Safety and feasibility of same-day discharge following catheter ablation of atrial fibrillation: what is known and what needs to be explored?

Catheter ablation of atrial fibrillation (AF) is the most effective rhythm control strategy and its role in the treatment of AF patients has been strengthened by recent guidelines. An increasing AF prevalence and the resulting demands on interventional electrophysiology call for improved resource allocation through both technical innovations and streamlined workflows and patient pathways. Same-day discharge is already established in the context of other electrophysiological interventions; however, its broad implementation in the practice of AF ablation is pending for several reasons, despite the fact that the body of evidence is growing and the majority of reports propagate early discharge to be feasible and safe under certain conditions. This review article is intended to provide an overview of the existing data, classify these into the specific study context, and to show limitations and open questions.

Feasibility and safety of same-day discharge after percutaneous coronary intervention: a tertiary care center experience

The exponential increase in percutaneous coronary intervention (PCI) and increasing use of the transradial approach has set an ideal scenario for the cost-effective and relatively safe same-day discharge (SDD) policy in various institutes. We hereby report a single-center, prospective, observational study of 628 consecutive PCI patients, who had SDD or had overnight observation followed by next day discharge (NDD). Patients of chronic stable angina (CSA), unstable angina, and acute myocardial infarction (MI) were enrolled in the study. The baseline characteristics, safety, feasibility and 6 weeks of clinical outcomes were assessed in the two groups. Out of the 628 patients, 187 (30%) had SDD, and 358 (57%) had NDD. Transradial access was significantly more in SDD compared to NDD (P<0.001). The syntax score was significantly higher in NDD compared to the SDD (P<0.001). Five patients of NDD had clinical events at 6 weeks of follow-up, while none of SDD had any events. Patients with unstable angina (P = 0.024), MI (P≤0.001), prior PCI (P = 0.037), femoral access (P = 0.012), and high syntax score (P = 0.001) were more frequently discharged on next day. Factors such as CSA (P = 0.991), type of lesion (P = 0.984) and left ventricle ejection fraction (P = 0.535) were not the limiting factors for SDD. The present study demonstrated that SDD is safe and feasible in CSA patients, and a careful pre- and post-procedural risk assessment could enable SDD even in the complex cases.

Increased efficiency of endocrine procedures performed in an ambulatory operating room

BACKGROUND

Thyroid and parathyroid procedures historically have been viewed as inpatient procedures. Because of the advancements in surgical techniques, these procedures were transferred from the inpatient operating room (OR) to the outpatient OR at a single academic institution approximately 7 y ago. The goal of this study was to determine whether this change has decreased turnover times and maximized OR utilization.

METHODS

We performed a retrospective review of 707 patients undergoing thyroid (34%) and parathyroid (66%) procedures by a single surgeon at our academic institution between 2005 and 2008. Inpatient and outpatient groups were compared using Student t-test, chi-square test, or the Kruskal-Wallis test where appropriate. Multiple regression analysis was used to determine how patient and hospital factors influenced turnover times.

RESULTS

Turnover times were significantly lower in the outpatient OR (mean 18 ± 0.7 min) when compared with the inpatient OR (mean 36 ± 1.4 min) (P < 0.001). When compared by type of procedure, all turnover times remained significantly lower in the outpatient OR. Patients in both ORs were similar in age, gender, and comorbidities. However, inpatients had a higher mean American Society of Anesthesiologists score (2.30 versus 2.13, P < 0.001) and were more likely to have an operative indication of cancer (23.1% versus 9.2%, P < 0.001). Using multiple regression, the inpatient OR remained highly significantly associated with higher turnover times when controlling for these small differences (P < 0.001).

CONCLUSIONS

Endocrine procedures performed in the outpatient OR have significantly faster turnover times leading to cost savings and greater OR utilization for hospitals.