Anaesthesia Management for Ablation Therapy in Post Heart Transplant Arrhythmia

doi:10.4236/ojanes.2013.38074

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Open Journal of Anesthesiology, 2013, 3, 349-352

http://dx.doi.org/10.4236/ojanes.2013.38074 Published Online October 2013 (http://www.scirp.org/journal/ojanes) 349

Anaesthesia Management for Ablation Therapy in Post

Heart Transplant Arrhythmia*

Sunisa Prapaitrakool, Daniel Tom Bainbridge, Ronit Lavi#

Department of Anaesthesia and Perioperative Medicine, London Health Science Centre, University of Western Ontario, London,

Canada.

Email: [email protected], Da[email protected], #[email protected]

Received April 30th, 2013; revised June 1st, 2013; accepted July 15th, 2013

cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

In this case series we describe the anaesthetic management of atrial ablation for arrhythmia in three post heart transplant

patients. These patients provide a unique challenge to the anaesthesiologist, as heart physiology, end organs effects,

procedural related factors should all be part of the specific anaesthetic plan tailored for each patient individually. The

different anaesthetic techniques applied, and procedure related complications are evaluated. Anaesthetic management,

procedural related difficulties, pharmacologic aspects, and possible associated complication s are reviewed .

Keywords: Ablation; Heart Transplant; Arrhythmia

1. Introduction

Heart transplantation has become a therapeutic option fo r

a variety of end-stage heart diseases with over 2000 cases

performed annually in the United States and approxi-

mately 3500 cases worldwide [1]. As a result of an in-

creasing number of patients surviving cardiac transplan-

tation and the relatively high incidence of atrial arrhyth-

mias in these patients, ablation procedures under anaes-

thesia may be required [2,3]. Percutaneous catheter abla-

tion is done with applying electrical triggers around the

pulmonary vein ostia in order to accomplish pulmonary

vein isolation using radiofrequency current. Radiofre-

quency ablation applies high-frequency, low-voltage

electrical energy to the endocardium via a catheter-based

electrode that leads to resistive thermal injury and sub-

sequent coagulative necrosis of the tissue, thereby block-

ing reentrant electrical circuits causing atrial fibrillation

[4]. Other reports have focused on the mechanism for

atrial flutter post heart transplantation and potential ther-

apy from cardiology perspective [5,6]. In this report we

will focus on Anaesthesia management for ablation ther-

apy in post heart transplant arrhythmia.

The transplanted he art physiology is different, and can

complicate anaesthetic management. Therefore, anaes-

thesiologists should be aware of particular problems and

risks associated with ablation procedures in this unique

group of patients. We present three cases of atrial abla-

tion due to arrhythmia after heart transplantation and

discuss the anaesthetic considerations for these proce-

dures.

2. Case Report

Written informed consent was obtained from all patients.

2.1. Case #1

A 47-year-old man received a cardiac transplantation due

to sarcoid cardiomyopathy 6 years before the ablation

procedure with a biatrial technique. He presented with

recurrent episodes of atrial fibrillation refractory to both

medical treatment and multiple cardioversion attempts.

He developed renal compromise with a slightly increase

in creatinine after the transplant. His current immuno-

suppressants were cyclosporine and mycophenolate mo-

fetil. Electrophysiologic (EP) studies and radiofrequency

ablation were done twice in the last 2 years.

The first EP study showed supraventricular tachycar-

dia (SVT) from Wolff-Parkinson-White syndrome. The

patient received sedation with both a propofol and fen-

tanyl infusion which was well tolerated for the first 90

minutes. It was then converted to a general anaesthetia

using a laryngeal mask airway, and sevoflurane to pro-

vide adequate level of anaesthesia for the next 100 min-

*The authors declare no financial support or conflict of interest.

#Corresponding author.

Anaesthesia Management for Ablation Therapy in Post Heart Transplant Arrhythmia

350

utes of the procedure.

The second EP study revealed atrial fibrillation origi-

nating from the recipients’ atrial cuff. Conscious sedation

was conducted with sufentanil and midazolam during the

procedure, which last ed over 4 ho u rs.

The ablation procedures were done successfully with-

out any complications.

2.2. Case #2

A 65-year-old received a cardiac transplant due to end

stage rheumatic valvular cardiomyopathy 13 years b efore

the ablation procedure with a biatrial technique. He pre-

sented with refractory atrial flutter. His current medica-

tions included cyclosporine, azathioprine, prednisolone,

diltiazem, atorvastatin, and furosemide. EP studies and

ablation showed peri-mitral flutter. The procedure was

performed under sedation with midazolam and fentanyl

with an anesthetic time of 145 minutes. The procedure

was done successfully, however the patient received 2

liters of normal saline as ablation catheter irrigation fluid

and developed orthopnea, and pulmonary edema after the

procedure which improved with intravenous furosemide.

2.3. Case #3

A 49-year-old man received his heart transplant 24 years

ago due to idiopathic cardiomyopathy by the biatrial

technique. He developed paroxysmal rapid atrial flutter

and underwent multiple cardioversions with medical

treatment during the last 2 years, however his atrial flut-

ter was refractory to those treatments and required an

ablation procedure. His post transplant course was com-

plicated by progressive renal failure and hypertension.

The EP study and pulmonary vein ablation were done

using the transseptal approach under Transesophageal

Echocardiography (TEE) which was technically very

difficult. The patient received general anesthesia with an

endotracheal tube, invasive intra-arterial monitoring and

maintaining the activated clotting time (ACT) > 300. As

the procedure concluded, and the lines were taken out,

the AV node was injured, and complete heart block oc-

curred. The patient did not respond to atropine and had to

be paced. The anaesthetic duration was over 6 hours.

3. Discussion

Cardiac arrhythmias are frequently encountered after

heart transplantation. Previous studies demonstrated that

about a quarter of these patients developed SVT attrib-

uted to macro-reentrant tachycardia, and about 4% un-

derwent EP studies [2,3]. Anesthesia for ablation proce-

dures in these patients mandate several considerations

including transplant technique used, interventional cardi-

ology procedure performed, and particular complications

common to post transplan t patients.

All three patients described had biatrial anastomosis

which altered heart anatomy and predisposed the atrium

to various re-entrant arrhythmias [7]. The third patient

who received heart transplant for the longest time in the

series (24 years before the ablation procedure) encoun-

tered a lot of technical difficulty during the lengthy pro-

cedure which is probably due to a combination of cardiac

fibrosis and complicated anatomy.

The specific considerations for patients undergoing

interventional cardiology procedures include pain man-

agement and increased incidence of complications. Pain

caused by the procedure is of variable intensity due to

radiofrequency ablation that generates heat and causes

tissue damage [8]. An 8-mm-tip ablation catheter is gen-

erally used at our institution, power (20 - 50 Watt) and

temperature use is limited to 50˚C, however power up to

100 Watt and temperature up to 65˚C may be required.

Post heart transplant patients, may have minimal pain

due to neuronal denervation. Periprocedural complica-

tions are usually related to mechanical trauma or the use

of radiofrequency power. This includes pericardial effu-

sion, cardiac tamponade, thromboembolism, persistent

defect of the inter atrial septum, aortic perforation, atrial

perforation, atrio-esophageal fistula, acute coronary ar-

tery occlusion (circumflex artery), phrenic nerve injury,

air emboli, periesophageal vagal injury, catheter entrap-

ment in the mitral valve, dysrrhythmia, and complete

heart block. An atrio-esophageal fistula is a rare but po-

tentially fatal complication, and may manifest weeks

after the ablation procedure [9]. If trans septal puncture is

expected, TEE may enhance safety by allowing monitor-

ing of catheter positioning as well as evaluation of com-

plications [10,11]. Anticoagulant and ACT monitoring is

crucial. Esophageal temperature monitoring may help

reduce thermal injury from ablation [9].

Cardiac denervation causes impaired autonomic regu-

latory mechanism, delayed stress response, loss of vagal

tone resulting in a resting heart rate of 90 - 100 per min-

ute and alterations to demands for increased cardiac out-

put. Therefore, maintenance of adequate preload is cru-

cial. Coronary atherosclerosis will be accelerated (silent

ischemia is likely). Renervation of the transplanted heart

may occur, but to an unknown extent. The first patient,

who underwent transplant 6 years before, had the atrial

fibrillation originating from the receipient’s atrial cuff

which dem onstra ted t he occ urren ce of renervation.

Immunosuppression is usually maintained with the

three-drug regimen which includes cyclosporine, azathio-

prine and corticosteroids is common (tacrolimus and

mycophenolate mofetil may replace cyclosporine and

azathioprine, respectively). Frequent consequences of

immunosuppressants include hypertension and renal im-

pairment, which may affect choices of anesthetic agents,

Anaesthesia Management for Ablation Therapy in Post Heart Transplant Arrhythmia 351

and are associated with tacrolimus and cyclosporine.

Steroids can commonly cause hyperlipidemia and osteo-

porosis whereas Azathioprine frequently causes bone

marrow suppression. Other infrequent complications

include malignancy, gastrointestinal biliary disease, pan-

creatitis and peptic ulcer disease [10].

Drugs that act indirectly on the heart via either sym-

pathetic or parasympathetic nervous system (ephedrine,

atropine) will be ineffective. Drugs with a mixture of

direct and indirect effects (digoxin, norepinephrine, and

neostigmine) will exhibit only their direct effects. Agents

with direct cardiac effects (epinephrine, isoproterenol)

are more reliable.

Providing anesthesia for a high risk patien t in a hostile

environment outside of the operating room mandates

careful assessment of the patient and meticulous ar-

rangements for any possible complication and emergen-

cies. Preoperative assessment should focus on graft func-

tion and end organs function, especially those that might

be compromised by the long standing immunosuppres-

sive therapy and possible dysfunction of the transplanted

heart. Ablation procedures in a transplanted heart are

technically challenging due to altered heart anatomy,

intra thoracic position, and cardiac fibrosis which may

increase the incidence of life threatening complications.

Transcutaneous pacing and a defibrillator should be pre-

pared as well as emergency resuscitation measures.

Procedures performed on the right side of the heart are

usually less complicated than left sided procedures,

which mandate inter-atrial septal puncture. For ablation

within the right side of the heart, conscious sedation with

adequate analgesia is adequate to ensure calm and pain

free status without compromising the airway. However

the expected long duration of the procedure in these pa-

tients may influence the anaesthetic choice. When deeper

level of anesthesia or a prolonged procedure is required,

laryngeal mask airway or intratracheal tube may be used.

If TEE is required, deeper general anesthesia with se-

cured airway with an endotracheal tube is mandatory.

In conclusion, the management of heart transplanted

patients undergoing atrial ablation procedures includes a

thorough history and physical examination, understand-

ing of the procedure type, the transplanted heart anatomy

and the heart and end organs function. Furthermore, spe-

cial considerations should be addressed for management

of high risk patients outside of the operating room in a

remote location, lengthy procedures associated with

technical difficulties, management of possible complica-

tions, and considerations in altered medications pharma-

cology. The anaesthetic plan shou ld be tailored individu-

ally, and in collaboration with the cardiologists in order

to provide the appropriate anaesthetic technique for the

specific patient according to the planed intervention.

REFERENCES

[1] M. S. Mulligan, T. H. Shea ron, D. Weill, F. D. Pagani, J.

Moore and S. Murray, “Heart and Lung Transplantation

in the United States, 1997-2006,” American Journal of

Transplantation, Vol. 8, No. 4p2, 2008, pp. 977-987.

http://dx.doi.org/10.1111/j.1600-6143.2008.02175.x

[2] M. Vaseghi, N. G. Boyle, R. Kedia, J. K. Patel, D. A. Ce-

sario, I. Wiener, J. A. Kobashigawa and K. Shivkumar,

“Supraventricular Tachycardia After Orthotopic Cardiac

Transplantation,” Journal of the American College of

Cardiology, Vol. 51, No. 23, 2008, pp. 2241-2249.

http://dx.doi.org/10.1016/j.jacc.2008.02.065

[3] S. A. L. Ahmari, T. J. Bunch, A. Chandra, V. Chandra, K.

Ujino, R. C. Daly, S. S. Kushwaha, B. S. Edwards, Y. F.

Maalouf, J. B. Seward, C. G. McGregor and K. Chandra-

sekaran, “Prevalence, Pathophysiology, and Clinical Sig-

nificance of Post-Heart Transplant Atrial Fibrillation and

Atrial Flutter,” The Journal of Heart and Lung Trans-

plantation, Vol. 25, No. 1, 2006, pp. 53-60.

http://dx.doi.org/10.1016/j.healun.2005.07.017

[4] H. Oral, C. Scharf, A. Chugh, B. Hall, P. Cheung, E.

Good, S. Veerareddy, F. Pelosi and F. Morady, “Catheter

Ablation for Paroxysmal Atrial Fibrillation: Segmental

Pulmonary Vein Ostial Ablation versus Left Atrial Abla-

tion,” 2003, pp. 2355-2360.

[5] F. Rodríguez-Entem, V. Expósito, S. González-Enríquez,

T. García-Camarero and J. Olalla, “Atrial Flutter after

Heart Transplantation: Mechanism and Catheter Abla-

tion,” Transplantation Proceedings, Vol. 42, No. 7, 2010,

pp. 2697-2701.

http://dx.doi.org/10.1016/j.transproceed.2010.04.067

[6] J. A. Mariani, M. A. McDonald, K. Nanthakumar, J. D.

Parker and H. J. Ross, “Cardiac Resynchronization Ther-

apy after Atrioventricular Node Ablation for Rapid Atrial

Fibrillation in a Heart Transplant Recipient with Late Al-

lograft Dysfunction,” The Journal of Heart and Lung

Transplantation, Vol. 29, No. 6, 2010, pp. 704-706.

http://dx.doi.org/10.1016/j.healun.2010.01.009

[7] A. Jeffrey and N. M. E. Morgan, “Orthotopic Cardiac

Transplantation: Comparison of Outcome Using Biatrial,

Bicaval, and Total Techniques,” Journal of Cardiac Sur-

gery, Vol. 20, No. 1, 2005, pp. 102-106.

http://dx.doi.org/10.1111/j.0886-0440.2005.05011.x

[8] P. Lena, C. Mariottini, N. Balarac, J. Jacques Arnulf, A.

Mihoubi and R. Martin, “Remifentanil versus Propofol

for Radio Frequency Treatment of Atrial Flutter,” Cana-

dian Journal of Anesthesia, Vol. 53, No. 4, 2006, pp. 357-

362. http://dx.doi.org/10.1007/BF03022499

[9] A. Natale, A. Raviele, T. Arentz, H. Calkins, S. Chen, M.

Haïssaguerre, G. Hindricks, Y. Ho, K. Kuck, F. March-

linski, C. Napolitano, D. Packer, C. Pappone, E. Prystow-

sky, R. Schilling, D. Shah, S. Themistoclakis and A. Ver-

ma, “Venice Chart International Consensus Document on

Atrial Fibrillation Ablation,” Journal of Cardiovascular

Electrophysiology, Vol. 18, No. 5, 2007, pp. 560-580.

http://dx.doi.org/10.1111/j.1540-8167.2007.00816.x

[10] L. Blier, M. Gilbert, J. Villeneuve, D. Mohty and G.

O’hara, “Endothelial Progenitor Cells Restore Renal Func-

tion in Chronic Experimental Renovascular Disease,”

Anaesthesia Management for Ablation Therapy in Post Heart Transplant Arrhythmia

352

Pacing and Clinical Electrophysiology, Vol. 30, 2007, pp.

116-119.

[11] G. B. Chierchia, L. Capulzini, C. de Asmundis, A. Sar-

kozy, M. Roos, G. Paparella, T. Boussy, G. Van Camp, D.

Kerkhove and P. Brugada, “First Experience with Real-

Time Three-Dimensional Transoesophageal Echocardi-

ography-Guided Transseptal in Patients Undergoing Atrial

Fibrillation Ablation,” 2008, pp. 1325-1328.