Abstract
Background
Patients undergoing atrial fibrillation (AF) ablation have historically been hospitalized overnight or longer postprocedure. National rates of same‐day discharge (SDD) following AF ablation remain unknown.
Methods and Results
The NCDR (National Cardiovascular Data Registry) AF Ablation Registry was used to identify index procedures from January 1, 2016 to June 30, 2023. Patients were stratified by postprocedure disposition: (1) SDD, (2) overnight hospitalization (<1 day), or (3) >1 day hospitalization. Rates, clinical factors, and hospital‐level variation associated with SDD were analyzed. Among 139 391 patients who underwent AF ablation across 197 hospitals, 51 622 (37.0%) underwent SDD, 78 220 (56.1%) were hospitalized overnight, and 9549 (6.9%) for >1 day postprocedure. SDD rates increased from 0.99% in Q1 2016 to 62.3% in Q2 2023 (P<0.0001), surpassing overnight hospitalization in Q1 of 2021. The likelihood of SDD increased significantly over time (odds ratio [OR], 1.26 per quarter‐year [95% CI, 1.26–1.26]) with substantial variation across hospitals (median OR, 4.12 [95% CI, 3.48–4.79]). Those discharged the same day were less likely of Black race (OR, 0.71 [95% CI, 0.65–0.78]) and to have persistent AF (OR, 0.85 [95% CI, 0.82–0.88]) and cardiomyopathy (OR, 0.87 [95% CI, 0.84–0.91]). In total, major and overall complication rates were 0.70% and 2.13%, respectively. Major and overall complication rates were 0.03% and 0.19% for SDD and 0.24% and 0.98%, respectively, for overnight hospitalization.
Conclusions
Rates of SDD following AF ablation markedly increased over time, corresponding with onset of the COVID‐19 pandemic, with substantial hospital variation. SDD patients had fewer comorbid conditions and were less likely to have persistent AF. Postprocedural complication rates with SDD were low and comparable with patients hospitalized overnight.
Keywords: atrial fibrillation, catheter ablation, same‐day discharge
Subject Categories: Arrhythmias, Atrial Fibrillation
Nonstandard Abbreviations and Acronyms
- MOR
median odds ratio
- NCDR
National Cardiovascular Data Registry
- SDD
same‐day discharge
Clinical Perspective.
What Is New?
Rates of same‐day discharge following catheter ablation of atrial fibrillation have markedly increased over time, corresponding with onset of the COVID‐19 pandemic and subsequently sustained.
What Are the Clinical Implications?
Those undergoing same‐day discharge have fewer comorbid conditions, were less likely to have persistent atrial fibrillation, and overall, low procedure‐related complication rates.
With growth in the development of ambulatory or outpatient procedural centers and momentum surrounding same‐day discharge following cardiovascular procedures, our findings may assist national procedural policy development.
More than 90 000 patients undergo atrial fibrillation (AF) ablation yearly in the United States. 1 Catheter ablation of AF has historically involved overnight hospitalization to monitor for risk of periprocedural complications. 2 However, AF ablation has evolved to become a safe and routine procedure. 1 , 3 As a consequence and to further reduce the risk of nosocomial infection associated with the COVID‐19 pandemic, small, primarily single‐center studies 4 , 5 , 6 , 7 , 8 or data via moderate‐sized regional registries 4 , 9 have emerged to indicate same‐day discharge (SDD) may occur safely among select patients. 6 , 10 Potential benefits include enhanced patient satisfaction and convenience, and increased hospital bed availability, coupled with the potential for higher hospital throughput with associated cost savings. 11 , 12 , 13 In addition to data suggesting favorable economic benefits, 13 , 14 due to a rapid rise in the use and development of outpatient or ambulatory procedural centers, 15 understanding patterns, safety, and use of SDD remains critical to guide future AF care delivery.
Owing to differences in operator and patient preference, hospital capacities, and postprocedure protocols, uptake of SDD may vary substantially across hospitals. In the current era, national rates of SDD after AF ablation, profiles of patients undergoing SDD, hospital‐level variation in SDD, and associated short‐term complications remain unknown. Accordingly, using the NCDR's (National Cardiovascular Data Registry) AF Ablation Registry, we sought to characterize: (1) national rates of SDD following catheter ablation of AF overall and over time, particularly in relation to the COVID‐19 pandemic; (2) factors associated with SDD; (3) hospital‐level variation in SDD after AF ablation; and (4) short‐term complications associated with SDD. Given the increasing trend toward SDD in addition to procedure care within ambulatory procedural centers without Centers for Medicare and Medicaid Services authorization, in part due to lack of national‐level data, large‐scale studies evaluating use of SDD may inform future AF care delivery.
METHODS
Data Availability
The authors declare that all supporting data are available within the article and associated online supplementary files.
Data Source
The American College of Cardiology initiated the NCDR AF Ablation Registry, a national registry of AF ablation procedures with >195 participating hospitals across the United States, in part to assess the continually changing landscape of AF ablation. The NCDR AF Ablation Registry and its development have been previously described. 1 The registry includes a standardized set of data elements, including detailed patient, procedural, hospital, and in‐hospital outcomes data. Approximately 230 data elements from the index procedure and hospital stay are collected, with the data collection form publicly available. 16 Race is self‐reported by the patient, and Asian include all associated subgroups (Indian, Chinese, Korean, Japanese, Vietnamese, Filipino, or Other) as captured within the data dictionary. A rigorous Data Quality Report process ensures data submissions are accurate and consistent. 17 Annual audit processes in addition to registry‐reported data adjudication via comparison review of source documents, with excellent correlation, have been reported previously. 17
Study Population
Patients who underwent elective, index AF ablation from January 1, 2016 to June 30, 2023 were included. Patients who (1) were <18 years of age at the time of catheter ablation, (2) underwent repeat ablation, (3) had a discharge status other than alive, or (4) had a discharge disposition other than home were excluded.
Exposure
SDD was defined as a discharge date matching the date of the AF ablation procedure. Overnight hospitalization was defined by a discharge date occurring 1 day after the admission or procedural date. Prolonged hospitalization was defined by a discharge date occurring >1 day after the admission or procedural date.
Clinical Outcomes
Clinical outcomes of interest were major and overall complications associated with catheter ablation of AF. Major complications, consistent with prior studies, 1 were defined as death, stroke, transient ischemic attack, cardiac arrest, need for cardiac surgery, vascular injury requiring intervention, access site bleeding requiring transfusion, and pericardial effusion requiring intervention. Overall complications included myocardial infarction, air embolism, heart failure, heart valve damage, adverse bradycardic events, anaphylaxis, sepsis, arterial thrombosis, vascular injuries such as arterio‐venous fistula, as well as pseudoaneurysm and other neurological events.
Statistical Analysis
Patients were stratified according to length of stay, including the same day as the date of admission, discharge occurring <24 hours postprocedure (overnight hospitalization), and discharge >1 hospital day after the procedure. Baseline characteristics are reported as mean±SD and median (interquartile range [IQR]). Potential between‐group differences were assessed. The proportion of patients undergoing SDD, overnight hospitalization, or with a hospital length of stay >1 day were calculated within each quarter‐year of the study to characterize temporal trends.
To identify factors associated with SDD compared with other lengths of stay, a mixed logistic model with patients clustered within hospitals and a random intercept for hospitals was constructed. Candidate variables included age, race, ethnicity, body mass index, chronic lung disease, obstructive sleep apnea, cardiomyopathy, CHA₂DS₂‐VASc score, HAS‐BLED score, preprocedural creatinine, prior non‐AF ablation, AF type (paroxysmal, persistent, long‐standing persistent), teaching hospital status, coronary artery disease, and inclusion of a temporal covariate to account for the possibility in change in the rate of SDD over time. Backward selection using a significance level of P<0.05 for removal was used. Hospital‐level variability in length of stay across sites was evaluated using a hierarchical logistic regression model with random intercepts for hospitals. Median odds ratios (MORs) were calculated from the random effect SD, with 95% credible interval derived by the Markov chain Monte Carlo method. The adjusted MOR can be interpreted as the adjusted odds when comparing a patient from a hypothetical 83rd percentile compared with a patient at a median hospital, stipulating that the patients have identical covariates. 18
Owing to inherent differences between study groups, unadjusted complication rates were compared using models for binomial probabilities. Analyses were conducted by using SAS version 9.4 (SAS Institute). P values of <0.05 were considered significant. The study was approved by the Yale Institutional Review Board, with a waiver of the requirement to obtain informed consent owing to minimal risk exposure.
RESULTS
Of 139 391 patients undergoing AF ablation, 51 622 (37.0%) underwent SDD, 78 220 (56.1%) were hospitalized overnight (<1 day), and 9549 (6.9%) were hospitalized for >1 day after the procedure (Table 1, Figure S1). Table 1 displays demographics, comorbid conditions, and procedural data for the full cohort, those discharged the same day, and those admitted for overnight hospitalization and requiring >1 day hospital stay after catheter ablation of AF. Across the overall cohort, the median age (±SD) was 67.0±7.0 years, 64.7% were men, and 93.3% were White. Compared with those hospitalized overnight, patients undergoing SDD had significantly lower rates of heart failure (18.9% SDD versus 20.9% overnight hospitalization), hypertension (69.7% versus 71.7%), diabetes (18.9% versus 20.6%), coronary artery disease (21.2% versus 23.1%), nonparoxysmal AF classification (59.8% paroxysmal versus 56.2%), and associated findings such as higher rates of normal left atrium size (43.7% versus 38.4%) and lower rates of presentation in AF at the time of catheter ablation (7.9% versus 10.1%). From a procedural standpoint, compared with those hospitalized overnight, patients who underwent SDD had significantly higher rates of single transseptal puncture (72.9% versus 58.9%), cryoablation (41.3% versus 30.9%), and less often received adjunct ablation at a site other than the cavo‐tricuspid isthmus (22.1% versus 28.2%). In contrast, those requiring >1 day hospital stay were older (69.0±7.0 years of age), less often men (57.6%), White (91.5%), and had higher rates of comorbid conditions, nonparoxysmal AF classification, double transseptal puncture, and non‐cavo‐tricuspid isthmus adjunctive ablation.
Table 1.
Demographics, Comorbid Conditions, and Procedural Data for the Overall Cohort, Those Discharged the Same Day, Hospitalized for Overnight Hospitalization, or >1 Day Hospital Stay After Catheter Ablation of AF
| Overall cohort (N=139 391) | Same‐d discharge (N=51 622) | Overnight hospitalization (<1 d) (N=78 220) | >1 d hospital stay (N=9549) | P value* | |||||
|---|---|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | N | % | ||
| Demographics | |||||||||
| Age, y, median (IQR) | 67.00 | (60.00–73.00) | 67.00 | (60.00–73.00) | 67.00 | (60.00–73.00) | 69.00 | (62.00–75.00) | <0.0001 |
| Male sex | 90 177 | 64.69 | 34 499 | 66.83 | 50 181 | 64.15 | 5497 | 57.57 | <0.0001 |
| BMI, kg/m2, median (IQR) | 30.12 | (26.40–34.80) | 29.87 | (26.31–34.42) | 30.21 | (26.43–34.88) | 30.84 | (26.67–36.11) | <0.0001 |
| Race | <0.0001 | ||||||||
| White | 129 987 | 93.25 | 48 233 | 93.43 | 73 021 | 93.35 | 8733 | 91.45 | |
| Black | 4569 | 3.28 | 1529 | 2.96 | 2555 | 3.27 | 485 | 5.08 | |
| American Indian/Alaskan Native | 351 | 0.25 | 167 | 0.32 | 162 | 0.21 | 22 | 0.23 | |
| Asian | 1838 | 1.32 | 694 | 1.34 | 1037 | 1.33 | 107 | 1.12 | |
| Native Hawaiian/Pacific Islander | 139 | 0.10 | 57 | 0.11 | 69 | 0.09 | 13 | 0.14 | |
| Missing | 2507 | 1.80 | 942 | 1.82 | 1376 | 1.76 | 189 | 1.98 | |
| Hispanic or Latino ethnicity | 5277 | 3.79 | 2069 | 4.01 | 2785 | 3.56 | 423 | 4.43 | <0.0001 |
| Episode of care | |||||||||
| Health insurance, n % yes) | 138 342 | 99.25 | 51 300 | 99.38 | 77 590 | 99.19 | 9452 | 98.98 | <0.0001 |
| Payment source | 107 530 | 77.14 | 40 036 | 77.56 | 60 647 | 77.53 | 6847 | 71.70 | |
| Private health insurance | 75 210 | 53.96 | 26 771 | 51.86 | 42 557 | 54.41 | 5882 | 61.60 | <0.0001 |
| Medicare | 6392 | 4.59 | 2164 | 4.19 | 3569 | 4.56 | 659 | 6.90 | <0.0001 |
| Medicaid | 5950 | 4.27 | 2232 | 4.32 | 3267 | 4.18 | 451 | 4.72 | <0.0001 |
| Military | 1765 | 1.27 | 521 | 1.01 | 1065 | 1.36 | 179 | 1.87 | 0.0329 |
| State‐specific (non‐Medicaid) | 80 | 0.06 | 30 | 0.06 | 42 | 0.05 | 8 | 0.08 | <0.0001 |
| Indian Health Service | 137 | 0.10 | 45 | 0.09 | 84 | 0.11 | 8 | 0.08 | 0.5091 |
| History and risk factors | |||||||||
| Congestive heart failure | 29 558 | 21.21 | 9775 | 18.94 | 16 362 | 20.92 | 3421 | 35.83 | <0.0001 |
| NYHA classification | <0.0001 | ||||||||
| Class I | 7631 | 30.10 | 2560 | 30.76 | 4412 | 31.20 | 659 | 22.79 | |
| Class II | 12 416 | 48.97 | 4292 | 51.57 | 6854 | 48.47 | 1270 | 43.93 | |
| Class III | 4967 | 19.59 | 1404 | 16.87 | 2712 | 19.18 | 851 | 29.44 | |
| Class IV | 339 | 1.34 | 66 | 0.79 | 162 | 1.15 | 111 | 3.84 | |
| Cardiomyopathy | 28 234 | 20.26 | 9492 | 18.39 | 15 893 | 20.32 | 2849 | 29.84 | <0.0001 |
| Cardiomyopathy type | |||||||||
| Ischemic | 5492 | 3.94 | 1632 | 3.16 | 3221 | 4.12 | 639 | 6.69 | <0.0001 |
| Nonischemic | 17 609 | 12.63 | 6177 | 11.97 | 9692 | 12.39 | 1740 | 18.22 | <0.0001 |
| Restrictive | 88 | 0.06 | 18 | 0.03 | 57 | 0.07 | 13 | 0.14 | 0.0004 |
| Hypertrophic | 1842 | 1.32 | 570 | 1.10 | 1111 | 1.42 | 161 | 1.69 | <0.0001 |
| Other | 4260 | 3.06 | 1410 | 2.73 | 2434 | 3.11 | 416 | 4.36 | <0.0001 |
| Chronic lung disease | 13 435 | 9.64 | 4431 | 8.58 | 7502 | 9.59 | 1502 | 15.73 | <0.0001 |
| Coronary artery disease | 31 784 | 22.80 | 10 921 | 21.16 | 18 070 | 23.10 | 2793 | 29.25 | <0.0001 |
| Sleep apnea | 47 359 | 33.98 | 17 443 | 33.79 | 26 447 | 33.81 | 3469 | 36.33 | <0.0001 |
| Diagnostic studies and echo data | |||||||||
| LVEF, %, median (IQR) | 55.00 | (50.00–60.00) | 55.00 | (50.00–60.00) | 55.00 | (50.00–60.00) | 55.00 | (40.00–60.00) | <0.0001 |
| TTE | 30 213 | 21.68 | 10 077 | 19.52 | 17 265 | 22.07 | 2871 | 30.07 | <0.0001 |
| LA size | <0.0001 | ||||||||
| Normal | 11 610 | 39.38 | 4274 | 43.67 | 6494 | 38.43 | 842 | 30.14 | |
| Mild | 8501 | 28.84 | 2722 | 27.81 | 4970 | 29.41 | 809 | 28.95 | |
| Moderate | 5521 | 18.73 | 1697 | 17.34 | 3183 | 18.84 | 641 | 22.94 | |
| Severe | 3849 | 13.06 | 1095 | 11.19 | 2252 | 13.33 | 502 | 17.97 | |
| Mitral regurgitation | <0.0001 | ||||||||
| None | 6656 | 22.51 | 2235 | 22.64 | 3851 | 22.78 | 570 | 20.37 | |
| Trace/trivial | 8717 | 29.47 | 3166 | 32.07 | 4898 | 28.98 | 653 | 23.34 | |
| Mild | 9874 | 33.39 | 3223 | 32.64 | 5711 | 33.78 | 940 | 33.60 | |
| Moderate | 3772 | 12.75 | 1105 | 11.19 | 2145 | 12.69 | 522 | 18.66 | |
| Moderate–severe | 357 | 1.21 | 88 | 0.89 | 194 | 1.15 | 75 | 2.68 | |
| Severe | 199 | 0.67 | 56 | 0.57 | 105 | 0.62 | 38 | 1.36 | |
| CHA2DS2‐VASc | |||||||||
| CHA2DS2‐VASc LV dysfunction | 11 818 | 8.48 | 3319 | 6.43 | 6955 | 8.89 | 1544 | 16.17 | <0.0001 |
| CHA2DS2‐VASc hypertension | 99 591 | 71.45 | 35 998 | 69.73 | 56 067 | 71.68 | 7526 | 78.81 | <0.0001 |
| CHA2DS2‐VASc diabetes | 28 540 | 20.47 | 9784 | 18.95 | 16 126 | 20.62 | 2630 | 27.54 | <0.0001 |
| CHA2DS2‐VASc stroke | 8390 | 6.02 | 2961 | 5.74 | 4677 | 5.98 | 752 | 7.88 | <0.0001 |
| CHA2DS2‐VASc TIA | 5777 | 4.14 | 1905 | 3.69 | 3361 | 4.30 | 511 | 5.35 | <0.0001 |
| CHA2DS2‐VASc thromboembolic event | 7740 | 5.55 | 2822 | 5.47 | 4251 | 5.43 | 667 | 6.99 | <0.0001 |
| CHA2DS2‐VASc vascular disease | 23 546 | 16.89 | 7916 | 15.33 | 13 532 | 17.30 | 2098 | 21.97 | <0.0001 |
| Prior MI | 11 694 | 8.39 | 3890 | 7.54 | 6737 | 8.61 | 1067 | 11.17 | <0.0001 |
| Peripheral arterial disease | 4462 | 3.20 | 1469 | 2.85 | 2556 | 3.27 | 437 | 4.58 | <0.0001 |
| Known aortic plaque | 2123 | 1.52 | 716 | 1.39 | 1225 | 1.57 | 182 | 1.91 | 0.0002 |
| CHA2DS2‐VASc score, median (IQR) | 3.00 | (2.00–4.00) | 2.00 | (1.00–4.00) | 3.00 | (2.00–4.00) | 3.00 | (2.00–4.00) | <0.0001 |
| HAS‐BLED | |||||||||
| HAS‐BLED uncontrolled hypertension | 13 944 | 10.00 | 5303 | 10.27 | 7570 | 9.68 | 1071 | 11.22 | <0.0001 |
| HAS‐BLED abnormal renal function | 5885 | 4.22 | 1912 | 3.70 | 3241 | 4.14 | 732 | 7.67 | <0.0001 |
| HAS‐BLED abnormal liver function | 1235 | 0.89 | 404 | 0.78 | 687 | 0.88 | 144 | 1.51 | <0.0001 |
| HAS‐BLED stroke | 6753 | 4.84 | 2356 | 4.56 | 3803 | 4.86 | 594 | 6.22 | <0.0001 |
| HAS‐BLED bleeding | 7260 | 5.21 | 2668 | 5.17 | 3848 | 4.92 | 744 | 7.79 | <0.0001 |
| HAS‐BLED labile INR | 1057 | 0.76 | 223 | 0.43 | 698 | 0.89 | 136 | 1.42 | <0.0001 |
| HAS‐BLED alcohol | 8464 | 6.07 | 3192 | 6.18 | 4673 | 5.97 | 599 | 6.27 | 0.2110 |
| HAS‐BLED drugs–antiplatelet | 20 363 | 14.61 | 7890 | 15.28 | 10 702 | 13.68 | 1771 | 18.55 | <0.0001 |
| HAS‐BLED drugs–NSAIDs | 20 063 | 14.39 | 5962 | 11.55 | 12 534 | 16.02 | 1567 | 16.41 | <0.0001 |
| Rhythm history | |||||||||
| In AF at the time of procedure | 13 091 | 9.39 | 4050 | 7.85 | 7912 | 10.12 | 1129 | 11.82 | <0.0001 |
| AF classification | <0.0001 | ||||||||
| Paroxysmal | 78 828 | 56.55 | 30 877 | 59.81 | 43 927 | 56.16 | 4024 | 42.14 | |
| Persistent | 56 593 | 40.6 | 19 388 | 37.56 | 32 160 | 41.11 | 5045 | 52.83 | |
| Long‐standing persistent | 3646 | 2.62 | 1270 | 2.46 | 1936 | 2.48 | 440 | 4.61 | |
| Permanent | 155 | 0.11 | 43 | 0.08 | 89 | 0.11 | 23 | 0.24 | |
| Missing | 169 | 0.12 | 44 | 0.09 | 108 | 0.14 | 17 | 0.18 | |
| Valvular AF | 2275 | 1.63 | 721 | 1.40 | 1338 | 1.71 | 216 | 2.26 | <0.0001 |
| Attempt at AF termination | 92 423 | 66.30 | 31 592 | 61.20 | 53 706 | 68.66 | 7125 | 74.62 | <0.0001 |
| Pharmacological cardioversion | 41 152 | 29.52 | 12 789 | 24.77 | 25 043 | 32.02 | 3320 | 34.77 | <0.0001 |
| DC cardioversion | 67 620 | 48.51 | 23 272 | 45.08 | 38 857 | 49.68 | 5491 | 57.50 | <0.0001 |
| History of non‐PVI catheter ablation | 20 258 | 14.53 | 6290 | 12.18 | 12 262 | 15.68 | 1706 | 17.87 | <0.0001 |
| Preprocedure laboratory results | |||||||||
| Creatinine, mg/dL, median (IQR) | 1.00 | (0.81–1.16) | 1.00 | (0.82–1.14) | 1.00 | (0.81–1.15) | 1.00 | (0.81–1.20) | <0.0001 |
| INR, median (IQR) | 1.10 | (1.00–1.40) | 1.10 | (1.00–1.30) | 1.10 | (1.00–1.40) | 1.20 | (1.10–1.60) | <0.0001 |
| Preprocedure medications | |||||||||
| Anticoagulant–warfarin | 8149 | 5.85 | 2079 | 4.03 | 5219 | 6.67 | 851 | 8.91 | <0.0001 |
| DOACs | 74 367 | 53.35 | 28 725 | 55.64 | 40 693 | 52.02 | 4949 | 51.83 | <0.0001 |
| P2Y12 inhibitors | 4884 | 3.50 | 1633 | 3.16 | 2779 | 3.55 | 472 | 4.94 | <0.0001 |
| Rate‐control therapies | 89 408 | 64.14 | 33 958 | 65.78 | 48 814 | 62.41 | 6636 | 69.49 | <0.0001 |
| Antiplatelet agents | 26 174 | 18.78 | 8498 | 16.46 | 15 520 | 19.84 | 2156 | 22.58 | <0.0001 |
| Antiarrhythmic medications | 51 924 | 37.25 | 19 846 | 38.44 | 28 822 | 36.85 | 3256 | 34.10 | <0.0001 |
| Procedure information | |||||||||
| Sedation | <0.0001 | ||||||||
| Minimal sedation/anxiolysis | 55 | 0.04 | 15 | 0.03 | 35 | 0.04 | 5 | 0.05 | |
| Moderate sedation | 1633 | 1.17 | 420 | 0.81 | 1087 | 1.39 | 126 | 1.32 | |
| Deep sedation | 1650 | 1.18 | 688 | 1.33 | 873 | 1.12 | 89 | 0.93 | |
| General anesthesia | 135 831 | 97.45 | 50 425 | 97.68 | 76 097 | 97.29 | 9309 | 97.49 | |
| Ablation strategy | |||||||||
| Complex fractionated atrial electrogram | 10 756 | 7.72 | 3327 | 6.44 | 6372 | 8.15 | 1057 | 11.07 | <0.0001 |
| Cryoablation | 48 327 | 34.67 | 21 317 | 41.29 | 24 205 | 30.94 | 2805 | 29.37 | <0.0001 |
| Convergent procedure | 846 | 0.61 | 120 | 0.23 | 283 | 0.36 | 443 | 4.64 | <0.0001 |
| Empiric LA linear lesions | 35 544 | 25.50 | 12 108 | 23.46 | 20 049 | 25.63 | 3387 | 35.47 | <0.0001 |
| Focal ablation | 16 873 | 12.10 | 5373 | 10.41 | 9915 | 12.68 | 1585 | 16.60 | <0.0001 |
| Pulmonary vein isolation | 130 043 | 93.29 | 47 926 | 92.84 | 73 307 | 93.72 | 8810 | 92.26 | <0.0001 |
| Wide area circumferential ablation | 55 547 | 39.85 | 21 722 | 42.08 | 30 129 | 38.52 | 3696 | 38.71 | <0.0001 |
| Adjunctive ablation lesions | 74 729 | 53.61 | 26 890 | 52.09 | 41 935 | 53.61 | 5904 | 61.83 | <0.0001 |
| Location of adjunctive ablation | <0.0001 | ||||||||
| CTI ablation | 55 138 | 73.78 | 20 944 | 77.89 | 30 096 | 71.77 | 4098 | 69.41 | |
| Adjunct location other than CTI | 19 591 | 26.22 | 5946 | 22.11 | 11 839 | 28.23 | 1806 | 30.59 | |
| Transseptal | <0.0001 | ||||||||
| Singular | 88 809 | 63.82 | 37 570 | 72.89 | 45 745 | 58.58 | 5494 | 57.64 | |
| Double | 50 350 | 36.18 | 13 970 | 27.11 | 32 343 | 41.42 | 4037 | 42.36 | |
| Cumulative air kerma, Gy, median (IQR) | 0.12 | (0.04–0.32) | 0.09 | (0.03–0.24) | 0.13 | (0.04–0.36) | 0.16 | (0.05–0.43) | <0.0001 |
| Hospital characteristics | |||||||||
| Bed number, median (IQR) | 522 | (356–741) | 489 | (346–769) | 530 | (366–741) | 530 | (368–787) | <0.0001 |
| Teaching hospital, yes | 72 866 | 52.27 | 25 737 | 49.86 | 42 191 | 53.94 | 4938 | 51.71 | <0.0001 |
| Census region | <0.0001 | ||||||||
| Midwest region | 35 213 | 25.26 | 12 053 | 23.35 | 20 920 | 26.75 | 2240 | 23.46 | |
| Northeast region | 15 877 | 11.39 | 5194 | 10.06 | 9247 | 11.82 | 1436 | 15.04 | |
| South region | 60 524 | 43.42 | 21 644 | 41.93 | 34 233 | 43.77 | 4647 | 48.66 | |
| West region | 27 777 | 19.93 | 12 731 | 24.66 | 13 820 | 17.67 | 1226 | 12.84 | |
| Hospital location | <0.0001 | ||||||||
| Rural | 7794 | 5.59 | 2520 | 4.88 | 4793 | 6.13 | 481 | 5.04 | |
| Suburban | 39 570 | 28.39 | 15 161 | 29.37 | 21 658 | 27.69 | 2751 | 28.81 | |
| Urban | 92 027 | 66.02 | 33 941 | 65.75 | 51 769 | 66.18 | 6317 | 66.15 | |
| Hospital type | <0.0001 | ||||||||
| Government | 4775 | 3.43 | 1579 | 3.06 | 2819 | 3.60 | 377 | 3.95 | |
| Private/community | 114 521 | 82.16 | 44 488 | 86.18 | 62 442 | 79.83 | 7591 | 79.50 | |
| University | 20 095 | 14.42 | 5555 | 10.76 | 12 959 | 16.57 | 1581 | 16.56 | |
AF indicates atrial fibrillation; BMI, body mass index; CTI, cavo‐tricuspid isthmus; DC, direct current; DOAC, direct oral anticoagulant; HAS‐BLED as prior; INR, international normalized ratio; IQR, interquartile range; LA, left atrium; LV, left ventricle; LVEF, left ventricular ejection fraction; MI, myocardial infarction; NYHA, New York Heart Association; PVI, pulmonary vein isolation; P2Y12 is a medication type and well‐accepted indicator for these types of medicines; TIA, transient ischemic attack; and TTE, transthoracic echocardiography.
P value calculations are based on χ2 tests for categorical variables and Kruskal‐Wallis tests for continuous variables.
In adjusted analyses, in comparison with overnight hospitalization, the quarter during which AF ablation procedure was conducted (per quarter odds ratio [OR], 1.26 [95% CI, 1.256–1.264]) was significantly associated with SDD (Figure 1). In addition, the presence of health insurance (OR, 1.31 [95% CI, 1.08–1.60]) was associated with greater likelihood of SDD. Key demographic and patient‐related factors associated with lower likelihood of SDD included: Black race (OR, 0.71 [95% CI, 0.65–0.78]), Asian race (all subgroups: OR, 0.79 [95% CI, 0.69–0.91]), chronic lung disease (OR, 0.82 [95% CI, 0.78–0.87]), cardiomyopathy (OR, 0.87 [95% CI, 0.84–0.91]), higher CHA2DS2‐VASc score (OR, 0.88 [95% CI, 0.87–0.89]), history of prior non‐AF catheter ablation (OR, 0.89 [95% CI, 0.85–0.93]), and persistent AF classification (OR, 0.85 [95% CI, 0.82–0.88]). After adjustment for patient‐level factors, in comparison with overnight hospitalization, the MOR, as a measure of hospital‐level variation of undergoing SDD, was 4.12 (95% CI, 3.48–4.79).
Figure 1. Patient and procedure‐related factors associated with SDD after AF ablation.
AF indicates atrial fibrillation; BMI, body mass index; CL, confidence limit; Ref, reference; and SDD, same‐day discharge.
Figure 2 displays rates of SDD across participating hospitals, which ranged from 0.0% to 98.0%, with a median (IQR) of 33.5% (7.5%–59.3%). Figure 3 displays rates of SDD, overnight hospitalization, and >1 day hospital stay over the study period. The rate of SDD increased from 1.0% in the first quarter of 2016 to 62.3% in the second quarter of 2023 (P<0.0001 for trend), with a corresponding decline in those admitted for overnight hospitalization (83.3% in first quarter of 2016 to 32.9% in the second quarter of 2023, P<0.0001 for trend). The rate of patients requiring >1 day hospital stay postprocedure declined from 15.8% in the first quarter of 2016 to 4.8% in the second quarter of 2023 (P<0.0001 for trend). A pronounced rise in the rate SDD (P<0.0001 for trend in comparison with before Q1 2020) was seen after onset of the COVID‐19 pandemic in the United States (March 2020 corresponding to the first quarter of 2020).
Figure 2. Hospital‐level rates of SDD over the study period and display of hospital quartiles, stratified by rates of SDD.
SDD indicates same‐day discharge.
Figure 3. Rates of SDD, overnight hospitalization, and >1 day hospital stay after catheter ablation for AF.
AF indicates atrial fibrillation; and SDD, same‐day discharge.
Unadjusted in‐hospital complication rates for the overall study cohort and stratified by length of stay are shown in Table 2. The overall procedure‐related complication rate was 2.13%, with 0.70% representing major complications. Those undergoing SDD and overnight hospitalization had major complication rates of 0.03% and 0.24%, respectively, and overall complication rates of 0.19% and 0.98%, respectively. In comparison, those requiring a >1 day hospital stay postprocedure experienced major and overall complication rates of 8.12% and 22.0%, respectively. Among this cohort, postprocedure complications were composed of heart failure exacerbation (4.52%), pericardial effusion resulting in tamponade (2.69%), pericardial effusion requiring intervention (4.44%), bradycardia (3.36%), and access‐site hematoma (2.28%).
Table 2.
In‐Hospital Complication Rates Among the 3 Cohorts and Overall Cohort
| Overall, Major and specific adverse Cardiac events | Overall cohort (N=139 391) | Same‐d discharge (N=51 622) | Overnight hospitalization (<1 d) (N=78 220) | >1 d hospital stay (N=9549) | P value | P value |
|---|---|---|---|---|---|---|
| Event rate, % (95% CI) | Event rate, % (95% CI) | Event rate, % (95% CI) | Event rate, % (95% CI) | Same‐d discharge vs overnight hospitalization (<1 d) | Same‐day discharge vs >1 d hospital stay | |
| Overall complication | 2.129 (2.055–2.206) | 0.188 (0.154–0.229) | 0.982 (0.915–1.053) | 22.023 (21.203–22.866) | <0.0001 | <0.0001 |
| Major complication | 0.702 (0.659–0.747) | 0.029 (0.018–0.048) | 0.240 (0.208–0.277) | 8.116 (7.585–8.681) | <0.0001 | <0.0001 |
| Cardiovascular events | ||||||
| Cardiac arrest | 0.056 (0.045–0.070) | 0.008 (0.003–0.021) | 0.022 (0.014–0.035) | 0.597 (0.461–0.773) | 0.0635 | <0.0001 |
| Myocardial infarction | 0.023 (0.016–0.032) | 0.002 (0.000–0.014) | 0.015 (0.009–0.027) | 0.199 (0.127–0.312) | 0.0468 | <0.0001 |
| Air embolism | 0.036 (0.027–0.047) | 0.010 (0.004–0.023) | 0.049 (0.035–0.067) | 0.073 (0.035–0.154) | 0.0007 | 0.0005 |
| Heart failure | 0.354 (0.324–0.386) | 0.014 (0.006–0.028) | 0.069 (0.053–0.090) | 4.524 (4.125–4.960) | <0.0001 | <0.0001 |
| Heart valve damage | 0.001 (0.000–0.005) | 0.002 (0.000–0.014) | 0 | 0 | NA | NA |
| Left atrial thrombus | 0.009 (0.005–0.016) | 0.006 (0.002–0.018) | 0.009 (0.004–0.019) | 0.031 (0.010–0.097) | 0.5315 | 0.0387 |
| Pericardial effusion resulting in cardiac tamponade | 0.211 (0.188–0.236) | 0.008 (0.003–0.021) | 0.042 (0.030–0.059) | 2.691 (2.385–3.036) | 0.0014 | <0.0001 |
| Pericardial effusion requiring intervention | 0.371 (0.340–0.404) | 0.014 (0.006–0.028) | 0.110 (0.089–0.136) | 4.440 (4.045–4.872) | <0.0001 | <0.0001 |
| Cardiac surgery (unplanned/emergent) | 0.060 (0.049–0.075) | 0.002 (0.000–0.014) | 0.005 (0.002–0.014) | 0.827 (0.664–1.030) | 0.3853 | <0.0001 |
| Cardiac thromboembolic event | 0.011 (0.006–0.018) | 0 | 0.004 (0.001–0.012) | 0.126 (0.071–0.221) | NA | NA |
| Bradycardia adverse events | 0.404 (0.372–0.439) | 0.064 (0.045–0.090) | 0.267 (0.233–0.306) | 3.362 (3.018–3.742) | <0.0001 | <0.0001 |
| Anaphylaxis | 0.004 (0.002–0.010) | 0 | 0 | 0.063 (0.028–0.140) | NA | NA |
| Hemorrhage (nonaccess site) | 0.107 (0.091–0.125) | 0.002 (0.000–0.014) | 0.024 (0.015–0.038) | 1.351 (1.138–1.603) | 0.0137 | <0.0001 |
| Sepsis | 0.009 (0.005–0.016) | 0 | 0.001 (0.000–0.009) | 0.126 (0.071–0.221) | NA | NA |
| Peripheral vascular events | ||||||
| Arterial thrombosis | 0.020 (0.014–0.029) | 0 | 0.026 (0.016–0.040) | 0.084 (0.042–0.167) | NA | NA |
| Access site bleeding requiring transfusion | 0.085 (0.071–0.101) | 0 | 0.029 (0.020–0.044) | 0.995 (0.814–1.215) | NA | NA |
| Arterio‐venous fistula requiring intervention | 0.025 (0.018–0.035) | 0 | 0.028 (0.019–0.043) | 0.136 (0.079–0.234) | NA | NA |
| Deep vein thrombosis | 0.032 (0.024–0.043) | 0.002 (0.000–0.014) | 0.027 (0.018–0.041) | 0.241 (0.160–0.362) | 0.0102 | <0.0001 |
| Hematoma at access site | 0.236 (0.212–0.263) | 0.015 (0.008–0.031) | 0.132 (0.109–0.160) | 2.283 (2.002–2.603) | <0.0001 | <0.0001 |
| Pseudoaneurysm requiring intervention | 0.101 (0.086–0.119) | 0 | 0.043 (0.031–0.061) | 1.121 (0.928–1.353) | NA | NA |
| Vascular injury requiring surgical intervention | 0.058 (0.047–0.072) | 0.002 (0.000–0.014) | 0.035 (0.024–0.050) | 0.555 (0.424–0.726) | 0.0047 | <0.0001 |
| Neurological events | ||||||
| Phrenic nerve damage | 0.129 (0.112–0.149) | 0.041 (0.027–0.062) | 0.150 (0.125–0.179) | 0.440 (0.325–0.595) | <0.0001 | <0.0001 |
| Peripheral nerve injury | 0.019 (0.013–0.027) | 0.008 (0.003–0.021) | 0.013 (0.007–0.024) | 0.126 (0.071–0.221) | 0.3973 | <0.0001 |
| Stroke | 0.065 (0.053–0.079) | 0.002 (0.000–0.014) | 0.014 (0.008–0.025) | 0.817 (0.655–1.019) | 0.0577 | <0.0001 |
| Transient ischemic attack | 0.039 (0.030–0.051) | 0.002 (0.000–0.014) | 0.046 (0.033–0.064) | 0.189 (0.119–0.299) | 0.0018 | <0.0001 |
NA, not applicable.
DISCUSSION
Using a large, US‐based registry of patients undergoing AF ablation across 197 hospitals, our work identifies 4 key findings. First, the rate of SDD following AF ablation increased significantly over time, with a corresponding decline in overnight hospitalization, a trend associated with onset of the COVID‐19 pandemic and sustained after conclusion of the associated lockdown phases. Second, patients with fewer comorbidities and thus at lower risk of periprocedural complications were more likely to undergo SDD. Third, at study end, most postablation patients underwent SDD with significant variation across hospitals. Fourth, in‐hospital complication rates among patients who underwent SDD were comparable with those observed with overnight hospitalization. These findings characterize an evolving landscape of postprocedure monitoring following AF ablation across the United States and suggest acceptable in‐hospital safety associated with SDD for select patients, comparable with that seen with overnight hospitalization.
Despite an increase in the complexity of patients undergoing catheter ablation for AF, aggregate complication rates associated with AF ablation have declined from approximately 5% in the early 2000s 2 , 19 to 2.1% to 2.3% via contemporary analyses of large‐scale registries, 1 including those with postablation follow‐up such as REAL‐AF. 20 With marked improvement in complication profile, we posit that SDD was accelerated by the pandemic onset with related desire to reduce the risk of nosocomial infection and perpetuated when astute operators observed it could safely be performed without significant increased risk of adverse events. Temporal analyses yielded a striking, sustained secondary impact of the COVID‐19 pandemic with an inflection point in SDD rates starting in the first quarter of 2020, correlating with pandemic onset. SDD overtook overnight hospitalization as the preferred postprocedure disposition by mid‐2021 and at study end; >3 of 5 of patients underwent SDD following AF ablation, indicating a migration away from routine overnight hospitalization in the current therapeutic era. Similar to invasive cardiovascular procedures such as percutaneous coronary intervention 21 , 22 or transcatheter aortic valve replacement, 23 our analysis indicates preferential application of SDD to patients at lower risk of procedural complications. Patient and AF profiles that favored overnight hospitalization included history of cardiomyopathy, chronic lung disease, history of prior catheter ablation, and ablation procedure conducted for nonparoxysmal AF.
Subject to operator, patient, and hospital preference; systems‐based protocols, experience with SDD for other cardiovascular procedures such as percutaneous coronary intervention 22 or implantable cardioverter‐defibrillator, 24 availability of technology such as vascular closure devices, and case mix, substantial hospital‐level variation in use of SDD after catheter ablation of AF (MOR, 4.12 [95% CI, 3.48–4.79]) was observed. Overall, 32.0% of hospitals account for 78.6% of SDDs following catheter ablation of AF. Our findings indicate an opportunity for sharing the best practices, such as existing 4 , 6 , 10 and newly refined protocols designed to identify, monitor, and arrange follow‐up for those being considered for SDD, incorporation of discharge approaches into societal‐based guideline documents, and collaborative efforts centered around longer‐term evaluation among those undergoing early discharge.
Consistent with prior analyses, 1 the overall complication rate was 2.13%, with <1% representing major complications. Secondary to inherent differences among the subcohorts analyzed, we report unadjusted event rates of postprocedural complications. With rapid evolution in procedural tools including ablation technologies, intracardiac echocardiography, and ablation approaches, our data confirm an excellent safety profile associated with AF ablation in the context of SDD. Consistent with SDD following percutaneous coronary intervention 21 or implantable cardioverter‐defibrillator, 24 short‐term total complication rates among those undergoing SDD and overnight hospitalization following AF ablation were <1%, suggesting safe application of SDD among select patients. Likely impacting operator decision to pursue prolonged hospitalization secondary to intra‐ or postprocedural events, patients hospitalized >1 day experienced higher rates of all complications and major complications compared with both the overnight hospitalization and SDD groups.
Similar to other cardiovascular procedures, 25 SDD following AF ablation may present numerous potential advantages for patients, providers, and health care systems, including patient satisfaction, stable health care use, and cost savings. The current analysis aligns with excellent patient satisfaction metrics and potentially increasing patient preference for SDD. 26 Several prior, smaller‐scale studies have demonstrated the absence of health care use (ie, postdischarge emergency room care or readmission) 4 and substantial cost savings 4 , 13 associated with SDD following AF ablation. Though larger‐scale analyses of cost associated with SDD for AF ablation are lacking, national‐level data for SDD associated with cardiovascular procedures such as percutaneous coronary intervention indicate significant cost savings. 11 These data demonstrate marked health care system and broader economic benefits associated with SDD 13 , 27 , 28 and should be considered in future policy development addressing reimbursement for AF care in the United States.
With growth in the development of ambulatory or outpatient procedural centers (APCs) and momentum surrounding SDD following cardiovascular procedures, our findings may assist national procedural policy development. Joint position statements from the American College of Cardiology and Heart Rhythm Society, requesting extension of Centers for Medicare and Medicaid Services coverage for AF ablation to APCs, have in part, been hampered due to lack of national‐level data showing growth and safety of an SDD approach. Evaluation of peripheral arterial disease interventions at APCs, approved by the Centers for Medicare and Medicaid Services in 2008, may provide insight on the implications of potential future approval of AF ablation in nonhospital settings. Recent data studying peripheral arterial disease interventions at APCs indicate a stark rise in peripheral arterial disease care in APC settings, with improved access, less cost, and reduced time to procedure, 29 balanced against conduct of procedures within APCs that allow higher reimbursement potential. 30 Importantly, assessment of real‐word safety through development of novel data collection methods within APCs, in addition to development of clear pathways to guide escalation of care such as hospitalization after procedural complications, are important considerations. With probable continued expansion of SDD, both within a traditional hospital or an APC setting, the current analysis may inform careful selection of patients suitable for this strategy based on AF subtype and comorbid conditions, among other factors.
Limitations of our work, due to data capture within the NCDR AF Ablation Registry, include inability to track patients outside of the episode of catheter ablation for AF, thereby limiting capture of rare, but possible, postdischarge complications or readmissions associated with AF ablation. In addition, residual confounding as well as potential crossover (ie, planned SDD converted to overnight or longer hospitalization), though rare clinically, may have impacted our results. Due to registry limitations, factors that are challenging to capture or unavailable in the current data capture tools within the registry, such as patient frailty or operator intraprocedural decisions and use of particular vascular closure devices, may impact disposition status and were not analyzed in this study. Our analysis is limited to hospitals participating in the NCDR AF Ablation Registry, and therefore may be biased toward those with a quality‐based focus. However, to our knowledge, this analysis represents the largest and most comprehensive study of discharge disposition after AF ablation in the United States. The NCDR AF Ablation Registry relies on voluntary participation and may introduce bias toward facilities with greater interest in quality improvement.
CONCLUSIONS
SDD following catheter ablation of AF increased significantly starting the first quarter of 2020, suggesting acceleration after onset of the COVID‐19 pandemic, and overtook overnight hospitalization by the first quarter of 2021. Those discharged the same day had fewer comorbid conditions, less complex AF, and comparable periprocedural complication rates relative to overnight hospitalization. Although there was significant variability in SDD uptake across hospitals, the safety of SDD was comparable with that of overnight hospitalization. With the changing landscape of AF reimbursement and growth in outpatient procedural centers, our findings may have important health policy implications and may assist with safe, effective implementation and dissemination of SDD nationally.
Sources of Funding
This work was supported by the American College of Cardiology and National Cardiovascular Data Registry.
Disclosures
Dr Sandhu is supported by VA Career Development Award HX003253 and American Heart Association Career Development Award 22CDA933316. Dr Hess is supported by VA Career Development Award HX002621 Merit Award 1I01HX003570‐01A2 from the Veteran's Affairs Health Systems Research. The remaining authors have no disclosures to report.
Supporting information
Figure S1
This article was sent to Kevin F. Kwaku, MD, PhD, Associate Editor, for review by expert referees, editorial decision, and final disposition.
Supplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/JAHA.124.039190
For Sources of Funding and Disclosures, see page 12.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Figure S1
Data Availability Statement
The authors declare that all supporting data are available within the article and associated online supplementary files.