Acknowledgments
The authors thank Drs. David Callans, Lee Fleisher, and Sean Kennedy for their comments on a draft of this chapter.
In the electrophysiology laboratory, procedures are performed to diagnose and treat abnormal cardiac rhythms. These procedures can be accomplished less invasively and more safely than major surgical procedures that were required in the past, especially with higher-risk, older, and sicker patients. Procedures commonly performed in electrophysiology laboratories to diagnose and treat abnormal cardiac rhythms include catheter-based ablations, device implants, lead extractions, noninvasive programmed stimulations (NIPS), and cardioversions ( Table 11-1 ). A fuller understanding of these procedures and their potential complications will provide a better framework for planning a more rational and safer anesthetic approach. With the exception of cardioversion procedures, which are discussed in Chapter 12 , the focus of this chapter will be the most common interventions, issues, and challenges for the anesthesiologist in the electrophysiology laboratory.
| Category | Procedure | Usual Anesthetic Technique | Time |
|---|---|---|---|
| MAC in recovery unit | Cardioversion | A short period of deep sedation usually using a bolus dose of propofol (or etomidate if the ejection fraction is low) | 15 min |
| — | TEE | Deeper sedation may be required for some patients undergoing TEE who are unable to tolerate the procedure with conscious sedation by the cardiology team | 60 min |
| — | NIPS | Deep sedation may be required for cardioversion or defibrillation | 30-45 min |
| MAC in electrophysiology laboratory | Pacemaker placement or battery change | Fentanyl/midazolam or infusions of propofol/remifentanil/midazolam | 3-4 hr |
| — | ICD or biventricular ICD placements or battery changes | Fentanyl/midazolam or infusions of propofol/remifentanil/midazolam (defibrillator threshold testing will require a short period of deeper anesthesia similar to that in a cardioversion) | 3-4 hr |
| — | Loop recorder placement in superficial anterior chest wall | Fentanyl/midazolam or infusions of propofol/remifentanil/midazolam | 2-3 hr |
| — | Atrial flutter radiofrequency ablation ∗ | Infusions of propofol/remifentanil/midazolam | 6-10 hr |
| — | Ventricular tachycardia or ventricular fibrillation or premature ventricular contraction radiofrequency ablation ∗ | Usually infusions of remifentanil only; discuss additional sedatives with cardiologist | 6-10 hr |
| General anesthesia in electrophysiology laboratory | Atrial fibrillation radiofrequency ablation | General endotracheal anesthesia using jet ventilation and TIVA, which predominantly involves propofol and remifentanil infusions Radial arterial lines commonly placed | 6-10 hr |
| — | Lead extraction (especially using laser) | General endotracheal anesthesia | 3-4 hr |
| — | Ventricular tachycardia or ventricular fibrillation radiofrequency ablation using an epicardial approach | General endotracheal anesthesia | 6-10 hr |
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Intravenous Anesthesia and Sedation Outside the Operating Room
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