Prolonged transesophageal echocardiography during percutaneous closure of the left atrial appendage without general anesthesia: the utility of the Janus mask

Abstract

Purpose Left atrial appendage (LAA) closure is an interventional procedure increasingly used to prevent stroke in patients with permanent atrial fibrillation and contraindications to anticoagulation therapy. As this procedure requires a relatively immobile patient and performance of continuous and prolonged transesophageal echocardiography (TEE), it is usually performed under general anesthesia. In this case series, we describe the feasibility of prolonged TEE for percutaneous LAA closure using a new noninvasive ventilation device that can avoid the need for endotracheal intubation and general anesthesia. Clinical features Percutaneous LAA closure was performed under deep sedation in three elderly patients with permanent atrial fibrillation. Sedation was obtained with a combination of midazolam, propofol, and remifentanil. Continuous intraoperative TEE was performed through the port of the newly available Janus mask (Biomedical Srl; Florence, Italy), allowing for noninvasive ventilation (pressure support = 12-16 cm H 2 O; positive end-expiratory pressure = 7 cm H 2 O; FIO 2 = 0.3) in these spontaneously breathing patients. The total procedure times ranged from 75-90 min. The patients reported excellent satisfaction with the sedation received in terms of discomfort experienced during the procedure, capacity to recall the procedure, and comfort with the mask. The operators also rated the procedural conditions as excellent. ConclusionDeep sedation with noninvasive ventilation may be a reasonable and safe alternative to general endotracheal anesthesia in patients requiring prolonged TEE for noninvasive cardiac procedures, including LAA closure. RésuméObjectif La fermeture de l'appendice auriculaire gauche (AAG) est une procédure interventionnelle de plus en plus utilisée pour prévenir les accidents vasculaires cérébraux chez les patients souffrant de fibrillation auriculaire chronique ou présentant des contre-indications à l'anticoagulothérapie. Comme cette intervention requiert que le patient soit relativement immobile et une échocardiographie transoesophagienne (ETO) continue et prolongée, elle est habituellement réalisée sous anesthésie générale. Dans cette série de cas, nous décrivons la faisabilité d'une ETO prolongée pour la fermeture Electronic supplementary material The online version of this article

Noninvasive ventilation in acute respiratory failure: which recipe for success?

“…The utility of NPPV in airway endoscopy is supported by stronger evidence: observational studies and RCTs have been performed showing that NPPV prevents hypoxia when compared to HFNC and oxygen therapy [61][62][63]. Specific masks for procedural NPPV optimisation have been developed and their clinical use is currently the object of promising studies [64].…”

Noninvasive ventilation during left atrial appendage closure under sedation: Preliminary experience with the Janus Mask

“…Our group recently published a case-series of three subjects undergoing LAAO under sedation and NIV with Janus mask, reporting for the first time feasibility of this approach. [13] In the current manuscript, we report for the first time a case–control study including a comparison with a group receiving general anesthesia (which is standard of care), and we expanded our case-series to a total of 11 subjects. Our preliminary experience suggests that sedation and ventilator support with the Janus mask may be an interesting alternative strategy to general anesthesia for LAAO procedures.…”

“…The Janus Mask (Biomedical Srl; Florence, Italy) [Figure 1] is a device designed to permit endoscopic procedures on airways or upper gastrointestinal tract during noninvasive ventilation (NIV). [11121314151617]…”

Two different endoscopic procedures made feasible by the Janus mask in a high-risk patient

“…This was made feasible thank to a new available mask for NIV (called “Janus”) that allows to perform upper endoscopic procedures during NIV. [9101112] The hole in the middle of the mask permits the introduction of the endoscopic probe into the mouth or the nose of a patient without interrupting the NIV support and with only minimal and nonrelevant air leakage around the probe. At the same time, as the mask can be opened in two halves, it can be placed on a patient's face even during an already ongoing endoscopic procedure if he requires NIV support for any cause.…”

“…Obviously, the Janus mask can be also used as a traditional full face mask for NIV regardless of upper endoscopies as the hole can be closed with an appropriate cap. [910] Since our patient had a sudden ARF due to pneumonia and pneumomediastinum, tracheal intubation could be an option to perform the endoscopic procedures safely. Anyway, he should have been transferred to the Intensive Care Unit (ICU) because it would have been impossible to extubate the patient after the procedures.…”