Curative ablation of atrial fibrillation: comparison between deep sedation and general anesthesia

General anesthesia is not superior to sedation in clinical outcome and cost-effectiveness for ablation of persistent atrial fibrillation

Background

The strategy of anesthesia used during ablation of atrial fibrillation (AF) remains controversial. This study aimed to compare sedation with general anesthesia (GA) for catheter ablation of AF.

Hypothesis

The presence of AF is associated with an increased risk of stroke and heart failure and decreased quality of life and survival.

Methods

We carried out a retrospective single‐centered study with 351 patients undergoing the first ablation procedure for AF under sedation or GA. The main outcome was freedom from recurrence of AF at 1 year. The total time of staying at the ablation laboratory and procedure cost were also calculated.

Results

Freedom from atrial arrhythmia and ablation time did not differ between AF patients under sedation and GA (77.9% vs 79.9% and 42.27 ± 9.84 minutes vs 41.51 ± 9.27 minutes, respectively), while the total procedure time and cost were lower in patients who underwent sedation than GA (171.39 ± 45.09 minutes vs 202.92 ± 43.85 and 8.00 ± 7.02 CNY vs 8.79 ± 11.63 CNY, respectively).

Conclusion

GA is not superior to sedation, in terms of ablation time and freedom from atrial arrhythmia at 1 year, whereas patients with GA had more anesthesia time and procedure cost than sedation.

Laryngeal mask versus facemask in the respiratory management during catheter ablation

BACKGROUND

The purpose of this study is to investigate if a laryngeal mask could improve respiratory condition during radiofrequency catheter ablation (RFCA).

METHODS

Twenty-four consecutive patients who underwent RFCA for atrial fibrillation were divided into two groups (Facemask group; n = 10, Laryngeal mask group; n = 14). All patients were completely sedated under intravenous anesthesia and fitted with artificial respirators during the RFCA. The capnography waveforms and their differential coefficients were analyzed to evaluate the changes of end-tidal CO₂ (ETCO₂) values, respiratory intervals, expiratory durations, and inspiratory durations.

RESULTS

During the RFCA, ETCO₂ values of the laryngeal mask group were higher than those of the facemask group (36.0 vs. 29.2 mmHg, p = 0.005). The respiratory interval was significantly longer in the laryngeal mask group than those in the facemask group (4.28 s vs.5.25 s, p < 0.001). In both expiratory and inspiratory phases, the mean of the maximum and minimum values of CO₂ was significantly higher when using a laryngeal mask than when using a facemask. The inspiratory-expiratory ratio of the laryngeal mask group was significantly larger than that of the facemask group (1.59 vs. 1.27, p < 0.001). The total procedure duration, fluoroscopic duration and the ablation energy were significantly lower in the laryngeal mask group than in the facemask group. The ETCO₂ value is the most influential parameter on the fluoroscopic duration during the RFCA procedure (β = - 0.477, p = 0.029).

CONCLUSIONS

The use of a laryngeal mask could stabilize respiration during intravenous anesthesia, which could improve the efficiency of RFCA.

Anaesthesia use in catheter ablation for atrial fibrillation: a systematic review and meta-analysis of observational studies

Objectives

This meta-analysis and systematic review seeks to compare both characteristic parameters and procedural outcomes of atrial fibrillation (AF) catheter ablation in patients under general anaesthesia (GA)/deep sedation and mild/moderate sedation.

Background

Catheter ablation has become a widely applied intervention for treating symptomatic AF and arrhythmias that are refractory to medical therapy. It can be conducted through from mild sedation to GA.

Methods

PubMed and Embase were searched up to July 2018 for randomised controlled trials, cohort and observational studies that assessed the outcomes of catheter ablation under GA/deep sedation or mild/moderate sedation. Nine studies were included in this meta-analysis after screening with the inclusion and exclusion criteria. Heterogeneity between studies and publication bias was evaluated by I² index and Egger's regression, respectively.

Results

Our meta-analysis found catheter AF ablation with GA/deep sedation to be associated with reduced risk of recurrence (RR: 0.79, 95% CI 0.56 to 1.13, p=0.20) and complications (RR: 0.95, 95% CI 0.64 to 1.42, p=0.82), though statistically insignificant. In terms of procedural parameters, there was no significant difference between the two groups for both procedural time (SMD: -0.13, 95% CI -0.90 to 0.63, p=0.74) and fluoroscopy time (SMD: -0.41, 95% CI -1.40 to 0.58, p=0.41). Univariate meta-regression did not reveal any covariates as a moderating factor for complication and recurrence risk.

Conclusion

Apart from an increased likelihood of procedural success, ablation by GA/deep sedation was found to be non-significantly different from the mild/moderate sedation approach in both procedural parameters and outcome measures.

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.