HRS, ACC Lay Out Principles for Same-Day Discharge After Catheter Ablation

Same-day discharge can be safely performed in appropriately selected patients after intracardiac catheter ablation procedures, according to a scientific statement from the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC).

Mounting evidence, much of it gathered since the start of the COVID-19 pandemic, indicates that many patients may be able to avoid an overnight hospital stay after ablation without increasing their risks of periprocedural complications, readmissions, or trips to the emergency department.

This is expected to not only increase patient access to ablation at a time of growing demand, but also lower costs for healthcare facilities and patients alike, authors led by co-chairs Amit Shanker, MD (St. Lawrence Health System, Potsdam, NY), and Samuel Jones, MD (Chattanooga Heart Institute, TN), detail in the statement, which was released Thursday to coincide with the first day of the Heart Rhythm 2025 meeting.

Though, historically, patients undergoing catheter ablation have been hospitalized overnight or longer after their procedures to watch for periprocedural complications, there has been a trend toward discharging patients on the same day.

One study published online recently in the Journal of the American Heart Association, for instance, showed that between January 2016 and June 2023, the rate of same-day discharge following ablation for atrial fibrillation (AF) at centers participating in the National Cardiovascular Data Registry AF Ablation Registry increased from about 1% to 62%, with an acceleration after the beginning of the COVID-19 pandemic. Rates of overall and major complications were low at 0.19% and 0.03%, respectively, for patients discharged the day of the procedure, and 0.98% and 0.24% for those who stayed the night in the hospital.

Speaking with TCTMD, Shanker noted that catheter ablation, and interventional electrophysiology (EP) procedures in general, have evolved over the years, with improvements in technology and procedures leading to higher success rates and lower complication rates.

That “has allowed us to really treat patients quicker and treat a larger variety of rhythm disturbances,” he said. Both the pressures of the COVID-19 pandemic and economic considerations have driven a movement to reduce the duration of hospital stays and optimize resource use, which has the EP field “moving more towards the same-day discharge strategy to address these challenges,” he added.

The new HRS/ACC statement, published in JACC: Clinical Electrophysiology and Heart Rhythm, “was written to really assess the global trends and the evidence supporting same-day discharge in light of these pressures to reduce overnight stays, lower healthcare costs, and maintain safety.”

In the document, the authors review evidence from global clinical studies and real-world claims data from the US Centers for Medicare & Medicaid Services demonstrating both proof of concept for same-day discharge and low rates of complications and return visits to the hospital.

“People may question: is this something that is safe and effective to do?” Jones said to TCTMD. “And all of our data shows that the electrophysiologist has a very acute ability to determine which patients are appropriate for this and which patients are not appropriate for it. . . . We know that it’s safe as long as the EP has the ability to adjudicate that this is a patient that is appropriate and they follow a protocol.”

Principles for Same-Day Discharge

After reviewing existing evidence around same-day discharge, the authors provide principles to guide protocols.

“Best practices for implementing a same-day discharge protocol following catheter ablation procedures require careful consideration and scrutiny of baseline patient factors during preprocedural screening, procedural planning, and postprocedure management,” they write.

The likelihood of sending a patient home on the day of their procedure depends partly on the type of ablation. Most patients undergoing treatment for cavotricuspid isthmus-dependent atrial flutter, atrioventricular nodal reentrant tachycardia, accessory pathways, and focal atrial tachycardias are likely suitable, the statement indicates, whereas the approach will be used more selectively in patients undergoing AF ablation due to the increased complexity of the procedure.

The document contains a table outlining eligibility criteria for same-day discharge after AF ablation. They include the absence of decompensated heart failure, significant pulmonary disease, unstable medical comorbidities likely to require acute management after the procedure, and significant bleeding diathesis, as well as proximity of the patient’s home to the hospital and the presence of social support. There is also a checklist that can be used at discharge after any catheter ablation procedure.

Importantly, any consideration of same-day discharge should be within a shared decision-making framework, the authors indicate.

“The patient’s best interests and preferences should always be of utmost importance to the operating physician and facility,” they write. “Although same-day discharge might economically benefit facilities and public/private payors (who might view reimbursement through the lens of the shortest length of stay and lowest resource utilization), it is incumbent upon both the operating physician and patient to share decision-making so as to optimize safety, patient comfort, and procedural outcomes.”

We know that it’s safe as long as the EP has the ability to adjudicate that this is a patient that is appropriate and they follow a protocol. Samuel Jones

Jones said that physicians and healthcare facilities considering use of same-day discharge can turn to this new scientific statement as a guide. “All healthcare is local and what works in one facility may not work in another facility. It depends on their geography and where their patients are coming from and what their social support is,” he said. “But I think we’ve outlined some of those steps that they can begin thinking about. Does this work for us? Does this work for our patients? In which procedures does it work for?”

Overall, this “is something that needs to be done with careful consideration,” Jones stressed. “But I think most electrophysiologists are finding that this is something that is good for patients, and patients want this, and it’s something good for facilities so that it opens up access.”

Commenting for TCTMD, Paul Zei, MD, PhD (Brigham and Women’s Hospital, Boston, MA), said a document like the HRS/ACC scientific statement may support more ablation centers in adopting same-day discharge. “For better or for worse, you can think of that as cover, right? They have a document to stand on to say that it’s safe so that in case there is a poor outcome, which unfortunately inevitably is going to happen on occasion, they can say that this is supported by both standard of practice and consensus-type statements,” he said.

Zei pointed out, too, that the rapid increase in use of pulsed-field ablation in recent years is likely going to drive even more interest in avoiding overnight hospital stays after procedures. “That has shortened procedures so tremendously,” he said, “that I think you’re going to see even more acceleration in the adoption of same-day discharge.”

Implications for Ambulatory Surgery Centers

Some of the pressures that have pushed the EP field toward same-day discharge have also fueled the spread of facilities—like ambulatory surgery centers (ASCs)—that can deliver some simpler EP procedures outside of the hospital setting.

Shanker said that initially, the task presented to the authors of this same-day discharge statement was to write a document addressing the performance of ablation procedures in ASCs. The societies decided, however, that the group should first develop a statement on same-day discharge, which would be followed by a separate document on ASCs. So, Shanker said, the current statement “is providing the groundwork for our next upcoming paper in the coming months.”

Jones added: “This was a foundational document of same-day discharge because we needed to make sure we understand that clearly. And once we showed that that is safe, we also have further information from our field about what is happening with ambulatory surgery centers, and that will be something that will be forthcoming.”

For now, when it comes to ablation in ASCs, Shanker said “we would still urge use of real-world registries and tracking quality measures to assess outcomes in real time as this continues to become more of the norm.”