(Originally presented by Dr Rebecca Landers)

Why is this important?

  • High risk procedures
  • Out of theatre anaesthesia
  • Anaesthetic implications are different for left vs right heart ablations
  • We need to understand what is required of us by the Cardiologist

How does it work?

  • Re-entrant arrhythmia are amenable to ablation- endocardium is cauterised at the area of re-entry to render it electrically inert
  • Choice of catheter and ablation energy varies depending on the pathology and site of re-entry
  • EP catheters enter the RA via the femoral or subclavian veins-> may cross the atrial septum by puncturing the foramen oval (usually guided by TOE)
  • Catheters create an ‘electrical map’ and specialised software (Carto, NavX) produces 3D reconstructions or cardiac chambers do direct the catheters to the target sites
  • Ablation energies include DC ablation (historical), radiofrequency (may include saline irrigation to cool the endocardium), and cryoablation (especially for AF)

Anaesthetic considerations

  • Pre-operative
    • Right sided lesions= day only
    • Left sided lesions (AF)= usually stay in hospital
    • Medications
      • Antiarrhythmics- withhold
      • Anticoagulants- usually continue
  • Intra-operative
    • Monitoring
      • Consider artline if: lengthy, multiple comorbidities, Left sided (require blood sampling and ACT)
      • Retrocardiac oesophageal temp probe if ablation of posterior LA wall
      • TOE if septal puncture- guides puncture site
    • Anticoagulation- heparin if arterial puncture (ACT >300-400sec)
    • Post ablation provocation- usually with isoprenaline (guided by Cardiologist)
    • LA and sedation vs GA?
      • Dependant on patient, duration, if TOE required, if low TV ventilation required
      • Note if paroxysmal sympathetically driven tachycardias- inducability may be better if patient awake
    • Volatile vs TIVA?
      • Doesn’t appear to make a significant difference
  • Post-operative
    • Complications may be rapid and catastrophic!
      • Mortality after ablation 1 in 1000
      • Major complications after SVT ablation 0.8%, AF ablation ~5%, VT ablation !6%
      • Included vascular access injuries, septal puncture complications, catheter injury, CVA, phrenic palsy, pericarditis, valve trauma, high grade AV block and coronary spasm

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