How is this decision made?

[www.medscape.com]

The actual paper has a bit more info. [www.ahajournals.org]

Are they saying that with the ketamine option you don’t have to be intubated because ketamine does not suppress respiration?

I’m getting worst cardiomyopathy because I don’t want a pvc ablation without anesthesia. I may have to cave. My PVCs are suppressed and I get nsr while asleep. I’m told I have to remain awake.

I talked to a patient in the waiting room who was fully awake. She said it was worst than childbirth.
There has to be another solution?

Ep's in the US are part of the more-you-knock-them-out, the better culture, where GA using Propofol is fairly standard, as is a breathing tube. The agent in the cited study is still deep sedation, probably with the patient unconscious, but no Propofol, and probably no breathing tube. In Europe and elsewhere, ablations are routinely performed under conscious sedation with lighter (and IMO much safer agents) such as Fentanyl and Versed. A different culture.

Personally, I would take conscious sedation over GA any day, if offered, but hard to find an ep in the US offering it, although there are a few. Conscious sedation is safer overall because it avoids intubation, allows natural breathing, and leads to faster recovery. In seniors, it also reduces the risk of postoperative cognitive dysfunction, a real problem. Personally, I was in a fog for many months after my PVI using Propofol, even without a breathing tube.

So why do US ep's use GA over conscious sedation? They will tell you it's because it keeps the patient still for mapping and burning, etc, but in reality European ep's get the same results with conscious sedation. So it's really more about habit and ep convenience, than anything else.

Jim