A day off to admIRE: same-day discharge after pulsed field ablation with a Variable-loop circular catheter

This editorial refers to ‘Procedural characteristics and clinical outcomes from same-day discharge after pulsed field ablation treatment for atrial fibrillation: an admIRE trial sub-analysis’, by L. Di Biase et al., https://doi.org/10.1093/europace/euaf270. The journey of catheter ablation for atrial fibrillation (AF) from a specialized procedure to a mainstream therapeutic strategy has reshaped rhythm control management across the globe.1 Yet, the increasing global demand for ablation is now exerting pressure on healthcare systems already constrained by limited procedural capacity, hospital bed availability, and reimbursement structures that differ widely across regions.2 In this context, same-day discharge (SDD) following AF ablation has gained momentum as a pragmatic solution—aiming to optimize resource utilization while maintaining procedural safety and patient satisfaction.2 Historically, the practice of overnight observation after ablation was grounded in the need to monitor early complications, mainly pericardial effusion/injury and post-procedural arrhythmias. With advances in procedural techniques, several studies have challenged the necessity of routine hospitalization.3–5 The recent expansion of pulsed field ablation (PFA)—a nonthermal energy source offering tissue-selective electroporation6—further strengthens the rationale for SDD by reducing the incidence of thermal injury to pulmonary veins and adjacent structures such as the oesophagus and phrenic nerve. In this issue of Europace, the sub-analysis of the admIRE trial provides important insights into the safety and feasibility of SDD following PFA using a variable-loop circular catheter.7 Among 277 participants, 43% were discharged on the same day. Compared with patients who stayed overnight (ONS), those undergoing SDD had shorter fluoroscopy times (4.0 vs. 8.9 min), higher first-pass isolation rates (97.5% vs. 82.9%), and fewer procedural adverse events (1.7% vs. 3.8%). Importantly, freedom from primary effectiveness failure at one year was equivalent (75.4% vs. 74.0%), and serious adverse event (SAE) rates were low (2.4% in the same-day discharge group vs. 1.3% in the overnight-stay group) and comparable between groups. These findings, derived from a multicenter, prospective trial, strongly support that PFA-SDD is both feasible and safe in a structured clinical environment. Di Biase et al. should be commended for this important contribution—the first prospective U.S. Food and Drug Administration (FDA) investigational device exemption trial to assess same-day discharge after PFA for atrial fibrillation—whose regulatory rigour minimizes potential underreporting bias. The procedural profile of PFA naturally aligns with the SDD paradigm. Shorter left atrial dwell times, minimal or no need for energy titration, and a low rate of post-procedure pericardial effusion collectively enable earlier mobilization and discharge. Moreover, as the admIRE investigators note, a substantial proportion of SDD cases were performed during morning sessions, reflecting pragmatic workflow integration rather than selective bias towards lower-risk patients. The admIRE findings are consistent with prior data from non-PFA series. In a landmark multicentre study, Deyell et al.3 analysed over 3000 ablations—primarily radiofrequency (RF)—and reported that SDD was applied in 79% of cases, with no increase in 30-day readmission (7.7% vs. 10.2%) or complication rates (0.37%) compared with overnight stay. Similarly, Jiménez-Candil et al.4 reported on a systematic SDD programme across cryoballoon and RF ablation in over 600 consecutive procedures, achieving 95% feasibility and only 1.7% re-hospitalizations, while reducing procedural costs by 63%. In a large multicentre UK experience, Honarbakhsh et al. confirmed the safety of same-day discharge in over 1600 cryoballoon ablations, with <1% complication rate and 97% same-day completion.5 At the aggregate level, Tang et al.’s meta-analysis of 26 488 patients (across 14 studies) found no significant difference in 30-day complications (OR 0.95, 95% CI 0.65–1.40) or readmissions between SDD and ONS.8 The more recent EHRA Health Economics Committee meta-analysis2 reinforced these results, by considering 154 716 patients and reporting pooled short-term complication rates of 2% and 30-day unplanned medical contact at 4%, with near zero mortality. Together, these data consolidate the concept that SDD can be safely implemented for most ablation modalities—provided appropriate patient selection and post-discharge support are ensured. Critics of SDD often cite concerns regarding early complications manifesting after discharge. The Sahashi et al.9 analysis from the US Nationwide Readmission Database found no significant increase in 30-day readmission (12.7% vs. 9.7%; HR 1.17; P = 0.47) after SDD compared with overnight stay. Predictors of readmission were largely patient-related (age, comorbidities, heart failure) rather than procedure-reòated. However, when procedure-related causes were identified, the most frequent were recurrent atrial arrhythmias (≈40%), heart failure exacerbation, and pericardial or vascular complications. These findings, consistent across modalities, underscore that appropriate case selection—not the discharge timing itself—is a crucial determinant of the safety of SDD. Notably, PFA may further mitigate several procedural drivers of readmission observed with thermal ablation. Indeed, the acute inflammatory response after PFA appears significantly milder than after radiofrequency or cryoballoon ablation, potentially translating into fewer acute post-procedural arrhythmia recurrences. Recent data stress that arrhythmia recurrences after PFA are relatively uncommon within the first month and, when they occur later—during the second or third month—they are strongly predictive of late recurrence and procedural failure.10 These findings suggest that the pro-inflammatory or ‘irritative’ window following PFA is shorter than that typically observed after thermal ablation.11 Consequently, this lower acute inflammatory response may reduce early recurrences—the leading cause of post-ablation readmission—and further reinforce the safety and feasibility of SDD following PFA procedures. Nevertheless, emerging PFA-specific considerations warrant attention. Haemolysis-related acute kidney injury (AKI) has been reported, though it remains exceedingly uncommon in large-scale clinical experience. In the MANIFEST-17K registry,12 the incidence of haemolysis-related renal failure requiring dialysis was only 0.03% (5 of 17 642 patients), and all affected cases had undergone very extensive lesion sets (>140 applications). Conversely, Mohanty et al.13 showed that transient haemoglobinuria occurred primarily in non-hydrated patients, with renal dysfunction confined to those who also received a high number of PFA deliveries; importantly, systematic post-procedural hydration (>2 L saline) prevented renal injury. In this subanalysis of the admIRE trial,7 patients discharged the same day received a median of 67 (57–83) PFA deliveries, notably below the threshold identified in previous studies using the pentaspline catheter to be associated with haemolysis, suggesting that fewer energy applications may have contributed to the absence of renal complications. Further research will be required to define whether a comparable threshold exists for the variable-loop circular catheter used in admIRE trial. While the overall risk of PFA-related AKI is very low, additional vigilance may be warranted in patients undergoing extensive ablation or in whom hydration is limited. Beyond ensuring adequate oral hydration during the first 24 h post-discharge, a future structured approach could include outpatient monitoring of serum creatinine one day after ablation in patients receiving a high number of applications, once procedural thresholds for haemolysis are better defined. The EHRA survey by König et al.14 offered the first comprehensive European snapshot of how SDD is implemented in electrophysiology. Among 218 responses from 49 countries, 77.5% of centres reported using SDD, with markedly higher adoption in tertiary (83.8%) and high-volume (85.3%) hospitals. Notably, nearly 90% of centres already performing SDD considered it recommendable or highly recommendable, reflecting strong confidence among experienced operators. Most respondents viewed SDD as a strategy that improves resource utilization (78%), cost-effectiveness (77%), and patient comfort (63%), but also cited persistent challenges, particularly regarding reimbursement issues (30%) and insufficient post-discharge primary care networks (53%). Indeed, in the United States, bundled procedural reimbursement offers limited incentive to prolong hospitalization, whereas in many European systems, diagnosis-related group (DRG) models do not necessarily reward early discharge, potentially offsetting the economic advantage of SDD, and this results in a quite heterogenous scenario when length of hospital stay is analysed in different settings.15 Looking ahead, the widespread adoption of SDD will depend not only on clinical validation but also on the establishment of clear safety standards, structured discharge pathways, and reimbursement models aligned with contemporary evidence. High-volume tertiary centres—where procedural throughput and bed availability are constant challenges—are poised to gain the most from this transition, achieving both clinical and operational efficiency. In contrast, for smaller or lower-volume hospitals with more flexible capacity, the imperative for rapid turnover may be less pressing, yet the opportunity to enhance patient experience and optimize resource use remains equally valuable. Lastly, the admIRE trial was conducted in experienced centres with established PFA programmes. Whether similar outcomes can be achieved in less experienced settings remains uncertain. Still, the consistency of results across technologies and regions suggests that, with standardized workflows and appropriate training, SDD can be safely extended, provided that patient selection remains individualized and safety remains paramount. The admIRE sub-analysis represents a pivotal step in redefining post-procedural care for AF ablation in the era of pulsed field technology.7 By demonstrating comparable safety and effectiveness between SDD and overnight hospitalization, it provides the strongest evidence to date supporting PFA-SDD as a viable and resource-efficient strategy. While vigilance remains essential—particularly regarding renal complications and appropriate patient selection—the paradigm is shifting. With growing pressure on hospital resources and the intrinsic safety profile of PFA, SDD is no longer an exception but increasingly the expectation. The challenge now lies in ensuring that this evolution is guided by evidence, standardization, and a steadfast commitment to patient safety across all levels of electrophysiology practice—and that it is equally supported by institutions and healthcare systems, particularly in Europe, through the adaptation of reimbursement models that reflect and sustain emerging clinical evidence. There are no new data associated with this article.