Anesthetic and Perioperative Considerations for Convergent Procedure for Atrial Fibrillation, A Retrospective Observational Cohort Study

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ObjectivesTo summarize anesthetic and perioperative considerations in patients undergoing the convergent procedure for atrial fibrillation (AF). DesignRetrospective observational study. SettingSingle center quaternary teaching hospital. ParticipantsAdult patients with atrial fibrillation undergoing the convergent procedure before January, 2024. InterventionsRetrospective chart review. Measurements/main resultsA total of 40 patients were included; of them 35 patients had persistent longstanding AF. The mean age (SD) was 64 (6) years and 33 patients (83%) were male. Common comorbidities included obesity 27 (68%), obstructive sleep apnea 29 (73%), history of tachycardia-mediated cardiomyopathy 10 (25%), and significant alcohol use 10 (25%). Sixteen of 40 patients (40%) had a history of prior endocardial ablation, and 37 patients (93%) required a cardioversion in the past. In all, 39 patients (98%) were anticoagulated and 38 (95%) were on at least 1 anti-arrhythmic medication prior to the procedure. All patients received general anesthesia; 39 patients (98%) inhalational and 1 patient (3%) total intravenous, with regional analgesia adjuncts in 36 patients (88%). All patients required lung isolation, arterial line, central venous access, and transesophageal echocardiographic monitoring. While cardiopulmonary bypass (CPB) was on standby and ready to be initiated for every patient, only 3 patients (8%) required CPB (1 planned, 2 emergent). Thirty seven of 40 patients (93%) were extubated in the operating room, and 11 (28%) of patients required intensive care unit (ICU) admission (planned or unplanned). The median ICU and hospital length of stay were 1 and 4 days, respectively. ConclusionsThis retrospective analysis of medical records showed that many patients with recurrent atrial fibrillation presenting for convergent procedure carry a burden of multiple comorbidities (obesity, obstructive sleep apnea), and history of unsuccessful ablations. Multistage multidisciplinary convergent procedure might be lengthy, potentially complicated and requires meticulous preparation (endotracheal intubation, lung isolation, advanced cardiac monitoring, central venous access) to ensure optimal outcomes. Anesthesiologists and perioperative physicians should tailor their approach to this multimorbid population, while anticipating perioperative respiratory events, rapid hemodynamic shifts, blood loss, and a possibility of cardiopulmonary bypass.