Implantable cardioverter-defibrillator placement in patients with mild-to- moderate left ventricular dysfunction: hemodynamics and recovery profile with two different anesthetics used during deep sedation

Periprocedural hypotension after conscious sedation versus local anesthesia during defibrillator implantation for left ventricular dysfunction: analysis of a national inpatient database in Japan

The association between periprocedural hypotension and conscious sedation (CS) during defibrillator implantation remains to be elucidated. The aim of the present study was to compare the occurrence of periprocedural hypotension after CS or local anesthesia (LA) during defibrillator implantation in a retrospective cohort study using a national inpatient database. Using the Japanese Diagnosis Procedure Combination database, we retrospectively collected data for adult inpatients who underwent implantation of a cardioverter defibrillator or cardiac resynchronization therapy device from July 2010 to March 2016. Multivariable logistic regression analyses were performed to compare the occurrence of periprocedural hypotension between the CS and LA groups with adjustment for patient background characteristics and hospital factors. Additional analysis was performed after dividing the CS group into each specific anesthetic use. We identified 4842 patients, comprising 1533 patients with CS and 3309 with LA. The CS group had a significantly higher proportion of periprocedural hypotension than the LA group (13.4% versus 9.7%; adjusted odds ratio, 1.56; 95% confidence interval, 1.19-2.04; p = 0.001). Body mass index < 18.5 kg/m², New York Heart Association Class IV, and use of cardiac resynchronization therapy device were independently associated with occurrence of periprocedural hypotension. Additionally, ketamine and dexmedetomidine were significantly associated with higher incidence of hypotension than the LA group (adjusted odds ratio, 2.64; 95% confidence interval, 1.32-5.26; p = 0.006; adjusted odds ratio, 1.86; 95% confidence interval, 1.11-3.12; p = 0.019, respectively). Periprocedural hypotension was significantly more likely to occur in the CS group than the LA group, and was associated with CS.

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.

Effects of propofol sedation on pacing thresholds : Results from an observational cohort study

BACKGROUND

Propofol is one of the most commonly used intravenous anaesthetic drugs for surgical procedures. The use of propofol for sedation is also common practice during endoscopic procedures, electrophysiology studies, and ablation procedures, as well as pacemaker and defibrillator implantation. It was found that propofol alters the electrophysiologic properties of the heart and its conduction system. The effects of propofol on pacing thresholds are unknown and could have implications for pacemaker (PM) and defibrillator (ICD) implantation procedures, as well as sedation and anaesthesia in PM and ICD patients in general.

OBJECTIVES

We sought to investigate the effects of propofol sedation on atrial and right ventricular pacing thresholds in PM and ICD patients.

MATERIALS AND METHODS

A total of 50 patients with PM, ICD, or cardiac resynchronization therapy (CRT) undergoing propofol sedation for electrophysiology (EP) investigation, transesophageal echocardiography (TEE), electrocardioversion (ECV), or bronchoscopy were included prospectively. Pacing thresholds, impedance, and sensing were assessed by device interrogation immediately prior to sedation and after the desired sedation depth was achieved by the administration of propofol.

RESULTS

Mean atrial (0.68 V vs 0.77 V, p = 0.136) and mean right ventricular thresholds (0.90 V vs 0.93 V, p = 0.274) remained unchanged. Impedances and sensing remained unaffected in all patients.

CONCLUSIONS

Propofol sedation did not affect pacing thresholds of atrial and right ventricular leads in this cohort of PM and ICD patients.

[Implantation of cardioverter-defibrillators. How much anesthesia is necessary?]

Updated cardiologic guidelines constitute the background for an extended spectrum of indications for the implantation of automatic implantable cardioverter defibrillators (AICDs) and lead to an increasing number of operative implantations of AICDs. Moreover, during implantation of devices for cardiac resynchronization therapy the anesthesiologist is responsible for the most critically ill patients with the longest duration of surgery. As a result anesthesiologists face an increasing number of critically ill patients, whose management contributes to perioperative outcome. Automatic implantable cardioverter defibrillators can be implanted either during general anesthesia, local anesthesia or during a combination of local anesthesia combined with deep conscious sedation accomplished by an anesthesiologist. Besides economic aspects there is an increasing demand for anesthesia with the least cardiovascular side effects and rapid recovery in the often seriously ill patient with preexisting limitations of cardiac and pulmonary functions. Accordingly procedure and anesthesia-associated risks are reviewed and an algorithm for anesthesia management is suggested.

Safety and Acceptability of Implantation of Internal Cardioverter-Defibrillators Under Local Anesthetic and Conscious Sedation

BACKGROUND

Implantation and testing of implantable defibrillators (ICDs) using local anesthetic and conscious sedation is widely practiced; however, some centers still use general anesthesia. We assessed safety and patient acceptability for implantation of defibrillators using local anesthetic and conscious sedation.

METHODS

The records of 500 consecutive device implants from two UK cardiac centers implanted under local anesthetic and conscious sedation from January 1996 to December 2004 were reviewed. Procedure time, left ventricular ejection fraction (LVEF) sedative dosage (midazolam), analgesic dosage (fentanyl or diamorphine), requirement for drug reversal, and respiratory support were recorded. Patient acceptability of the procedure was also assessed.

RESULTS

Of 500 implants examined, 387 were ICDs, 88 were biventricular ICDs, and 25 were generator changes. Patients with biventricular-ICDs had significantly longer (mean +/- SD) procedure times 129.7 +/- 7.6 minutes versus 63.3 +/- 32.3 minutes; P < 0.0001 and lower LVEF 24.4 +/- 8.4% versus 35.7 +/- 15.4%; P < 0.0001. There were no differences in the doses (mean +/- SD) of midazolam 8.9 +/- 3.5 mg versus 8.0 +/- 3.1 mg; P = NS, diamorphine 4.3 +/- 2.0 mg versus 3.8 +/- 1.7 mg; P = NS or fentanyl 94.4 +/- 53.7 mcg versus 92.2 +/- 48.6 mcg; P = NS, between the two groups. There were no deaths or tracheal intubations in either group. Acceptability was available for 373 of 500 (75%) patients, 41 of 373 (11%) described "discomfort," but from these 41 patients only 14 of 373 (3.8%) declined a second procedure under the same conditions.

CONCLUSIONS

Implantation of defibrillators under local anesthetic and sedation is safe and acceptable to patients. General anesthesia is no longer routinely required for implantation of defibrillators.

Can we implant cardioverter defibrillator under minimal sedation?

Aim In a prospective study, we tested the feasibility of implantable cardioverter-defibrillator (ICD) implantation under local anaesthesia (LA) with minimal sedation (MS) vs. short general anaesthesia (SGA) for defibrillation test (DT).

METHODS AND RESULTS

We implanted ICDs in 118 patients between October 2002 and November 2003. Surgery was performed under LA with MS. Depending on the day of admission, patients had DT without SGA with a shock delivered when patient is unconscious (MS group, n = 73) or with short general anaesthesia (SGA group, n = 45). The patients were asked to rate the intensity of pain on a 10-point visual analogue scale (VAS) at the end of the implantation procedure and for the patient of MS group just after DT (VAS-DT). Visual analogue scale was not influenced by the type of anaesthesia (MS vs. SGA). Univariate analysis showed that NYHA >III, 3 leads implanted and an incomplete understanding of the explanation on the procedure were risk factors of VAS >4. Only understanding of the explanation on the procedure has an influence on pain in multivariate analysis.

CONCLUSION

ICD implantation under MS even for DT is feasible and acceptable for the patient.