What to remember during ablation procedures about mapping?
Mapping : it is paramount that the
patient does not mot move at any point during the procedure: GA or sedation. Should the patient move, the mapping system used to guide the ablation can be “thrown off”,
and necessitate remapping at a 30-45 minute delay.
What ventilation settings have been shown to yield to amazing results for catheter stability during ablation?
Low-volume high-rate ventilation: We have used 250cc- 400cc breaths with a frequency of 20-30 breaths, with close attention to the CO2 and PO2.
How can ventilation affect catheter stability?
thoracic excursion results in displacement of the ablation catheter and decreased contact force (CF).
What is another ONE of the most important anesthesia considerations in the EP lab?
Paralytics: Should be discussed beginning of every case. They can certainly be given at the beginning of the case for intubation, but if they are going to be re-dosed, this requires a discussion with the attending electrophysiologist. Let covering staff (break/lunch/relief) know as well.
There are 2 types of patients where we cannot have paralytics on board
during a significant portion of the procedure: what are they?
Catheter ablation procedures; Radio Frequency Ablation (RFA) and Cryoablation in general, the R phrenic nerve can be injured by ablation along the posterolateral
wall of the right atrium. It can also be injured especially during ablation of the R superior pulmonary vein, during radiofrequency catheter ablation or cryoablation.
Why should paralytics not be given during cryoablation of the RIGHT PULMONARY VEINS?
During cryoablation of the R-sided pulmonary veins, the R phrenic nerve is continuously paced, and any reduction in the strength of the diaphragmatic excursions triggers
an immediate discontinuation of energy delivery.(undesired) In all of these circumstances, the phrenic nerve needs to be paced to determine its location; if paralytics are given, this cannot be assessed.
What is one of the more common complications of cryoablation?
Phrenic nerve paralysis
What to be immediately communicate with surgeon?
- acute drop in BP
- If there is an INCREASING PRESSOR REQUIREMENT TO MAINTAIN BP
In what cases is Norepinephrine the pressor of choice:
severe LV dysfunction
When is Prophylactic antibiotics given for ablation procedures at YNHH?
when hey have what preexisting implanted devices such as pacemakers and AICD’s
What is a critical safety measure to avoid thermal injury during radiofrequency or cryoenergy ablation in the posterior LA near the esophagus.
Esophageal temperature monitoring
Why is esophageal temperature monitoring no longer required? What procedure eliminated the risk of esophageal injury?
Pulsed field ablation (PFA) as a near non-thermal energy source for left atrial ablation procedures in patients with atrial fibrillation. The risk of injury to collateral structures, such as the phrenic nerve and esophagus, with PFA is negligible compared with the use of thermal energy sources, such as radiofrequency or cryoenergy.
Intra-arterial access: what patients should you consider inserting A-lines?
- very low ejection fraction
- frequent episodes of malignant arrhythmias
- acute coronary syndrome
- severe heart failure
- hemodynamic instability.
Anticipated use of high-dose intravenous nitroglycerin to prevent coronary artery spasm related to the planned delivery of PFA near the coronary arteries along what two structures?
- Cavotricuspid
- Lateral mitral isthmus for atrial flutter
What may preclude accurate monitoring BP with a blood pressure cuff meaning necessitate an arterial line?
Arrhythmias with a rapid ventricular response that may
What is a good MAC regimen for MAC anesthetic technique during an EP procedure?
Propofol infusion titrated at 25 to 75 mcg/kg per minute, with or without an initial propofol bolus + A short-acting opioid may be added, usually a remifentanil infusion 0.025 to 0.1 mcg/kg per minute.
When is any long-acting NMBA avoided for ablation procedures?
Notably, administration of any long-acting NMBA is avoided altogether if PHRENIC NERVE STIMULATION is planned during procedures utilizing cryoballoon ablation of the right-sided pulmonary veins.
What are anesthetic considerations if TEE examination is to be performed to inspect the cardiac chambers before beginning the procedure,
A short-acting anesthetic agents and a short-acting NMBA are selected to allow rapid awakening if thrombus is detected since the procedure may be cancelled and rescheduled if intracardiac thrombus is detected.
An esophageal temperature probe is inserted orally in selected cases with planned what and what anatomical locations?
radiofrequency ablation in the posterior LA near the esophagus.
What happens during pulse field ablation (PFA)?
When PFA is used to ablate cardiac tissue, very brief high-voltage electrical pulses are delivered from an electrode catheter placed in contact with the cardiac tissue to cause irreversible electroporation of the cardiac myocytes.
Why is NMBA critical during Pulse Field Ablation?
At the time when the pulses are delivered, there is commonly direct skeletal muscle and diaphragmatic contraction, or phrenic nerve capture that leads to diaphragmatic contraction (movement).
When a high number of PFA pulses are delivered during an ablation procedure, what can some patients rarely develop that may be clinically significant?
hemolysis that can lead to acute kidney failure
Radiofrequency ablation (RFA) – Considerations influencing anesthetic care for HFJV include:
If the electrophysiologist uses HFJV during critical portions of the procedure, a total intravenous anesthesia (TIVA) technique is necessary.
RFA is associated with a Risk of fluid overload –Why?
Saline irrigation from the tip of the ablation electrode is used to cool the myocardium throughout the RFA procedure; however, this may result in administration of several liters of fluid. The anesthesiologist should minimize intravenous (IV) fluid administration and calculate total fluid balance at frequent intervals (approximately every 30 minutes).
