Deep Sedation for Catheter Ablation of Atrial Fibrillation: A Prospective Study in 650 Consecutive Patients

Endovascular ablation of atrial fibrillation

Atrial fibrillation is the most common arrhythmia. The anesthetic considerations of endovascular ablation for the treatment of atrial fibrillation are reviewed.

Sedation for electrophysiological procedures

Administration of intravenous sedation (IVS) has become an integral component of procedural cardiac electrophysiology. IVS is employed in diagnostic and ablation procedures for transcutaneous treatment of cardiac arrhythmias, electrical cardioversion of arrhythmias, and the insertion of implantable electronic devices including pacemakers, defibrillators, and loop recorders. Sedation is frequently performed by nursing staff under the supervision of the proceduralist and in the absence of specialist anesthesiologists. The sedation requirements vary depending on the nature of the procedure. A wide range of sedation techniques have been reported with sedation from the near fully conscious to levels approaching that of general anesthesia. This review examines the methods employed and outcomes associated with reported sedation techniques. There is a large experience with the combination of benzodiazepines and narcotics. These drugs have a broad therapeutic range and the advantage of readily available reversal agents. More recently, the use of propofol without serious adverse events has been reported. The results provide a guide regarding the expected outcomes of these approaches. The complication rate and need for emergency assistance is low in reported series where sedation is administered by nonspecialist anesthesiology staff.

Usefulness of dabigatran etexilate as periprocedural anticoagulation therapy for atrial fibrillation ablation

BACKGROUND

The usefulness of dabigatran etexilate for the prevention of stroke in patients with atrial fibrillation (AF) has been reported.

OBJECTIVES

In this study the efficacy and safety of dabigatran etexilate for anticoagulation for AF ablation were examined.

METHOD

Patients were divided into three groups: Group 1, interrupted warfarin bridged by heparin between pre- and post-ablation; Group 2, continuous warfarin therapy; and Group 3, dabigatran etexilate therapy. Anticoagulation therapy with warfarin or dabigatran etexilate was performed from 30 days before to at least 90 days after AF ablation. Dabigatran etexilate was administered at 110 or 150 mg twice daily, depending on renal function and age.

RESULTS

Patients' clinical characteristics, associated disorders, echocardiographic parameters and arrhythmia status were not different among the three groups. Procedural parameters such as procedural time and radiofrequency energy supply were also not different among the three groups. The dabigatran etexilate group and the warfarin groups had no embolic complications (stroke, cerebral transient ischaemic attack, deep venous thrombosis or pulmonary embolism). No pericardial tamponade was observed in the dabigatran etexilate group, while two patients in each of Group 1 (2/194, 1.0 %) and Group 2 (2/203, 0.98 %) developed cardiac tamponade, though the differences were not significant. Pericardial effusion and groin haematoma were observed in one patient each (1/105, 0.9 %) in the dabigatran etexilate group, and the incidences were not different from the warfarin group (Group 1: 4/194, 2.1 % and 2/194, 1.0 %; Group 2: 3/203, 1.5 % and 2/203, 1.0 %, respectively). As a whole, the safety outcomes did not differ among the three groups.

CONCLUSION

Dabigatran etexilate is an effective and safe anticoagulation therapy for AF ablation. Thus, dabigatran etexilate appears to be useful as an alternative anticoagulant therapy to warfarin for AF ablation.

Deep sedation during catheter ablation for atrial fibrillation in elderly patients

BACKGROUND

Atrial fibrillation (AF) is the most common cardiac arrhythmia. AF incidence increases with age. AF ablation procedures are routinely performed under deep sedation with propofol. The purpose of the study was to evaluate if propofol deep sedation during AF ablation is safe in elderly patients.

METHODS

Four hundred one consecutive patients (mean age, 61.4 ± 11.1 years; range, 20-82; 66.3 % men) who were presented to our institution for ablation of symptomatic AF were enrolled. Patients were divided into three groups: Patients in group A were ≤50 years old; patients in group B were 51-74 years old; and patients in group C were ≥75 years old. Procedures were performed under deep sedation with propofol, midazolam, and piritramide. SaO2, electrocardiogram, arterial blood pressure, and arterial blood gas were monitored throughout the procedure. Sedation-related complications, intraprocedural complications, and other adverse events were evaluated. Fisher exact or χ (2) tests were used for comparison of adverse events and complications among groups. Analysis of variance was used to compare sedation- and procedure-related parameters.

RESULTS

Fifty-three (13.2 %) elderly patients were in group C and were compared to 73 (18.2 %) patients in group A and 275 (68.8 %) in group B. No significant differences in sedation-related or intraprocedural complications were seen (group A, 1.4 %; group B, 1.1 %; group C, 3.7 %; p = 0.336). Despite a significantly greater drop in systolic blood pressure in under sedation in group C (group A, 15.5 ± 9.5 mmHg; group B, 18.9 ± 16.3 mmHg; group C, 32.3 ± 15.5 mmHg; p < 0.001), no prolonged hypotension was observed. The rate of other adverse events (delirium, respiratory infection, renal failure) was significantly higher in group C (9.4 %), compared to group A (0 %) and group B (2.2 %; p = 0.004).

CONCLUSION

Deep sedation with propofol and midazolam during AF ablation did not result in an increased rate in sedation-related complications in elderly patients. Similarly, the rate of procedural complications was not significantly different among the study groups. The rate of respiratory infections and renal failure was significantly higher in the elderly. All adverse events were treated successfully without any remaining sequelae.

Electrophysiology Procedures

Invasive electrophysiologic procedures have evolved and increased in frequency significantly over the past 2 decades. The complexity and nature of the various procedures offered have also changed, and complex ablations for atrial fibrillation and ventricular tachycardia have become commonplace. These procedures often require the services of an anesthesiologist. An understanding of the specific nature and challenges of these procedures may be helpful in planning the optimal anesthetic and patient management. A paired review of these issues has been written from the standpoint of a practicing anesthesiologist. This review is written from the viewpoint of a cardiac electrophysiologist and will focus on the intra-procedural management of patients undergoing both cardiac implantable device implantation as well as catheter-based ablations, with a specific focus on the catheter ablation of atrial fibrillation. Ultimately, the proper management of these patients will facilitate successful procedural outcomes while maintaining a high degree of patient safety.

Adaptive-servo ventilation combined with deep sedation is an effective strategy during pulmonary vein isolation

AIMS

Pulmonary vein isolation (PVI) by catheter ablation for atrial fibrillation (AF) requires suppression of patient restlessness by sufficient sedation in addition to maintaining stable respiration. We applied adaptive-servo ventilation (ASV) and examined the effects of ASV combined with deep propofol sedation on PVI using a NavX.

METHODS AND RESULTS

We analysed 75 paroxysmal AF (PAF) patients (62 ± 11 years; 53 men and 22 women) who underwent PVI for treatment of PAF using an ASV system combined with deep sedation (ASV group). Control patients included 75 consecutive PAF patients (62 ± 11 years; 51 men and 24 women) who underwent PVI just before introduction of the ASV system. Deep sedation was defined as a Ramsay sedation score of 6. The ASV group had a lower frequency of restless body movements compared with the control group during PVI (1.5 ± 0.7 vs. 7.8 ± 1.4 times, P < 0.01). The frequency of respiratory compensation and EnGuide alignment of catheter position by the NavX was lower in the ASV (4.2 ± 3.3 and 8.8 ± 7.1 times) than control group (7.1 ± 5.1 and 15.2 ± 10.0 times, P < 0.05 and <0.01, respectively). Consequently, significantly lower total electrical energy supply (48.7 ± 6.0 KJ) was required in the ASV than control group (64.5 ± 24.9 KJ, P < 0.01). Further, significantly shorter fluoroscopy and procedural times were observed in the ASV (28 ± 5 and 109 ± 25 min) than the control group (33 ± 6 and 141 ± 38 min, respectively, P < 0.01) and the AF recurrence rate was significantly lower in the ASV than the control group (12 vs. 25%, P < 0.01).

CONCLUSION

ASV combined with deep sedation is an effective strategy during PVI using the NavX in patients with PAF.

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

This is a report of the Heart Rhythm Society (HRS) Task Force on Catheter and Surgical Ablation of Atrial Fibrillation, developed in partnership with the European Heart Rhythm Association (EHRA), a registered branch of the European Society of Cardiology and the European Cardiac Arrhythmia Society (ECAS), and in collaboration with the American College of Cardiology (ACC), American Heart Association (AHA), the Asia Pacific Heart Rhythm Society (APHRS), and the Society of Thoracic Surgeons (STS). This is endorsed by the governing bodies of the ACC Foundation, the AHA, the ECAS, the EHRA, the STS, the APHRS, and the HRS.