Anesthesia?

Hi everyone.
It may have been discussed some time ago, but I wonder if general anesthesia is usually done for an ablation, or if you've been offered to choose.
Both the EP who ablated for my right flutter and the second one who made my PVI and the first touch-up required general anesthesia.
The third EP - connected with the team at Bordeaux - who did my touch up in March only made a local anesthesia. It seems it's the way he processes unless the patient asks for a general anesthesia.
I was happy avoiding a general anesthesia and the three to five days of awful headache I've to go through after that. The procedure in local anesthesia was interesting, as the EP talked with me, explaining what he was doing. I felt afib come and go during the procedure, as he was ablating then waiting for other possible ectopic sources.
It was really interesting and I recovered more easily.
Did you were offered to choose for your own procedures?

I have had 3 ablations all done under general anesthesia. I think it would be interesting though to have it done just under local. I wonder what the reasoning doing it one way over the other is.

For a complex proceedure I can almost understand general as it pertains to time of the procedure. But for a simple precedure I wonder what the benefit is. Then again I suppose it is almost impossible to know if a case is going to become complex or not.

Bordeaux always use sedation (midazolam and opiates) rather than GA - although a low dose of propofol will likely be used for any cardioversion required as part of the procedure.

Conscious sedation for an ablation makes no sense to me whatsoever. I would never even consider it. The safety reasons alone are enough to rule it out.

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Carey
Conscious sedation for an ablation makes no sense to me whatsoever. I would never even consider it. The safety reasons alone are enough to rule it out.

CS is certainly better than GA from the POV of atrio-esophageal fistula. With sedation the patient can comment when the burning is getting a bit much and also the swallowing action (that stops under GA) keeps the esophagus more mobile rather than parked in the same place a few mm behind the left atria. OK; so AEF is very rare, but it needs to be as the prognosis if one occurs isn't good at all and even though rare its still the 2nd most frequent cause of death associated with ablation after cardiac tamponade. Maybe that's something to do with why in 10s of 1000s of ablations Bordeaux have never had an AEF.



Edited 1 time(s). Last edit at 09/07/2018 12:41PM by mwcf.

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mwcf
Bordeaux always use sedation (midazolam and opiates) rather than GA - although a low dose of propofol will likely be used for any cardioversion required as part of the procedure.

This explains why my third EP worked this way...

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Carey
Conscious sedation for an ablation makes no sense to me whatsoever. I would never even consider it. The safety reasons alone are enough to rule it out.

Would you elaborate a little?

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Carey
Conscious sedation for an ablation makes no sense to me whatsoever. I would never even consider it. The safety reasons alone are enough to rule it out.

How many have you done?

Interesting study

[academic.oup.com]

Lots of fun stuff on twitter.

Here's an answer to the OP question

[twitter.com]

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Pompon
Would you elaborate a little?

Movement. You have catheters in direct contact with the atrial wall, a wall which is very thin and fragile. Move just a couple of millimeters and you're the proud owner of a hole in your atrium and the resulting pericardial effusion. Depending on severity, it could require open heart surgery to repair. In fact, one of the members here recently left Bordeaux with a pericardial effusion. Maybe that's why. I know of two other people on another forum who ended up with pericardial effusions and although they didn't need surgery, they did need surgical drainage and their recovery time was over a month.

Airway isn't secured. You're not intubated, which means that if something really serious goes wrong they're going to have to emergently intubate you. That's precious time you may not have and intubation can be difficult with some patients.

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jpeters
How many have you done?

How many what?

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Brian_og
Here's an answer to the OP question

[twitter.com]

Inga is saying that propofol is a good alternative, but propofol renders you unconscious too so I'm not sure what she means. And I have no idea why Mandrola says he can't use propofol. EPs use propofol routinely. I've been put under with it for every one of my six ablations.

Good question! I'm having my ablation and have no idea what my doc prefers or does.
Being a nerdy curious type I would consider staying awake. I did that for hernia surgery many years ago.
Avoiding serious anesthesia drugs would certainly be a bonus. I hadn't though thought through Carry's safety concerns.

I'm guessing my doc will want to knock me out to shut me up since I'm a question gal. Lol

The standard in the US is pretty much general anesthesia (GA). Maybe the Cleveland Clinic still does sedation. You really don’t want to able to move with red hot catheters in your heart. Nothing good can come of that.

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wolfpack
The standard in the US is pretty much general anesthesia (GA). Maybe the Cleveland Clinic still does sedation. You really don’t want to able to move with red hot catheters in your heart. Nothing good can come of that.

"Seconds later, after a dose of the powerful anesthetic drug propofol, his ... lose pain perception, awareness, memory, and the ability to move"

Amazing discussion, like EP's don't know that a patient moving around during an ablation might not be safe.

Well... Having had both type of anesthesias, I'd say moving is likely not to happen in any case. Of course, I was conscious and able to talk, but I'm not sure I was able to move. I was firmly secured on the table with a "floating" sensation I can't precisely describe, but I felt really neither pain nor tiredness. The two hours were short time for me. Above this, the"burning" time is only a small part of the two hours, the EP each time saying what he was ready to do, the last thing I'd have wanted to do was moving even a fingertip.
I agree, when you're under GA, you're ready for the worst, which may spare precious time ; but IMO, no incident would likely be induced by the patient himself. The EP's skill is the key. And I'm sure some of them would feel more nervous with a sedated patient.
The EP who performed my PVI and my first touch-up was in that league. When we planned my touch-up, I asked him if we could avoid a GA and he replied "yes, why not ?", but when the day came, he said "No, we'll go for a GA. You don't have to move a millimeter."
I know now he was cheating. He didn't want me to be conscious during the procedure, he was likely not used to perform that way. I'm okay with this, the crucial point being him doing his best in the best conditions, but he should have said this at once, not the day I entered the hospital.
I agree with your answer, Carey, but the EP saying he wants a GA because the patient must stay perfectly still doesn't tell the truth. There are good reasons to go for a GA, as you wrote, but not that one, IMO.

At Bordeaux another reason they prefer you awake is so that they can ask you can stop breathing during each burn duration. GA obviously precludes this option and you will still obviously be breathing in and out whilst burns are being applied which for obvious reasons makes the job a bit more difficult. Pros and cons both ways as always.

It's still unclear whether recent Bordeaux ablatee Sam to whom Carey refers actually had any degree of perfusion or not. My understanding is that what he still does have is a lot of gastric issues likely comprising some degree of gastroparesis/hypomotility with bloating. These issues - along with acid reflux (hence PPI for a month post-procedure) for folks who've never (knowingly at least) are quite frequent and whilst often still persistent at 3 months invariably resolve by 6 months.



Edited 1 time(s). Last edit at 09/08/2018 05:35AM by mwcf.

Carey clearly was referring to me. After my Bordeaux ablation I had a degree of Effusion (very common after an ablation) which was clearing up nicely three days later.

My post was "Possible Pericardial Effusion after Ablation" as I had symptoms which could have meant Effusion.

An Echocardiogram show there was no effusion.

Th symptoms are either side effects of Flec and Pradaxa or lack of normal mobility in intervertabral or costovertabral joints.

I finish my 3 months of both medications on Sunday so the actual cause should soon be revealed.

Sam

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Pompon
I agree with your answer, Carey, but the EP saying he wants a GA because the patient must stay perfectly still doesn't tell the truth. There are good reasons to go for a GA, as you wrote, but not that one, IMO.

Of course it's the truth. Although ablations can be done with conscious sedation that doesn't change the fact that a conscious patient presents an increased risk of movement. Even though you were aware that you shouldn't move and remained vigilant not to do so, that doesn't mean everyone can do that reliably. And anyone, no matter how careful, might cough, sneeze or reflexively withdraw from pain.

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Sam
Carey clearly was referring to me. After my Bordeaux ablation I had a degree of Effusion (very common after an ablation) which was clearing up nicely three days later.

Glad to hear it cleared up for you but no, it's not very common. Pericardial effusion is a rare complication. If it's common for an EP to see it in his patients, I wouldn't go near that EP.

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Carey

Carey clearly was referring to me. After my Bordeaux ablation I had a degree of Effusion (very common after an ablation) which was clearing up nicely three days later.

Glad to hear it cleared up for you but no, it's not very common. Pericardial effusion is a rare complication. If it's common for an EP to see it in his patients, I wouldn't go near that EP.

Nothing at all related to local anaesthsia


. Pericardial effusion (PE) is certainly one of the most frequently observed complications during AF ablation.
Pericardial effusion was detected in 19 (14.2%) of 133 patients.
. Ablation was performed under general anaesthesia

[www.ncbi.nlm.nih.gov]

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Carey

I agree with your answer, Carey, but the EP saying he wants a GA because the patient must stay perfectly still doesn't tell the truth. There are good reasons to go for a GA, as you wrote, but not that one, IMO.

Of course it's the truth. Although ablations can be done with conscious sedation that doesn't change the fact that a conscious patient presents an increased risk of movement. Even though you were aware that you shouldn't move and remained vigilant not to do so, that doesn't mean everyone can do that reliably. And anyone, no matter how careful, might cough, sneeze or reflexively withdraw from pain.

If it adds so much risk, why do they use this technique in Bordeaux ? I'm sure a GA adds its own risks too, so I guess it's somewhat equal. If one choice proved to be really better, I think it's what they would go for nearly everywhere.

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Pompon


I agree with your answer, Carey, but the EP saying he wants a GA because the patient must stay perfectly still doesn't tell the truth. There are good reasons to go for a GA, as you wrote, but not that one, IMO.

Of course it's the truth. Although ablations can be done with conscious sedation that doesn't change the fact that a conscious patient presents an increased risk of movement. Even though you were aware that you shouldn't move and remained vigilant not to do so, that doesn't mean everyone can do that reliably. And anyone, no matter how careful, might cough, sneeze or reflexively withdraw from pain.

If it adds so much risk, why do they use this technique in Bordeaux ? I'm sure a GA adds its own risks too, so I guess it's somewhat equal. If one choice proved to be really better, I think it's what they would go for nearly everywhere.

From the study noted above


Conclusions: Using GA for PeAF ablation is both clinically and financially effective. Patient immobility leads to improved accuracy of mapping and catheter stability, and optimizes lesion quality.

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Brian_og



I agree with your answer, Carey, but the EP saying he wants a GA because the patient must stay perfectly still doesn't tell the truth. There are good reasons to go for a GA, as you wrote, but not that one, IMO.

Of course it's the truth. Although ablations can be done with conscious sedation that doesn't change the fact that a conscious patient presents an increased risk of movement. Even though you were aware that you shouldn't move and remained vigilant not to do so, that doesn't mean everyone can do that reliably. And anyone, no matter how careful, might cough, sneeze or reflexively withdraw from pain.

If it adds so much risk, why do they use this technique in Bordeaux ? I'm sure a GA adds its own risks too, so I guess it's somewhat equal. If one choice proved to be really better, I think it's what they would go for nearly everywhere.


From the study noted above


Conclusions: Using GA for PeAF ablation is both clinically and financially effective. Patient immobility leads to improved accuracy of mapping and catheter stability, and optimizes lesion quality.

Appears advantage is eliminated with remote magnetic ablation, so unlikely that "cough, sneeze or reflexively withdraw from pain." is the problem. Most likely, the elite EP's in Bordeaux effectively eliminate the advantage also.

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I'm sure a GA adds its own risks too

Absolutely



Edited 3 time(s). Last edit at 09/08/2018 02:04PM by jpeters.

Took a look for articles about incidence of PE following AF ablation. Here are the first pertinent two I found.

[www.em-consulte.com]

Patients referred for a first radiofrequency AF ablation were studied prospectively. Transthoracic echocardiography was performed before and 24h after the procedure. If PE was present, transthoracic echocardiography was repeated at 1month to evaluate PE evolution. Early arrhythmia recurrences (EARs) were defined as any arrhythmia documented within 1month of the procedure.

PE was diagnosed in 18/81 patients (22%); and was present in significantly more patients with persistent versus paroxysmal AF (14/40 [35%] vs 4/41 [10%]; P =0.008). PEs were mild (mean 6±3mm), mainly asymptomatic (89%), and none required pericardiocentesis. Early and late arrhythmia recurrences were present in 25/81 (31%) and 29/81 (36%), respectively. The incidence of PE was significantly higher among patients with EARs versus those without (12/25 [48%] vs 6/56 [11%]; P =0.0004). By multivariable analysis, PE and duration in AF were the two independent predictors of EARs. PE incidence was similar in patients with and without late arrhythmia recurrences. At 1month, no patients had PE on transthoracic echocardiography.

PE following radiofrequency AF ablation is frequent, particularly following persistent AF ablation. This effusion is generally mild, mainly asymptomatic, and independently associated with EARs.

[www.researchgate.net]

We analyzed the incidence, risk factors and managements of PE post AFB (radiofrequency catheter ablation). A total of 156 consecutive patients with AF [male 108, paroxysmal AF 114, (57.6 +/- 11.3) years], who underwent AFB guided by a three-dimensional mapping system (CARTO or CARTO-Merge, Biosense-Webster Inc., Diamond Bar, California) and a circular mapping catheter (Lasso, Biosense-Webster Inc., Diamond Bar, California), were included in this study. The ablation strategy included circumferential pulmonary veins isolation (CPVI), linear ablation and/or complex fractionated atrial electrograms (CFAEs). Incidence of PE was 10.3% (16/156) post AF ablation. One patient developed acute cardiac tamponade and emergency drainage of the pericardial effusion was performed through a median sternotomy and patient recovered without complications during the 18 months follow-up. The remaining 15 PE patients with small PE received outpatient care and no invasive treatment was needed and PE disappeared after 3 months in 6 patients and after 6 months in 9 patients.

Serious question. Is PE a very rare occurrence in the top US centres as opposed to elsewhere in the world?

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mwcf


Serious question. Is PE a very rare occurrence in the top US centres as opposed to elsewhere in the world?

From "Ten things to expect after AF ablation", John Mandrola:

"A majority of patients have chest pain for a few days after the procedure. The severity of the pain varies a lot. Most often, it hurts to take a deep breath or cough. Some patients say their chest feels tight. These symptoms are likely due to irritation of the lining of the heart, called the pericardium"

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jpeters
Nothing at all related to local anaesthsia


. Pericardial effusion (PE) is certainly one of the most frequently observed complications during AF ablation.
Pericardial effusion was detected in 19 (14.2%) of 133 patients.
. Ablation was performed under general anaesthesia

[www.ncbi.nlm.nih.gov]

That's an eight-year old article that must have used very broad criteria for identifying pericardial effusion. Even a rookie EP these days doesn't see a rate even vaguely approaching 14% for ALL complications. Pericardial effusions happen in about 1% of all ablations even in mediocre centers, and less than 1% in top centers.

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Pompon
If it adds so much risk, why do they use this technique in Bordeaux ? I'm sure a GA adds its own risks too, so I guess it's somewhat equal. If one choice proved to be really better, I think it's what they would go for nearly everywhere.

I can't speak for why Bordeaux does what they do, but I would point out that not using GA is cheaper since no anesthesiologist is required. I'm quite sure the risks aren't equalized by the risks involved with GA or GA wouldn't be used for elective procedures like colonoscopy, and yet it is. Extensively.

No top EP anywhere in the US uses conscious sedation. They all use GA. In fact, I've only heard one or two people in the US say they had an ablation using conscious sedation, and they all described a miserable, painful procedure that they wouldn't dream of repeating.

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jpeters
From "Ten things to expect after AF ablation", John Mandrola:

"A majority of patients have chest pain for a few days after the procedure. The severity of the pain varies a lot. Most often, it hurts to take a deep breath or cough. Some patients say their chest feels tight. These symptoms are likely due to irritation of the lining of the heart, called the pericardium"

Pericardial irritation isn't a pericardial effusion.

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Carey
I'm quite sure the risks aren't equalized by the risks involved with GA or GA wouldn't be used for elective procedures like colonoscopy, and yet it is. Extensively.

Not for anyone I know, including myself.

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Carey
Pericardial irritation isn't a pericardial effusion.

Right, but inflammation probably triggers a degree of effusion ??

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Carey
That's an eight-year old article that must have used very broad criteria for identifying pericardial effusion.

16 of the 19 people had "mild" symptoms, so a question of degree. Hopefully, with irrigation,improved catheters, pressure gauges,etc., there is less inflammation...but I definitely had some and needed a cardio-version. No doubt greater for people in persistent.

As of now, not an ablation candidate. However I have an ApoE 4 allele (3/4). Brain is very important to me as E4's don't do well with any brain insults. 11 years ago I did a colonoscopy where I could watch the video. I just redid it with a CT scan for the same reason. Not saying I wouldn't do it for a Natale ablation, but it would be a consideration. My E4/4 wife has the same concerns.. I weigh GA very carefully before I choose it. Any activity that has any velocity has me in a helmet... It also figures into OAC consideration for me as I am much more prone to brain bleeds because of my genetics (at this time I take none because of very little AF burden). Of course AF is also negatively associated with cognition, so minimizing burden is also a high priority for this reason.

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Carey



I can't speak for why Bordeaux does what they do, but I would point out that not using GA is cheaper since no anesthesiologist is required.

I had one (i.e, an anesthesiologist....not a GA) for my cardio. Also, for every TEE.



Edited 2 time(s). Last edit at 09/09/2018 10:16AM by jpeters.

Carey, when you're speaking about the cost of the procedure, I think we can't make a fair comparison between different countries, because health insurance systems are different too. There may exist motivations, other than strictly medical, to make the procedures cheaper or costlier.
I remember having read something from Dr Mandrola about a trip he made in Germany and how he had been surprised by the differences between the procedures (notably the mood in the room) performed there and those he knew from his own country.

I clearly remember the agitation in the room before my GA, there were half a dozen people or so all around, until a mask were applied on my face. Then, a gentle voice pronounced my name close to my ear and it was done. I didn't know the heck what happened other than I was told later. The following hours and days were painful. I had nearly continuous headache and memory troubles.
Comparatively, the recent touch-up was nearly a pleasure. There were merely three to four people around me, in a relaxed mood, the EP quietly explaining what was happening, the burns he made and asking if I was fine. It was incredibly interesting to feel the changes in my HR, the afib coming and going. I recovered easily, with no headache and clear memory.

About a procedure being painful without GA, I think it's a highly personal thing. It seems here in Belgium and France the patient may be offered to choose, and I've read about people fearing a GA and others fearing being conscious during the procedure.
I know of people asking to be fully unconscious for a TEE, but it's not my case.
The whole ablation procedure involves taking risks here and there. The risks are clearly explained from the start by the EP, it's the patient who has to balance the risks and make the choice having a procedure or not and, in some cases, having a GA or not.

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Pompon
Carey, when you're speaking about the cost of the procedure, I think we can't make a fair comparison between different countries, because health insurance systems are different too. There may exist motivations, other than strictly medical, to make the procedures cheaper or costlier.

I clearly remember the agitation in the room before my GA, there were half a dozen people or so all around, until a mask were applied on my face. Then, a gentle voice pronounced my name close to my ear and it was done. I didn't know the heck what happened other than I was told later. The following hours and days were painful. I had nearly continuous headache and memory troubles.
Comparatively, the recent touch-up was nearly a pleasure. There were merely three to four people around me, in a relaxed mood, the EP quietly explaining what was happening, the burns he made and asking if I was fine. It was incredibly interesting to feel the changes in my HR, the afib coming and going. I recovered easily, with no headache and clear memory.

+1 (especially the ‘There may exist motivations, other than strictly medical, to make the procedures cheaper or costlier’ part!......speaking of which.....and noting George N’s comment above......my surgeon other half was just telling me that her colorectal colleague (and his colleagues) are not happy about the current shift here in the U.K. from colonoscopy to CT adversely impacting their earnings.... TBH I’d no idea whatsoever that colonoscopies in the US are done under GA! The last one I had in 2015 I didn’t have any sedation whatsoever for! All present were a bit amazed but I wanted to walk out as soon as possible afterwards with a clear head so as to drive home. A bit eye watering here and there around those two sharp corners going in but a doddle otherwise!!)



Edited 3 time(s). Last edit at 09/09/2018 05:52AM by mwcf.

"Propofol sedation is different. Today, when surgeons say an operation can be done under “sedation,” they assume the patient will be asleep under propofol. The same is true for the gastroenterologist who needs to perform an uncomfortable endoscopy. Understandably, they want their patients asleep and still. Few patients want to be awake. On goes the propofol drip, and everyone is happy — most of the time.

What’s the difference between deep sedation and general anesthesia? Not much except semantics."


[www.kevinmd.com]