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Anesthesia-in-EP

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Jonathan Munro

on 23 June 2015

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Transcript of Anesthesia-in-EP

Anesthesia in the EP Lab
Generators and Leads
Catheter Ablations
Anesthesia in the EP Lab
Atrial Appendage Procedures
Non-complex Ablations
Lariat Procedure
Watchman Insertion

Pacemaker Insertion
Implantable
Cardioverter Defibrillator

Atrial Fibrillation
Atrial Flutter
Supraventricular Tachycardias/
Accessory Pathways
Paroxysmal Ventricular Contractions (PVCs)
Idiopathic Ventricular Tachycardias

(Structurally normal hearts with VT)
Atrial Fibrillation Ablation
Radiofrequency Ablation
Cryoablation
Indication: AF refractory or intolerant to at least one anti-arrhythmic medication

Goal: eliminate triggers of AF and modify atrial subtrate responsible for maintenance
Paroxysmal AF, focus on Pulmonary Veins
Anatomically based - no electrophysiology mapping
Typically < 4 hours
Anesthesia services sometimes required
Persistent AF, wider area of ablation
Accounts for majority of Anesthesia EP cases
Typically 4 - 6 hour duration
Typically General Anesthesia
Preoperative Evaluation
Medications
Anti-arrhythmic medications often held
Anticoagulants
Trend towards continuing warfarin
Novel anticoagulants held
Medical History
Persistent Atrial Fibrillation
At least 1 comorbidity (75%)
Heart Failure (44%)
Coronary artery disease (33%)
Concomittant valve disease (21%)
Cerebrovascular disease (11%)
Pulmonary disease (9%)
Obstructive sleep apnea (40%?)


Preoperative Investigations

Blood Chemistry
CBC/Differential
Coagulation Studies

EKG

CT scan or MRI - informs electroanatomical mapping, balloon sizing

Echocardiography - excluding atrial thrombi
AF Radiofrequency Ablation
Procedure Outline
1. Access femoral veins bilaterally
Left groin:
Intracardiac ECHO catheter
Coronary sinus catheter
Right groin
Mapping catheter
Radiofrequency ablation catheter

2. Transeptal puncture
Under fluoroscopy and intracardiac ECHO
3. Mapping in left atrium
4. Ablate tissue
Create a transmural endocardial scar
Additional subtrate other than pulmonary veins
AF Radiofrequency Ablation Anesthetic Goals
Maintain a stationary patient
Remain vigilant to complications
Electroanatomical mapping assumes a stationary patient

Stability of the catheter for mapping and ablation is critical to effective and safe ablation
Main benefits of General Anesthesia for RF Ablation
Higher rate of cure seen in single ablations under GA
Procedural time and fluoroscopy time reduced under GA
At second procedure, fewer veins remained connected
Findings are not universal
Taking a stationary chest to the extreme...
Centers report use of High Frequency Jet Ventilation to maintain motionless thorax during ablation procedures.

Reduces fluctuations in left atrial volume

Suggested settings:
15 to 20 PSI
120 to 130 breaths/min
FiO2 of 60% to 100%
Blood gas prior to initiation, after 30 minutes, then 1 - 2 hourly
Use Total Intravenous Anesthesia

Pericardial Effusion/Tamponade
Incidence 1 -2 %
Transeptal puncture
Frequent manipulation
Anticoagulation
What can we do?
Hypotension is tamponade until proven otherwise
Esophageal Injury

In close apposition to the posterior wall of the LA and one or more of the PVs
Ulceration, perforation, arterioesophageal fistula
Associated vagal nerve injury

Move temperature probe, observe for changes
Phrenic nerve injury

Typically right-sided
More frequently associated with cryoablation

Enable SVC pacing of right phrenic nerve
Emboli

CVA rate around 1%
Thromboembolism - mitigated by cooling of RF catheter
Air embolism - shunt precautions

Hematoma

Venous hematoma at groin puncture site
Occult retroperitoneal blood loss after femoral cannulation
AF Radiofrequency Ablation Anesthetic Plan
Deep sedation versus General Anesthesia
Opinions differ

External Defibrillator Pads

ASA Standard Monitors
Arterial line dictated by patient comorbidity

Patient Warming

Medications
Discuss treatment of tachycardia with cardiology
Heparin after septal puncture (protamine reversal)
Do not maintain paralysis
Avoid QT prolonging agents
Ibutilide given IV by cardiologists
Facilitate post-procedure neurological exam

Fluid/Foley
Minimize fluid - catheters may give litres during procedure

Extubation
While pressure held on the groin
Ventricular Tachycardia Ablations
ICD remains cornerstone: ablation is adjunctive
Pharmacologic antiarrhythmics have only modest efficacy in hearts with structural disorder
Ventricular tachycardia in structural heart disease
Ischemic or non-ischemic cardiomyopathy

Indications:
Symptomatic sustained monomorphic VT
Frequent PVCs or symptomatic non-sustained VT
Others

Goal: Location and ablation of site of arrhythmia focus
Endocardial or epicardial.



Preoperative Evaluation
Medications
Anti-arrhythmic medications
Likely held prior to ablation procedure
May be given to aid tolerance of VT
Heart failure medications
Beta-blockers likely held - should be tapered


Medical History
Heavy burden of cardiac Disease
Ischemic (>80%) or non-ischemic cardiomyopathy
Reduced EF (average 30%)
ICD implantation, history
History of VT
Is the tachcyardia well tolerated?
Can it be reliably pace-terminated?
Other comorbidities
Preoperative Investigations

Blood Chemistry
CBC/Differential
Coagulation Studies

EKG

Angiography - coronary vascular status

Echocardiography
Ejection fraction
LV thrombus
Wall motion abnormalities - location of focus
LV Tachycardia Ablation Procedure Outline
1. Access femoral artery and femoral vein
Retrograde aortic access to LV preferred to septal puncture
Catheter floated into coronary sinus
Catheter into the RV for pacing and induction of VT
3. Mapping in left ventricle
4. Ablate tissue
Create a transmural endocardial scar
Frequently multiple foci requiring ablation
2. Stimulate/Induce VT
Cathether induced
Isoproterenol infusion to augment induction (cardiology managed)
Frequently takes over 6 hours
LV Tachycardia Ablation Anesthetic Plan
General Anesthesia
Other opinions are available

Patient warming and positioning for long procedure

External Defibrillator Pads

ASA Standard Monitors
Arterial line is standard - femoral sheath unreliable

Medications:
Treat tachycardia only if asked to do so
Avoid Lidocaine on induction
Heparin on entry to LV (Protamine)
Facilitate post-procedure neurological exam
Paralysis should not be required

Foley/Fluid
Sparing - CHF population, irrigated catheters

Extubation
Extubate while pressure held on groin sites
Anesthetic Goals
Maintain a stationary patient
Maintain stable sympathetic drive

Avoid sympathetic stimulation during mapping
Cardiologists may start isoproterenol
Vasodilates, raises BIS
May be asked to start dopamine infusion
Support blood pressure during VT episodes -
Communication
Some centers looking at use of IABP or VAD
Patient movement is hazardous and reduces success

Remain attentive to procedure

Epicardial access (subxiphoid) may be required
Ventricular Tachycardia
Routinely placed under sedation and without anesthesia support
Routinely placed under sedation and without anesthesia support
Complications of VT Ablations
Thromboembolism


Air embolism
Cerebral emobolism
Coronary embolism

Effusion/tamponade

Valve injury

Damage to the conduction system

AV block

Myocardial ischemia

Demand
Coronary injury

Vascular injury

Groin hematomas
AV fistulas
Even patients with low ejection fraction
Except:
Anesthesia consulted for all subcutaneous ICD placements
ICD Implants Under Anesthesia
Preoperative Evaluation
Medical History
Low LV ejection fraction
Poor cardiopulmonary reserve
Heart failure should be stable
Tendency towards ventricular arrhythmias
CRT patients especially comorbid:
Renal disease (51%)
Diabetes (26%)
Cerebrovascular disease (13%)
COPD (10%)

Medications
Coumadin - continue if high thrombotic risk
Withhold novel anticoagulants
Preoperative Investigations

Blood Chemistry
CBC/Differential
Coagulation Studies
Urinalysis

EKG

Echocardiography
Quantifying LV size and EF

Device Insertion - Procedure Outline
1. Make incision/create pocket
Subclavicular placement
May be subpectoral in thin patients
2 Access Vein
Subclavian or axillary vein
For CRT, access coronary sinus
3. Lead placement
Place leads
Tie down leads
4. Attach generator
In case of ICD placement, Defibrillation Threshold Testing (DFT)

Device Insertion - Anesthetic Plan
General Anesthesia versus deep sedation
Be aware of plans for DFT test - deepen sedation
Deepen for subpectoral pocket
GA required for subcutaneous ICD

External defibrillator pads

Monitors:
Arterial line dictated by patient risk factors
DFT testing routinely performed without arterial line

Medications:
Diligence with prophylactic antibiotics
Avoid paralytics for CRT which may mask phrenic stimulation from coronary sinus lead

Fluid:
Judicious IV fluid in CHF population
Nephrotoxic contast dye used in CRT
Implantable Cardioverter-Defibrillator
Indications:
Primary prevention
Impaired LV function (EF < 35%)
Hypertrophic cardiomyopathy
Long QT syndrome
Brugada syndrome with syncope

Secondary prevention
Cardiac arrest
Sustained ventricular tachycardia

Cardiac Resynchronization Therapy (CRT)
LV EF < 35%
QRS > 120 msecs
Sinus rhythm
NYHA class III or IV symptoms

5. Closure


Complications of ICD placement
Pocket hematoma
Hemo/Pneumothorax
Cardiac perforation
Device/lead infection
Malfunction
Complications specific to CRT
Dissection of the coronary sinus
Usually managed conservatively
Exacerbation of heart failure
Lead Extraction
Lead Extraction
Indications:
Infection
Lead Dysfunction
Lead fracture
Device upgrade
Myocardial perforation
Low risk:
Leads in place for < 1 year (no anesthesia involvement)

High risk:
Dual-coil leads
Prolonged placement

Preoperative Evaluation
Medical History
Indications for lead placement
Comorbidities

Device/Lead History
Number of leads
Type of leads (eg shock coil)
Vegetations, size if present
Device interrogation
Need for pacing during procedure
Antitachycardia detection set to "off"

Medications
Need for anticoagulation should be considered
Careful antibiotic selection

Consent - awareness of high risk procedure
Preoperative Investigations

CBC/Differential
Coagulation Studies
2 PRBCs

CXR - lead locations

Echocardiography - vegetations
Lead Extraction - Procedure Outline
2. Sternum of patient is "prepped" and draped for emergent sternotomy
Numerous scrubbed and unscrubbed assistants
4. Incision made over generator
Leads located, disconnected from generator
Duration: 2 - 4 hours
3. Femoral venous access obtained
Placement of temporary pacing wire, if needed
1. Availability of CT surgeon and cardiologist confirmed
Perfusionist with dry bypass circuit
5. Excimer laser sheath introduced over lead
Fluoroscopic guidance:
Sheath advanced
Laser energy delivered fibreoptically to distal end, surrounding fibrous tissue destroyed
Lead removed

6. Lead/Generator replacement and testing
Anesthetic Plan
All involved must be prepared for emergent cardiopulmonary bypass

General Anesthesia

External defibrillator pads

Vascular access:
Arterial line
Two large bore peripheral IVs
Femoral venous access

Pacer setting
Pacer-dependent pace through temporary leads
Non-pacer dependent - set low back-up rate

Intraoperative TEE
Provides early detection of effusion

Complications from Lead Extraction
Major venous injury (mainly SVC)
Atrial injury
Myocardial tear
Tamponade, exsanguination
Pneumothorax/Hemothorax
Valve injury
Major complication rate: 1.9 - 3.4%
With 3 or 4 leads, increases to 8%

Mortality risk 1 - 2%
"Through the external review of fatal cases around the world, it was the strong consensus that when the superior vena cava was torn or perforated, delays from the injury to having open access to the heart of more than 5-10 minutes were often associated with a fatal outcome."
Why would sedation be preferred?
Not all sedation is preferred - up to 50% of centers perform atrial ablations without anesthesiologists
However, this frequently reflects lack of availability

Impaired conduction/induction of arrhythmia?
Reduced adrenergic tone

Responsive to ablation pain
Unclear specificity for adverse events

Avoid complications:
Intubation
Foley catheters, UTIs

Expense/resource

Complexity of scheduling

Improved turnover time

Complex Catheter
Ablations

Percutaneous Left Atrial Appendage Closure
Indication:

High risk of stroke with atrial fibrillation (CHADS2 score >1)
and oral anticoagulation is contraindicated
Anesthetic Plan
Preoperative evaluation
As per Atrial Fibrillation ablation
Continue any anti-arrhythmic medications

General Anesthesia
Groin puncture plus subxiphoid incision required

Invasive monitoring
Only if dictated by patient risk

Intraoperative TEE

Location
Performed in the EP lab - no surgical back-up
Role of Intraoperative TEE
Exclude presence of thrombus in the LAA

Guide puncture of interatrial septum
Also guided by intracardiac ECHO and Fluoroscopy

Early signs of major complication
Pericardial effusion
Perforation/rupture of left atrial appendage
Complication rate?


Anesthetic Plan
Preoperative evaluation
As per Atrial Fibrillation ablation
Continue any anti-arrhythmic medications

General Anesthesia

Invasive monitoring
Only if dictated by patient risk

Intraoperative TEE

Location
Performed in the EP lab - no surgical back-up
5. Remove sheath
Hold pressure/closure
5. Sheath removal
Closure/hold pressure
Duration - Longer with CRT; average 3.5 hours
Machine is on left side
Bed control is at base of bed
Nursing less familiar
with our needs
Help is not immediately available
Monitor is not in view
No access to IV sites
No access to arms
Reduced Lighting
Bed is less functional
Bed is moved by proceduralists
Obstruction to
patient airway
Space you do have is remote
from the patient
IV port is remote from patient
Radiation exposure
Hazards to lines/circuit
TEE Operator
Electrophysiology Procedures
Anesthesiology involved in an expanding repertoire
of procedures
Mortality benefit and quality of life benefit
Practicing off-site on patients with high comorbidities
A co-ordinated anesthetic makes a measurable difference on patient outcomes
Procedures to Cover
Catheter Ablations
Non-complex Catheter ablations
Complex Catheter ablations
Generators and Leads
Pacemaker insertions
Implantable Cardioverter/
Defibrillator Placement
Cardiac Resynchronization Therapy
Lead Extraction
Atrial Appendage Procedure
Lariat Procedure
Watchman Device
Cases that require sedation, but patient is high-risk
High risk/abnormal airway
Unable to lie flat
Others

Cases for which sedation may not be adequate
Procedure duration expected > 4 hrs
Pericardial access:
Lariat procedure, Epicardial VT ablation

TEE guidance needed
Lead extraction
Lariat/Watchman Device
When is General Anesthesia Required?
Types of Non-Complex Catheter Ablations
Routinely placed under sedation and without anesthesia support
Location for Procedure
Thank you
1 Class II, Level B recommendation in the Heart Rhythm Society Expert Consensus Statement, 2012.
2
3
1
1 Calkins et al. 2012 HRS/EHRA/ECAS Expert Consensus Statement on Catheter
and Surgical Ablation of Atrial Fibrillation. Heart Rhythm 2012;9(4):632-717.
2 Chiang et al. Distribution and Risk Profile of Paroxysmal, Persistent, and Permanent Atrial Fibrillation in Routine Clinical Practice: Insight From the Real-Life Global Survey Evaluating Patients With Atrial Fibrillation International Registry. Circulation Arrythmia and Electrophysiology 2012;5:632-639.
3 Bitter T et al. Sleep-Disordered Breathing in patients with atrial fibrillation and normal systolic left ventricular function. Dtsch Arztebl Int 2009;106:164- 170.
4
1
4 Kwak, J. Anesthesia for Electrophysiology Studies and Catheter Ablations. Seminars in Cardiothoracic and Vascular Anesthesia 2012;17(3)195-202.
5
6
7
7 Goode JS, Taylor RL, Buffington CW, et al: High-frequency jet ventilation: Utility in posterior left atrial catheter ablation. Heart Rhythm 2006;3:13-19.

6 Elkassabany et al. Anesthetic Management of Patients Undergoing Pulmonary Vein Isolation for Treatment of Atrial Fibrillation Using High-Frequency Jet Ventilation. Journal of Cardiothoracic and Vascular Anesthesia 2012;26(3):433-438.
5 Di Biase et al. General anesthesia reduces the prevalence of pulmonary vein reconnection during repeat ablation when compared with conscious sedation: Results from a randomized study. Heart Rhythm 2011:8(3);368-372.
8
1
8 Patel KD, Crowley R, Mahajan A. Cardiac electrophysiology procedures in clinical practice. Int Anesthesiol Clin 2012;50:90–110

9
9 Indications from the consensus guidelines of the European Heart Rhythm Association and the Heart Rhythm Society, 2009.
Aliot et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm 2009;6(6):886-933.
10
Calkins et al. Catheter Ablation of ventricular tachycardia in patients with structural heart disease using colled radiofrequency energy. J Am Coll Cardiol 2000;35(7):1905-1914.
11
12
O’Neill DK, Aizer A, Linton P, et al. Isoproterenol infusion increases level of consciousness during catheter ablation of atrial fibrillation. J Interv Card Electrophysiol
2012;34:137–42.

Miller MA, Dukkipati SR, Mittnacht AJ, et al. Activation and entrainment mapping of hemodynamically unstable ventricular tachycardia using a percutaneous left ventricular assist device. J Am Coll Cardiol. 2011;58:1363-1371.
9 Aliot et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm 2009;6(6):886-933.
References
13 Russo wt al. ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR2013 Appropriate Use Criteria formplantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy. Heart Rhythm 2013;10(4):1-48.
13 Russo wt al. ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR2013 Appropriate Use Criteria formplantable Cardioverter-Defibrillators and Cardiac Resynchronization Therapy. Heart Rhythm 2013;10(4):1-48
14
Tell the Cardiologists before treating hypotension
Communicate - delayed diagnosis is deadly
Treatment: immediate drainage, protamine
14, 15
15 Wilkoff et al. Transvenous Lead Extraction: Heart Rhythm Society Expert Consensus on Facilities, Training, Indications, and Patient Management. Heart Rhythm 2009;6(7):105-1104
16 Gaca et al. Laser-Assisted Extraction of Pacemaker and
Defibrillator Leads: The Role of the Cardiac Surgeon. Ann Thorac Surg 2009;87:1446 –51
15 Wilkoff et al. Transvenous Lead Extraction: Heart Rhythm Society Expert Consensus on Facilities, Training, Indications, and Patient Management. Heart Rhythm 2009:6(7);1085-1104
16
17 Chang et al. Nonpharmacologic therapy to prevent embolization in patients with atrial fibrillation. http://www.uptodate.com. Accessed 2/1/2014
18 Chua et al. Anesthetic management of electrophysiology procedures. Curr Opin Anesthesiol 2012:25;470–481
19 Hayman et al. Anesthesia for Interventional Cardiology. Journal of cardiothoracic and vascular anesthesia 2012:26(1);134-47
20 Patel et al. Cardiac Electrophysiology Procedures in Clinical Practice. Internationl Anesthesiology Clinics 2012:50(2);90-110
9 Aliot et al. EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. Heart Rhythm 2009:6(6);1085-1133
10 Theuns et al. The Prognosis of Implantable Defibrillator Patients Treated With Cardiac Resynchronization Therapy: Comorbidity Burden as Predictor of Mortality. Europace 2011:13;62-69
11 O’Neill DK, Aizer A, Linton P, et al. Isoproterenol infusion increases level of
consciousness during catheter ablation of atrial fibrillation. J Interv Card Electrophysiol
2012;34:137–42

12 Reddy et al. Role of Percutaneous Left Ventricular Assist Devices in Unstable Ventricular Arrhythmia Ablation. JACC 2012:59(13);E626
References
10 Calkins et al. Catheter Ablation of Ventricular Tachycardia in Patients with Structural Heart Disease Using Cooled Radiofrequency Energy. JACC;35(7):1905-1914
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