Intracardiac catheter ablation for the treatment of arrhythmia

Ablation is a procedure to treat atrial fibrillation. It uses small burns or freezes to cause some scarring on the inside of the heart to help break up the electrical signals that cause irregular heartbeats.

Intracardiac catheter ablation for the treatment of arrhythmia

Anesthesia type	General
Airway	ETT
Lines and access	2 PIVs (Usually one larger gauge 16/18). +/- arterial line
Monitors	Standard, Esophageal Temperature Probe
Primary anesthetic considerations
Preoperative	These patients are usually already on anticoagulants. If they are not, expect a TEE to be performed before the start of the procedure to rule out any thrombus in the LAA.
Intraoperative	Before ablation, the proceduralist will often ask you to reposition the esophageal temperature probe to ensure that the esophagus is not damaged during ablation. Monitor closely and frequently inform proceduralists of esophageal temperature. Serial ACTs will be drawn throughout the procedure. Patients will receive IV heparin throughout the case as instructed by proceduralists. Paralytic is often contraindicated during maintenance as the proceduralist will pace the phrenic nerve during the ablation to ensure it remains intact. An excellent alternative is to run a remifentanil infusion during the case.
Postoperative
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Preoperative management

Patient evaluation

System	Considerations
Airway
Neurologic
Cardiovascular
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Intraoperative management

Monitoring and access

Standard Monitors. Establish two PIVs (one large bore in case of myocardial perforation). +/- arterial line (consider EF). +/- OG tube.

Positioning

Supine. Arms will be tucked. Ensure all lines are neatly tucked and off of the floor to ensure they are not caught by the swinging C-arm.

Maintenance and surgical considerations

Maintenance of anesthesia with inhalation agent at 0.7 - 1 MAC with a remifentanil infusion (0.05 - 0.5 mcg/kg/min). Consider addition of phenylephrine infusion as well. Proceduralists like to know if any vasopressors are added during the case as they monitor for cardiac tamponade/atrial perforation. I have found it helpful to start a low dose phenylephrine infusion at the beginning of case to maintain hemodynamics.

Emergence

Standard emergence. Closure of access site in groin often requires pressure to be held for 15- 30 min. Consider timing emergence to include this. Today, a closure device may be used at access site which negates this additional time.

Procedure variants

	Variant 1	Variant 2
Unique considerations
Position	Supine	Supine
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications