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\begin{document}

\title{Rebooting Atrial Fibrillation Ablation in the COVID-19 Pandemic}



\author[1]{Chirag Barbhaiya}%
\author[1]{Lalit Wadhwani}%
\author[1]{Arun Manmadhan}%
\author[1]{Ahmed Selim}%
\author[1]{Robert Knotts}%
\author[1]{Alexander Kushnir}%
\author[1]{Michael Spinelli}%
\author[1]{Lior Jankelson}%
\author[1]{Scott Bernstein}%
\author[1]{David Park}%
\author[1]{Douglas Holmes}%
\author[1]{Anthony Aizer}%
\author[2]{Larry Chinitz}%
\affil[1]{NYU Langone Health}%
\affil[2]{New York University School of Medicine}%


\vspace{-1em}



  
  \date{May 19, 2024}


\begingroup
\let\center\flushleft
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\selectlanguage{english}
\begin{abstract}
Background: Catheter ablation procedures for atrial fibrillation (AF)
were significantly curtailed during the peak of coronavirus disease 2019
(COVID-19) pandemic to conserve healthcare resources and limit exposure.
There is little data regarding peri-procedural outcomes of medical
procedures during the COVID-19 pandemic. We enacted protocols to safely
reboot AF ablation while limiting healthcare resource utilization.
Objective: To evaluate acute and subacute outcomes of protocols
instituted for reboot of AF ablation during the COVID-19 pandemic.
Methods: Perioperative healthcare utilization and acute procedural
outcomes were analyzed for consecutive patients undergoing AF ablation
under COVID-19 protocols (2020 cohort; n=111) and compared to those of
patients who underwent AF ablation during the same time period in 2019
(2019 cohort; n=200). Newly implemented practices included pre-operative
COVID-19 testing, selective transesophageal echocardiography (TEE),
utilization of venous closure, and same-day discharge when clinically
appropriate. Results: Pre-ablation COVID-19 testing was positive in 1 of
111 patients. There were 0 cases ablation-related COVID-19 transmission,
and 0 major complications in either cohort. Pre-procedure TEE was
performed in significantly fewer 2020 cohort patients compared to the
2019 cohort patients (68.4\% vs. 97.5\%, p \textless{}0.001,
respectively) despite greater prevalence of persistent arrhythmia in the
2020 cohort. Same day discharge was achieved in 68\% of patients in the
2020 cohort, compared to 0\% of patients in the 2019 cohort.
Conclusions: Our findings demonstrate safe resumption of complex
electrophysiology procedures during the COVID-19 pandemic, reducing
healthcare utilization and maintaining quality of care. Protocols
instituted may be generalizable to other types of procedures and
settings.%
\end{abstract}%



\sloppy


\textbf{Rebooting Atrial Fibrillation Ablation in the COVID-19 Pandemic}

\textbf{Brief Title:} \textbf{Rebooting AF Ablation in the COVID-19
Pandemic}

Chirag R. Barbhaiya, MD

Lalit Wadhwani, MD

Arun Manmadhan, MD

Ahmed Selim, MD

Robert J. Knotts, MD

Alexander Kushnir, MD, PhD

Michael Spinelli, MD

Lior Jankelson, MD, PhD

Scott Bernstein, MD

David Park, MD, PhD

Douglas Holmes, MD

Anthony Aizer, MD, MSc

Larry A. Chinitz, MD

Leon H. Charney Division of Cardiology. New York University Langone
Health. New York, NY, USA

Relationships to industry are all modest (\textless{} \$10,000). Dr.
Barbhaiya has received speaking fees/honoraria from Abbott, Inc. and
Zoll, Inc. Dr. Holmes has research support from Abbott. Dr. Aizer has
served as a consultant for Biosense Webster, Inc., received research
support from Abbott Inc., and Sentreheart, Inc., and received fellowship
support from Abbott, Inc., Biotronik, Inc., Boston Scientific, Inc., and
Medtronic, Inc. Dr. Chinitz has received speaking fees / honoraria from
Abbott, Medtronic, Biotronik, Biosense and Fellowship / Research from
Medtronic, Biotronik, and Biosense.

Funding: None

Address for Correspondence:

Dr. Chirag Barbhaiya

Leon H. Charney Division of Cardiology

New York University School of Medicine

550 1st Avenue

New York, NY 10016, USA

Phone: 212-263-5555

Fax: 212-263-8685

E-mail address: chirag.barbhaiya@nyulangone.org

Total word count: 2,844

\textbf{Structured Abstract}

\textbf{Background:} Catheter ablation procedures for atrial
fibrillation (AF) were significantly curtailed during the peak of
coronavirus disease 2019 (COVID-19) pandemic to conserve healthcare
resources and limit exposure. There is little data regarding
peri-procedural outcomes of medical procedures during the COVID-19
pandemic. We enacted protocols to safely reboot AF ablation while
limiting healthcare resource utilization.

\textbf{Objective:} To evaluate acute and subacute outcomes of protocols
instituted for reboot of AF ablation during the COVID-19 pandemic.

\textbf{Methods:} Perioperative healthcare utilization and acute
procedural outcomes were analyzed for consecutive patients undergoing AF
ablation under COVID-19 protocols (2020 cohort; n=111) and compared to
those of patients who underwent AF ablation during the same time period
in 2019 (2019 cohort; n=200). Newly implemented practices included
pre-operative COVID-19 testing, selective transesophageal
echocardiography (TEE), utilization of venous closure, and same-day
discharge when clinically appropriate.

\textbf{Results:} Pre-ablation COVID-19 testing was positive in 1 of 111
patients. There were 0 cases ablation-related COVID-19 transmission, and
0 major complications in either cohort. Pre-procedure TEE was performed
in significantly fewer 2020 cohort patients compared to the 2019 cohort
patients (68.4\% vs. 97.5\%, p \textless{}0.001, respectively) despite
greater prevalence of persistent arrhythmia in the 2020 cohort. Same day
discharge was achieved in 68\% of patients in the 2020 cohort, compared
to 0\% of patients in the 2019 cohort.

\textbf{Conclusions:} Our findings demonstrate safe resumption of
complex electrophysiology procedures during the COVID-19 pandemic,
reducing healthcare utilization and maintaining quality of care.
Protocols instituted may be generalizable to other types of procedures
and settings.



\textbf{Graphical Abstract}

\textbf{Hosted file}

\verb`image1.emf`  available at \url{https://authorea.com/users/321187/articles/487956-rebooting-atrial-fibrillation-ablation-in-the-covid-19-pandemic}



\textbf{Key Words}

COVID

Atrial Fibrillation

Catheter Ablation

Radiofrequency Ablation

Procedural Outcomes

\textbf{Abbreviations}

COVID-19 -- Coronavirus Disease 2019

PPE -- personal protective equipment

AF -- atrial fibrillation

NYU -- New York University

PCR -- polymerase chain reaction



\textbf{Introduction:}

Coronavirus disease 2019 (COVID-19) resulted in curtailment of
non-emergent medical care in order to limit exposure to patients and
healthcare workers and preserve limited personal protective equipment
(PPE) \textsuperscript{1}. Meeting the challenges of peak COVID-19
infection resulted in reassignment of hospital beds and repurposing of
personnel throughout the United States. Electrophysiology programs like
ours, in accordance with recommendations collectively provided by
professional societies\textsuperscript{1,2} and local regulations
prioritized urgent electrophysiological procedures during periods of
high healthcare utilization related to COVID-19\textsuperscript{3}.
These efforts have helped to minimize patient and health care
professional exposure by postponement of elective cases and careful
management of urgent or otherwise time-sensitive conditions.

As local COVID-19 cases ebb and healthcare resource availability is less
constrained, uncertainty remains regarding best practices for
re-initiating less urgent procedures. In addition, there has been
increasing recognition of morbidity and mortality associated with delays
in cardiac care, including arrhythmia procedures such as ablation for
those with severe symptoms from atrial fibrillation (AF) or atrial
flutter\textsuperscript{4}\textbf{.}

Catheter ablation of AF is most frequently performed with overnight
post-procedure monitoring. Rhythm control via cardioversion or catheter
ablation is an important means of reducing AF related
hospitalization\textsuperscript{5}. The limited prior literature
regarding the safety of same-day discharge following AF ablation has
included procedures performed under conscious
sedation\textsuperscript{6}, using Cryoballoon technology, and/or with 4
hour post-procedure bed-rest\textsuperscript{6}. A minority of patients
were discharged on the day of catheter ablation in a recent study
reporting outcomes of same-day discharge following radiofrequency
ablation of AF under general anesthesia\textsuperscript{7}. We sought to
implement policies and procedures to ensure safety of patients and
healthcare workers, while reducing utilization of healthcare resources
and maintaining quality of care for AF ablation performed under general
anesthesia with high-frequency jet ventilation. We systematically
evaluated acute and subacute outcomes of these interventions as a
quality initiative.

\textbf{Methods:}

All elective procedures in New York City were cancelled following an
executive order on March 16, 2020, and on June 8, 2020 all New York City
Hospitals were authorized to resume elective procedures. In the period
between March 16, 2020 and June 8, 2020, as safety protocols were
enacted and healthcare resources became more available, medically
necessary, non-emergent procedures were performed after detailed
discussion of risks and benefits with patients. Patients were
prioritized based on severity of AF related symptoms, cardiomyopathy
risk, and frequency of AF related healthcare utilization.

Baseline characteristics and clinical outcomes were evaluated in two
cohorts of consecutive patients undergoing catheter ablation of AF or
prior AF-ablation related atrial arrhythmia at New York University (NYU)
Langone Health. The 2020 cohort included 111 patients that underwent
catheter ablation between April 15, 2020 and June 15, 2020 with COVID-19
related policies and procedures in-effect, and the 2019 cohort included
200 consecutive patients that underwent catheter ablation between April
15, 2019 and June 15, 2019. All electrophysiology lab staff underwent
COVID-19 nasal polymerase chain reaction (PCR) testing and were
monitored for new COVID-19 infection symptoms throughout the study
period. In-hospital time was defined as time from presentation to the
electrophysiology lab pre-operative area to the time of discharge from
the hospital.

\textbf{COVID-19 Related Interventions}

Interventions to ensure the safety of patients and healthcare workers
while reducing utilization of healthcare resources in 2020 cohort
included:

\begin{itemize}
\tightlist
\item
  Pre-operative COVID-19 nasal PCR
\item
  Appropriate personal protective equipment use by all hospital staff
\item
  Periprocedural mask use by all patients
\item
  Case-by-case assessment for omission of pre-ablation transesophageal
  echocardiography (TEE)
\item
  Post-ablation echocardiographic pericardial evaluation to rule-out
  pericardial effusion
\item
  Venous closure of two, unilateral venous access sites to allow
  ambulation 2 hours after sheath removal\textsuperscript{8}
\item
  Same day discharge when clinically appropriate
\item
  Staged re-introduction of limited visitors with monitoring for
  appropriate PPE
\end{itemize}

Electrophysiology Study and Ablation

Data collection and analysis were performed according to protocols
approved by the NYU Langone Health Institutional Review Board. Surface
and intracardiac electrograms were digitally recorded and stored (EP
Workmate, Abbott Medical, Inc.,). Non-fluoroscopic 3-dimensional mapping
was performed using the Carto 3 (Biosense-Webster, Inc.,) mapping
system.

All procedures were performed under general anesthesia with high
frequency jet ventilation. A 7-French 20-pole catheter (Daig DuoDeca
2-10-2, Abbott Medical, Inc.) was used with the distal poles placed
within the coronary sinus and the proximal electrodes located along the
tricuspid annulus in the lateral and inferior right atrium. For left
atrial mapping and recording, a 10- or 20-pole circumferential PV
mapping catheter (Lasso, Biosense-Webster, Inc.), or a five-spline
mapping catheter (PentaRay Nav, Biosense-Webster, Inc.) was utilized.
Left atrial three-dimensional anatomy and voltage mapping was created
with manipulation of the multi-electrode mapping catheter. Ablation was
performed in each group with an open-irrigated, 3.5-mm RFA catheter
(Thermocool SMARTTOUCH SF, Biosense Webster Inc.). Ablation lesions were
generated in a power-controlled mode applying 35 to 50 W for 6 to 30
seconds per lesion during irrigation at a rate of 8 to 15-mL/min while
maintaining a goal ACT of \textgreater{} 350 seconds. A waiting period
of 30 minutes, followed by administration of adenosine, was utilized to
confirm pulmonary venous entrance and exit block. A major complication
is a complication that results in permanent injury or death, requires
intervention for treatment, or prolongs or requires hospitalization for
more than 48 hours\textsuperscript{9}. All patients received in-person
or telehealth post-procedure follow-up 10 to 20 days after discharge,
and all patient charts were reviewed 30 days after discharge.

\textbf{Statistical Analysis}

The statistical analysis was performed using Stata version 14.0
(StataCorp LLC, College Station, TX). Descriptive statistics were used
to summarize demographic characteristics. Continuous variables were
assessed for normality with the Kolmogorov-Smirnov test. All normally
distributed data were analyzed using an unpaired Student t test. A
2-tailed P value \textless{} 0.05 was considered statistically
significant. Data found to be non-normally distributed were analyzed
using Mann--Whitney U test. Comparisons of proportions between different
groups of patients were carried out using a Chi square and Fisher's
exact test.

\textbf{Results}

\textbf{Baseline Characteristics}

Baseline characteristics of the 2020 cohort and the 2019 cohort are
displayed in Table 1. Patients in the 2020 cohort were more likely to
have prior history of stroke/transient ischemic attack (TIA) in
comparison to the 2019 cohort (14\% and 6\%, p=0.03), and more often
presented with persistent atrial arrhythmia (50\% and 32\% respectively,
p\textless{}0.01). On the first day of the study period (4/15/20), there
were 9,282 COVID-19 tests performed in New York City, of which 4,368
(38\%) were positive tests\textsuperscript{10}. On the last day of the
study period (6/15/20) there were 25,754 COVID-19 tests performed in New
York City, of which 639 (1.7\%) were positive tests\textsuperscript{10}.

\textbf{Procedural outcomes}

All 111 patients in the 2020 cohort underwent preoperative COVID-19
nasal polymerase chain reaction (PCR) testing, of whom 1 (0.9\%)
asymptomatic patient tested positive. Following detailed discussion of
risks and benefits with patient and healthcare staff, the procedure was
completed in this patient without acute complication. COVID-19 nasal PCR
testing was performed on the day of the procedure in 29 of 111 patients
(26\%), and 1-3 days prior to the procedure in 82 of 111 patients
(74\%). At 30 days follow-up, 0 of 110 (0\%) patients of 2020 cohort
were diagnosed with new COVID-19 infection. Fewer patients underwent
preoperative TEE in 2020 compared to 2019 (76 of 111 patients (68.4\%)
vs. 195 of 200 patients (97.5\%), respectively, p\textless{}.001).

Same day discharge was achieved in 76 of 111 patients (68.4\%) in the
2020 cohort compared to 0 of 200 patients (0\%) in the 2019 cohort.
Overnight observation was required in 35 of 111 patients (31.6\%)
patients. The most common reason for overnight observation was late
procedure end time (n = 13, Table 3). Median 2020 cohort in-hospital
time was significantly shorter than that of the 2019 cohort (12h {[}IQR
11h -- 26h{]} vs. 29h {[}IQR 28h -- 31h{]}, p \textless{} 0.001, Figure
1).

There were no major complications in either cohort, and there was no
significant difference in overall procedure-related complications at 30
days between the 2020 cohort and the 2019 cohort (5.4\% and 4.5\%
respectively, p=0.71, Table 2). Two patients (2\%) developed heart
failure exacerbation requiring hospitalization or emergency room visit
in the 2020 cohort compared to 3 patients (1.5\%) in the 2019 cohort
(p=0.83).

\textbf{Discussion:}

The COVID-19 global pandemic continues regional resurgence despite
containment efforts. Following the initial peak of local infection in
New York City, as healthcare resource availability allowed resumption of
non-emergent procedures, we instituted measures to ensure patient and
hospital staff safety while reducing healthcare resource utilization.
Our key COVID-19 pandemic related interventions included: 1) COVID-19
nasal PCR testing for all electrophysiology lab staff, and for all
patients within 72 hours prior to a scheduled ablation procedure, 2)
Reducing pre-procedure TEE utilization, 3) Utilization of a venous
closure device to facilitate early ambulation and same-day discharge, 4)
staged re-introduction of limited visitors with monitoring for
appropriate PPE.

The main findings of our reboot of AF ablation in the setting of
significant local COVID-19 prevalence are: 1) Zero new COVID-19
infections in patients 30 days post ablation, 2) Zero cases of new
COVID-19 infections amongst electrophysiology lab staff, 3) Same day
discharge achieved in 68\% of patients in the 2020 cohort, compared to
0\% of patients in the 2019 cohort, 4) Significantly reduced median
duration of hospitalization in the 2020 cohort compared to the 2019
cohort (12h vs. 29h, p\textless{}0.001, respectively), 5) Significantly
reduced utilization of pre-procedure TEE in the 2020 cohort compared to
the 2019 cohort (68.4\% vs. 97.5\%, p \textless{}0.001, respectively)
despite greater prevalence of persistent arrhythmia in the 2020 cohort.

In contrast to prior reports of same-day discharge after AF ablation,
all patients in our 2020 cohort underwent radiofrequency ablation under
general anesthesia with high-frequency jet ventilation. Additionally,
2020 cohort patients had a higher prevalence of comorbidities including
stroke/TIA, and persistent atrial arrhythmias when compared to patients
in the 2019 cohort. Despite these patient characteristics and
accelerated post-ablation discharge, there was no significant difference
in the procedure related complications between cohorts. The advantage of
same day discharge was two-fold. First, this reduced the probability of
patients' COVID-19 exposure and second, it reduced the need for
overnight observation beds which could be potentially utilized for
patients with acute illnesses during the pandemic.

\textbf{Limitations}

This is a single-center, non-randomized, observational study, thus the
generalizability of these findings remains unclear. While outcomes are
reported for a single procedure type, radiofrequency ablation of atrial
fibrillation under general anesthesia is a complex procedure performed
in patients with substantial comorbidities.

\textbf{Conclusion:}

Our findings demonstrate safe resumption of complex electrophysiology
procedures, reducing healthcare utilization and maintaining quality of
care. COVID-19 pandemic related interventions that we undertook to
``reboot'' AF ablation in the electrophysiology lab may be generalizable
to other types of procedures and settings.

Perspectives



\textbf{References}

1. Lakkireddy DR, Chung MK, Deering TF, et al. Guidance for rebooting
electrophysiology through the COVID-19 pandemic from the Heart Rhythm
Society and the American Heart Association Electrocardiography and
Arrhythmias Committee of the Council on Clinical Cardiology: Endorsed by
the American College of Cardiology. \emph{Heart rhythm : the official
journal of the Heart Rhythm Society.} 2020.

2. Diaz A, Sarac BA, Schoenbrunner AR, Janis JE, Pawlik TM. Elective
surgery in the time of COVID-19. \emph{Am J Surg.} 2020;219(6):900-902.

3. Rubin GA, Wan EY, Saluja D, et al. Restructuring Electrophysiology
During the COVID-19 Pandemic: A Practical Guide From a New York City
Hospital Network. \emph{Crit Pathw Cardiol.} 2020;19(3):105-111.

4. Czeisler M\selectlanguage{ngerman}É, Marynak K, Clarke KEN, et al. Delay or Avoidance of
Medical Care Because of COVID-19--Related Concerns --- United States,
June 2020. \emph{MMWR Morb Mortal Wkly Rep} 2020;69:1250-1257.

5. Tripathi B, Atti V, Kumar V, et al. Outcomes and Resource Utilization
Associated With Readmissions After Atrial Fibrillation
Hospitalizations.\emph{J Am Heart Assoc.} 2019;8(19):e013026.

6. Haegeli LM, Duru F, Lockwood EE, et al. Feasibility and safety of
outpatient radiofrequency catheter ablation procedures for atrial
fibrillation. \emph{Postgrad Med J.} 2010;86(1017):395-398.

7. Ignacio M, Jarma JJ, Nicolas V, et al. Current Safety of Pulmonary
Vein Isolation in Paroxysmal Atrial Fibrillation: First Experience of
Same Day Discharge. \emph{Journal of Atrial Fibrillation.} 2019;11(4).

8. Natale A, Mohanty S, Liu PY, et al. Venous Vascular Closure System
Versus Manual Compression Following Multiple Access Electrophysiology
Procedures: The AMBULATE Trial. \emph{JACC Clin
Electrophysiol.}2020;6(1):111-124.

9. Calkins H, Kuck KH, Cappato R, et al. 2012 HRS/EHRA/ECAS Expert
Consensus Statement on Catheter and Surgical Ablation of Atrial
Fibrillation: recommendations for patient selection, procedural
techniques, patient management and follow-up, definitions, endpoints,
and research trial design. \emph{Europace : European pacing,
arrhythmias, and cardiac electrophysiology : journal of the working
groups on cardiac pacing, arrhythmias, and cardiac cellular
electrophysiology of the European Society of
Cardiology.}2012;14(4):528-606.

10. COVID-19: Data. \emph{NYC Health.} 2020.

\textbf{Tables and Figures} \textbf{Table 1: Baseline characteristics}\selectlanguage{english}
\begin{longtable}[]{@{}lllll@{}}
\toprule
\begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{All patients} \textbf{(n = 311)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{2020} \textbf{(n = 111)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{2019} \textbf{(n = 200)}\strut
\end{minipage} & \begin{minipage}[t]{0.19\columnwidth}\raggedright\strut
\textbf{P}\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Age (yrs)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
66 \emph{+} 11\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
67 \emph{+} 10\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
66 \emph{+} 12\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.4\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Male (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
205 (66)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
77 (69)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
128 (64)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.6\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
BMI (Kg/m\textsuperscript{2})\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29 \emph{+} 6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29 \emph{+} 6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
29 \emph{+} 6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Creatinine (mg/dL)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.0 \emph{+} 0.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.0 \emph{+} 0.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
1.0 \emph{+} 0.3\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
LA diameter (cm)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.3 \emph{+} 0.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.0 \emph{+} 0.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
4.3 \emph{+} 0.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.3\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Ejection Fraction (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
58 (10)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
58 (12)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
58 (9)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
CHA\textsubscript{2}DS\textsubscript{2}-VASc\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.4 \emph{+} 1.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.0 \emph{+} 1.6\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
2.4 \emph{+} 1.7\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Hypertension (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
188 (61)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
71 (64)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
117 (59)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.5\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Diabetes (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
45 (15)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12 (11)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
33 (16)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.2\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Coronary Disease (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
57 (18)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
20 (18)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
37 (18)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Stroke or TIA (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
27 (9)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
15 (14)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
12 (6)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.03\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Heart Failure (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
48 (15)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
16 (14)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
32 (16)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
0.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
Persistent AF (\%)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
121 (39)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
56 (50)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
65 (32)\strut
\end{minipage} & \begin{minipage}[t]{0.17\columnwidth}\raggedright\strut
\textless{}0.01\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}



\textbf{Table 2: Procedure related complications}\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
\begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{2019} \textbf{n=200 (\%)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{2020} \textbf{n=111 (\%)}\strut
\end{minipage} & \begin{minipage}[b]{0.24\columnwidth}\raggedright\strut
\textbf{P value}\strut
\end{minipage}\tabularnewline
\midrule
\endhead
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Major Complications\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
CHF exacerbation\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 (1.5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2 (1.8)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Transient Ischemic Attack\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (0.5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0 (0)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.9\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Access site hematoma\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (0.5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (0.9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Pericarditis\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (0.5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
1 (0.9)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.7\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
Anesthesia related\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
3 (1.5)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
2 (1.8)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.8\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
All complications\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
9 (4.50)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
6 (5.4)\strut
\end{minipage} & \begin{minipage}[t]{0.22\columnwidth}\raggedright\strut
0.7\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

Data presented as number of patients (\%). CHF: congestive heart failure



\textbf{Table 3: Reasons for overnight observation in 2020}\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\textbf{Reason for overnight observation} & \textbf{Number of
patients}\tabularnewline
\midrule
\endhead
Late procedure end time & 13\tabularnewline
Patient preference & 4\tabularnewline
Groin access site bleeding & 3\tabularnewline
Discharge planning & 2\tabularnewline
Anesthesia complications & 3\tabularnewline
Escort unavailable & 2\tabularnewline
Vasovagal episode & 2\tabularnewline
Post-operative bradycardia & 2\tabularnewline
Urinary retention & 2\tabularnewline
Pulmonary edema & 1\tabularnewline
Post-operative hypotension & 1\tabularnewline
\bottomrule
\end{longtable}

\textbf{Hosted file}

\verb`image2.emf`  available at \url{https://authorea.com/users/321187/articles/487956-rebooting-atrial-fibrillation-ablation-in-the-covid-19-pandemic}

Figure 1. Scatter plot displaying length of stay in hours for the 2020
cohort of atrial fibrillation ablation patients under COVID-19 protocols
and the 2019 cohort of atrial fibrillation ablation patients under usual
care.

\selectlanguage{english}
\FloatBarrier
\end{document}

