Expansion of Cardiac Ablations Into Ambulatory Surgery Centers: Evidence, Barriers, and Unmet Needs

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EP LAB DIGEST. 2026;26(4):7-8.

Arash Aryana, MD, PhD¹, and Vijendra Swarup, MD^2
1Mercy General Hospital and Dignity Health Heart and Vascular Institute, Sacramento, California; ²The Arizona Heart Rhythm Center, Phoenix, Arizona

Cardiac electrophysiology (EP) is among the fastest-growing medical subspecialties, driven significantly by the rising prevalence of atrial fibrillation (AF), expanding indications for catheter ablation, and technological advances in mapping, imaging, and ablation. Historically, EP procedures have been performed almost exclusively in hospital outpatient departments (HODs). However, improvements in procedural safety, workflow efficiency, and widespread adoption of same-day discharge (SDD) protocols now support the feasibility of outpatient EP procedures, including complex ablations.¹

In parallel, ambulatory surgery centers (ASCs) have become central to procedural care across multiple specialties, offering streamlined operations, lower costs, and greater patient satisfaction.² Despite these advantages, EP has lagged behind other procedural specialties in ASC migration due to its technical complexity and capital requirements. This landscape is poised for change following the Centers for Medicare & Medicaid Services’ (CMS) decision to add a comprehensive set of catheter ablation codes, including AF ablation, to the ASC Covered Procedures List commencing calendar year 2026. This policy shift represents a pivotal change in the economics and accessibility of EP care. Herein, we examine the evidence base, operational and regulatory requirements, ownership considerations, and unresolved structural needs shaping the future of EP-capable ASCs in the United States.

Origins and Evolution of ASCs
The ASC model emerged in 1970 to address hospital delays, limited operating room access, and rising procedural costs. Today, more than 6300 Medicare-certified ASCs perform over 23 million procedures annually, with CMS reimbursing approximately 3500 procedures—a list that continues to expand as safety and cost-effectiveness data accumulate.

ASCs operate with focused service lines, standardized workflows, and lower overhead than HODs. Cost analyses consistently show that ASC-based care is substantially less expensive while maintaining high patient satisfaction, positioning ASCs as an appropriate environment for cardiac ablation when clinical, operational, and regulatory standards are met.²

Evidence Regarding EP Procedures in ASCs
The rapid expansion of ablation indications has strained HOD capacity, contributing to prolonged wait times nationwide. Delays in AF ablation are associated with higher risks of stroke, heart failure, hospitalization, mortality, and increased health care costs.³ With EP volumes projected to grow by approximately 14% annually through 2030, improving access is urgent.

Advances in procedural techniques and periprocedural care now enable SDD in over 90% of ablation cases at many centers, and growing evidence supports the safety and feasibility of performing catheter ablation in ASCs. Multicenter studies from the United States and Europe, encompassing more than 4000 patients, demonstrate favorable outcomes for both right- and left-sided arrhythmias, including AF, atrial flutter, supraventricular tachycardia, and selected ventricular arrhythmias, when performed in properly selected patients and appropriately equipped ASCs.¹,⁴ Moreover, contemporary national registry data show major adverse event rates for AF ablation below 1%,⁵ which is lower than rates associated with elective percutaneous coronary intervention or total joint replacement—procedures long performed in ASCs.

Opportunities and Persistent Barriers
Procedural specialties historically migrate to ASCs once technology, workflow, and reimbursement align. Cardiac EP now appears at a similar inflection point, yet several barriers remain. Regulatory requirements vary widely by state, including differences in permissible cardiovascular services and certificate-of-need restrictions. Cardiac EP is also capital intensive, requiring advanced imaging, mapping and ablation systems, radiation shielding, emergency equipment, and robust inventory management. In addition, EP procedures depend on specialized nurses, technologists, and anesthesia personnel trained in arrhythmia management and SDD pathways. Financial sustainability may be further challenged by high-cost disposables, complex payer contracts, and variable reimbursement.

Collectively, these challenges underscore a significant unmet need for coordinated, EP-specific infrastructure to support safe, efficient, and economically viable EP ASCs.

Ownership Models and the Structural Gaps
Physician ownership remains central to the ASC model. Currently, >90% of ASCs include physician ownership and approximately 65% are entirely physician-owned. Physician-led ASCs are consistently associated with improved access, operational efficiency, and favorable clinical outcomes. However, regulatory frameworks, including Stark Law considerations, fair market value rules, and utilization thresholds, introduce added complexity. As EP ASCs become more financially attractive and profitable, hospitals, management companies, and private equity firms may increasingly pursue controlling interests, potentially eroding physician governance and clinical autonomy.

Hence, cardiac EP would benefit from a unified, cost-effective, and specialty-specific framework to guide the development and operation of EP ASCs. At present, most electrophysiologists rely on fragmented combinations of consultants, vendors, management firms, and billing entities, resulting in higher costs, inefficiencies, compliance challenges, and exposure to unfavorable ownership structures. Addressing this structural gap requires a physician-governed, nationally coordinated, EP-aligned framework—distinct from a traditional management company or equity partner—that preserves physician ownership while standardizing operations, ensuring regulatory compliance, leveraging purchasing power, and providing EP-specific clinical, financial, and digital support. Closing this gap represents both the principal barrier to and the greatest opportunity for safe, scalable expansion of EP-capable ASCs in the United States.

Proposed Model
An emerging example of such a coordinated, physician-led infrastructure is the ACCESS ecosystem. ACCESS consists of 2 complementary entities designed to support the responsible expansion of EP services into the ambulatory setting. The ACCESS Foundation is a nonprofit organization focused on EP-specific ASC education, safety and quality standards, regulatory preparedness, workforce development, and the establishment of evidence-informed best practices. ACCESS, Inc, serves as the operational counterpart, providing nonequity infrastructure support, including compliance pathways, accreditation readiness, digital workflow integration, revenue cycle strategy, and supply chain coordination. Together, these entities are structured to safeguard physician governance and ownership while advancing standardized, transparent, and accountable care models. This coordinated approach offers a scalable national framework intended to promote quality assurance, regulatory alignment, and sustainable growth of cardiac EP services across ASCs. 

Disclosures: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Aryana has no conflicts of interest to report. Dr Swarup reports ownership in the ASC.

Listen to our podcast discussion with Dr Aryana here!

1. Aryana A, Thihalolipavan S, Willcox ME, et al. Safety and feasibility of cardiac electrophysiology procedures in ambulatory surgery centers. Heart Rhythm. 2025;22(3):717-724. doi:10.1016/j.hrthm.2024.07.123
    
2. Munnich EL, Parente ST. Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up. Health Aff (Millwood). 2014;33(5):764-769. doi:10.1377/hlthaff.2013.1281
    
3. Qeska D, Qiu F, Manoragavan R, Wijeysundera HC, Cheung CC. Relationship between wait times and postatrial fibrillation ablation outcomes: a population-based study. Heart Rhythm. 2024;21(9):1477-1484. doi:10.1016/j.hrthm.2024.04.043
    
4. Kanthasamy V, Finlay M, Early M, et al. Safety and efficacy of catheter ablation for atrial fibrillation in an ambulatory day surgery center outside the hospital setting. Heart Rhythm. 2025;22(8):1935-1945. doi:10.1016/j.hrthm.2025.02.010
    
5. Hsu JC, Darden D, Du C, et al. Initial findings from the National Cardiovascular Data Registry of Atrial Fibrillation Ablation Procedures. J Am Coll Cardiol. 2023;81(9):867-878. doi:10.1016/j.jacc.2022.11.060