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Rapid Pacing and High Frequency Jet Ventilation Additively Improve Catheter Stability during AF Ablation

Aizer, Anthony; Qiu, Jessica K; Cheng, Austin V; Wu, Patrick B; Barbhaiya, Chirag R; Jankelson, Lior; Linton, Patrick; Bernstein, Scott A; Park, David S; Holmes, Douglas S; Chinitz, Larry A
INTRODUCTION/BACKGROUND:Catheter stability during atrial fibrillation ablation is associated with higher ablation success rates. Rapid cardiac pacing and high frequency jet ventilation (HFJV) independently improve catheter stability. Simultaneous modulation of cardiac and respiratory motion has not been previously studied. The objective of this study was to determine the effect of simultaneous heart rate and respiratory rate modulation on catheter stability. METHODS:Forty patients undergoing paroxysmal atrial fibrillation ablation received ablation lesions at 15 pre-specified locations (12 left atria, 3 right atria). Patients were randomly assigned to undergo rapid atrial pacing for either the first or the second half of each lesion. Within each group, half of patients received HFJV and half standard ventilation. Contact force and ablation data for all lesions were compared among the study groups. Standard deviation of contact force was the primary endpoint defined to examine contact force variability. RESULTS:Lesions with no pacing and standard ventilation had the greatest contact force standard deviation (5.86 + 3.08g), compared to lesions with pacing and standard ventilation (5.45+3.28g, p<0.01) or to lesions with no pacing and HFJV (4.92+3.00g, P<0.01). Lesions with both pacing and HFJV had the greatest reduction in contact force standard deviation, (4.35+2.81g, p<0.01), confirming an additive benefit of each maneuver. Pacing and HFJV together was also associated with a reduction in the proportion of lesions with excessive maximum contact force (p<0.001). DISCUSSION/CONCLUSIONS:Rapid pacing and HFJV additively improve catheter stability. Simultaneous pacing with HFJV further improves catheter stability over pacing or HFJV alone to optimize ablation lesions. This article is protected by copyright. All rights reserved.
PMID: 32314841
ISSN: 1540-8167
CID: 4396962


Aizer, A; Qiu, J K; Cheng, A; Wu, P; Holmes, D; Jankelson, L; Bernstein, S A; Park, D S; Linton, P; Barbhaiya, C R; Chinitz, L A
Background: Increased catheter stability during AF ablation is associated with higher ablation success rates. Rapid cardiac pacing and high frequency jet ventilation (HFJV) have both been independently shown to improve catheter stability. Simultaneous modulation of cardiac and respiratory motion has not been previously studied.
Objective(s): To study the effects of modulating heart rate and respiratory rate simultaneously on catheter stability.
Method(s): Forty paroxysmal AF patients were randomized to four study conditions. Ablation lesions were created at 15 prespecified locations. Twenty patients received atrial pacing (500 msec) during the first half of each lesion; twenty patients were paced during the second half of each lesion. Within each group, half received HFJV and half received standard ventilation. Contact force (CF) variability, defined as CF standard deviation, was compared between study groups.
Result(s): Compared to sinus rhythm and standard ventilation, rapid pacing (5.45 g vs. 5.86 g; p=0.006) and HFJV (5.10 g; p=0.003) each significantly reduced mean CF standard deviation. Simultaneous pacing and HFJV produced even greater reduction of mean CF standard deviation (4.29 g; p<0.001) (Figure). Pacing and HFJV alone had similar effects on mean CF variability (p=0.2).
Conclusion(s): Rapid pacing and HFJV synergistically improve catheter stability during AF ablation. Simultaneous pacing with HFJV further optimizes catheter stability over pacing or HFJV alone and may improve ablation outcomes. [Figure presented]
ISSN: 1556-3871
CID: 4001842

Isoproterenol Increases BIS and Arousal during Catheter Ablation for Atrial Fibrillation

O'Neill, DK; Aizer, A; Bloom, MJ; Kline, RP; Chinitz, L; Linton, PL; Blanck, TJ
ISSN: 2456-5490
CID: 4418512

Perioperative use of bispectral (BIS) monitor for a pressure ulcer patient with locked-in syndrome (LIS)

Yoo, Christine; Ayello, Elizabeth A; Robins, Bryan; Salamanca, Victor R; Bloom, Marc J; Linton, Patrick; Brem, Harold; O'Neill, Daniel K
The bispectral (BIS) monitor uses brain electroencephalographic data to measure the depth of sedation and pharmacological response during anaesthetic procedures. In this case, the BIS monitor was used for another purpose, to demonstrate postoperatively to the nursing staff that a patient with history of locked-in syndrome (LIS), who underwent pressure ulcer debridement, had periods of wakefulness and apparent sensation, even with his eyes closed. Furthermore, as patients with LIS can feel pain, despite being unable to move, local block or general anaesthesia should be provided for sharp surgical debridement and other painful procedures. This use of the BIS has shown that as a general rule, the staff should treat the patient as though he might be awake and sensate even if he does not open his eyes or move his limbs. The goal of this study was to continuously monitor pain level and communicate these findings to the entire wound team, i.e. anaesthesiologists, surgeons and nurses.
PMID: 25252146
ISSN: 1742-4801
CID: 1252522

Wounds in Patients with HIV

McMeeking, Alexander; Kim, In; Ross, Frank; Ayello, Elizabeth A; Brem, Harold; Linton, Patrick; O'Neill, Daniel K
Highly active antiretroviral therapy has dramatically reduced morbidity and mortality among patients who are HIV-positive. A retrospective review of the authors' data separated subjects into cohorts based on HIV status and matched them for age and gender. The authors' data reveal a higher fraction of venous ulcers compared with a lower fraction of pressure ulcers in the seropositive population.
PMID: 25133341
ISSN: 1527-7941
CID: 1132102

Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers

O'Neill, Daniel K; Robins, Bryan; Ayello, Elizabeth A; Cuff, Germaine; Linton, Patrick; Brem, Harold
A treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgical debridement with appropriate anaesthesia management. We are functioning under the hypothesis that regional anaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol for perioperative and postoperative management.
PMID: 22520149
ISSN: 1742-4801
CID: 179184

Isoproterenol infusion increases level of consciousness during catheter ablation of atrial fibrillation

O'Neill, Daniel K; Aizer, Anthony; Linton, Patrick; Bloom, Marc; Rose, Emily; Chinitz, Larry
INTRODUCTION: The objective of this study was to determine the effects of isoproterenol infusion on level of consciousness during ablation using total intravenous anesthesia. METHODS AND RESULTS: Seven patients undergoing total intravenous anesthesia for atrial fibrillation ablation were monitored for level of consciousness using bispectral EEG levels (BIS). Isoproterenol infusion was performed after the ablation during anesthesia. BIS levels prior to, during, and post-isoproterenol infusion were recorded and correlated to isoproterenol infusion doses. In all patients, BIS levels significantly increased during isoproterenol infusion (median BIS prior to infusion, 46; during infusion, 64 (p < 0.02)). With a subsequent increase in anesthetic medication, BIS levels could again be reduced. CONCLUSION: Isoproterenol infusion alters consciousness level during total intravenous anesthesia for atrial fibrillation ablation. BIS monitoring is a novel way to modulate anesthesia during ablation to potentially optimize patient comfort and ablation success.
PMID: 22366997
ISSN: 1383-875x
CID: 173013

Isoproternol increases BIS and arousal during catheter ablation of atrial fibrillation [Meeting Abstract]

O'Neill D.K.; Rose E.; Linton P.; Hull M.; Aizer A.; Bloom M.
Introduction : With the increase in anesthesia utilization in the electrophysiology laboratory, there is greater potential for arrhythmia suppression during electrophysiology study. Intravenous isoproterenol is frequently used to counteract the significant antiadrenergic impact of anesthesia, as well as induce arrhythmias and identify reconnection of pulmonary vein conduction. The effects of isoproterenol on cerebral and respiratory function during the sedated state have not been well studied. The Bispectral (BIS) Vista TM Monitor is a non-invasive device that measures electrical activity of the brain and computes a BIS value, which corresponds to a level of consciousness. The purpose of this study was to determine changes in BIS values during isoproterenol administration. Methods : Twenty consecutive patients underwent electrophysiology study under total intravenous anesthesia using propofol and remifentanil infusions. Isoproterenol was infused at a rate of 5mcg/kg/min and escalated to up to 20mcg/kg/min over 20 minutes. BIS levels were recorded before and throughout isoproterenol administration. Results : Patients demonstrated significant elevation in BIS value during isoproterenol infusion. The mean difference between pre- and post- BIS values was 21.3 [5.4, 37.2] (p = 0.00013). The isoproterenol doses which triggered a BIS spike ranged from 10.8 mcg to 90.8 mcg. The median effective isoproternol dose was 25.2 mcg. The median onset time for an isoproternol stimulated BIS spike was 6.9 minutes with rates from 2 to 20 mcg/minute. Discussion : Isoproterenol significantly increases BIS values during sedated electrophysiology study. Monitoring BIS values may be helpful in assessing the isoproterenol dosage required to overcome the suppressive effects of anesthesia on arrhythmia induction, as well as the potential need for additional anesthetics to prevent patient arousal. Conversely, decreasing BIS values are known to correlate with hypotensive episodes signaling cerebral hypoperfusion. This may be relevant in cases of hemodynamically unstable tachycardias. BIS appears to be an important tool for the optimization of anesthesia when isoproterenol is administered during electrophysiology study
ISSN: 0003-2999
CID: 146278

Blind orotracheal intubation with the intubating laryngeal mask versus fibreoptic guided orotracheal intubation with the Ovassapian airway. A pilot study of awake patients

Dhar P; Osborn I; Brimacombe J; Meenan M; Linton P
In a randomized, prospective pilot study, we compared awake blind orotracheal intubation using the intubating laryngeal mask airway (blind-ILM) with awake fibreoptic-guided orotracheal intubation using an Ovassapian airway (FOS-OA). Fifty-four patients (ASA 1 to 3, aged 18 to 85 years) requiring awake intubation for elective surgery were randomly allocated by coin toss into two groups: 31 patients were intubated blindly through the ILM (blind-ILM) and 23 were intubated using fibreoptic guidance through the Ovassapian airway (FOS-OA). Sedation to a target clinical end-point (spontaneous eye-closing, but responsive to verbal command) was obtained with fentanyl/midazolam and a cricothyroid puncture was performed with 3 ml lignocaine 4%. The oropharynx was then topicalized until tolerance of a Guedel airway was achieved. The number of failed attempts (maximum of three allowed), overall success rates, the time from insertion of the airway to capnographic (blind-ILM) or fibreoptic (FOS-OA) confirmation of intubation or until three failed attempts, and cardiovascular responses before and during intubation, were recorded. The first time (blind-ILM, 25/31 [81%]; FOS-OA, 20/23 [87%], P = 0.6) and overall (blind-ILM, 26/31 [84%]; FOS-OA, 22/23 [96%], P = 0.2) intubation success rates were similar. The mean +/- SD time to intubation was shorter for the blind-ILM group (104 +/- 65 vs 158 +/- 115 sec, P = 0.05). There were no clinically significant differences in blood pressure or heart rate between groups. Compared with baseline values, there was no cardiovascular response to intubation in either group. We conclude that the blind-ILM and FOS-OA techniques have similar success rates and cardiovascular responses, but intubation is slightly quicker with the blind-ILM technique
PMID: 11439795
ISSN: 0310-057x
CID: 21146