2025 HRS／ACC 科学声明： 心内导管消融术当日出院指导原则

ABSTRACT

Percutaneous catheter ablation in interventional cardiac electrophysiology has evolved over the past several decades. Technologic advances and evolving procedural strategies have improved procedural ef fi ciencies, increased success rates, and lowered complication rates. These advances have increased the ability to treat more patients successfully; however, limitations to access have grown. Access challenges (exacerbated during the COVID-19 public health emergency) and economic pressures have driven a shift in practice trends to reduce hospitalization duration and optimize resource utilization. A same-day discharge (SDD) strategy has increasingly been used to address these challenges. Incorporating a SDD strategy has recently been supported by global clinical studies (demonstrating proof of concept) and real-world evidence/United States Centers for Medicare & Medicaid Services claims data (characterizing a low incidence of complications and need for readmission/emergency department visits). This document analyzes available global clinical data and real-world evidence examining the impact of a cardiac ablation SDD strategy on patient safety, patient access, operational ef fi ciencies, and health care expenditures. Recommended best practices will also be characterized built on the foundation of a shared decision-making strategy that optimizes patient safety, comfort, and procedural outcomes. As clinical fl ow paradigms evolve with alternate sites of care (ie, ambulatory surgery centers), real-world registries to track outcomes should inform future decision-making.

KEYWORDS Ablation; Same-day discharge; Outpatient; Atrial fi brillation; Readmission; ASC (Heart Rhythm 2025; - :e1 – e10) © 2025 Heart Rhythm Society and American College of Cardiology. Published by Elsevier Inc on behalf of Heart Rhythm Society and American College of Cardiology. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

This paper was jointly developed by the Heart Rhythm Society and the American College of Cardiology and jointly published by Elsevier Inc. The articles are identical except for minor stylistic and spelling differences in keeping with each journal ’ s style. Either citation can be used when citing this article. Developed in partnership with and endorsed by the American College of Cardiology (ACC). For copies of this document, please contact the Elsevier Inc. Reprint Department ( reprints@ elsevier.com ).

https://doi.org/10.1016/j.hrthm.2025.02.029 1547-5271/\$-see front matter $\circledcirc$ 2025 Heart Rhythm Society and American College of Cardiology. Published by Elsevier Inc on behalf of Heart Rhythm Society and American College of Cardiology. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Heart Rhythm, Vol - , No - , - 2025

ABBREVIATIONS ACC $=$ American College of Cardiology; AF $=$ atrial fi brillation; ASC $=$ ambulatory surgery center; CHA DS -VASc $=$ congestive heart failure, hypertension, 2 2 age ${\geq}75$ (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 and sex category (female); CMS = Centers for Medicare & Medicaid Services; CPT $=$ Current Procedural Terminology; cryo $=$ cryoballoon; CV = cardiovascular; ED = emergency department; EF $=$ ejection fraction; EP $=$ electro

physiology; HRS = Heart Rhythm Society; LVEF $=$ left ventricular ejection fraction; $\mathsf{O N S}=$ overnight stay; OPPS = Hospital Outpatient Prospective Payment System; $\mathsf{P C I}=$ percutaneous coronary intervention; PVC $=$ premature ventricular complex; REAL-AF $=$ Real-world Experience of Catheter Ablation for the Treatment of Paroxysmal and Persistent Atrial Fibrillation; RF $=$ radiofrequency; SDD $=$ same-day discharge; SVT $=$ supraventricular tachycardia

TABLE OF CONTENTS

Introduction ....................................................................... e2 Preamble: An Evolving Global Landscape in Patient Access Impacting the Duration and Site of Clinical Work fl ows for Intracardiac Ablations ............................. e2 De fi nitions ...................................................................... e2 Worldwide Experience With SDD for Intracardiac Ablation Therapy: Global Clinical Studies, United States Claims Data, and Physician/Patient Surveys ................................. e3 Global Clinical Studies Examining SDD for Atrial Fibrillation Ablation Therapy: Demonstrating Proof of Concept ......................................................................... e3 Real-World Evidence From the United States CMS Claims Database: Low Incidence of Inpatient Readmission/ED Visits With Intracardiac Ablation Therapy .......................................................................... e4 Patient and Physician Surveys: Worldwide Experience of SDD for Intracardiac Ablation Therapy and Perceived Bene fi ts .......................................................................... e4

Guiding Clinical Principles for Implementation of a SDD Protocol for Intracardiac Ablations .................................... e5 Implementation of a SDD Strategy for Intracardiac Ablation Therapy to Expand Patient Access, Drive New Sites of Care, and Reduce Costs .................................................... e7 Performance of Intracardiac Ablations in ASCs: An Evolving Paradigm ............................................................................ e8 Ethical Considerations in Shared Decision-Making Between the Patient and Physician ................................... e8 Summary and the Path Forward ........................................ e8 References ......................................................................... e9 Appendix 1 Authors ’ disclosures of relationships with industry and other entities ................................................. e10 Appendix 2 Reviewers ’ disclosures of relationships with industry and other entities ................................................. e12

Introduction

Preamble: An Evolving Global Landscape in Patient Access Impacting the Duration and Site of Clinical Work fl ows for Intracardiac Ablations

Percutaneous intracardiac catheter ablation in interventional cardiac electrophysiology (EP) has evolved tremendously over the past 40 years. Novel technologies (eg, ultra-highresolution intracardiac mapping and imaging, evolving catheter designs and ablative energy sources) and improved procedural strategies have reduced procedure times, increased procedural success rates, and lowered complication rates. These transformative advances have driven the diagnosis and treatment of “ historically untreatable ” arrhythmias in a progressively larger pool of patients.

This expanded pool of ablation-eligible patients has posed challenges to global health care systems regarding patient access, hospital/facility resources, and associated clinical/operational work fl ows. This challenge will only grow as the global population ages with increasing comorbidities and related arrhythmias. More recently, during the COVID-19 public health emergency, patient access issues drove changes to patient care paradigms involving clinical work fl ow

strategies to support same-day discharges (SDDs) for intracardiac ablations worldwide. Ongoing economic pressures have necessitated a shift in practice trends to reduce hospital duration and increase resource ef fi ciency. This has also led to considering the expansion of the sites of care beyond traditional hospital settings to ambulatory surgery centers (ASCs).

In response to these growing trends, the Heart Rhythm Society (HRS) and the American College of Cardiology (ACC) sought to review data and characterize the quality of care with SDD for intracardiac ablation procedures. This document was commissioned to examine shifting global practice trends, review literature and data supporting reduced hospitalization duration, and provide additional considerations for SDD for intracardiac ablation procedures agnostic to the site of care. In this clinical context, this statement provides a perspective that empowers shared clinical decision-making tailored to the individual patient but does not prescribe the length of stay after intracardiac catheter ablation procedures.

De fi nitions

The majority of intracardiac catheter ablations are considered elective and will be the focus of this document. These

procedures are not classi fi ed based on the site where patient care is provided.

An elective procedure is de fi ned as a procedure that can be performed at any time or date as determined between the physician and the patient (ie, it can be booked in advance rather than required to be performed without delay). A SDD is de fi ned as a clinical circumstance when a patient presents on a particular calendar day, undergoes an elective EP study/ ablation, is monitored after the procedure, and is discharged home that same calendar day. An overnight stay (ONS) is de fi ned as a clinical circumstance when a patient presents on a particular calendar day, undergoes an elective EP study/ablation, is monitored after the procedure but stays past midnight, and is discharged home the next calendar day (possibly due to a procedure ending later in the day, lack of transportation, need for additional monitoring/treatsment, or lack of support at patient ’ s home). An outpatient procedure is de fi ned by the Centers for Medicare & Medicaid Services (CMS) as a reimbursement classi fi cation related to the status of a patient in the hospital for $^{<2}$ midnights.

Worldwide Experience With SDD for Intracardiac Ablation Therapy: Global Clinical Studies, United States Claims Data, and Physician/Patient Surveys

## Global Clinical Studies Examining SDD for Atrial Fibrillation Ablation Therapy: Demonstrating Proof of Concept

Evidence for SDD for intracardiac ablations is growing as the EP community expands patient access while assuring excellent clinical outcomes. With the signi fi cant increase in atrial fi brillation (AF) ablation procedures performed worldwide, there has recently been a focus on demonstrating the quality of care with SDD for this procedure.

In Canada, Deyell et al 1 conducted a study involving 2 tertiary centers where all AF ablations from 2010 to 2014 underwent attempted SDD after a 3- to 8-hour observation period. Out of 3054 cases, SDD was achieved in $79.2\%$ (ONS was based on the discretion of the treating team). Readmission at 30 days was $7.7\%$ post-SDD vs $10.2\%$ post-ONS without complications vs $19.5\%$ post-ONS with complications. Overall subacute complication rates from postdischarge to 30 days were $0.37\%$ in SDD vs $0.36\%$ in ONS without complications vs $2.5\%$ ONS with complications. In a small subgroup with emergency department (ED) data available, $19.3\%$ of SDD patients had ED visits within the initial 30 days. This early study showed the feasibility of SDD of AF ablations, although several limitations were noted regarding the patient population and variable work fl ows.

In the United Kingdom, Creta et al 2 reported retrospective outcomes from a single center from 2016 to 2019 involving 2628 patients. Of 727 patients who achieved SDD ( $79.2\%$ cryoballoon [cryo], $91.6\%$ under conscious sedation), $1.8\%$ had any complication and presentation to a hospital within 48 hours, and $0.7\%$ required $\geq\!1$ day of hospitalization. Overall, after SDD, $3.7\%$ had any complication or presented to a hospital within 30 days.

In 2 analyses from U.S. claims databases, Field et al 3 , 4 examined the Optum database for AF ablations in 2016 to 2020 (6600 cases; $25.2\%$ SDD, mean age 66.6 years): a propensity-score match analysis was done 1:3 SDD-ONS, with no signi fi cant difference in 30-day postprocedure complication rates $(4.7\%$ SDD vs $3.8\%$ ONS). The IBM MarketScan Commercial claims database showed similar results for this same period, 2016 to 2020 (9509 total AF ablation cases, age ${<\!65}$ years, $17\%$ SDD): propensity-score match analysis 1:3 SDD-ONS showed no signi fi cant difference in 30-day postprocedure complication rates $(2.7\%$ SDD vs $2.8\%$ ONS).

Several meta-analyses have been published examining SDD data. Rashedi et al 5 examined SDD studies after AF ablation in the Cochrane library from inception up to August 2021, identifying 12 studies reporting 18,065 ablations, of which $40.5\%$ were discharged on the same calendar day. The major complication rate was $1.1\%,$ , and the readmission rate from day of discharge to 1 to 4 months was $3.0\%$ in planned SDD. There was no signi fi cant difference in major complication rates between the planned SDD group and ONS group. Jafry et ${\mathsf{a l}}^{\circ}$ performed a meta-analysis of 10,102 patients in 8 observational studies and found no statistical difference between SDD and ONS in all studied outcomes, including postdischarge 30-day hospital visits, vascular/bleeding complications, stroke/transient ischemic attack/systemic embolism, and recurrent arrhythmias. Tang et al 7 performed a meta-analysis of 26,488 patients undergoing AF ablation from 14 observational studies, with 9766 SDD (pooled success rate in SDD was $83.2\%)$ ). Most studies were retrospective, so confounding factors may have in fl uenced the results. There was no signi fi cant difference in 30-day complication rates or 30-day readmission between SDD and ONS.

Sahashi et al 8 analyzed data from the National Readmission Database for 2016 to 2018, examining 30,776 patients after AF ablation with $1.42\%$ SDD. In a 1:3 propensity-matched analysis, 30-day readmission was numerically but not signi fi - cantly higher in SDD $(12.7\%)$ vs ONS $(9.7\%,$ , $P=.47)$ ). Overall health care cost was higher in ONS (\$25,237 SDD vs $\S30,749$ ONS, $P<.01$ ).

Recent studies in 2023 have examined the default strategy of SDD in smaller studies. Jimenez-Candil et al 9 reported 617 patients with AF ablation from 2019 to 2022 from a single center in Spain where a systematic SDD strategy was implemented. SDD was achieved in $95\% $ (with increasing proportions over time), with similar rates in radiofrequency (RF) vs cryo. The 10-day incidence of urgent/unplanned medical care occurred in $11.3\%$ after SDD; rehospitalization occurred in $1.7\%$ and was similar to those hospitalized. There was no difference between RF and cryo. The Cleveland Clinic reported a single-center series evaluating 2142 consecutive patients with AF ablation from 2020 to 2021, in which $19\%$ had SDD based on prespeci fi ed protocol. 10 Of interest, patients in the SDD group tended to be younger and were more likely to be male, white, with lower $\mathsf{C H A}_{2}\mathsf{D S}_{2}$ -VASc [congestive heart failure, hypertension, age ${\geq}75$ (doubled), diabetes, stroke (doubled), vascular disease, age 65 to 74 and sex category (female)] score and less likely to utilize

Table 1 CMS claims data for CY2022 \*

||| Resulted in inpatient admission |Resulted in|| |---|---|---|---|---| |CPT codet| Total procedures, n | inpatient admission within 1 Day, n (%) | inpatient admission within 30 days, n (%) | Emergency department| |||||visit within 1 day, n (%)| | PCI-DES, single vessel (C9600) |97.817|2150 (2.2%)|8905 (9.1%)|1419 (1.5%)| | PTCA, single vessel (92920)|9384|294 (3.1%)|1066 (11.4%)|189 (2.0%)| | PM insertion, dual leads (33208)|42,475|824 (1.9%)|3052 (7.2%)|936 (2.2%)| | PM gen change, dual (33228)|29.429|90 (0.3%)|1328 (4.5%)|119 (0.4%)| |ICD implant (33249)|20,117|255 (1.3%)|1580 (7.9%)|65 (0.3%)| |AV node ablation (93650)|8425|64 (0.8%)|831 (9.9%)|21 (0.2%)| |SVT ablation (93653)|22.489|208 (0.9%)|1064 (4.7%)|46 (0.2%)| |VT ablation (93654)|5792|74 (1.3%)|369 (6.4%)|6 (0.1%)| |Add-on SVT/VT ablation (93655)|34,011|380 (1.1%)|2331 (6.9%)|65 (0.2%)| |AF ablation (93656)|62,149|784 (1.3%)|4252 (6.8%)|82 (0.2%)| |Add-on AF ablation (93657)|24,670|322 (1.3%)|1968 (8.0%)||

AF 5 atrial fi brillation; AV $=$ atrioventricular; CMS 5 Centers for Medicare & Medicaid Services; CPT $=$ Current Procedural Terminology; CY 5 calendar year; DES 5 drug eluting stent; ICD 5 implantable cardioverter de fi brillator; PCI 5 percutaneous coronary intervention; PM 5 pacemaker; PTCA $=$ percutaneous transluminal coronary angioplasty; $\mathsf{S V T=}$ supraventricular tachycardia; VT 5 ventricular tachycardia. \*Data compiled from The Moran Group. † CPT codes are reported to third-party payors by physicians in the United States to describe the medical, surgical, and diagnostic procedures/services performed.

warfarin. After propensity-score matching, there was a lower rate of major complications and higher patient satisfaction scores in the SDD group. There was no difference in readmissions, ED visits, or adverse events; the authors noted that the majority of “ life-threatening ” complications occurred intraprocedurally or within 6 hours after procedure.

The REAL-AF (Real-world Experience of Catheter Ablation for the Treatment of Paroxysmal and Persistent Atrial Fibrillation) study was a prospective multicenter study using prespeci fi ed SDD protocol eligibility criteria (stable anticoagulation, no bleeding history, left ventricular ejection fraction [EF] ${>}40\%$ , no pulmonary disease, no procedures within 60 days, and body mass index ${<\!35\,\mathsf{k g}/\mathsf{m}^{2}})$ , in which operators prospectively determined whether patients undergoing AF ablation were candidates for SDD. 11 This study included 2332 patients with $85\%$ meeting SDD criteria and $86.1\%$ undergoing successful SDD. Within 30 days, SDD vs ONS groups had similar rates of complications $\left(0.8\%\right)$ vs $1.1\%)$ ) and readmissions $(0.8\%$ vs $0.9\%$ ). The EASY PVI randomized prospective trial of SDD was conducted at 3 U.S. centers in which 45 patients undergoing cryo AF ablation and meeting inclusion criteria (EF ${>}40,$ , creatinine clearance ${>}50$ , CHA 2 DS 2 -VASc ${\leq}3$ , <4 hours of general anesthesia time, no acute complications, and no early arrhythmia during 6-hour observation period) were randomized to SDD vs ONS. 12 There were no signi fi cant adverse events in either group, with 1 ED visit per group during the 30-day follow-up period.

Real-World Evidence From the United States CMS Claims Database: Low Incidence of Inpatient Readmission/ED Visits With Intracardiac Ablation Therapy

HRS/ACC obtained all CMS claims data from the calendar year 2021 to 2022 for cardiovascular (CV) procedures under the Hospital Outpatient Prospective Payment System (OPPS). More speci fi cally, we examined outcomes between intracardiac ablation and other CV procedures already

deemed appropriate for SDD based on inclusion in the ASC covered procedure list (ie, percutaneous coronary interventions [PCIs] and cardiac implantable electronic devices). OPPS data were analyzed using Current Procedural Terminology (CPT) codes to examine the number of procedures performed, 1- and 30-day inpatient readmission rates, and ED visits within 1 day of hospital discharge after the index procedure. Findings are summarized in Table 1 .

For interventional cardiac procedures already considered appropriate for ASC, the 30-day readmission rates were $7\%$ to $1\,\uparrow\,\%$ and ED visits within 1 day were $2\%$ to $3\%$ . In contrast, supraventricular tachycardia (SVT) ablations had rates of $5\%$ and $0.2\%,$ , respectively. When looking at the 62,149 procedures for AF ablation, the 30-day readmissions were $6.8\%$ and the ED visits within 1 day were $0.2\%$ . Of note, the 30- day readmission rate increased to $8\%$ when CPT code 93657 (additional ablation for AF) was billed as an add-on code. This suggests that additional ablation increases the risk for readmission.

Available CMS claims data strongly suggest that 1-day/30- day readmission and ED visit within 1-day rates for intracardiac ablations are lower vis- a-vis PCI and cardiac implantable electronic devices (the latter 2 procedures already with reimbursement coverage in CMS ’ ASC Covered Procedure List). However, the absence of data on patient comorbidities, clinical presentation, or facility characteristics limits data analysis. Moreover, it is plausible that the assessment of readmissions might have been underappreciated with the interpretation of limited available CMS claims data (ie, limited information regarding possible readmission diagnosis codes in instances where readmission was required).

Patient and Physician Surveys: Worldwide Experience of SDD for Intracardiac Ablation Therapy and Perceived Bene fi ts

In Germany, the FAST AFA study surveyed patients ’ willingness (between 2021 and 2022) to consider SDD after AF

 Survey of intracardiac ablations performed in a SDD and ASC setting. Responses regarding SDD_current (currently allowing SDD), ASC_current (currently doing in ASC), ASC_yes (believe could be safely performed in ASC), and ASC_no (should not be performed in ASC) are grouped by procedure. Total respondents for each question are in parentheses. AFib $=$ atrial fi brillation; A fl utter $=$ atrial fl utter; ASC $=$ ambulatory surgery center; ${\mathsf{C}}{\mathsf{M}}\;=\;$ cardiomyopathy; $|C D\rrangle=$ implantable cardioverter-de fi brillator; $\mathsf{L}=$ left; $\mathsf{L}\mathsf{V}=$ left ventricle; PM 5 pacemaker; PVC 5 premature ventricular contraction; ${\mathsf{R}}=$ right; SDD $=$ same-day discharge; SVT 5 supraventricular tachycardia; VT 5 ventricular tachycardia; w/o $=$ without. (Adapted with permission from Liu et al. 15 )

ablation. 13 Of 248 patients who completed the survey (mean age 61.8 years, $33.9\%$ female), $50\%$ expressed willingness to have SDD with perceived bene fi ts including increased comfort, shorter waiting times, and cost-ef fi ciency.

The European Heart Rhythm Association surveyed its physician members (245 respondents across 35 European hospitals) to examine the length of stay for elective EP procedures in 2023. 14 SDD after ablation was reported in $5.7\%$ of AF cases, $10.7\%$ of left-side ablation cases, and $17.5\%$ of right-side ablation cases. Of note, heterogeneous country-speci fi c reimbursement coverage policies within the EU might be 1 reason for the lower percentage of SDD. For example, a 2-midnight hospitalization requirement for coverage in speci fi c areas would theoretically exert downward pressures on SDD rates.

In 2023, HRS surveyed its physician members (705 respondents, $94\%$ based in the United States) regarding current practices of SDD in ASCs. 15 SDD was reported in $90\%$ of right-side SVT/ fl utter ablation cases, $80\%$ of right-side premature ventricular complex (PVC) ablation cases, $76\%$ of AF/ left-side SVT/ fl utter ablation cases, and $62\%$ of left-side PVC ablation cases ( Figure 1 ). Similar SDD rates were reported across all U.S. regions and operator experience levels. The survey also indicated a majority $(77\%–94\%)$ of practicing EPs believed right-sided SVT/ fl utter ablations were appropriate

for ASC, while nearly half $(45\%)$ indicated AF ablations could be safely performed in ASCs.

Guiding Clinical Principles for Implementation of a SDD Protocol for Intracardiac Ablations

Best practices for implementing a SDD protocol following catheter ablation procedures require careful consideration and scrutiny of baseline patient factors during preprocedural screening, procedural planning, and postprocedure management. The fi rst step in initial screening for patient eligibility for SDD is identifying the type of catheter ablation procedure. The majority of patients undergoing routine catheter ablation of cavotricuspid isthmus-dependent atrial fl utter, atrioventricular nodal reentrant tachycardia, accessory pathways, and focal atrial tachycardias have been candidates for SDD for many years. 16 In contrast, owing to the increased complexity of AF ablation procedures, patient selection for SDD following catheter ablation of AF requires heightened scrutiny with more speci fi c considerations. Data on patient selection for SDD following catheter ablation of ventricular arrhythmias are limited.

Eligibility criteria investigated in studies of prospective SDD patient screening protocols after AF ablation have included

Table 2 Proposed patient eligibility criteria for same-day discharge following catheter ablation of atrial fi brillation

|Patient criteria|Comments|| |---|---|---| | Absence of decompensated heart failure ||| | Absence of decompensated heart failure | Monitor volume status in patients with history of heart failure due to reduced or preserved left ventricular ejection fraction Caution in patients with asthma, || | Caution in patients with asthma, chronic obstructive pulmonary disease, interstitial lung disease, or obstructive sleep apnea Provide more monitoring in ||| | Caution in patients with asthma, chronic obstructive pulmonary disease, interstitial lung disease, or obstructive sleep apnea Provide more monitoring in ||| |||| |||| | Absence of unstable medical comorbidities likely to require acute management postprocedure | Provide more monitoring in patients with poorly controlled conditions such as diabetes mellitus, renal || | Absence of unstable medical comorbidities likely to require acute management postprocedure ||| | Absence of unstable medical comorbidities likely to require acute management postprocedure |disease, hypertension, etc.|| | Absence of significant bleeding diathesis || Strict attention to vital signs and hemostasis in patients with | | Absence of significant bleeding diathesis || significant bleeding history or disorders of coagulation | | Proximity of patient's home/ place of recovery to hospital || Caution in patients who live a substantial distance from the hospital | | Proximity of patient's home/ place of recovery to hospital ||| |Presence of social support| Includes designated family member or friend to provide || |Presence of social support|transport to and basic|| ||assistance at patient home||

stability of anticoagulation use, absence of bleeding history, absence of systolic heart failure with speci fi c left ventricular ejection fraction (LVEF) cut-offs, absence of pulmonary disease, body mass index ${\footnotesize<35~\mathrm{kg}/\mathrm{m}^{2},}$ , and proximity of patient residence to a hospital. 11 , 17 , 18 These studies demonstrated that $79\%$ to $85\%$ of patients who underwent screening for SDD met eligibility criteria. Of these preselected “ eligible ” patients, $86\%$ to $91\%$ were successfully discharged on the same day. Factors associated with unsuccessful SDD following AF ablation included older age, female sex, increased ${\mathsf{C H A}}_{2}{\mathsf{D S}}_{2}.$ - VASc and HAS-BLED (Hypertension, Abnormal Renal/Liver Function, Stroke, Bleeding History or Predisposition, Labile INR, Elderly, Drugs/Alcohol Concomitantly) scores, heart failure, decreased LVEF, increased left atrial size, and persistent AF. 11 Potential patient eligibility criteria for SDD following AF ablation are summarized in Table 2 .

Social support from a family member or friend is also a requisite consideration, irrespective of the type of cardiac catheter ablation procedure considered for SDD. Social support ensures an independent party is available for assistance with transportation and postprocedure care, surveillance for recovery and early detection of complications, and assistance with basic needs at the patient ’ s home (or any location of recovery, understanding this is not always “ home ” ). In the REAL-AF registry study, social issues accounted for $70\%$ of cases where patients who initially planned for SDD ultimately required an ONS. 11 These issues included patient preference, inadequate social support, and the distance from the patient ’ s home to the hospital. These data suggest that social and clinical factors are

equally signi fi cant considerations in determining the appropriateness of SDD following cardiac catheter ablations.

Procedure duration, complexity, and risk; type of anesthesia employed; time to recovery from anesthesia and ability to voluntarily void; best procedural safety practices; and vascular hemostasis strategy are all relevant procedural considerations with SDD for cardiac catheter ablation procedures. Depending on the availability of nurses and ancillary support staff to monitor and discharge patients, procedure termination after speci fi c times in the later hours of a calendar day may render patients ineligible for SDD. 18 The prolonged duration of catheter ablation procedures impacts patient recovery time (due to extended administration of anesthetic agents) and time to potential discharge from the facility. Conversely, administering short-acting anesthetic agents such as propofol and minimizing intravenous fl uids can facilitate rapid recovery after cardiac catheter ablation. 19 Optimal procedural safety practices, such as ultrasound guidance for vascular access, minimize vascular access complications that can impede safe SDD. 18 Moreover, adjunctive imaging with intracardiac echocardiography provides optimal visualization for transseptal access and catheter manipulation/ablation while providing real-time monitoring for the development of pericardial effusions. Finally, strategies for vascular hemostasis (including vascular closure devices or fi gure-of-eight sutures) can affect the required bed rest postprocedure duration. A validated standardized postprocedure protocol (for assessing adequate hemostasis and appropriateness for discharge) and a predetermined follow-up plan should be established before patient dismissal from the facility. Patients should understand how to access on-call clinicians after discharge if necessary and the instructions for possible emergencies.

Establishing standardized discharge criteria is paramount to safe SDD following intracardiac catheter ablation. A checklist for safe discharge should include the absence of procedural or postprocedural complications, vascular access bleeding, or hemodynamic instability. The checklist should also include successful ambulation, spontaneous micturition, tolerance of oral intake, and information regarding access to the on-call physician ( Table 3 ). 11 , 18 Before dismissal from the facility, the patient and accompanying family or support member should receive comprehensive discharge instructions regarding new medications and postprocedure care.

The use of a standardized SDD protocol that incorporates the triad of patient screening, procedural optimization, and a standardized discharge strategy has been shown in prospective studies to result in a high rate of successful SDD coupled with an acceptably low rate of readmissions $(1\%{-2\%}$ at 30 days). 11 , 18 Successful implementation of a SDD protocol requires extensive organization, close coordination of patient screening, enhanced communication with patients and caregivers, and ef fi cient handling of hospital logistics. As increasing clinical demands limit physician availability, some have proposed a model focused on nurse-led protocols (including but not limited to next-day telephonic follow-up) with oversight by a dedicated ambulatory cardiac nurse coordinator for the implementation of SDD protocols. 18

Table 3 Discharge criteria checklist for same-day discharge following catheter ablation

|Criteria|Comments|| |---|---|---| |Absence of procedural or| Consider predischarge limited bedside echocardiogram to || | postprocedural||| |complications| bedside echocardiogram to rule out presence of an effusion after complex procedures if intracardiac echocardiography was not || || echocardiography was not performed || |Hemodynamic stability| Ensure protocol designates|| || parameters for acceptable vital signs for discharge || |Vascular hemostasis||| || Ensure safe removal of figure- of-eight suture (if placed) || | Successful ambulation|Includes hemostasis, lack of || || concerning discomfort, and|| || gait stability|| |Tolerance of oral intake| Ensure good control of || |Spontaneous micturition| postanesthesia nausea|| || Consider patient, anesthesia|| ||and medication factors to|| ||determine need for|| ||indwelling urinary catheter|| | Confirmation of social support|placement preprocedure|| | Confirmation of social support| Designated person to assist with transportation and || | Confirmation of social support|Comprehensive discharge|assistance with recovery| ||Detailed instructions for|| |instructions provided to|monitoring for|| |patient and caregiver| postprocedure complications|| ||and use of new medications| (eg, colchicine, proton pump inhibitors, antiarrhythmic drugs if required) and contact | || drugs if required) and contact information to reach on-call || |||members of the procedure| ||care team with questions|| ||and/or concerns; follow-up|| ||visit arranged and|| || appropriate medications prescribed ||

Implementation of a SDD Strategy for Intracardiac Ablation Therapy to Expand Patient Access, Drive New Sites of Care, and Reduce Costs

Worldwide growing demand for intracardiac ablation procedures and device implantations notwithstanding, patient access has remained constrained. 20 Access to cardiac EP services has historically been limited to large, specialized centers or health care systems. In Canada, wait times of up to 211 days have been reported for EP procedures. 21 Anecdotal reports of similar challenges have increasingly emerged in the United States, particularly in rural areas limited to smaller critical access facilities. Signi fi cant gaps in arrhythmia care are also well known across Asia-Paci fi c, Middle East, Africa, and South America. This has exacerbated regional disparities in patient access. Loccoh et al 22 highlight disparities in outcomes among Medicare patients receiving treatment for CV and cerebrovascular conditions, with patients living in a rural

area experiencing increased morbidity attributed to limited access to care. Given the resource-intensive nature of cardiac arrhythmia services (identi fi cation of highly trained staff, high cost of capital equipment and EP technologies), cardiac EP programs have traditionally only existed in larger health care care systems. Costs have remained a signi fi cant barrier to smaller health care facilities.

Strategies to reduce health care facility costs and increase revenues by facilitating patient throughput could improve patient access. Implementation of a SDD strategy avoids routine overnight observation after elective procedures, resulting in operational ef fi ciencies at the hospital/facility level. SDD initiatives have demonstrated their integral role in ensuring patient access to cardiac EP procedures. During the COVID-19 public health emergency (when access to inpatient services was severely limited), many facilities worldwide demonstrated proof of this concept by modeling novel clinical work fl ows to preserve patient access. The SDD strategy became one of the primary mechanisms to ensure patient access to essential EP services.

In the United States, understanding the economics of SDD requires distinguishing between inpatient and outpatient status, as de fi ned in the 2-midnight rule set forth by CMS. 23 From the CMS perspective, both SDD and an ONS after an elective procedure (ie, 23-hour observation) are considered “ outpatient ” services. Hospitals receive the same reimbursement under the OPPS Ambulatory Payment Classi fi cation regardless of whether a patient is discharged on the same calendar day as an elective procedure or admitted for overnight observation and discharged the next calendar day. As such, the facility/hospital does not receive incremental reimbursement for the costs of ONS. The additional operating expenses incurred by ONS reduce the margin/pro fi t for the facility. A SDD strategy reduces operating expenses associated with ONS, representing signi fi cant cost-savings for the facility.

Modeling potential cost-savings for hospitals is complicated and subject to signi fi cant geographic variability in fair market value assessments. SDD after elective PCI has been performed for over a decade, and coverage for elective PCI in ASCs was approved by CMS in 2019. For elective PCI cases performed from 2009 to 2012, SDD was associated with reduced hospital operating expenses of $\S3502$ $\textlangle95\%$ con fi - dence interval $\mathbb{S}3486–\mathbb{S}3902)$ . 24 In a separate analysis of SDD after PCI for procedures performed from 2006 to 2015, SDD was associated with hospital savings of $\mathopen{}\mathclose\bgroup\left.>\Phi5000\aftergroup\egroup\right.$ per procedure, with the majority of the savings coming from 2 major drivers of hospital cost: (1) room and board and (2) central supply. 25

Data are also available on potential cost-savings associated with SDD for AF ablation. In a study examining national administrative data for AF ablations performed from 2016 to 2018, only $1.4\%$ of patients were discharged on the same day. In this highly selected population, SDD was associated with signi fi cantly lower hospital costs vs ONS $(\S25,\!237\ \pm$ $\mathbb{S}14{,}036$ vs $\S30,749\pm\S16,383,\,P\,{<}.01)$ , which represents an $\sim\!\Phi5000$ reduction in facility operating expenses per procedure. However, there was a nonsigni fi cant higher 30-day

readmission rate in the SDD group ( $12.7\%$ vs $9.7\%)$ ). 8 Other studies have not demonstrated a higher readmission rate associated with SDD for AF ablation. 1 Several other smaller, retrospective studies have also demonstrated cost-savings associated with SDD after AF ablation. However, many of these studies have performed limited analysis using average ONS hospitalization costs (as opposed to granular, patientlevel data on actual costs associated with the ONS). 26 – 28

Overall, these data suggest that the estimated costsavings associated with SDD appear similar for PCI and AF ablation $(\sim\!\Updownarrow5000$ per procedure). 8 , 25 Elective PCI provides a validated framework (for over a decade) when incorporating a SDD strategy for intracardiac catheter ablation procedures. With continued in fl ationary price pressures and increases in hospital operating expenses over the coming years, the potential savings accrued with a SDD strategy will become of greater importance in contemporary EP practice. 29

A SDD strategy can also reduce out-of-pocket costs to the patient. These estimates are more dif fi cult to model given the variabilityin different types of insurance coverage,deductibles, and limits on out-of-pocket costs. Medicare patients who are observed overnight after an elective procedure can incur significant out-of-pocket costs, the extent of which will differ between traditional Medicare and Medicare Advantage plans. For Medicare Part B (which covers outpatient hospital services), patients generally pay a copayment for hospital services, the magnitude of which varies based on the service provided. SDD can signi fi cantly reduce the burden of out-of-pocket copayments for outpatient services. 30 Importantly, out-ofpocket copayments for patients with Medicare Part B cannot exceed the deductible for inpatient service. However, total copayments for all outpatient services can exceed the inpatient deductible. As such, the patient cost might be impacted by additional outpatient services. Similar out-of-pocket cost considerations also apply to private insurance coverage, although the details can vary signi fi cantly based on the nature of the coverage plan. In addition to copayment considerations, SDD after AF ablation and other invasive CV procedures has also been associated with improved patient satisfaction and quality of life, which might be in fl uenced by avoiding the fi nancial stresses (and other encumbrances) associated with an ONS. 31

Performance of Intracardiac Ablations in ASCs: An Evolving Paradigm

Although the purpose of this paper is not to provide a priori justi fi cation for the performance of cardiac ablations in the ASC setting, the SDD principles discussed do have relevance to cardiac ablation procedures performed outside the hospital environment. As of calendar year 2024, cardiac catheter ablation procedures are being covered in the ASC setting by several private payors in the United States in de fi ned geographies. Worldwide experience-based data on catheter ablation procedures and from pandemic-era practices (including the Hospitals Without Walls Program during the COVID-19 public health emergency) have empirically suggested that select cardiac catheter ablations may be safely performed in

the ASC setting in appropriately selected patients as adjudicated by physician judgment (with case selection determined by physician factors, facility considerations, and patient social support factors/coexisting clinical conditions). 32 , 33 Moreover, analysis of both claims and clinical data (in the context of SDD) has suggested that cardiac catheter ablation procedures (often performed in the context of SDD) have lower complication rates vs other cardiac procedures already included in the CMS ASC covered procedure list (ie, PCI, cardiac implantable electronic device procedures).

As this landscape evolves (rife with economic incentives for multiple stakeholders), using real-world registries and quality measures to track outcomes in real time will be critical to inform future decision-making by authorities and assist with shared decision-making between the patient and physician. Importantly, available data for SDD have largely been examined in a hospital setting, but the safety of SDD outside a hospital environment needs further clari fi cation. To that end, widespread use of registries designed to evaluate care in the ASC environment will be important in transparently tracking real-world outcomes in real time.

To mitigate procedural complications in the ASC setting, preexisting operational clinical work fl ows must be validated and rigorously scrutinized to safeguard patient care. Moreover, the decision to commute patient status to medical observation or an inpatient admission might be more complex in an ASC environment (vs in a hospital environment). This required decision for patient transfer for an ONS to another facility might be obfuscated by patient expectations, transportation, and relationships with the inpatient facility. Before undertaking a SDD strategy outside a hospital environment, clinicians should establish well-considered ironclad plans for rescue for anticipatable failure modes/complications, preestablished memoranda of understanding, and transfer agreements with inpatient facilities.

Ethical Considerations in Shared Decision-Making Between the Patient and Physician

The patient ’ s best interests and preferences should always be of utmost importance to the operating physician and facility. Although SDD might economically bene fi t 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.

Summary and the Path Forward

An expanding pool of ablation-eligible patients has posed access challenges to global health care systems. Access challenges (exacerbated during the COVID-19 public health emergency) and economic pressures have driven a shift in practice trends to reduce hospitalization duration and optimize resource utilization. This has necessitated an evolution in clinical fl ow paradigms to include alternate sites of care (ie, ASCs and of fi ce-based laboratories). To that end, a SDD strategy

could result in signi fi cant operational ef fi ciencies at the hospital/facility level, improvement in patient access, improvement in the patient ’ s perceived bene fi t, and result in reduction in overall health care expenditures and resource utilization.

WhenconsideringaSDDstrategy,ashareddecision-making process between the patient and physician should occur (without in fl uence from fi nancial or other external pressures) focused on patient safety, comfort, and procedural outcomes. A SDD protocol should require careful consideration and scrutiny of baseline patient factors during preprocedural screening, procedural planning, and postprocedure management. Wellconsidered plans should be established for rescue for anticipatable failure modes/complications and transfer to inpatient facilities (when the procedure is performed in an ASC). Successful implementationofa SDDprotocolrequiresconsiderablefacility organization and logistics that intentionally support close coordination of care with patients and their caregivers. As such, social support is a requisite consideration irrespective of the type of cardiac catheter ablation procedure considered for SDD.

HRS and ACC support principles of evidence-based health care. Incorporating a SDD strategy has been supported by available global clinical studies (demonstrating proof of concept) and real-world evidence/U.S. CMS claims data (characterizing a low incidence of complications and need for readmission/ED visits). As clinical fl ow paradigms evolve with alternate sites of care (ie, ASCs), use of real-world registries and quality measures to track outcomes in real time will help inform future decision-making by global competent authorities and assist with shared decision-making between the patient and physician.

Relationships With Industry and Other Entities

Members of the writing group were asked to disclose fi nancial relationships from the 12 months prior to their nomination. Author disclosures are included in Appendix 1 . The HRS and ACC have rigorous policies and methods to ensure that documents are developed without bias or improper in fl uence. The complete policies on relationships with industry and other entities (RWI) can be found online. The work of the writing committee was supported exclusively by HRS and ACC without commercial support. Writing group members contributed as volunteers and did not receive any payment from HRS or ACC. This document re fl ects primarily expert consensus opinion. The draft manuscript was peer reviewed in September 2024 and the document was revised to address pertinent comments. Reviewer disclosures are included in Appendix 2 . The writing group unanimously approved the fi nal version of the document.

Address reprint requests and correspondence: Dr. Amit J. Shanker, 50 Leroy Street, Potsdam, New York 13676. E-mail address: shankeraep@yahoo.com

2. Creta A, Ventrella N, Provid encia R, et al. Same-day discharge following catheter ablation of atrial fi brillation: a safe and cost-effective approach. J Cardiovasc Electrophysiol 2020;31:3097 – 3103. https://doi.org/10.1111/jce.14789 . 3. Field ME, Goldstein L, Corriveau K, Khanna R, Fan X, Gold MR. Same-day discharge after catheter ablation in patients with atrial fi brillation in a large nationwide administrative claims database. J Cardiovasc Electrophysiol 2021; 32:2432 – 2440. https://doi.org/10.1111/jce.15193 . 4. Field ME, Goldstein L, Corriveau K, Khanna R, Fan X, Gold MR. Evaluating outcomes of same-day discharge after catheter ablation for atrial fi brillation in a realworld cohort. Heart Rhythm O2 2021;2:333 – 340. https://doi.org/10.1016/ j.hroo.2021.07.001 . 5. Rashedi S, Tavolinejad H, Kazemian S, et al. Ef fi cacy and safety of same-day discharge after atrial fi brillation ablation: a systematic review and meta-analysis. Clin Cardiol 2022;45:162 – 172. https://doi.org/10.1002/clc.23778 . 6. Jafry AH, Akhtar KH, Khan JA, et al. Safety and feasibility of same-day discharge for catheter ablation of atrial fi brillation: a systematic review and meta-analysis. J Interv Card Electrophysiol 2022;65:803 – 811. https://doi.org/10.1007/s10840-022-01145-9 . 7. Tang PT, Davies M, Bashir Y, et al. Ef fi cacy and safety of same-day discharge after atrial fi brillation ablation compared with post-procedural overnight stay: a systematic review and meta-analysis. Europace 2022;24:1569 – 1584. https://doi.org/10.1093/europace/euac068 . 8. Sahashi Y, Kuno T, Tanaka Y, Passman R, Briasoulis A, Malik AH. The 30-day readmission rate of same-day discharge protocol following catheter ablation for atrial fi brillation: a propensity score-matched analysis from National Readmission Database. Europace 2022;24:755 – 761. https://doi.org/10.1093/europace/euab296 . 9. Jimenez-Candil J, Hernandez JH, Galban AC, et al. Clinical and economic outcomes of a systematic same-day discharge programme after pulmonary vein isolation: comparison between cryoballoon vs. radiofrequency ablation. Europace 2023;25:euad265 https://doi.org/10.1093/europace/euad265 . 10. Aguilera J, Hutt E, Madden R, et al. Same-day discharge after atrial fi brillation ablation. Heliyon 2023;9:e22178. https://doi.org/10.1016/j.heliyon.2023.e22178 . 11. Rajendra A, Osorio J, Diaz JC, et al. Performance of the REAL-AF same-day discharge protocol in patients undergoing catheter ablation of atrial fi brillation. JACC Clin Electrophysiol 2023;9(8 Pt 2):1515 – 1526. https://doi.org/10.1016/j.jacep.2023.04.014 . 12. Sangrigoli R, Harding J, Venkataraman G, Tomaiko-Clark E, Bai R, Su W. Randomized prospective evaluation of same-day discharge after cryoballoon ablation of atrial fi brillation: results of the EASY PVI study. J Interv Card Electrophysiol 2023;66:1601 – 1607. https://doi.org/10.1007/s10840-022-01465-w . 13. K onig S, Wolhrab L, Leiner J, et al. Patient perspectives on same-day discharge following catheter ablation for atrial fi brillation: results from a patient survey as part of the monocentric FAST AFA trial. Europace 2023;25:euad262 https://doi.org/10.1093/europace/euad262 . 14. Boriani G, Imberti JF, Leyva F, et al. Length of hospital stay for elective electrophysiological procedures: a survey from the European Heart Rhythm Association. Europace 2023;25:euad297 https://doi.org/10.1093/europace/euad297 . 15. Liu CF, Hurwitz JL, Krahn AD, et al. Heart Rhythm Society ’ s survey assessing sameday discharge after electrophysiology procedures and implementation in ambulatory surgical centers. Heart Rhythm 2024;21:1746 – 1748. https://doi.org/10. 1016/j.hrthm.2024.03.1812 . 16. Marijon E, Albenque JP, Boveda S, et al; RETAC Group. Feasibility and safety of same-day home discharge after radiofrequency catheter ablation. Am J Cardiol 2009;104:254 – 258. https://doi.org/10.1016/j.amjcard.2009.03.024 . 17. Rajendra A, Hunter TD, Morales G, Osorio J. Prospective implementation of a sameday discharge protocol for catheter ablation of paroxysmal atrial fi brillation. J Interv Card Electrophysiol 2021;62:419 – 425. https://doi.org/10.1007/s10840-020- 00914-8 . 18. Espinosa T, Farrus A, Venturas M, et al. Same-day discharge after atrial fi brillation ablation under a nurse-coordinated standardized protocol. Europace 2024; 26:euae083 https://doi.org/10.1093/europace/euae083 . 19. Osorio J, Rajendra A, Varley A, et al. General anesthesia during atrial fi brillation ablation: standardized protocol and experience. Pacing Clin Electrophysiol 2020;43:602 – 608. https://doi.org/10.1111/pace.13928 . 20. Scott M, Baykaner T, Bunch TJ, et al. Contemporary trends in cardiac electrophysiology procedures in the United States, and impact of a global pandemic. Heart Rhythm O2 2023;4:193 – 199. https://doi.org/10.1016/j.hroo.2022.12.005 . 21. Qeska D, Singh S, Qiu F, et al. Variation and clinical consequences of wait-times for atrial fi brillation ablation: population level study in Ontario, Canada. Europace 2023;25:euad074 https://doi.org/10.1093/europace/euad074 . 22. Loccoh E, Joynt Maddox KE, Wang Y, Kazi DS, Yeh RW, Wadhera RK. Rural-urban disparities in outcomes of myocardial infarction, heart failure, and stroke in the United States. J Am Coll Cardiol 2022;79:267 – 279. https://doi.org/10.1016/j.- jacc.2021.10.045 . 23. Sheehy AM, Caponi B, Gangireddy S, et al. Observation and inpatient status: clinical impact of the 2-midnight rule. J Hosp Med 2014;9:203 – 209. https://doi.org/10.1002/jhm.2163 . 24. Amin AP, Patterson M, House JA, et al. Costs associated with access site and same-day discharge among Medicare bene fi ciaries undergoing percutaneous coronary intervention: an evaluation of the current percutaneous coronary intervention care pathways in the United States. JACC Cardiovasc Interv 2017; 10:342 – 351. https://doi.org/10.1016/j.jcin.2016.11.049 . 25. Amin AP, Pinto D, House JA, et al. Association of same-day discharge after elective percutaneous coronary intervention in the United States with costs and outcomes. JAMA Cardiol 2018;3:1041 – 1049. https://doi.org/10.1001/jama cardio.2018.3029 . 26. He H, Datla S, Weight N, et al. Safety and cost-effectiveness of same-day complex left atrial ablation. Int J Cardiol 2021;322:170 – 174. https://doi.org/10.1016/j.ijcard.2020.09.066 . 27. Kowalski M, Parikh V, Salcido JR, et al. Same-day discharge after cryoballoon ablation of atrial fi brillation: a multicenter experience. J Cardiovasc Electrophysiol 2021;32:183 – 190. https://doi.org/10.1111/jce.14843 . 28. Opel A, Mansell J, Butler A, et al. Comparison of a high throughput day case atrial fi brillation ablation service in a local hospital with standard regional tertiary cardiac centre care. Europace 2019;21:440 – 444. https://doi.org/10.1093/europace/euy153 . 29. KFF. Hospital adjusted expenses per inpatient day by ownership. 2022. https:// www.kff.org/health-costs/state-indicator/expenses-per-inpatient-day-by-ownership/ ?currentTimeframe 5 0&sortModel 5 %7B%22colId%22:%22Location%22,%22sort% 22:%22asc%22%7D . Accessed March 15, 2024. 30. Sobal L, Knight N. You are leaving money on the table by admitting low-risk PCIs. Cath Lab Digest 2017;25(10), https://www.hmpgloballearningnetwork.com/site/ cathlab/article/you-are-leaving-money-table-admitting-low-risk-pcis-1 . Accessed February 2, 2025. 31. Krishnaswamy A, Isogai T, Brilakis ES, et al. Same-day discharge after elective percutaneous transcatheter cardiovascular interventions. JACC Cardiovasc Interv 2023;16:1561 – 1578. https://doi.org/10.1016/j.jcin.2023.05.015 . 32. Heart Rhythm Society. HRS position on ablations in ambulatory surgical centers, https://www.hrsonline.org/guidance/advocacy-in-action/hrs-position-ablationsambulatory-centers . Accessed February 2, 2025. 33. Center for Medicare & Medicaid Services. CMS announces comprehensive strategy to enhance hospital capacity amid COVID-19 Surge. November 25, 2020. https:// www.cms.gov/newsroom/press-releases/cms-announces-comprehensive-strategyenhance-hospital-capacity-amid-covid-19-surge . Accessed February 2, 2025.

Shanker et al

Principles on Same-Day Discharge for Catheter Ablations

e11

’

Employment

St. Lawrence Health

Potsdam, NY

Amit J. Shanker, MD, FACC, FHRS (Co

System

Chattanooga Heart

Chair)

Chattanooga, TN

Samuel O. Jones MD,

MPH, FACC, FHRS

Institute

University of New

FHRS

(Co-Chair)

Ijeoma A. Ekeruo, MD,

MD, MACC,

Mexico Health

James C. Blankenship,

Sciences Center Albuquerque, NM

MHCM, MSCAI

Jim W. Cheung, MD,

Weill Cornell

FACC, FHRS

Medicine Center

New York, NY

Arrhythmia Care

Center

FACC, FHRS

Houston, TX

North Texas Heart

Jodie L. Hurwitz, MD,

Center

Dallas, TX

Christopher F. Liu,

College

MD, FACC, FHRS

Weill Cornell Medical

New York NY Emory Healthcare Atlanta, GA

Faisal M. Merchant, MD, FACC, FHRS

Wilber W. Su, MD, FACC, FHRS

Banner Health

Phoenix, AZ

Appendix 1

Authors

Paul D. Varosy, MD,

Denver, CO

UC Health

FACC, FHRS

Author

\$10,000; 2: >\$10,000 to

Number value: 0: \$0; 1:

'

5

NCDR

National Cardiovascular Data Registry.

|Author| Employment | Honoraria/ speaking/consulting | Speakers' bureau | Research*| Fellowship support* | Ownership/ partnership/ principal/ majority stockholder | Stock or stock options | Intellectual property/ royalties |Other| |---|---|---|---|---|---|---|---|---|---| | Amit J. Shanker, MD,| St. Lawrence Health System |None|None|None|None|None|None||| | FACC, FHRS (Co- Chair | System Potsdam, NY |||||||None|None| | Samuel O. Jones MD, MPH, FACC, FHRSMPH, FACC, FHRS (Co-Chair) | Chattanooga Heart Institute Chattanooga, TN |None|None|None|None|None|None|None|None| | James C. Blankenship, MD,mACC, MHCm, mSCAI | University of New Mexico Health Sciences Center |None|None| Zoll Medical AMIHOT III Trial |None|None|None|None|None| | Jim W. Cheung, MD, FACC,FHRS | Weill Corneli Medicine Center New York, NY | 2:Abbott 2:Boston Scientific 1: Biosense 2: Medtronic |None| 1:Boston Scientific | 3:Abbott 3:Boston Scientific 3:Biosense 3:Biotronik 3:Medtronic |None|None| None |None| | ljeoma A. Ekeruo, MD, FACC, FHRS | Arrhythmia Care Center Houston, TX | 1: Medtronic O:Sanofi |None|None|None|None|None|None|None| | Jodie L. Hurwitz, MD, FHRS | North Texas Heart Center | 1: Medtronic|None|None|None|None|None|None|None| | Christopher F. Liu, MD, FACC, FHRS | Weill Cornell Medical CollegeCollege New York NY |None|None|None|None|None|None|None|None| | Faisal M. Merchant, MD, FACC, FHRS | Emory Healthcare Atlanta, GA |None|None|None|None|None|None|None| 0: American College of Cardiology | |Wilber W. Su, MD,|||| 4:Boston Scientific 4:Abbott 3: Synaptic ||None|None|None|| |FACC, FHRS| Banner Health Phoenix, AZ | 3: Boston Scientific 1: Medtronic |None|| 3: Medtronic 3:Boston 3: Scientific 3:Abbott ||||None| | Paul D. Varosy, MD, FACC, FHRS | UC Health Denver, CO |None|None|4:NIH|None|None| 2: Heart Rhythm Clinical Research Solutions/3PH Alliance |None| 0: American College of Cardiology | ||||||||||| ||||||||||1:NCDR|

Honoraria/ ${\leq}\mathbb{1}_{0,000,\alpha}$ $2\colon\ast\S10,000 $ $\leq\S25,000;$ 2: Boston $\3\colon\mathopen>\mathparagraph25,000$ 1: Biosense 2: Medtronic 1: Medtronic $\leq\!\Phi50{,}000$ 1: Medtronic $4\colon\ast\ast50{,}000 $ ${\leq}\mathbb{S}100{,}000{;}$ $5\colon\mathopen>\Phi\mathclose\bgroup\left100,000$ 1: Medtronic \$25,000; 3: >\$25,000 to None None None 2: Abbott 0: Sano None None None $=$

'

e12

Heart Rhythm, Vol - , No - , - 2025

’

Appendix 2

Reviewers

Employment

Author

Virginia Commonwealth University Medical

Kenneth A. Ellenbogen, MD, FACC, FHRS

Center

Richmond, VA

Kansas City Heart Rhythm

Dhanunjaya R. Lakkireddy,

Kansas City, MI

Institute

MD, FACC, FHRS

University of Virginia Health

1: American College of Cardiology

Pamela K. Mason, MD,

FACC, FHRS

System

Charlottesville, VA NYU Langone Health

|Author| Employment | Honoraria/ speaking/consulting | Speakers' bureau || Fellowship support* | partnership/ principal/ majority stockholder | Stock or stock options | Intellectual property/royalties || |---|---|---|---|---|---|---|---|---|---| ||| 1: Heart Rhythm Society 1:American ||Research*|||||Other| | Kenneth A. Ellenbogen, MD, FACC, FHRS | Virginia Commonwealth University Medical Richmond, VA | 1:American College of |None|None|None|None|None| 1: Wiley-Blackwell 1: Elsevier |None| | Dhanunjaya R. Lakkireddy, MD, FACC, FHRS || 2:Abbott 1:AtriCure | 1: Biosense Webster |None|||||| || Institute Kansas City, MI | 1:AtriCure 1: Medtronic |None||None|None|None|None|None| | Pamela K. Mason, MD, FACC,FHRS Sunil V. Rao, MD, FACC, FSCAI | Kansas City, MI University of Virginia Health SystemSystem Charlottesville, VA |None||None|None|None|None|None|None| | Emily P. Zeitler, MD, FACC| NYU Langone Health System New York, NY |None|None| 5: National Heart, Lung, and Blood Institute 4: American College |None|None|None|None|none| || Dartmouth Hitchcock Medical Center Lebanon, NH | 1:Boston Scientific 1: Biosense Webster 1: Medtronic |None| 5: NIH/NIGMS P20GM148278 |None|None|None|None|None| ||||| O: Biosense Webster O:Sanofi ||||||

5: NIH/NIGMS fi \$100,000; 5: >\$100,000. regardless of relevance to the document topic HRS Code of Ethics and Professionalism ${\leq}\mathbb{1}_{0,000} $ $:>\!\S10,000 $ $\leq\!\Phi25,\!000;$ $\3\colon\mathopen>\Phi25,000 $ $\leq\!\Phi50{,}000$ 0: Sano $\substack{>\nparallel\nparallel_{0},000} $ ${\leq}\Phi100{,}000,$ None None None

Sunil V. Rao, MD, FACC,

FSCAI

System

New York, NY

Emily P. Zeitler, MD, FACC

Dartmouth Hitchcock

Medical Center Lebanon, NH

Number value: 0: \$0; 1:

\$10,000; 2: >\$10,000 to

' This table is a comprehensive list of the relationships with industry and other entities (RWI)

does not necessarily re

fl

the disclosure of relationships with industry and other entities.

ect the RWI of the authors at the time of publication. Please refer to the

disclosures of relationships with industry and other entities

’

Speakers bureau

None

Webster

None

None

None

'

Honoraria/ speaking/consulting

\$50,000; 4: >\$50,000 to —

1: Heart Rhythm

Society

1: AtriCure 1: Medtronic

2: Abbott

None

None

1: Abbott

fi

1: Boston

c

Scienti

fi

1: Biosense

Webster

1: Sano

'

1: Medtronic

\$25,000; 3: >\$25,000 to '