The Year in Electrophysiology: Selected Highlights From 2023.

This special article is a continuation of an annual series for the Journal of Cardiothoracic and Vascular Anesthesia, highlighting the latest developments in the field of electrophysiology, particularly concerning cardiac anesthesiologists. The selected topics in the specialty for 2023 include consensus statements on left atrial appendage closure, outcomes in patients with atrial fibrillation and heart failure after ablation, further developments in the field of pulse field ablation, alternate defibrillation strategies for refractory ventricular fibrillation, updates on conduction system pacing, new devices such as the Aurora EV system and AVEIR leadless pacemaker system, artificial intelligence and its use in electrocardiogram-based diagnosis and latest evidence regarding the impact of anesthetic techniques on patient outcomes undergoing electrophysiology procedures.

Venous waveform analysis detects acute right ventricular failure in a rat respiratory arrest model.

BACKGROUND: Peripheral intravenous analysis (PIVA) has been shown to be more sensitive than central venous pressure (CVP) for detecting hemorrhage and volume overload. We hypothesized that PIVA is superior to CVP for detecting right ventricular (RV) failure in a rat model of respiratory arrest. METHODS: Eight Wistar rats were studied in accordance with the ARRIVE guidelines. CVP, mean arterial pressure (MAP), and PIVA were recorded. Respiratory arrest was achieved with IV Rocuronium. PIVA utilizes Fourier transform to quantify the amplitude of the peripheral venous waveform, expressed as the "f1 amplitude". RV diameter was measured with transthoracic echocardiography. RESULTS: RV diameter increased from 0.34 to 0.54 cm during arrest, p = 0.001, and returned to 0.33 cm post arrest, p = 0.97. There was an increase in f1 amplitude from 0.07 to 0.38 mmHg, p = 0.01 and returned to 0.08 mmHg, p = 1.0. MAP decreased from 119 to 67 mmHg, p = 0.004 and returned to 136 mmHg, p = 0.50. There was no significant increase in CVP from 9.3 mmHg at baseline to 10.5 mmHg during respiratory arrest, p = 0.91, and recovery to 8.6 mmHg, p = 0.81. CONCLUSIONS: This study highlights the utility of PIVA to detect RV failure in small-caliber vessels, comparable to peripheral veins in the human pediatric population. IMPACT: Right ventricular failure remains a diagnostic challenge, particularly in pediatric patients with small vessel sizes limiting invasive intravascular monitor use. Intravenous analysis has shown promise in detecting hypovolemia and volume overload. Intravenous analysis successfully detects right ventricular failure in a rat respiratory arrest model. Intravenous analysis showed utility despite utilizing small peripheral venous access and therefore may be applicable to a pediatric population. Intravenous analysis may be helpful in differentiating various types of shock.

Peripheral Intravenous Waveform Analysis Responsiveness to Subclinical Hemorrhage in a Rat Model.

BACKGROUND: Early detection and quantification of perioperative hemorrhage remains challenging. Peripheral intravenous waveform analysis (PIVA) is a novel method that uses a standard intravenous catheter to detect interval hemorrhage. We hypothesize that subclinical blood loss of 2% of the estimated blood volume (EBV) in a rat model of hemorrhage is associated with significant changes in PIVA. Secondarily, we will compare PIVA association with volume loss to other static, invasive, and dynamic markers. METHODS: Eleven male Sprague Dawley rats were anesthetized and mechanically ventilated. A total of 20% of the EBV was removed over ten 5 minute-intervals. The peripheral intravenous pressure waveform was continuously transduced via a 22-G angiocatheter in the saphenous vein and analyzed using MATLAB. Mean arterial pressure (MAP) and central venous pressure (CVP) were continuously monitored. Cardiac output (CO), right ventricular diameter (RVd), and left ventricular end-diastolic area (LVEDA) were evaluated via transthoracic echocardiogram using the short axis left ventricular view. Dynamic markers such as pulse pressure variation (PPV) were calculated from the arterial waveform. The primary outcome was change in the first fundamental frequency (F1) of the venous waveform, which was assessed using analysis of variance (ANOVA). Mean F1 at each blood loss interval was compared to the mean at the subsequent interval. Additionally, the strength of the association between blood loss and F1 and each other marker was quantified using the marginal R2 in a linear mixed-effects model. RESULTS: PIVA derived mean F1 decreased significantly after hemorrhage of only 2% of the EBV, from 0.17 to 0.11 mm Hg, P = .001, 95% confidence interval (CI) of difference in means 0.02 to 0.10, and decreased significantly from the prior hemorrhage interval at 4%, 6%, 8%, 10%, and 12%. Log F1 demonstrated a marginal R2 value of 0.57 (95% CI 0.40-0.73), followed by PPV 0.41 (0.28-0.56) and CO 0.39 (0.26-0.58). MAP, LVEDA, and systolic pressure variation displayed R2 values of 0.31, and the remaining predictors had R2 values ≤0.2. The difference in log F1 R2 was not significant when compared to PPV 0.16 (95% CI -0.07 to 0.38), CO 0.18 (-0.06 to 0.04), or MAP 0.25 (-0.01 to 0.49) but was significant for the remaining markers. CONCLUSIONS: The mean F1 amplitude of PIVA was significantly associated with subclinical blood loss and most strongly associated with blood volume among the markers considered. This study demonstrates feasibility of a minimally invasive, low-cost method for monitoring perioperative blood loss.

The Year in Electrophysiology: Selected Highlights From 2022.

This special article is the fifth in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors would like to thank the Editor-in-Chief, Dr Kaplan, the Associate Editor-in-Chief, Dr Augoustides, and the editorial board for the opportunity to author this series, which summarizes the key research papers in the electrophysiology (EP) field relevant to cardiothoracic and vascular anesthesiologists. These articles are shaping perioperative EP procedures and practices, such as pulsed-field ablation, cryoablation for first-line treatment for atrial fibrillation, advancements in conduction system pacing, safety issues related to smartphones and cardiac implantable electronic devices, and alterations in EP workflow as the world emerges from the COVID-19 pandemic. Special emphasis is placed on the implications of these advancements for the anesthetic care of patients undergoing EP procedures.

Unintended ICD discharge in a patient undergoing bladder tumor resection utilizing monopolar cautery and full-body return electrode.

Patients with cardiac implantable electronic devices (CIED) and implantable cardioverter-defibrillator (ICD) devices frequently present for surgical procedures. If electrocautery is used, careful planning is needed to avoid inappropriate device function or device damage. Published consensus statements suggest that if the surgery is below the umbilicus, interference is typically minimal, and therefore it is not recommended to reprogram or disable the CIED. When these guidelines were published, full-body return electrodes were not commonly used in clinical practice, and therefore were not addressed in the recommendations. A 76-year-old male with a single chamber ICD underwent bladder surgery under general anesthesia. Monopolar cautery was used with a full-body return electrode. The patient had undergone a similar procedure multiple times prior utilizing a traditional thigh adhesive return electrode without any inappropriate ICD discharges. During the procedure, the patient's movement was noted with electrocautery use which was suspected to be an inappropriate discharge of his ICD. Device interrogation was performed confirming two antitachycardia pacing therapies and four defibrillations due to interference from the electrocautery. This case examines inappropriate ICD discharge related to interference from electrocautery when utilizing a full-body return electrode, despite a subumbilical location of surgery. Current consensus statement guidelines do not recommend device reprogramming or magnet used when surgery is below the umbilicus, however, these full-body return electrodes were not routinely used when these guidelines were published. Based on these results, the authors avoid full-body return electrodes in patients with CIEDs.

Comparison of i-gel® and LMA® Supreme™ for Facilitating Fiberoptic Endotracheal Intubation: A Prospective Randomized Trial.

Supraglottic airway (SGA) is an alternative to endotracheal intubation, however endotracheal intubation is often essential. One method to convert from an SGA to an endotracheal tube (ETT) is utilizing the SGA as a conduit for fiberoptic-guided advancement of an Aintree catheter (airway exchange catheter), and exchange of the SGA for an ETT. In this prospective randomized study, we compared two SGA devices in facilitating this exchange. Subjects were randomized to receive either the i-gel® or LMA® Supreme™ SGA. The SGA was placed and an Aintree intubation catheter was inserted through the SGA over a fiberoptic bronchoscope. Next, the SGA was removed, leaving the Aintree within the trachea, and an ETT was placed over the Aintree catheter and advanced into the trachea. The i-gel group exhibited shorter time to successful intubation (median, 191 vs. 434 seconds; P = .002). The i-gel group also had fewer study subjects requiring more than one attempt for successful Aintree placement (33% vs. 75%, P = .02). The i-gel group showed superior laryngeal view score (LVS) (6 vs. 4; P = .003). The i-gel SGA achieved a faster time to successful intubation, higher rate of first attempt Aintree placement, and superior LVS.

Large animal preclinical investigation into the optimal extracorporeal life support configuration for pulmonary hypertension and right ventricular failure.

INTRODUCTION: Right ventricular failure (RVF) is a major cause of mortality in pulmonary hypertension (PH). Mechanical circulatory support holds promise for patients with medically refractory PH, but there are no clinical devices for long-term right ventricular (RV) support. Investigations into optimal device parameters and circuit configurations for PH-induced RVF (PH-RVF) are needed. METHODS: Eleven sheep underwent previously published chronic PH model. We then evaluated a low-profile, ventricular assist device (VAD)-quality pump combined with a novel low-resistance membrane oxygenator (Pulmonary Assist Device, PAD) under one of four central cannulation strategies: right atrium-to-left atrium (RA-LA, N = 3), RA-to-pulmonary artery (RA-PA, N=3), pumpless pulmonary artery-to-left atrium (PA-LA, N = 2), and RA-to-ascending aorta (RA-Ao, N = 3). Acute-on-chronic RVF (AoC RVF) was induced, and mechanical support was provided for up to 6 hours at blood flow rates of 1 to 3 liter/min. Circuit parameters, physiologic, hemodynamic, and echocardiography data were collected. RESULTS: The RA-LA configuration achieved blood flow of 3 liter/min. Meanwhile, RA-PA and RA-Ao faced challenges maintaining 3 liter/min of flow due to higher circuit afterload. Pumpless PA-LA was flow-limited due to anatomical limitations inherent to this animal model. RA-LA and RA-Ao demonstrated serial RV unloading with increasing circuit flow, while RA-PA did not. RA-LA also improved left ventricular (LV) and septal geometry by echocardiographic assessment and had the lowest inotropic dependence. CONCLUSION: RA-LA and RA-Ao configurations unload the RV, while RA-LA also lowers pump speed and inotropic requirements, and improves LV mechanics. RA-PA provide inferior support for PH-RVF, while an alternate animal model is needed to evaluate PA-LA.

Venous Waveform Analysis Correlates With Echocardiography in Detecting Hypovolemia in a Rat Hemorrhage Model.

BACKGROUND: Assessing intravascular hypovolemia due to hemorrhage remains a clinical challenge. Central venous pressure (CVP) remains a commonly used monitor in surgical and intensive care settings for evaluating blood loss, despite well-described pitfalls of static pressure measurements. The authors investigated an alternative to CVP, intravenous waveform analysis (IVA) as a method for detecting blood loss and examined its correlation with echocardiography. METHODS: Seven anesthetized, spontaneously breathing male Sprague Dawley rats with right internal jugular central venous and femoral arterial catheters underwent hemorrhage. Mean arterial pressure (MAP), heart rate, CVP, and IVA were assessed and recorded. Hemorrhage was performed until each rat had 25% estimated blood volume removed. IVA was obtained using fast Fourier transform and the amplitude of the fundamental frequency (f1) was measured. Transthoracic echocardiography was performed utilizing a parasternal short axis image of the left ventricle during hemorrhage. MAP, CVP, and IVA were compared with blood removed and correlated with left ventricular end diastolic area (LVEDA). RESULTS: All 7 rats underwent successful hemorrhage. MAP and f1 peak amplitude obtained by IVA showed significant changes with hemorrhage. MAP and f1 peak amplitude also significantly correlated with LVEDA during hemorrhage (R = 0.82 and 0.77, respectively). CVP did not significantly change with hemorrhage, and there was no significant correlation between CVP and LVEDA. CONCLUSIONS: In this study, f1 peak amplitude obtained by IVA was superior to CVP for detecting acute, massive hemorrhage. In addition, f1 peak amplitude correlated well with LVEDA on echocardiography. Translated clinically, IVA might provide a viable alternative to CVP for detecting hemorrhage.