Same‐Day Discharge: It's Not Always Better to Sleep Over

Catheter ablation for atrial fibrillation (AF) in the United States has increased significantly over the past 20 years. An analysis of the Nationwide Inpatient Sample database showed up to a 940% increase in AF ablation between 2000 and 2012. ¹ Data from the NCDR (National Cardiovascular Data Registry) AFib Ablation Registry and Medicare beneficiaries support the increasing trend in catheter ablation procedures across all regions of the United States. ² , ³ Historically, patients undergoing AF ablation have been admitted for overnight observation due to concerns about postprocedure complications. However, with advancements in procedural techniques, periprocedural care, and risk stratification, same‐day discharge (SDD) protocols are gaining traction as a safe and effective alternative to overnight hospitalization following AF ablation.

In this issue of the Journal of the American Heart Association (JAHA), Sandhu et al add to the growing body of evidence describing the use of SDD protocols. ⁴ Our editorial contextualizes the key findings of this article within the current landscape of SDD following AF ablation. We also explore future care pathways and the implications of implementing widespread SDD protocols.

Key Findings

Sandhu et al present trends in SDD following AF ablation from the NCDR AFib Ablation Registry, emphasizing its feasibility in select patient populations. ⁴ The data analysis begins with 2016 and includes the COVID‐19 pandemic period, revealing a rapid adoption of SDD starting in 2020 without return to prepandemic practices. ⁴ The SDD rate in this study was 62.3% in 2023, lower than previously reported rates of up to 86%. ⁴ , ⁵ , ⁶ The study shows that SDD is more common among patients with postprocedural complication rates of <1%, a rate that is slightly less than in those requiring an overnight stay and significantly lower than in those hospitalized for >1 day. ⁴ Patients with persistent AF and coexisting cardiomyopathy were less likely to be discharged the same day. ⁴ The study also identifies medical insurance coverage associated with higher SDD. ⁴ Overall, the findings of the study align with existing evidence suggesting that overnight hospitalization may be unnecessary for select patients undergoing AF ablation.

As the largest registry of its kind, the NCDR AFib Ablation Registry includes voluntarily enrolled centers capable of data collection and sharing. The selectivity of the site‐level inclusion criteria used by the NCDR registry may skew the results, potentially limiting their representation of national trends in SDD. While rigorous quality measures (including random audits) support data accuracy, the registry lacks detailed procedural information (such as ablation energy source, type of anesthesia, details of ablation performed, readmission rates, and follow‐up) that could lead to underreporting of adverse events. ⁷ Despite the potential limitations of the NCDR registry, the study's findings are consistent with previously published data supporting the lack of association between specific details of the ablation procedure and candidacy for same‐day discharge.

Current Trends in Same‐Day Discharge

The shift toward SDD following AF ablation is reflective of broader trends in minimally invasive cardiac procedures. ⁸ , ⁹ , ¹⁰ , ¹¹ A comprehensive review and meta‐analysis by the European Heart Rhythm Association Health Economics Committee found that SDD after AF ablation is associated with low rates of postdischarge complications, rehospitalizations, and death, with no significant difference in complication rates compared with overnight stay. Both general anesthesia and conscious sedation were part of the anesthesia protocol of the included procedures. This meta‐analysis studied 154 716 patients across 24 publications and demonstrated that the pooled estimates for complications were low, both in the short term (2%) and at 30 days (2%) for SDD. ⁵ In the United States, analysis from multicenter REAL‐AF (Real‐World Experience of Catheter Ablation for the Treatment of Symptomatic Paroxysmal and Persistent Atrial Fibrillation) registry showed comparable rates of readmission and subacute complications in SDD versus non‐SDD patients following radiofrequency ablation for AF. ⁶

Several factors have contributed to this transition in post‐AF ablation care. The introduction of contact‐force sensing catheters for radiofrequency ablation has improved procedural efficacy while reducing complications, making early discharge more feasible. ¹² , ¹³ Uptake of ultrasound‐guided vascular access and use of vascular closure devices has reduced the rate of vascular complications. ¹⁴ Optimized periprocedural anticoagulation protocols, including uninterrupted direct oral anticoagulant use, have minimized the risk of thromboembolic and bleeding events. ¹⁵ The use of wearable devices and remote telemetry provides additional reassurance, allowing early detection of recurrent arrhythmias outside the hospital setting.

Importantly, patient preferences for shorter hospital stays and personalized recovery pathways may play a role in SDD adoption. Despite these advancements, Sandhu et al describe variations in SDD adoption due to institutional inertia, concerns regarding liability, and regional differences in health care reimbursement policies. ⁴

Future Implications

Several studies have been designed to evaluate the economic benefits of SDD protocols in AF ablation. Kowalski et al reported that SDD implementation for 50% of AF ablation cases could result in an annual cost savings ranging from $45 825 to $83 813 per US hospital offering this service. ¹⁶ Another study showed that a financial saving from SDD could range from $1 110 096 to $1 480 128 annually, if 60% to 80% of the first cases of the day could be discharged the same day before 8:00 pm. ¹⁷ Data from hospitals based outside the United States indicate an average savings per procedure of 63% with SDD of patients undergoing pulmonary vein isolation. ¹⁸ Cost analysis of SDD remains inconsistent due to lack of uniform methodology used for these studies. Nonetheless, cost saving should not be the primary reason for higher use of SDD protocols.

As the paradigm shifts toward SDD as a standard of care for AF ablation, several critical considerations must be addressed to ensure its successful integration into clinical practice. As identified by the authors in this manuscript, developing universally accepted risk assessment models to identify candidates best suited for SDD will be essential in minimizing adverse events and ensuring patient safety. ⁴ Effective SDD protocols require coordination among electrophysiologists, anesthesia team members, nursing staff, pharmacists, and outpatient care teams to optimize discharge readiness and patient education. Structured preprocedural counseling and postdischarge support programs can empower patients, improving adherence to postablation management strategies and reducing unnecessary emergency department visits.

As the authors noted, social determinants of health may influence the selection of appropriate candidates for SDD. This aspect of health care remains largely unexplored in the context of discharge protocols following AF ablation and other cardiovascular interventions. Future research focusing on socioeconomic factors could further elucidate which patient populations are best suited for SDD.

Identifying appropriate candidates for SDD may also help optimize the use of ambulatory surgical centers for AF ablation. Ambulatory surgical centers can offer an efficient alternative to hospital settings while reducing health care costs and enhancing patient experience. Published data support similar safety and outcomes for left‐sided atrial ablation in ambulatory surgical centers and hospitals. ¹⁹ The Society for Cardiovascular Angiography and Interventions endorses percutaneous coronary interventions in ambulatory surgical centers, provided high‐quality standards are maintained, a model that could potentially extend to electrophysiology procedures as well. ²⁰

Finally, the advancement of pulsed field ablation may add to the adoption of SDD. The growing adoption of this technology, due to its reduced risk of esophageal and phrenic nerve injury in AF ablation, coupled with the expanding scope of AF ablation is expected to further enhance SDD rates while prioritizing safety and optimal patient outcomes. ¹³

Conclusions

The evolution of SDD following AF ablation marks a significant advancement in electrophysiology, integrating safety, efficiency, and patient‐centered care. The findings presented here further validate the feasibility of SDD, aligning with contemporary trends in procedural streamlining and health care cost containment. Safety remains the foundational premise for implementing SDD protocols, and as its use increases over time, establishing a seamless transition plan becomes imperative. This progression also opens the door to alternative care settings, a prospect that may gain even greater relevance in the era of pulsed field ablation, where anticipated safety improvements over traditional thermal energy sources could further support the SDD approach.

Disclosures

None.