Deep sedation during catheter ablation for atrial fibrillation in elderly patients

Laryngeal mask airway versus endotracheal intubation as general anesthesia airway managements for atrial fibrillation catheter ablation: a comparative analysis based on propensity score matching

BACKGROUND

The current evidence on the use of laryngeal mask airway (LMA) as an airway management technique for general anesthesia (GA) during atrial fibrillation (AF) catheter ablation (CA) is insufficient. This study aims to compare the feasibility, safety, and clinical benefits of LMA and endotracheal intubation (ETI) for airway management in AF CA.

METHODS

One hundred fifty-two consecutive patients with AF who underwent CA under GA were included and divided into two groups based on different airway management methods (66 in the LMA group, 86 in the ETI group). After propensity score matching, a final analysis cohort of 132 patients was obtained to compare procedural parameters, adverse events, and prognosis between the two groups.

RESULTS

The LMA group exhibited significantly shorter total procedural time (p = 0.039), anesthesia induction time (p = 0.015), and recovery time (p = 0.006) compared to the ETI group. The mean arterial pressure (MAP) and heart rate were significantly lower in the LMA group during extubation and 1-min post-extubation (p < 0.05). Furthermore, the LMA group demonstrated lower MAP levels during intubation (p = 0.029). The incidences of intraoperative hypotension (p = 0.017) and bradycardia (p = 0.032) were significantly lower in the LMA group. The incidences of delayed recovery or delirium (p = 0.027), laryngeal or airway injury (p = 0.016), cough or bucking (p = 0.001), and sore throat (p < 0.001) were significantly lower in the LMA group. There were no statistically significant differences in catheter stability parameters and sinus rhythm maintenance rates between the two groups (p > 0.05).

CONCLUSION

LMA is feasible, safe, and effective in AF CA as an optimized airway management technique for GA.

Silent Brain Infarction, Delirium, and Cognition in Three Invasive Cardiovascular Procedures: a Systematic Review

Silent brain infarctions (SBIs) are brain lesions noted on neuroimaging that are not associated with clinical symptoms. SBIs are associated with a number of vascular risk factors and are common following invasive cardiovascular procedures such as atrial fibrillation (AF) ablation, coronary artery bypass graft (CABG), and transcatheter aortic valve replacement (TAVR). Although not eliciting signs of clinical stroke, SBIs are associated with increased frailty, and motor and mood features. Less is known, however, about the relationship between SBI, cognition, and delirium following invasive cardiac procedures and most investigations into these relationships have been reported in large-scale epidemiological studies. In the current paper, we conducted a systematic review to evaluate evidence of a relationship between SBI, delirium, and cognitive decline following CABG, AF ablation, and TAVR. Twenty studies met inclusion criteria. In general, our review identified conflicting results for each cardiac procedure, with some studies suggesting a relationship between SBI, cognitive impairment, and delirium, whereas others showed no relationship between SBI, cognitive impairment, and delirium. Potential reasons for this discrepancy as well as suggestions for future research are discussed.

The Practice of Deep Sedation in Electrophysiology and Cardiac Pacing Laboratories: Results of an Italian Survey Promoted by the AIAC (Italian Association of Arrhythmology and Cardiac Pacing)

The aim of this survey, which was open to all Italian cardiologists involved in arrhythmia, was to assess common practice regarding sedation and analgesia in interventional electrophysiology procedures in Italy. The survey consisted of 28 questions regarding the approach to sedation used for elective direct-current cardioversion (DCC), subcutaneous implantable cardioverter-defibrillator (S-ICD) implantation, atrial fibrillation (AF) ablation, ventricular tachycardia (VT) ablation, and transvenous lead extraction procedures. A total of 105 cardiologists from 92 Italian centres took part in the survey. The rate of centres where DCC, S-ICD implantation, AF ablation, VT ablation and lead extraction procedures were performed without anaesthesiologic assistance was 60.9%, 23.6%, 51.2%, 37.3%, and 66.7%, respectively. When these procedures were performed without anaesthesiologic assistance, the drugs (in addition to local anaesthetics) commonly administered were benzodiazepines (from 64.3% to 79.6%), opioids (from 74.4% to 88.1%), and general anaesthetics (from 7.1% to 30.4%). Twenty-three (21.9%) of the 105 cardiologists declared that they routinely administered propofol, without the supervision of an anaesthesiologist, in at least one of the above-mentioned procedures. In current Italian clinical practice, there is a lack of uniformity in the sedation/analgesia approach used in interventional electrophysiology procedures.

Comparing between second-generation cryoballoon vs open-irrigated radiofrequency ablation in elderly patients: Acute and long-term outcomes

Background

Limited comparative data are available regarding catheter ablation (CA) of atrial fibrillation (AF) using second‐generation cryoballoon (CB‐2) vs radiofrequency (RF) ablation in elderly patients (>75‐year‐old).

Hypothesis

CB‐2 ablation may demonstrate different outcomes compared with that using RF ablation for elderly patients with AF.

Method

Elderly patients with symptomatic drug‐refractory AF were included in the study. Pulmonary vein isolation was performed in all patients.

Results

A total of 324 elderly patients were included (RF: 176, CB‐2:148) from September 2016 to April 2019. The CB‐2 was associated with shorter procedure time and left atrial dwell time (112.9 ± 11.1 vs 135.1 ± 9.9 minutes, P < .001; 53.7 ± 8.9 vs 65.1.9 ± 9.0 minutes, P < .001), but marked fluoroscopy utilization (22.1 ± 3.3 vs 18.5 ± 3.6 minutes, P < .001). Complications occurred in 3.3% (CB‐2) and 6.2% (RF) of patients with no significant different (P = .307). The length of stay after ablation was shorter, but the costs were higher in the CB‐2 group (1.94 vs 2.53 days, P < .001 and 91 132.6 ± 3723.5 vs 81 149.4 ± 6824.1 CNY, P < .001) compared to the RF group. Additionally, the rate of early recurrence of atrial arrhythmia was lower in the CB‐2 group (14.2 vs 23.3%, P = .047), but the long‐term success rate was similar between two groups.

Conclusions

CB‐2 is associated with shorter procedure time, left atrial dwell time, and length of stay after ablation, but its costs and fluoroscopy time are greater than the RF group. Moreover, the rate of complications and long‐term success are similar between the two groups.

Monitored Anesthesia Care for Cardiovascular Interventions

The interventional cardiology is growing and evolving. Many complex procedures are now performed outside the operating room to manage cardiovascular pathologies which had been traditionally treated with cardiac surgery. Appropriate sedation strategy is crucial for improved patient comfort and successful procedure while ensuring safety. Sedation for cardiovascular intervention is frequently challenging, especially in critically-ill, high-risk patients. This review addresses pre-procedure evaluation and preparation of patients, proper monitoring, commonly used sedatives and analgesics, and considerations for specific procedures. Appropriate depth of sedation and analgesia should be balanced with patient, procedural and institutional factors. Understanding of the pharmacology of sedatives/analgesics, vigilant monitoring, ability and proper preparation for management of potential complications may improve outcomes in patients undergoing sedation for cardiovascular procedures.

Predictive Factors and Safety of Noninvasive Mechanical Ventilation in Combination With Propofol Deep Sedation in Left Atrial Ablation Procedures

Catheter ablation is nowadays the core treatment of atrial fibrillation (AF). Propofol infusion sedation is an accepted safety strategy; however, respiratory depression with respiratory variations is frequent. Noninvasive mechanical ventilation (NIV) added to deep sedation could improve procedural safety and success. We sought to assess the predictive factors and safety of NIV in combination to propofol deep sedation in left atrial ablation procedures. Procedural data from 252 consecutive patients who underwent left atrial ablation (166 [66%] persistent, 86 [34%] for paroxysmal AF) were analyzed. Sedation with 1% propofol was used in all procedures and controlled by electrophysiologists. Arterial blood gas analysis was performed regularly during the procedure. NIV was indicated for respiratory depression with pH <7.25 and pCO₂ >50 mm Hg or agitated patient with the need for more profound sedation. No patient needed endotracheal intubation, and no procedure was abandoned due to adverse effects of sedation. NIV was used in 25 patients (10%). Predictive factors for the use of NIV were high-dose propofol sedation (p = 0.010), persistent AF (p = 0.029), prolonged procedure time (p = 0.006), increased body mass index (p = 0.008) and presence of obstructive sleep apnea (OSA; p <0.001). In a Cox regression analysis, OSA was an independent factor for NIV use (p = 0.016). In conclusion, propofol deep sedation for patients who underwent left atrial ablation is safe. Adding NIV in high-risk patients (i.e., OSA, high body mass index, and lengthy procedure duration) provides better respiratory homeostasis and could impact long-term procedure results.

Deep sedation for transvenous lead extraction: a large single-centre experience

Aims

Transvenous lead extraction for cardiac implantable electronic devices (CIED) is of growing importance. Nevertheless, the optimal anaesthetic approach, general anaesthesia vs. deep sedation (DS), remains unresolved. We describe our tertiary centre experience of the feasibility and safety of DS.

Methods and results

Extraction procedures were performed in the electrophysiology (EP) laboratory by two experienced electrophysiologists. We used intravenous Fentanyl, Midazolam, and Propofol for DS. A stepwise approach with locking stylets, dilator sheaths, and mechanical sheaths via subclavian, femoral, or internal jugular venous access was utilized. Patient characteristics and procedural data were collected. Logistic regression models were used to identify parameters associated with sedation-related complications. Extraction of 476 leads (dwelling time/patient 88 ± 49 months, 30% ICD leads) was performed in 220 patients (64 ± 17 years, 80% male). Deep sedation was initiated with bolus administration of Fentanyl, Midazolam, and Propofol; mean doses 0.34 ± 0.12 μg/kg, 24.3 ± 6.8 μg/kg, and 0.26 ± 0.13 mg/kg, respectively. Deep sedation was maintained with continuous Propofol infusion (initial dose 3.7 ± 1.1 mg/kg/h; subsequently increased to 4.7 ± 1.2 mg/kg/h with 3.9 ± 2.6 adjustments) and boluses of Midazolam and Fentanyl as indicated. Sedation-related episodes of hypotension, requiring vasopressors, and hypoxia, requiring additional airway management, occurred in 25 (11.4%) and 5 (2.3%) patients, respectively. These were managed without adverse consequences. Five patients (2.3%) experienced major intraprocedural complications; there were no procedure-related deaths. All of our logistic regression models indicated intraprocedural support was associated with administration higher Fentanyl doses.

Conclusion

Transvenous lead extraction under DS in the EP laboratory is a safe procedure with high success rates when performed by experienced staff.

Tolerability of Midazolam to treat acute agitation in elderly demented patients: A systematic review

WHAT IS KNOWN AND OBJECTIVE

Behavioural disorders are difficult to manage in elderly demented patients because of the lack of appropriate drugs or difficulties surrounding the route of administration. The tolerability of Midazolam is well described in the emergency management of agitation for young patients, when administered intramuscularly or intravenously. However, very little data are available on the use of oral Midazolam for this indication and in the elderly population.

METHODS

A literature review was conducted, and studies were included if involving adults, receiving Midazolam, alone or in combination, whatever the route, dosage or indication and if they reported adverse events related to the use of Midazolam.

RESULTS AND DISCUSSION

Forty-one articles were included. Eleven different adverse events were identified from the studies. Hypotension and desaturation were the two most frequent adverse events reported. Adverse reactions appear to be more common in older patients but also when Midazolam was used in combination with other drugs. The frequency of these adverse effects was lower than those reported for neuroleptic drugs.

WHAT IS NEW AND CONCLUSION

The oral route appears to be appropriate to provide a rapid and well-tolerated response. Further studies will be needed to confirm the good tolerance of oral Midazolam in the management of acute agitation in elderly demented patients.

Sedation in cardiac arrhythmias management

INTRODUCTION

Procedural sedation is of paramount importance for a plethora of electrophysiological procedures. From electrical cardioversion to electrophysiology studies, device implantations, and catheter ablations, intraprocedural sedation and anesthesia have a pivotal role in allowing procedural success while ensuring patient safety and avoiding discomfort. Areas covered: The present review will discuss the current state-of-the-art in sedation and anesthesia during electrical cardioversion, cardiac implantable electronic device implantation, catheter ablation and electrophysiology studies. Specific information will be provided for each procedure in order to reach the core of this important clinical issue, and specific protocols will be compared. The main pro-arrhythmic and anti-arrhythmic effects of the most commonly used sedatives will also be discussed. Expert commentary: According to much recent evidence, the cardiologist can be the only person responsible for sedation administration in many settings, highlighting few safety issues associated with the absence of a dedicated anesthesiologist thus a concomitant reduction in costs. However, many concerns have been raised in allowing non-anesthesiologists to manage sedatives, as adverse events, while rare, could have catastrophic consequences. The present paper will highlight when a cardiologist-directed sedation is considered safe, how it should be performed, and the pros and cons related to this strategy.

High Patient Satisfaction with Deep Sedation for Catheter Ablation of Cardiac Arrhythmia

BACKGROUND

Patients' satisfaction with invasive procedures largely relies on periprocedural perception of pain and discomfort. The necessity for intraprocedural sedation during catheter ablation of cardiac arrhythmias for technical reasons is widely accepted, but data on patients' experience of pain and satisfaction with the procedural sedation are scarce. We have assessed patients' pain and discomfort during and after the procedure using a standardized questionnaire.

METHODS

One hundred seventeen patients who underwent catheter ablation answered a standardized questionnaire on periprocedural perception of pain and discomfort after different anesthetic protocols with propofol/midazolam with and without additional piritramide and ketamine/midazolam.

RESULTS

Patients report a high level of satisfaction with periprocedural sedation with 83% judging sedation as good or very good. The majority of patients was unconscious of the whole procedure and did not recollect experiencing pain. Procedural pain was reported by 7.7% of the patients and 16% reported adverse effects, e.g., postprocedural nausea and episodes of headache.

CONCLUSION

The results of our study show that deep sedation during catheter ablation of cardiac arrhythmias is generally well tolerated and patients are satisfied with the procedure. Yet, a number of patients reports pain or adverse events. Therefore, studies comparing different sedation strategies should be conducted in order to optimize sedation and analgesia.

Airway support using a pediatric intubation tube in adult patients with atrial fibrillation: A simple and unique method to prevent heart movement during catheter ablation under continuous deep sedation

Background

The present study aimed to elucidate the safety and effectiveness of a noble and unique airway management technique in which a pediatric intubation tube is used in adult patients with atrial fibrillation (AF) undergoing catheter ablation (CA) under continuous deep sedation.

Methods

In total, 246 consecutive patients with AF (mean age, 65±10 years; 60 women) underwent CA under dexmedetomidine-based continuous deep sedation. A 4-mm pediatric intubation tube guided by a 10-French intratracheal suction tube was inserted smoothly, and the tip of the tube was located at the base of the epiglottis. The maximum shifting distance of the heart (MSDH) was measured with the 3D mapping system (Ensite NavX system) before and after inserting the pediatric intubation tube.

Results

At baseline, the MSDH of patients under continuous deep sedation was 23±14 mm. The pediatric intubation tube reduced the MSDH to 13±6 mm (mean reduction from baseline, 38.4±21.7%; P<0.0001). In contrast, oxygen saturation was significantly increased from 89±8% to 95±3% (P<0.0001). The mean distance between the nostril and base of the epiglottis was 16.6±0.5 mm. Major periprocedural complications occurred in 9 (3.6%) patients including 3 (1.2%) cardiac tamponade and 6 (2.4%) phrenic nerve injury cases. Larger MSDH (odds ratio, 1.13; 95% confidence interval, 1.04–1.25; P=0.007) was a significant predictor of major periprocedural complications. No major airway complications occurred, except in 3 patients (1.2%) who had minor nasal bleeding.

Conclusion

This unique airway management technique using a pediatric intubation tube for CA procedures performed in adult patients with AF under continuous deep sedation was easy, safe, and effective.

[Ablation for atrial fibrillation in the elderly]

Atrial fibrillation is mainly an arrhythmia among the elderly. The current ESC guideline determines that there is no justification to deny atrial fibrillation ablation to any age group; however, the guideline does not provide specific scientific data. Thus, the goal of this article is to summarize the data on efficacy and safety of atrial fibrillation ablation among elderly people and give treatment recommendations: (1) The success of atrial fibrillation ablation is the same between elderly and younger patients. (2) In cohort studies there was a trend to higher stroke rates among elderly people. (3) Negative predictors for stroke are an age >80 years, heart failure, stroke in history, or/and CHA₂DS₂-VASc score ≥6.

Catheter ablation of premature ventricular contractions in elderly patients: feasibility and success

BACKGROUND

Catheter ablation has become a standard curative treatment for symptomatic, drug refractory premature ventricular contractions (PVC). The aim of this study was to investigate the efficacy and safety of this procedure in elderly patients.

METHODS AND RESULTS

A total of 101 consecutive patients (mean age 50.7 ± 16.9, 53 % women) presenting to our center for ablation of PVC were included and assigned to two age groups (<65 and ≥65 years). Clinical characteristics, procedural parameters, complications and success after 6-month follow up were compared between the two groups. Patients ≥65 years (n = 27) showed a higher rate of hypertension (78 vs. 27 %, p < 0.001), coronary artery disease (19 vs. 12 %, p = 0.01), renal insufficiency (22 vs. 1 %, p < 0.001) and diabetes (22 vs. 3 %, p = 0.001). Left ventricular ejection fraction did not differ between the two groups (56.6 vs. 57.4 %, p = 0.497). In patients <65 years the origin of the PVC was significantly more often in RVOT or LVOT (95 vs. 70 %, p = 0.001). Acute success rates (67 vs. 73 %, p = 0.545) and success rates after 6 months (81 vs. 86 %, p = 0.795) were not different between the two groups. Two complications were observed, both occurred in the <65 years group (1 pericardial effusion and 1 large groin hematoma).

CONCLUSION

Catheter ablation of PVC is feasible in elderly patients without overt heart disease. Success rates are not significantly different compared to patients <65 years. Procedural complications are rare in both the groups. Ablation of this arrhythmia can therefore be regarded as a promising curative treatment in advanced age.

Inhibition of cardiac Kv1.5 potassium current by the anesthetic midazolam: mode of action

Midazolam is a short-acting benzodiazepine that is widely used in anesthesia. Despite its widespread clinical use, detailed information about cardiac side effects of midazolam is largely lacking. Using the double-electrode voltage clamp technique, we studied pharmacological effects of midazolam on heterologously expressed Kv1.5 channels underlying atrial repolarizing current I(Kur). Midazolam dose-dependently inhibited Kv1.5 current, yielding an IC50 of 17 μM in an HEK cell line and an IC50 of 104 μM in Xenopus oocytes. We further showed that midazolam did not affect the half-maximal activation voltage of Kv1.5 channels. However, a small negative shift of the inactivation curve could be observed. Midazolam acted as a typical open-channel inhibitor with rapid onset of block and without frequency dependence of block. Taken together, midazolam is an open channel inhibitor of cardiac Kv1.5 channels. These data add to the current understanding of the pharmacological profile of midazolam.