Implantation of subcutaneous defibrillator is feasible and safe with monitored anesthesia care

Abstract

Background The perioperative anesthesia care during subcutaneous implantable cardioverter‐defibrillator (S‐ICD) implantation is still evolving. Objective To assess the feasibility and safety of S‐ICD implantation with monitored anesthesia care (MAC) versus general anesthesia (GA) in a tertiary care center. Methods This is a single‐center retrospective study of patients undergoing S‐ICD implantation between October 2012 and May 2019. Patients were categorized into MAC and GA group based on the mode of anesthesia. Procedural success without escalation to GA was the primary endpoint of the study, whereas intraprocedural hemodynamics, need of pharmacological support for hypotension and bradycardia, length of the procedure, stay in the post‐anesthesia care unit, and postoperative pain were assessed as secondary endpoints. Results The study comprises 287 patients with MAC in 111 and GA in 176 patients. Compared to MAC, patients in GA group were younger and had a higher body mass index. All patients had successful S‐ICD implantation. Only one patient (0.9%) in the MAC group was converted to GA. Despite a similar baseline heart rate (HR) and mean arterial blood pressure (MAP) in both groups, patients with GA had significantly lower HR and MAP during the procedure and more frequently required pharmacological hemodynamic support. Length of the procedure, stay in the postanesthesia care unit, and postoperative pain was similar in both groups. Conclusion This retrospective experience suggests that implantation of S‐ICD is feasible and safe with MAC. Use of GA is associated with more frequent administration of hemodynamic drugs during S‐ICD implantation.

Subcutaneous implantable cardioverter defibrillator: Can it overtake its transvenous counterpart

“…Those in the GA group had lower heart rate (HR) and mean arterial pressure (MAP) during the procedure and more frequently needing hemodynamic support. Length of stay, post‐operative pain and stay in the post anesthesia unit remained the same in both groups, however the MAC group was associated with less requirement for hemodynamic support 13 …”

Tumescent local anesthesia for subcutaneous implantable cardioverter-defibrillator implantation: An alternative for general anesthesia

“…One fundamental advantage of MAC is that it bypasses the need for airway manipulation, but this is not translated into reduced procedural times. 9 Moreover, MAC has been related to increased risk of hypoxemia, similarly to GA. 2 This is particularly evident in patients with a body mass index greater than 30 kg/m 2 , even in the absence of other comorbidities. 10 As a consequence, the use of S-ICD has been limited in scenarios where GA is not convenient owing to a high risk of complications, such as the cases presented above with BMD, morbid obesity, and severe pulmonary hypertension.…”

“…The procedural times recorded in this series were shorter than those reported on GA or MAC. 9 This reduction was observed owing to the avoidance of airway manipulation and DFT. Our protocol is to deliver a 10 J shock after device implantation to obtain impedance measurements as a surrogate of DFT, as the latter has been related to myocardial damage and prolonged asystole.…”

Postoperative Pain Control Following Cardiac Implantable Electronic Device Implantation

“…However, there is a trend toward moving away from general anesthesia and postoperative opioids to a different type of pain control [9]. Monitored anesthesia care (MAC) has been reported in the literature to be a safe and effective method for subcutaneous ICD implantation [10,11]. The truncal plane block along with perioperative nonopioid analgesics is being considered and appears feasible and effective [12].…”