JACC: One in 10 readmitted after AF ablation
“AF is the most common clinically significant arrhythmia and is associated with increased morbidity and mortality,” according to background information from the article. “Radiofrequency or cryotherapy ablation of AF is a relatively new treatment option, and data on post procedural outcomes in large general populations are limited.”
To understand the rates and reasons for 30-day readmissions post-AF ablation, Rashmee U. Shah, MD, MS, of the Stanford University School of Medicine in Stanford, Calif., and colleagues used the California State Inpatient Database to identify 4,156 patients who underwent an AF ablation between 2005 and 2008.
Of these 4,156 patients, 5.1 percent had periprocedural complications and 9.4 percent were readmitted within 30 days. It has been previously reported that procedural complications affect between 1 and 8 percent of patients at academic hospitals and 7 to 10 percent of Medicare patients.
Patients included in the study had a mean age of 61.7 years, 50.3 percent had hypertension and 14.7 percent had coronary artery disease.
During the study period, one person died. Length of stay was 1.46 days for patients who did not experience complications and 3.42 days for those who did experience a complication post-procedure. Of those who were readmitted, atrial flutter accounted for 26.9 percent of readmissions and procedural complications accounted for 19.5 percent of these readmissions.
The authors found age, sex, primary payor, heart failure, hypertension, chronic renal disease, lung disease, number of AF hospitalizations and procedural volume quartiles to be predictors of inpatient complications and/or 30-day rehospitalizations. Additionally, operator volume was an indicator of procedural complications. The authors found the mean volume of AF ablation per hospital to be 15.4 per year.
The researchers also conducted a long-term follow-up. During this analysis, 1,816 patients were readmitted post-AF ablation for any reason. At one year, 61.5 percent of patients were free of hospital readmission and 1,022 patients were readmitted to the hospital for an arrhythmia recurrence or repeat ablation.
Shah and colleagues reported that recurrent arrhythmias or repeat ablation affected 22 percent of patients in the first year and 30 percent of patients at two years. Previous studies have shown that AF recurrence occurs in 13 percent to 44 percent of AF ablation patients. During the current study, the researchers found that one in 20 patients experienced a periprocedural complication and one in 10 was readmitted within 30 days of a AF ablation.
“[T]hese recurrences were often severe enough to result in costly hospitalizations,” the researchers wrote. “We found that that recent procedural experience with AF ablation was inversely related to complication rates, which was consistent with the general observation that higher hospital volume has been associated with better outcomes for various procedures and medical conditions.
“Future investigations should be directed at identifying ways to decrease procedural complication rates, arrhythmia recurrence and readmissions,” Shah and colleagues concluded.
In an accompanying editorial, David E. Haines, MD, of the Oakland University William Beaumont School of Medicine in Royal Oak, Mich., wrote, “The present study raises many familiar concerns for the field of catheter ablation of AF.”
Haines said that the real-world success rate of catheter ablation is “unknown.” However, he said that the rate of this procedure is probably lower than what has been reported in previous studies. Additionally, Haines wrote, “Data from many investigations in AF ablation as well as different disciplines within cardiovascular medicine have repeatedly demonstrated that operator and hospital procedure volume are inversely correlated with poor outcomes.”
Dubbing it “problematic,” Haines said that these complex procedures are performed at low-volume centers and offered that “as long as a hospital is able to profit from supporting interventional procedures by its physicians, there will be a tendency to set a low bar for granting privileges to any doctor who claims proficiency.”
He added, “Although no honest healthcare provider would ever consciously place a patient needlessly in harm’s way, there are strong forces (economic, reputational, convenience) that prevent subspecialists from referring patients to other subspecialists within the same field.”
Haines urged that centers performing these types of procedures establish an AF ablation program to reinstate quality and improve outcomes.