Atrial fibrillation ablation performed under general anesthesia is associated with significantly low arterial blood pressure and higher incidence of hypotensive events

Abstract

Abstract Introduction Catheter ablation is a pivotal treatment for atrial fibrillation (AF). When performed under general anesthesia (GA), it may be associated to hypotensive events, with unclear prevalence and prognostic impact. Continuous non-invasive blood pressure (CNBP) measurement is a validated and reliable tool for intraprocedural beat-to-beat advanced hemodynamic monitoring. Purpose To assess and compare the hemodynamic impact of GA during AF ablation using a CNBP (ClearSight) system. Methods In an observational single large volume center study we prospectively enrolled all patients undergoing AF ablation at our institution with CNBP monitoring, as per local practice. Patients were assigned to deep sedation (DS) or general anesthesia (GA) group according to the chosen sedation regimen. The following parameters were compared between the two strategies: systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), cardiac output (CO), cardiac index (CI), stroke volume (SV), stroke volume index (SVI). Hypotension events (HE) (MAP < 65 mmHg) were counted and compared between groups. Results Two hundred patients were enrolled from September 2022 to August 2023. 170 patients underwent AF ablation under DS (76,7% male, mean age 56,77±15,76), while 30 patients were treated under GA (70% male, mean age 60,72±13,79). A total of 117709 measurements were analyzed and compared, for an overall monitoring time of 39293,66 minutes. Patients treated under GA had significantly lower average SBP (104,83±21,48 mmHg vs 138,05±22,09 mmHg, p<0,001), DBP (59,59±11,89 mmHg vs 76,12±12,75 mmHg, p<0,001), MAP (74,96±15,02 mmHg vs 97,12±15,38 mmHg, p<0,001). We also observed significantly lower CO (4,40±1,47 L/min vs 5,16±1,62 L/min, p<0,001), CI (2,22±0,71 L/min/m2 vs 2,61±0,78 L/min/m2, p<0,001) SV (62,37±18,04 mL/beat vs 70,65±24,95 mL/beat, p<0,001) and SVI (31,40±8,54 mL/beat/m2 vs 35,80±12,07 mL/beat/m2, p<0,001). Patients treated under GA witnessed a higher number of per-patient HE (10,53±9,16 vs 0,61±2,07, p<0,001), and higher HE duration (4,8±6,62 min vs 2,82±3,66, p<0,001). Conclusion AF ablation performed under general anesthesia is associated with significantly lower systolic, diastolic, and mean arterial pressure, reduced cardiac output, stroke volume and stroke volume index when compared to deep sedation. Patients undergoing AF ablation under GA witness higher incidence and duration of hypotensive events. CNBP is a valid tool for beat-to-beat procedural hemodynamic assessment and can help identifying and treat hypotensive events. Further studies are needed to assess the potential prognostic impact of intraprocedural hypotension during AF ablation.