

Several studies have shown that, in experienced centers, AF catheter ablation with same-day discharge is feasible (more than 80% of cases) and safe.4,5 Our data support this: 90% of our patients were able to be discharged after less than 12 hours in hospital, with a similar frequency for cryoablation and radiofrequency procedures. Compared with the conventional strategy, the early-discharge strategy is safe, in that the need for ED-10 was similar, and was mainly due to recurrence of AF/flutter or small hematomas. Regarding timing, only 1 patient from the early-discharge group attended the ED, the day after the procedure, due to a small hematoma. This was the only incidence of ED care that could have been avoided by hospitalization after the procedure.

The early-discharge strategy allows a reduction in hospital stay. This becomes more even more relevant in the context of the COVID-19 pandemic, as several scientific societies have suggested prioritizing day-case procedures.6 Given that same-day discharge does not increase short-term mortality, it also generates a significant economic saving.

References
[1]
D.L. Packer, D.B. Mark, K.L. Lee.
Catheter ablation compared with drug therapy for atrial fibrillation—reply.
[2]
A. Sairaku, Y. Yoshida, H. Hirayama, Y. Nakano, M. Ando, Y. Kihara.
Procedural sedation with dexmedetomidine during ablation of atrial fibrillation: a randomized controlled trial.
Europace., 16 (2014), pp. 994-999
[3]
K. Aytemir, U. Canpolat, H. Yorgun, et al.
Usefulness of ‘figure-of-eight’ suture to achieve haemostasis after removal of 15-French calibre femoral venous sheath in patients undergoing cryoablation.
Europace., 18 (2016), pp. 1545-1550
[4]
A. Opel, J. Mansell, A. Butler, et al.
Comparison of a high throughput day case atrial fibrillation ablation service in a local hospital with standard regional tertiary cardiac centre care.
Europace., 21 (2019), pp. 440-444
[5]
M.W. Deyell, R.A. Leather, L. Macle, et al.
Efficacy and safety of same-day discharge for atrial fibrillation ablation.
JACC Clin Electrophysiol., 6 (2020), pp. 609-619
[6]
D.R. Lakkireddy, M.K. Chung, R. Gopinathannair, et al.
Guidance for cardiac electrophysiology during the COVID-19 pandemic from the Heart Rhythm Society COVID-19 Task Force; Electrophysiology Section of the American College of Cardiology; and the Electrocardiography and Arrhythmias Committee of the Council on Clinical Cardiology. American Heart Association.
Heart Rhythm., (2020), pp. e233-e241
Copyright © 2020. Sociedad Española de Cardiología
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