Deep sedation with dexmedetomidine administered by electrophysiologists during COVID-19 pandemic compared with propofol administered by anesthesiologists for transcatheter ablation of atrial fibrillation (preprint)

Background: COVID-19 pandemic, limiting the availability of anesthesiologists, has impacted heavily on the organization of invasive cardiac procedures such as transcatheter atrial fibrillation (AF) ablation. Objective We compared the safety and efficacy of deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision, against the standard protocol performed with propofol. Methods We retrospectively included all AF ablation procedures performed in 2020: 23 patients sedated with 1% propofol (2 ml bolus followed by infusion starting at 1 mg/Kg/h), 26 patients with dexmedetomidine (infusion starting at 0.7 mcg/Kg/h). Both groups additionally received 1 mcg/Kg of midazolam as a single bolus and 0.05 mg single boluses of fentanyl prior to ablation on each pair of pulmonary veins (PV). Primary outcomes were oxygen desaturation (<90%) or need for assisted ventilation/intubation, bradycardia (heart rate <45 bpm) and persistent hypotension (systolic blood pressure <90 mmHg). Results Baseline characteristics and hemodynamic variables did not differ between the two groups (all p>0.05). In 8/23 (35%) patients propofol infusion velocity reduction was necessary to maintain the hemodynamic values, compared to 7/26 (27%) with dexmedetomidine. Inter-group comparison of hemodynamic variables during the procedure showed no statistically significant difference, despite a trend in favor of dexmedetomidine (3 respiratory depressions and 3 persistent hypotension episodes with propofol vs. 0 with dexmedetomidine; p = 0.057). Conclusion Deep sedation with dexmedetomidine administered by electrophysiologists without anesthesiologist supervision is safe and effective for AF transcatheter ablation. A trend towards a lower incidence of hypotension and respiratory depression was noted when compared to propofol.

Reorganizing the device clinic: remote monitoring of cardiac implantable electronic devices during the COVID-19 pandemic (preprint)

COVID-19 pandemic has caused a necessary reorganization of the elective outpatient device clinic. Remote monitoring (RM) of cardiac implantable electronic devices (CIEDs) has been validated as a safe and effective tool to follow patients, limiting the need for in-person visits. We provided a snapshot of the current clinical practice in a tertiary electrophysiology center in Italy, suggesting a potential model of care for patients with CIEDs. Before the COVID-19 pandemic, patients with implantable cardioverter defibrillators/cardiac resynchronization therapy (ICD/CRTs) were evaluated in the device clinic twice a year and patients with pacemakers (PMs) once a year; loop recorder (ILR) patients were followed remotely only. In the COVID-19 period RM was implemented for all compatible CIEDs. Patients with RM were not seen in clinic anymore and were followed with RM. In the COVID-19 period, 100% of newly implanted devices received RM (82 ILR, 194 PMs, 80 ICDs/CRTs), compared to 68% in the same months of 2019 (106/106 ILR, 83/203 PMs, 78/82 ICD/CRTs), p<0.01. Moreover, 502 previously implanted patients with RM compatible devices were contacted and received RM. By the end of February 2021, 1676 patients were remotely monitored at our Institution, with a potential saving of outpatient visits of 1683 visits/year, against an average of 8514 RM transmissions/year needing evaluation. RM of CIEDs is essential to reduce in-person visits during the COVID-19 pandemic. The potential for elective outpatient appointments reduction has to be counterbalanced by the sustainability of a large number of transmissions and data to analyze.