Difference between revisions of "Intracardiac catheter ablation for the treatment of arrhythmia"
m (Tony.Wang moved page Intracardiac catheter ablation for the treatment of arrhythmia) to Intracardiac catheter ablation for the treatment of arrhythmia without leaving a redirect: typo in title) |
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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.<ref>{{Cite web|date=2022-05-17|title=Atrial Fibrillation Ablation|url=https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation|access-date=2022-08-08|website=www.hopkinsmedicine.org|language=en}}</ref> | 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.<ref>{{Cite web|date=2022-05-17|title=Atrial Fibrillation Ablation|url=https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/atrial-fibrillation-ablation|access-date=2022-08-08|website=www.hopkinsmedicine.org|language=en}}</ref> | ||
In adults, atrial fibrillation is the most commonly encountered cardiac arrythmia, overall around 1% (much increase in adults > 65 years of age). Morbidity associated with heart failure and stroke. Thrombus formation promoted in left atria due to incomplete ejection from abnormal rhythm. Atrial rates up to 300-600 beats per minute, although AV node blocks most (resulting in around 90-170 beats per minute). ECG shows irregular R-R intervals (in absence of complete AV nodal blockade), absence of P waves, variable atrial cycle length (usually < 200 ms) (Malladi). | |||
Risk factors for atrial fibrillation (Malladi): | |||
* Hypertension | |||
* Congestive heart failure | |||
* Diabetes mellitus | |||
* Men > women | |||
* Caucasians > African Americans | |||
* Heavy alcohol consumption | |||
* Coronary artery disease/acute myocardial infarction | |||
* Valvular heart disease | |||
* Obesity | |||
* Thyroid dysfunction | |||
* Cardiac surgery | |||
* Electrolyte abnormalities | |||
* Family history | |||
{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = General | | anesthesia_type = General (sometimes MAC/sedation) | ||
| airway = ETT | | airway = ETT | ||
| lines_access = 2 PIVs (Usually one larger gauge 16/18). +/- arterial line | | lines_access = 2 PIVs (Usually one larger gauge 16/18). +/- arterial line | ||
| Line 13: | Line 29: | ||
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. | 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. | ||
| considerations_postoperative = | | considerations_postoperative = PACU then usually home (or short stay), patient to remain flat for several hours, watch for late complications of procedure | ||
}} | }} | ||
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|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Paroxysmal or chronic atrial fibrillation, CHADS2 scoring, history (cardiac history, risk factors for atrial fibrillation), review if patient has valvular abnormalities | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| Line 46: | Line 62: | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Review anticoagulation status | ||
|- | |- | ||
|Renal | |Renal | ||
| Line 59: | Line 75: | ||
===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->=== | ===Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. -->=== | ||
* CBC, metabolic panel (electrolytes, renal function), ECG | |||
===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->=== | ===Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. -->=== | ||
* Usually in cath lab or hybrid room | |||
* Standard setup | |||
* Arterial line transducer | |||
* Esophageal temperature probe (may have specific one supplied by procedural team) | |||
* Defib/cardioversion pads | |||
* Lead/radiation shielding for providers | |||
===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ===Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. -->=== | ||
| Line 70: | Line 95: | ||
===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ===Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. -->=== | ||
Standard GETA, occasionally performed under MAC (Kottkamp) (although general preferred to help keep patient immobile for arrhythmia mapping, additionally procedure may take many hours, and general anesthesia associated with higher cure rate with single procedure compared to conscious sedation (Di Biase)) | |||
===Positioning=== | ===Positioning=== | ||
| Line 75: | Line 101: | ||
===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ===Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. -->=== | ||
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. | |||
* 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. | |||
* Use of heparin if crossing into left side of heart, monitoring ACT if on heparin (300 seconds, Anderson) | |||
* Consider avoid redosing NMB to help with phrenic nerve monitoring (if being employed) (Yildiz) | |||
* Procedure team may administer isoproterenol to induce arrhythmias, additionally adenosine may be requested to help with eliciting pathways | |||
* May need to reverse heparin with protamine at the end | |||
===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ===Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. -->=== | ||
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. | 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. Some proceduralists may request antibiotics if closure device is being used. | ||
==Postoperative management== | ==Postoperative management== | ||
===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ===Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. -->=== | ||
* PACU, then usually home (or short stay) | |||
* Will likely need to remain flat for a few hours due to vascular access sites | |||
===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ===Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. -->=== | ||
* Usually minimal pain, post-op pain for radiofrequency > post-op pain for cryoablation; acetaminophen or NSAIDs (if no contraindications) (Ashley) | |||
===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ===Potential complications<!-- List and/or describe any potential postoperative complications for this case. -->=== | ||
* Arrhythmia | |||
* Perforation of aorta or heart | |||
* Phrenic nerve injury, stroke | |||
* Retroperitoneal hemorrhage | |||
* Air embolism (atrial ablation) | |||
* Esophageal injury | |||
* Vascular access-related complications encountered 3-4% of time (Anderson) | |||
==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ==Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). -->== | ||
| Line 128: | Line 172: | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
<references /> | <references />Anderson R, Harukuni I, Sera V. Anesthetic considerations for electrophysiologic procedures. Anesthesiol Clin. 2013 Jun;31(2):479-89. doi: 10.1016/j.anclin.2013.01.005. Epub 2013 Feb 23. PMID: 23711654. | ||
Ashley, Elizabeth MC, BSc MB ChB FRCA FFICM, Anaesthesia for electrophysiology procedures in the cardiac catheter laboratory, ''Continuing Education in Anaesthesia Critical Care & Pain'', Volume 12, Issue 5, October 2012, Pages 230–236, <nowiki>https://doi.org/10.1093/bjaceaccp/mks032</nowiki> | |||
Di Biase L, Conti S, Mohanty P, Bai R, Sanchez J, Walton D, John A, Santangeli P, Elayi CS, Beheiry S, Gallinghouse GJ, Mohanty S, Horton R, Bailey S, Burkhardt JD, Natale A. 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 Mar;8(3):368-72. doi: 10.1016/j.hrthm.2010.10.043. Epub 2010 Nov 2. PMID: 21055479. | |||
Kottkamp H, Hindricks G, Eitel C, Müller K, Siedziako A, Koch J, Anastasiou-Nana M, Varounis C, Arya A, Sommer P, Gaspar T, Piorkowski C, Dagres N. Deep sedation for catheter ablation of atrial fibrillation: a prospective study in 650 consecutive patients. J Cardiovasc Electrophysiol. 2011 Dec;22(12):1339-43. doi: 10.1111/j.1540-8167.2011.02120.x. Epub 2011 Jun 21. PMID: 21692895. | |||
Malladi V, Naeini PS, Razavi M, Collard CD, Anton JM, Tolpin DA. Endovascular ablation of atrial fibrillation. Anesthesiology. 2014 Jun;120(6):1513-9. doi: 10.1097/ALN.0000000000000261. PMID: 24714120. | |||
Yildiz M, Yilmaz Ak H, Oksen D, Oral S. Anesthetic Management In Electrophysiology Laboratory: A Multidisciplinary Review. J Atr Fibrillation. 2018 Feb 28;10(5):1775. doi: 10.4022/jafib.1775. PMID: 29988243; PMCID: PMC6006978. | |||
Revision as of 22:12, 11 November 2022
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.[1]
In adults, atrial fibrillation is the most commonly encountered cardiac arrythmia, overall around 1% (much increase in adults > 65 years of age). Morbidity associated with heart failure and stroke. Thrombus formation promoted in left atria due to incomplete ejection from abnormal rhythm. Atrial rates up to 300-600 beats per minute, although AV node blocks most (resulting in around 90-170 beats per minute). ECG shows irregular R-R intervals (in absence of complete AV nodal blockade), absence of P waves, variable atrial cycle length (usually < 200 ms) (Malladi).
Risk factors for atrial fibrillation (Malladi):
- Hypertension
- Congestive heart failure
- Diabetes mellitus
- Men > women
- Caucasians > African Americans
- Heavy alcohol consumption
- Coronary artery disease/acute myocardial infarction
- Valvular heart disease
- Obesity
- Thyroid dysfunction
- Cardiac surgery
- Electrolyte abnormalities
- Family history
| Anesthesia type |
General (sometimes MAC/sedation) |
|---|---|
| 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 |
PACU then usually home (or short stay), patient to remain flat for several hours, watch for late complications of procedure |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Overview
Indications
Surgical procedure
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Airway | |
| Neurologic | |
| Cardiovascular | Paroxysmal or chronic atrial fibrillation, CHADS2 scoring, history (cardiac history, risk factors for atrial fibrillation), review if patient has valvular abnormalities |
| Pulmonary | |
| Gastrointestinal | |
| Hematologic | Review anticoagulation status |
| Renal | |
| Endocrine | |
| Other |
Labs and studies
- CBC, metabolic panel (electrolytes, renal function), ECG
Operating room setup
- Usually in cath lab or hybrid room
- Standard setup
- Arterial line transducer
- Esophageal temperature probe (may have specific one supplied by procedural team)
- Defib/cardioversion pads
- Lead/radiation shielding for providers
Patient preparation and premedication
Intraoperative management
Monitoring and access
Standard Monitors. Establish two PIVs (one large bore in case of myocardial perforation). +/- arterial line (consider EF). +/- OG tube.
Induction and airway management
Standard GETA, occasionally performed under MAC (Kottkamp) (although general preferred to help keep patient immobile for arrhythmia mapping, additionally procedure may take many hours, and general anesthesia associated with higher cure rate with single procedure compared to conscious sedation (Di Biase))
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.
- Use of heparin if crossing into left side of heart, monitoring ACT if on heparin (300 seconds, Anderson)
- Consider avoid redosing NMB to help with phrenic nerve monitoring (if being employed) (Yildiz)
- Procedure team may administer isoproterenol to induce arrhythmias, additionally adenosine may be requested to help with eliciting pathways
- May need to reverse heparin with protamine at the end
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. Some proceduralists may request antibiotics if closure device is being used.
Postoperative management
Disposition
- PACU, then usually home (or short stay)
- Will likely need to remain flat for a few hours due to vascular access sites
Pain management
- Usually minimal pain, post-op pain for radiofrequency > post-op pain for cryoablation; acetaminophen or NSAIDs (if no contraindications) (Ashley)
Potential complications
- Arrhythmia
- Perforation of aorta or heart
- Phrenic nerve injury, stroke
- Retroperitoneal hemorrhage
- Air embolism (atrial ablation)
- Esophageal injury
- Vascular access-related complications encountered 3-4% of time (Anderson)
Procedure variants
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | Supine | Supine |
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ "Atrial Fibrillation Ablation". www.hopkinsmedicine.org. 2022-05-17. Retrieved 2022-08-08.
Anderson R, Harukuni I, Sera V. Anesthetic considerations for electrophysiologic procedures. Anesthesiol Clin. 2013 Jun;31(2):479-89. doi: 10.1016/j.anclin.2013.01.005. Epub 2013 Feb 23. PMID: 23711654.
Ashley, Elizabeth MC, BSc MB ChB FRCA FFICM, Anaesthesia for electrophysiology procedures in the cardiac catheter laboratory, Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 5, October 2012, Pages 230–236, https://doi.org/10.1093/bjaceaccp/mks032
Di Biase L, Conti S, Mohanty P, Bai R, Sanchez J, Walton D, John A, Santangeli P, Elayi CS, Beheiry S, Gallinghouse GJ, Mohanty S, Horton R, Bailey S, Burkhardt JD, Natale A. 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 Mar;8(3):368-72. doi: 10.1016/j.hrthm.2010.10.043. Epub 2010 Nov 2. PMID: 21055479.
Kottkamp H, Hindricks G, Eitel C, Müller K, Siedziako A, Koch J, Anastasiou-Nana M, Varounis C, Arya A, Sommer P, Gaspar T, Piorkowski C, Dagres N. Deep sedation for catheter ablation of atrial fibrillation: a prospective study in 650 consecutive patients. J Cardiovasc Electrophysiol. 2011 Dec;22(12):1339-43. doi: 10.1111/j.1540-8167.2011.02120.x. Epub 2011 Jun 21. PMID: 21692895.
Malladi V, Naeini PS, Razavi M, Collard CD, Anton JM, Tolpin DA. Endovascular ablation of atrial fibrillation. Anesthesiology. 2014 Jun;120(6):1513-9. doi: 10.1097/ALN.0000000000000261. PMID: 24714120.
Yildiz M, Yilmaz Ak H, Oksen D, Oral S. Anesthetic Management In Electrophysiology Laboratory: A Multidisciplinary Review. J Atr Fibrillation. 2018 Feb 28;10(5):1775. doi: 10.4022/jafib.1775. PMID: 29988243; PMCID: PMC6006978.