Analgosedation in invasive electrophysiology: protocol in the absence of an anesthesiologist

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Abstract Background Common practice regarding deep analgosedation in interventional electrophysiology (EP) worldwide is not yet well established and outlined. it is subject to institutional, local and international rules-laws. AF Ablation procedures require analgosedation. It is important for patient not to move during ablation to minimize the risk of complications through transeptal puncture and reducing the risk of re-mapping and complications in catheter navigation and ablation. Currently, Pulsed Field Ablation (PFA) is performed under general anesthetic (GA) deep sedation (i.e. propofol), necessitating anesthesiologists support due to restricting propofol use regulations. Purpose This work aims to evaluate the efficacy of and determine/optimize the best available therapeutic plan to relieve pain during complex and more painful atrial fibrillation catheter ablation procedures in the absence of an anesthesiologist, considering that in Italy, currently, the use of propofol is the prerogative of the anesthesiologist-resuscitator, and not of the cardiologist. Methods 218 consecutive subjects presented to our Laboratory for EP study and possible ablation (April 10, 2024 - January 23, 2025), under elective EP procedure regimen. Of these, 113 subjects were enrolled in the study, 86 male (76%) and 27 female (24%). The deep analgosedation protocol of our EP laboratory uses i.v. Midazolam and Pethidine boluses intraprocedurally, under continuous blood pressure, pulse oximetry, heart and respiratory rhythm and rate monitoring. After ablation, patients were monitored for 2-3 hours until discharge. The EP procedures were divided into groups: Pulmonary Vein Isolation (PVI) only, PVI + Lines, PVI + CTI. Ablation energy modes: Point-by-point Radiofrequency, Cryo and PFA. Results In Figures. Conclusions · In symptomatic atrial fibrillation cases, with indication for ablation, male gender is prevalent (76%). · The most important data is the complete asymptomatic nature and intraprocedural clinical stability of patients and the absolute absence of movement. The maintenance of deep analgosedation was easy and effective. · Trend of indexed dosage per kg for both Pethidine and Midazolam is not closely related to procedure duration. · Correlation between dosage trend of Pethidine and Midazolam does not exhibit strong positive correlation. · In summary: despite the impossibility to organize this study into a randomized trial, due to the Italian legislation regarding propofol, the management and maintenance of deep analgosedation was easy, effective and safe. No intra- or post-procedural side effects related were reported. Good sedation parameters were achieved and positive feedback reported by patients obtained. The use of this deep analgosedation protocol, asks for EP professionals be trained in cardiac sedation and advanced cardiac life support. Currently, there is no standardized strategy for deep analgosedation protocols.Figure1 Figure2

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