Figure-of-eight sutures for hemostasis result in shorter lab recovery time after ablation for atrial fibrillation

Feasibility and safety of same-day discharge and shortened bedrest after atrial fibrillation ablation

Background

While initial studies suggest that same-day discharge or shortened bedrest may be feasible for some patients following atrial fibrillation (AF) ablation, the risks and benefits of this approach remain unclear for patients undergoing hemostasis with figure-of-eight (FO8) suture technique.

Methods

We prospectively evaluated access site bleeding, length of hospitalization, urinary catheterization, and other clinical outcomes in patients undergoing AF ablation with 3 hours of bedrest between April and May 2021, and compared them to a control group that had undergone AF ablation with 6 hours of bedrest from April to July 2019. FO8 sutures were used for hemostasis in all patients. Independent risk factors for bleeding and urinary catheterization were determined using multiple logistic regression.

Results

Same-day discharge was achieved in 74% of patients in the 3-hour bedrest group compared to 7% of patients in the 6-hour bedrest group (p < 0.001). There were no differences between 3-hour and 6-hour bedrest groups in the rates of serious adverse events (2% vs. 1%, p = 0.45) or rehospitalizations or ED visits (1% vs. 3%, p = 0.45) within 30 days of ablation. The 3-hour bedrest group showed a non-significant trend toward more access site bleeding (15% vs. 8%, p = 0.10), but had a significant reduction in urinary catheterization (27% vs. 64%, p < 0.001) and opioid analgesia use (20% vs. 33%, p = 0.04).

Conclusions

Same-day discharge after 3 hours of bedrest is safe and feasible following AF ablation and is not associated with higher rates of complications or rehospitalizations at 30 days. Reduced bedrest resulted in decreased opioid analgesia and urinary catheterization.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10840-022-01255-4.

A comparison of figure-of-8-suture versus manual compression for venous access closure after cardiac procedures: An updated meta-analysis

BACKGROUND

Manual compression (MC) is the current standard to achieve postprocedural hemostasis in patients who need venous vascular access closure after cardiovascular procedures. Figure-of-8 (F8) suture for venous access closure has been reported to be a safe and efficacious alternative to MC.

METHODS

A systematic search was done using PubMed, Google Scholar, EMBASE, SCOPUS, and ClinicalTrials.gov without language restriction up until April 15, 2020 for studies comparing F8 suture versus MC. Risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI) were calculated using a random effects model.

RESULTS

Time to achieve hemostasis was significantly reduced in the F8 arm [MD -21.04 min (95% CI: -35.66 to -6.42; P = .005)]. Access site bleeding was significantly lower in the F8 group [RR 0.35 (95% CI: 0.18 to 0.66; P = .001)] along with a lower incidence of hematoma formation [RR 0.42 (95% CI: 0.26 to 0.67; P = .0003)]. There was no significant difference in rates of fistula or pseudoaneurysm formation between the two groups. Overall access site complications were lower in the F8 arm [RR 0.38 (95% CI: 0.26 to 0.55; P < .00001)] and the effect was more pronounced for sheaths ≥10 Fr [RR 0.33 (95% CI: 0.18 to 0.60; P = .0003)]. There was lower postprocedural protamine use in the F8 group [RR 0.07 (95% CI: 0.01 to 0.36; P = .001)].

CONCLUSION

For large-bore venous access closure, the F8 suture results in a shortened time to achieve hemostasis along with a lower overall risk of access site complications and postprocedural protamine use.

Feasibility of the Figure-of-8-Suture as Venous Closure in Interventional Electrophysiology: One Strategy for All?

Background: Venous vascular access with higher sheath size is common in interventional electrophysiology. In contrast to arterial vascular access, no dedicated closure devices exist for closure after venous access with higher sheath sizes. The Figure-of-8-Suture, an easy to apply suture, may be as a feasible approach for closure venous puncture. Our aim was to evaluate the feasibility of closure of femoral venous access. Methods: From November 2016 to February 2018, patients undergoing electrophysiological procedures, closure of left atrial appendage or patent foramen ovale were included. Until May 2017, manual compression was performed to achieve haemostasis at venous access site (control group). From May 2017, patients were treated with a Figure-of-8-Suture (treatment group, Figure 1). Turnaround time and incidence of vascular complications were compared between the two groups. Results: In total, 290 patients were included, 132 in the control group and 158 in the Figure-of-8-Suture group. Hemostasis after sheath removal was achieved in 100% of the cases in the control group by manual compression and in 98.7% of the cases with the Figure-of-8-Suture (p=0.2). Vascular complications were more common in the control group (6.8 vs. 1.3 %, p=0.01). Turnaround time was significantly lower in the Figure-of-8-Suture group (58.6 ± 14 vs. 77 ± 33.9 min, p=0.004). In a sub-analysis in obese patients with body mass index (BMI) ≥30 kg/m² (Figure-of-8 n=45, controls n=35), vascular complications were significantly more common in the control group (9.4 vs 0%, p=0.045). Conclusion: The Figure-of-8-Suture is an easy-to-apply, effective approach for venous closure after electrophysiological procedures.

Heparin reversal with protamine sulfate is not required in atrial fibrillation ablation with suture hemostasis

BACKGROUND

The utility of protamine sulfate for heparin reversal in catheter-based atrial fibrillation (AF) ablation is unclear when using the suture closure technique for vascular hemostasis.

OBJECTIVE

This study sought to address if protamine sulfate use for heparin reversal reduces vascular access complications in AF catheter ablation when suture techniques are used for postprocedural vascular hemostasis.

METHODS

This is a retrospective multicenter observational study of 294 consecutive patients who underwent catheter ablation for AF with subsequent vascular access hemostasis by means of a figure-of-eight suture or stopcock technique. A total of 156 patients received protamine for heparin reversal before sheath removal while 138 patients did not receive protamine. The two groups were compared for procedural activated clotting time (ACT), access site complications, and duration of hospital stay.

RESULTS

Baseline demographic characteristics were comparable in both groups. Despite higher ACT before venous sheath removal in patients not receiving protamine (288.0 ± 44.3 vs 153.9 ± 32.0 seconds; P < .001), there was no significant difference in groin complications, postoperative thromboembolic events, or duration of hospital stay between the two groups. Suture failure requiring manual compression was rarely observed in this cohort (0.34%).

CONCLUSION

With modern vascular access and sheath management techniques, for patients undergoing catheter ablation for AF, simple suture closure techniques can obviate the need for protamine administration to safely achieve hemostasis after removal of vascular sheaths.

Comparison of standard vs modified "figure-of-eight" suture to achieve femoral venous hemostasis after cryoballoon based atrial fibrillation ablation

BACKGROUND

Immediate hemostasis following removal of sheaths is essential to prevent access site complications after atrial fibrillation (AF) ablation. Despite various precautions to achieve complete hemostasis in a safe and effective manner, no standard approach is present yet.

OBJECTIVE

We aimed to compare the efficacy and safety of standard vs modified figure-of-eight (sFoE vs mFoE) suture for immediate venous hemostasis after cryoballoon (CB) AF ablation.

METHODS

A total of 150 patients who underwent CB catheter ablation were sequentially allocated to either sFoE (n = 75) or mFoE (n = 75) suture to achieve immediate venous hemostasis at right femoral access site after 15 Fr sheath removal. A "three-way stopcock" was used in the mFoE group rather than tying the knot as in a sFoE group. Demographics, clinical and procedural data, and access site complications were recorded.

RESULTS

Immediate haemostasis was achieved in all patients (n = 75) with mFoE suture as compared to 90.7% (n = 68) of sFoE suture group (P < .001). Light manual pressure of ≤1 min was required in five patients (6.7%) due to looseness and conventional manual compression because of the snapped silk suture during knotting was required in two patients (2.6%) in the sFoE group. Time to hemostasis was shorter in the mFoE group (P < .001), but time to ambulation and time to discharge were similar in both groups (P > .05). Although no minor or major access site complication has occurred in the mFoE group, in-hospital rebleeding (n = 2, 2.7%) and early local access site infection (n = 2, 2.7%) were observed in the sFoE group.

CONCLUSION

The mFoE suture using three-way stopcock is an available, effective, maybe safe, and time- and cost-saving alternative technique to achieve immediate hemostasis after removal of 15 Fr right femoral venous sheath in patients undergoing cryoablation.

Efficacy and safety of figure-of-eight suture versus manual pressure for venous access closure: a systematic review and meta-analysis

BACKGROUND

Vascular hemostasis after venous access in cardiovascular procedures remains a challenge. Figure-of-eight (FoE) emerged as an alternative technique to manual pressure. However, its feasibility and safety is unknown.

METHODS

A comprehensive search in clinicalTrials.gov, PubMed, Web of Science, EBSCO Services, Cochrane Central Register of Controlled Trials, Google Scholar, and various scientific conference sessions from inception to December 1, 2018, was performed. A meta-analysis was performed using random effects model to calculate risk ratio (RR) and mean difference (MD) with 95% confidence interval (CI).

RESULTS

Seven studies were eligible and included 1978 patients, of whom 982 patients received the FoE suture, while 996 received manual pressure. There was no difference in the risk of access site pseudoaneurysm (RR 0.48, 95%CI 0.13 to 1.73, p = 0.26) and fistula (RR 0.90, 95%CI 0.22 to 3.75, p = 0.89) between the two techniques. Compared with manual pressure, FoE was associated with lower risk of access site complications (RR 0.37, 95%CI 0.24 to 0.58, 0.65, p < 0.0001) including bleeding (RR 0.30, 95%CI 0.18 to 0.50, p < 0.00001) and hematoma (RR 0.41, 95%CI 0.25 to 0.68, 0.83, p = 0.0005). Time to hemostasis was significantly lower in FoE group compared with manual pressure (MD - 21.04 min, 95%CI - 35.66 to - 6.42, p = 0.005).

CONCLUSIONS

The results of our meta-analysis showed that there was no difference in the risk of access site pseudoaneurysm and fistula between FoE and manual pressure. FoE was associated with lower risk of access site hematoma and bleeding compared with manual pressure. Our results reiterate the safety and feasibility of FoE suture for venous access closure.

Three-way stopcock suture technique for hemostasis after ablation for atrial fibrillation

BACKGROUND

Figure-of-eight sutures (F8S) have emerged as an alternative to the standard practice of manual compression to achieve venous hemostasis after catheter ablation for atrial fibrillation (AF). In lieu of a knot to secure the sutures in place, a three-way stopcock can be used, which can be loosened or tightened as needed to achieve hemostasis and is easier to remove. The safety and effectiveness of this technique, when compared to traditional F8S, are unknown. In this case series, we sought to describe this stopcock closure (SC) technique and compare procedural characteristics and outcomes to the traditional F8S.

METHODS

Charts of consecutive patients who underwent AF radiofrequency at two centers were reviewed for the type of hemostasis (SC or F8S), demographics, periprocedural anticoagulation, groin complications, and procedural duration.

RESULTS

A total of 100 patients were included (50 in the F8S group and 50 in the SC group). The two groups were similar in terms of mean age, gender, weight, renal function, oral anticoagulant use, and procedural heparin dosing. There was one groin bleeding complication in each group. The procedural time was shortened in the SC group (220 ± 8 minutes vs 313 ± 8 minutes), and there was more protamine use (25 vs 3 patients) owing to the differences in preferences among two operators.

CONCLUSION

In this proof-of-concept study, a simple stopcock device provided comparable hemostasis to standard F8S after radiofrequency catheter ablation of AF.