Choosing the anesthetic and sedative drugs for supraventricular tachycardia ablations: A focused review

Abstract

This study provides a review of the contemporary literature for the effects of most commonly used anesthetic drugs for sedation and anesthesia during adult electrophysiologic (EP) studies where supraventricular tachycardias (SVT) need to be induced for diagnostic purposes and/or catheter ablation. Some medications may affect cardiac electrophysiology and conduction, altering the ability to induce the arrhythmia, and may have negative impact on mapping and ablation treatment. The objective of the study is to determine the best sedative choice during SVT ablations. The authors searched MEDLINE, PubMed, and Google Scholar databases for published articles within the past 20 years (1998-2018) that have evaluated the effects of common anesthetic drugs during SVT ablations. Further articles were identified through crossreferencing, discussion with electrophysiologists, and hand-searching key electrophysiology and anesthesia journals. Eight review articles, two randomized control trials, six prospective observational studies, one retrospective observational study, and two case reports were included in this review. Seven of the studies focused on the pediatric population. The findings about the effects of the commonly used anesthetics are discussed further in detail. Sevoflurane had no clinically important effects on sinoatrial (SA) node activity, or the normal atrioventricular (AV), or accessory pathway. Midazolam and fentanyl, alone or in combination, neither alter the inducibility of reentrant tachycardia nor have they shown to affect the SA node, refractory periods of AV conduction, or accessory pathways. Similar findings were reported by investigators with propofol, except for ectopic atrial tachycardia in children, which remained un-inducible in one of the studies. Remifentanil and dexmedetomidine lengthened both sinus cycle and AV conduction. Dexmedetomidine increased the atrial refractory period and diminished atrial excitability. Ketamine shortened atrial conduction and successfully returned prolongation of sinus node conduction due to dexmedetomidine. In conclusion, the current literature regarding sedation for SVT studies in the adult population is sparse. Midazolam, propofol, fentanyl, and remifentanil can be used safely in patients undergoing EP studies without significant interference with electrophysiological variables or the inducibility of reentrant tachycardias in usual clinical doses. Low-dose ketamine has potential use as an adjunctive medication in the EP lab and additional studies would be beneficial. The effects of dexmedetomidine on conduction and arrhythmia inducibility during SVT ablation is not as clear as studies have yielded conflicting results, and may not be the best choice for sedation in this patient population.

Keywords: SVT ablation; anesthetic drugs; electrophysiology-clinical; sedation for SVT.