Comparison of Outcomes of Pediatric Catheter Ablation by Anesthesia Strategy: A Report From the NCDR IMPACT Registry

Abstract

Background - Anesthesia strategies for pediatric ablation procedures include general anesthesia (GA) and monitored anesthesia care (MAC). The effects of anesthesia strategy on arrhythmia inducibility and procedural outcomes have not been investigated. Methods - A multicenter retrospective study was performed, utilizing data from the NCDR ® IMPACT Registry. Data from subjects 1-21 years undergoing elective first-time electrophysiology study (EPS) for evaluation of documented SVT, EAT, or PVC/VT from 4/1/16-12/31/19 were included, excluding cases with WPW, congenital heart disease, and/or cardiomyopathy. The primary outcome was a negative EPS, defined as failure to induce the clinical tachyarrhythmia. Secondary outcomes included ablation success and adverse events (AE). Results - 6621 subjects from 78 centers were evaluated: 49% male; mean age 13.3±3.8 years. GA was utilized in 5913 (89%), with MAC in 708 (11%). A negative EPS occurred in 9% of cases overall, with no difference by anesthesia strategy (9% GA vs. 10% MAC, p=0.2). In SVT and EAT, there was no significant difference in likelihood of a negative EPS by anesthesia strategy. In PVC/VT, there was a higher rate of negative EPS under GA (28% GA vs. 16% MAC, p=0.02), translating to a higher rate of non-ablation (34% GA vs. 14% MAC, p<0.001). In multivariable models, GA was associated with negative EPS in PVC/VT (OR 2.2, 95% CI 1.1-4.4, p=0.03), but not in SVT or EAT. Acute ablation success was not different between strategies (94% GA vs. 94% MAC, p=0.2). Major AE were rare, with no differences between GA and MAC. Conclusions - In this first report on pediatric ablation data in IMPACT, there were no differences between GA and MAC in SVT or EAT inducibility, acute ablation success, or major AE. GA was associated with higher rates of non-inducibility and non-ablation in PVC/VT cases. A MAC strategy should be considered for PVC/VT ablation in the pediatric population.

Inducibility of atrioventricular nodal reentrant tachycardia and ectopic atrial tachycardia in children under general anesthesia

“…However, children often require general anesthesia, and AVNRT can only be induced in 74% 1 to 89% 2,5 of cases. In pediatric EAT patients, inducibility during EPS has been shown to account for 80% 6 …”

“…Sevoflurane is an anesthetic gas that prolongs the QT interval in adults and children. Its use has been shown to significantly decrease AVNRT inducibility 6 and to modify the accessory pathway in Wolff‐Parkinson‐White (WPW) patients 8 . Mixing sevoflurane with nitrous oxide (N 2 O) allows its minimum alveolar concentration to be reduced from 1.71% to 0.66% to achieve immobility in adults 9 .…”

“…Mixing sevoflurane with nitrous oxide (N 2 O) allows its minimum alveolar concentration to be reduced from 1.71% to 0.66% to achieve immobility in adults 9 . N 2 O has a sympathomimetic effect and does not seem to affect arrhythmia inducibility in pediatric AVNRT 6 and WPW 10 patients.…”

“…It is usually based on propofol, which is known to have a bradycardic effect 11 . However, AVNRT induction seems to be facilitated in pediatric patients under propofol infusion 6 or at least to be unaffected in adults 12 and children 10 . The sparse data on pediatric EAT patients are ambiguous 2,13 .…”

“…Remifentanil is an opioid often given in a continuous infusion and known to cause bradycardia, an effect also observed in a few pediatric AVNRT patients 14 . However, no influence has been shown on tachycardia induction 6 …”