Conscious Sedation Group Research Articles

Effect of Valve Type and Anesthesia Strategy for TAVR: 5-YearResultsoftheSOLVE-TAVITrial.

In the randomized SOLVE-TAVI (compariSon of secOnd-generation seLf-expandable vs. balloon-expandable Valves and gEneral vs. local anesthesia in Transcatheter Aortic Valve Implantation) trial comparing newer-generation self-expanding valves (SEV) and balloon-expandable valves (BEV), as well as conscious sedation (CS) and general anesthesia (GA), clinical outcomes were similar both for valve and anesthesia comparison at 30days and 1 year. Prosthesis durability may affect clinical outcomes during long-term follow-up. Moreover, the impact of the anesthesia strategy on long-term clinical outcomes is unknown so far. The authors sought to compare clinical outcomes during 5-year follow-up in the randomized SOLVE-TAVI trial. In the randomized, multicenter, 2× 2 factorial, open-label SOLVE-TAVI trial, 447 intermediate- to high-risk patients with severe, symptomatic aortic stenosis were randomly assigned to transfemoral transcatheter aortic valve replacement (TAVR) using either SEV (Evolut R, Medtronic) or BEV (SAPIEN 3, Edwards Lifesciences) and also to CS vs GA. Patients were followed-up for 5 years. During 5 years of follow-up, the combined predefined endpoint of all-cause mortality, stroke, moderate or severe paravalvular leakage, and permanent pacemaker implantation was similar in the SEV and BEV groups (67.7% vs 63.4%; HR: 0.89; 95%CI: 0.70-1.13; P=0.34). Stroke rates at 5 years were lower in the SEV group (2.2% vs 9.6%; HR: 4.84; 95%CI: 1.65-14.18; P=0.002). Regarding the anesthesia comparison, the primary endpoint of all-cause mortality, stroke, myocardial infarction, and acute kidney injury occurred in 51.4% in the CS group and 61.3% in the GA group (HR: 0.80; 95%CI: 0.62-1.04; P=0.09). All-cause mortality at 5 years was lower for CS (41.5% vs 54.3%; HR: 0.70; 95%CI: 0.53-0.94; P=0.02). Transfemoral TAVR using either SEV and BEV as well as CS and GA showed similar clinical outcomes at 5 years using a combined clinical endpoint.

General anaesthesia compared to conscious sedation for first-time atrial fibrillation catheter ablation-a Danish nationwide cohort study.

Catheter ablation (CA) is a well-established treatment option for atrial fibrillation (AF), where sedation and analgesia are pivotal for patient comfort and lesion formation. The impact of anaesthesia type on AF recurrence rates remains uncertain. This study aimed to examine AF recurrence rates depending on conscious sedation (CS) vs. general anaesthesia (GA) during CA. Utilizing nationwide data from the Danish healthcare registries, we conducted this cohort study involving adults (≥18 years) undergoing first-time CA for AF between 2010 and 2018. Patients were categorized by anaesthesia type (CS or GA), with the primary endpoint being AF recurrence, defined by a composite endpoint of either antiarrhythmic drug (AAD) prescriptions, AF-related hospital admissions, electrical cardioversions, or AF re-ablation. The impact of anaesthesia type was evaluated using multivariable Cox proportional hazards analysis. The study cohort comprised 7957 (6421 CS and 1536 GA) patients. Persistent AF, hypertension, and heart failure, as well as use of AAD, were more prevalent in the GA group. Cumulative incidences of recurrent AF were higher in the CS group at 1 (46% vs. 37%) and at 5 (68% vs. 63%) years. Multivariate analysis revealed CS as significantly associated with increased risk of AF recurrence at 5-year follow-up [hazard ratio 1.26 (95% confidence interval 1.15-1.38)], consistent across paroxysmal and persistent AF subtypes. This nationwide cohort study suggests a higher risk of AF recurrence with CS during CA compared to GA. These results advocate for considering GA as the preferred anaesthesia type for improved CA outcomes.

A Meta-Analysis Comparing General Anesthesia, Deep Sedation, and Conscious Sedation for Catheter Ablation of Atrial Fibrillation

Background: The optimal anesthesia strategy during catheter ablation of atrial fibrillation (AF) remains controversial. This meta-analysis compared general anesthesia, deep sedation, and conscious sedation in terms of procedural time and complications. Methods: Literature searches were conducted in PubMed, EMBASE, and Web of Science databases. Mean differences (MDs) and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using fixed- and random-effect models on the basis of the heterogeneity among studies, as assessed by I2 statistics. The random-effect model was used when the heterogeneity was high (I2 > 50%). Publication bias was evaluated through funnel plots and Egger's tests. Results: Sixteen studies were included in this study. No significant difference was observed in procedural time between the general anesthesia and conscious sedation groups (MD: –8.1479 minutes, 95% CI: from –27.6836 to 11.3878, seven studies). Deep sedation was associated with procedural time (MD: 131.8436 minutes, 95% CI: 99.6540–164.0332, eight studies). The rate of serious intraprocedural complications was 1.5% (95% CI: 1.2%–1.9%) with deep sedation (seven studies). Conscious/analog sedation had 26%–29% higher odds of perioperative complications than general anesthesia (OR: 1.2622, 95% CI: 1.0273–1.5507, nine studies). Significant heterogeneity was present across studies. Conclusions: This meta-analysis found no significant difference in procedural time between general anesthesia and conscious sedation for AF ablation. Deep sedation was associated with longer procedural time. Conscious sedation appeared to have a higher risk of perioperative complications than general anesthesia. Further randomized trials are warranted to determine the optimal anesthesia strategy.

Conscious sedation for the management of peritonsillar abscess in pediatric patients: A prospective case series and literature review

ObjectivePeritonsillar abscess (PTA) is a common pediatric infection requiring drainage. Conscious Sedation (CS) can facilitate drainage in uncooperative children. However, it carries risks, especially if the airway is compromised. Moreover, evidence on its safety and efficacy is limited. This study examined the safety, pain reduction, and anxiety management of hospitalized pediatric patients treated for PTA under CS. Materials and methodsWe performed a prospective observational case series of 118 children aged 2–15 years with 155 PTA episodes, managed from 2016 to 2023. Conscious sedation was used in 42 episodes. Outcomes were compared among CS and non-CS (local anesthesia only). Complications assessed safety. Efficacy was evaluated by the amount of pus, hospitalization parameters, pain scores, and recurrence. ResultsNo significant differences were found regarding the demographic and presentation parameters except for younger age among the CS group (9 vs 11 years p = 0.001). One minor oxygen desaturation (2 %) event occurred with CS. Abscess drainage amount was greater with CS than non-CS, 4.9±4 mL vs. 3.2±2 mL, respectively (p = 0.03). Hospitalization stays were similar among groups. Maximum pain scores were lower with CS than non-CS, 1.4 ± 2 vs 4.2 ± 3 (p < 0.001); similarly, IV pain medication was used less frequently, 0.9 ± 1 vs. 1.6 ± 3 (p = 0.045), and the need for re-aspiration was less common 14 % vs. 28 % (p = 0.04), with CS than non-CS, respectively. The three-month recurrence rate was numerically lower with CS (5 % vs. 14 % non-CS). ConclusionsConscious sedation facilitates PTA drainage with excellent safety and improved efficacy compared to local anesthesia in children. Pain scores are reduced both during drainage and hospitalization. Our prospective data add to the limited evidence supporting CS as a viable option for abscess drainage in uncooperative pediatric patients. Further study is warranted to confirm potential long-term reductions in recurrence.

EVALUATING ERCP OUTCOMES: GENERAL ANESTHESIA VS. CONSCIOUS SEDATION IN A TERTIARY CARE SETTING

Endoscopic Retrograde Cholangiopancreatography (ERCP) is a critical technique for diagnosing and treating conditions affecting the biliary and pancreatic ducts. Recently, there has been a shift towards employing general anesthesia instead of conscious sedation for these interventions to enhance comfort and efficiency, particularly in intricate cases. This investigation evaluates the decision-making process behind general anesthesia over conscious sedation and assesses their comparative effectiveness and associated complication rates. Methods: Conducted as a retrospective cohort study at Akhtar Saeed Medical and Dental College Lahore, Pakistan, in the period from November 2023 to April 2024, this research involved 380 ERCP patients equally divided into two groups: one administered general anesthesia and the other, conscious sedation. Comprehensive data collection included patient demographics, specific criteria before the procedure, procedural details, and outcomes. The analysis utilized SPSS version 26.0, applying independent t-tests and chi-square tests for continuous and categorical variables, respectively, alongside logistic regression to pinpoint procedural outcomes and complications predictors. Results: Both the general anesthesia and conscious sedation groups, averaging ages of 55.2 and 54.8 years, respectively, showed no significant disparity in BMI, ASA scores, or reasons for ERCP. Success rates of the procedures did not significantly differ, standing at 85% for general anesthesia and 83% for conscious sedation, with complication rates at 20% and 18%, respectively. Metrics such as post-procedure pain, hospitalization duration, and patient satisfaction remained statistically similar across both groups. Conclusions: The study concludes that general anesthesia for ERCP is just as effective and safe as conscious sedation, with both methods showing equivalent success and complication rates. These results advocate for a tailored, patient-centric approach in selecting anesthesia techniques for ERCP, ensuring no procedural effectiveness or patient safety compromise.

Impact of different ablation strategies during very high power short duration ablation: insights from the multicentric AIR HPSD registry

Abstract Background The very high power short duration ablation by mean of the QDOT Micro catheter was demonstrated to be safe and effective to achieve pulmonary vein isolation (PVI) in atrial fibrillation (AF) patients. Data from large multicentric registries are still lacking. Purpose We sought to investigate whether different ablation approaches may impact procedural outcomes. First, the hybrid approach (Qmode+, 90 W for 4 sec, at the posterior wall of the left atrium and Qmode modality AI-guided at the anterior wall) was compared to the ablation performed exclusively with the Qmode+ modality. Second, we investigated the impact of the type of anesthesia. Methods The AIR HPSD registry is a multicentric real world data registry including patients undergoing AF ablation by mean of the QDOT Micro catheter. The ablation modality (hybrid/ Qmode+) and the type of anesthesia were left to operators’ preference. Results Overall, 330 patients were enrolled, 67% males, 71% had paroxysmal AF, the mean age was 61±11. Pulmonary vein isolation was reached in 100% regardless of the ablation modality or the anesthesia used. As for the first pass isolation (FPI) there was a trend toward higher rates in the hybrid group compared to the Qmode+ group (85% vs 74%, p=0.1). No differences in FPI were found between the general anesthesia/deep sedation group and the conscious sedation group (83% vs 81%, p=0.8), however when considering the Qmode+ group solely, the FPI was significantly higher in the general anesthesia/deep sedation group (84% vs 56%, p=0.006). As for the procedural time, this was significantly shorter in the general anesthesia/deep sedation compared to conscious sedation (82±21 vs 97±35 min, p&amp;lt;0.01), as well as in the Qmode+ group compared to the hybrid group (80±31 vs 102±30 min, p&amp;lt;0.01). Minor complications were observed in 1% of patients with no significant differences between groups. Conclusions The PVI can be safely and effectively obtained with both approaches, hybrid or Qmode+ solely, however the rate of FPI seems higher with the hybrid one. When adopting solely the Qmode+ modality the general anesthesia increases the rate of FPI.

Outcomes with General Anesthesia Compared to Conscious Sedation for Endovascular Treatment of Medium Vessel Occlusions: Results of an International Multicentric Study.

Optimal anesthetic strategy for the endovascular treatment of stroke is still under debate. Despite scarce data concerning anesthetic management for medium and distal vessel occlusions (MeVOs) some centers empirically support ageneral anesthesia (GA) strategy in these patients. We conducted an international retrospective study of MeVO cases. Apropensity score matching algorithm was used to mitigate potential differences across patients undergoing GA and conscious sedation (CS). Comparisons in clinical and safety outcomes were performed between the two study groups GA and CS. The favourable outcome was defined as amodified Rankin Scale (mRS) 0-2 at 90days. Safety outcomes were 90-days mortality and symptomatic intracranial hemorrhage (sICH). Predictors of afavourable outcome and sICH were evaluated with backward logistic regression. After propensity score matching 668 patients were included in the CS and 264 patients in the GA group. In the matched cohort, either strategy CS or GA resulted in similar rates of good functional outcomes (50.1% vs. 48.4%), and successful recanalization (89.4% vs. 90.2%). The GA group had higher rates of 90-day mortality (22.6% vs. 16.5%, p < 0.041) and sICH (4.2% vs. 0.9%, p = 0.001) compared to the CS group. Backward logistic regression did not identify GA vs CS as apredictor of good functional outcome (OR for GA vs CS = 0.95 (0.67-1.35)), but GA remained asignificant predictor of sICH (OR = 5.32, 95% CI 1.92-14.72). Anaesthetic strategy in MeVOs does not influence favorable outcomes or final successful recanalization rates, however, GA may be associated with an increased risk of sICH and mortality.

A Comparative Analysis of Erector Spinae Plane Block Versus Conscious Sedation in Managing Percutaneous Cholecystostomy Pain.

This study investigates the efficacy of erector spinae plane block (ESPB) for managing perioperative and postoperative pain in patients undergoing percutaneous cholecystostomy (PC) for acute cholecystitis, particularly in high-risk elderly patients with extensive comorbidities and limited functional status. In a retrospective single-center study, 58 high-risk patients scheduled for PC were assessed. ESPB was administered to 23 patients, while 22 received conscious sedation. Pain intensity was measured using the numeric rating scale before any analgesic or ESPB administration, during the procedure and at 1 and 12h post-procedure and secondary outcomes included adverse effects and additional analgesic requirements. The ESPB group experienced significant pain reduction during and post-procedure compared to the conscious sedation group (p = 0.002). Procedure times were shorter (p = 0.015), and postoperative tramadol was less frequently needed in the ESPB group (p = 0.007). The incidence of nausea was also lower in the ESPB group (p = 0.001). No ESPB-related complications were reported. ESPB significantly alleviates perioperative and postoperative pain in PC patients, reducing additional analgesic use and side effects. It holds promise as a key component of pain management for high-risk surgical patients. Level 3, Non-randomized controlled cohort/follow-up study.

Choice of anesthesia technique is associated with earlier hospital discharge and reduced costs after transcatheter transfemoral aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has become a viable alternative to palliation in patients with severe aortic stenosis. We compared general anesthesia to conscious sedation for TAVI procedures with respect to post operative morbidity, hospital length of stay, and financial burden. We conducted a retrospective review of prospectively collected data in patients undergoing transfemoral TAVI procedures from 2012 to 2017. Patients were matched based on age and sex and classed into either general anesthesia or conscious sedation groups respectively. Conscious sedation was provided with a dexmedetomidine infusion, and patients in general anesthesia group received a standard induction, tracheal intubation, and maintenance with sevoflurane. The hospital case costs were compared between the two groups before and after adjustment for inflation. We matched 124 pairs for a total of 248 patients. Both groups were similar with respect to demographic data, past medical history, medications, and intraoperative characteristics. There was no difference in postoperative morbidity and mortality between the two groups. The median hospital length of stay was 5 [interquartile range (IQR): 3, 10] and 7 (IQR: 4, 12) days, P=0.01, and after adjustment for inflation, the total hospital case costs were $48,984 (IQR: $44,802, $61,438) Canadian (CAD) vs. $55,333 (IQR: $46,832, $68,702) CAD, P=0.01, in the conscious sedation and general anesthesia groups, respectively. Advancements in TAVI technologies, conscious sedation and a collaborative, multidisciplinary team approach reduces overall length of hospital stay and procedure costs.

Effect of anesthesia mode during endovascular treatment on neurological functional outcomes in patients with acute posterior circulation stroke.

To compare the effect of anesthesia mode on the neurological functional outcomes in patients undergoing endovascular treatment for acute posterior circulation ischemic stroke. Clinical data of 656 patients undergoing intravascular therapy for acute posterior circulation ischemic stroke registered in online Acute Stroke Patients for Stroke Management Quality Evaluation Database from January 2017 to December 2022 were retrospectively analyzed. The data included 163 cases with conscious sedation and 493 cases with general anesthesia during the procedure. After propensity score matching, 428 patients were included in the analysis, including 155 cases in the conscious sedation group and 273 cases in the general anesthesia group. The differences of operation mode, etiology type, vascular recanalization, hemorrhagic transformation at 24 h, modified Rankin Scale (mRS) score at 3 months and mortality within 3 months were compared between the two groups. Binary logistic regression was used to explore the effect of different anesthesia mode on neurological functional outcomes. There was a significant difference in operation mode between the two groups (P<0.01), while there were no significant differences in etiology type, vascular recanalization, hemorrhagic transformation at 24 h, mRS score at 3 months or mortality within 3 months (all P>0.05). Binary logistic regression analysis revealed that anesthesia modes were not significantly associated with functional outcomes of patients (OR=1.151, 95%CI: 0.751-1.765, P>0.05). Anesthesia mode (conscious sedation or general anesthesia) will not affect the neurological functional outcomes in patients with acute posterior circulation ischemic stroke undergoing endovascular treatment.

Trends in transcatheter aortic valve implantation practice and clinical outcomes at an Irish tertiary referral centre

ObjectiveA paucity of data exists on how transcatheter aortic valve implantation (TAVI) practice has evolved in Ireland. This study sought to analyse temporal trends in patient demographics, procedural characteristics, and...

Type of anesthesia for endovascular therapy in acute ischemic stroke: A literature review and meta-analysis.

Endovascular thrombectomy (EVT) has been proven as the standard treatment for acute ischemic stroke (AIS) patients due to large vessel occlusion (LVO). However, the ideal anesthetic strategy during EVT still remains unclear. Therefore, this systematic review and meta-analysis aimed to determine the optimal anesthetic modality for patients with AIS undergoing EVT based on current randomized controlled trials (RCTs). The databases Medline (via PubMed), EMBASE, Web of Science, and the Cochrane Library were searched for RCTs comparing general anesthesia (GA) and conscious sedation (CS) in AIS patients undergoing EVT. The primary outcome was a favorable functional outcome at 90 days postintervention. Data analysis was conducted using the Review Manager software (RevMan V.5.3). Eight RCTs involving 1199 patients were included. There was no significant difference between GA and CS group in the rate of functional independence (risk ratio (RR) = 1.10, 95% confidence interval (CI) = 0.96 to 1.25; p = 0.17; I2 = 30%). Compared with the CS group, the GA group attained a higher successful recanalization rate (RR = 1.14, 95% CI = 1.08 to 1.20; p < 0.00001; I2 = 17%). In addition, patients in the GA were associated with a higher rate of hypotension (RR = 1.87, 95% CI = 1.44 to 2.41; p < 0.00001; I2 = 66%) and a higher incidence of pneumonia (RR = 1.38, 95% CI = 1.05 to 1.8; p = 0.02; I2 = 37%). For AIS patients receiving EVT, the choice of anesthetic modality did not influence the 3-month neurological outcome while GA is superior to CS in terms of successful reperfusion rate. Moreover, the patients in the GA group were at a higher risk of developing hypotension and pneumonia. Further studies are required to provide more sufficient evidence.

(167) Penile Plication is Well Tolerated Under Conscious Sedation: A Prospective Comparison of Deep Intravenous Vs. Nursing Administered Conscious Sedation

Abstract Introduction Penile plication is a common and effective surgical treatment for Peyronie's Disease. Although generally performed under general or spinal anesthesia, patient tolerability of penile plication under conscious sedation (CS) has several advantages: reduced anesthetic risk, health care cost savings, decrease wait times, and the ability conduct in outpatient facilities. While CS would provide significant potential benefit, there have been no evaluations of patient-reported tolerability to penile plication completed under conscious sedation nor comparisons with varying administrations. Objective To evaluate and compare patient-reported tolerability of penile plication performed under two CS sedation approaches: (1) deep intravenous conscious sedation (IVCS) administered by anesthesiologists and (2) nursing administered conscious sedation (NACS). Methods We evaluated procedure tolerability in a prospective cohort of 40 adult patients (23 IVCS; 17 NACS) undergoing primary penile plication between August 2022 and May 2023. Revision surgeries, and those with hourglass or hinge deformities were excluded. IVCS patients were administered midazolam (5mg) and ketamine (20mg) along with a continuous infusion of propofol (25-50 mcg/kg/min) and remifentanil (0.05 mcg/kg/min). NACS sedation protocol consisted of midazolam (1-2 mg) and fentanyl (50-100 ug). Patient baseline characteristics, procedure information, pain assessments (Likert scale; 0 [no pain]-10[most pain]) made by the patient and surgeon before during and after the procedure were collected. Following a post-surgical healing period, patients were contacted and administered an evaluated standardized patient tolerability questionnaire. Overall patient tolerability, pain assessments, and complication rates were compared descriptively, and using Wilcoxon sign-rank tests and McNemar tests. Results Baseline characteristics were similar between IVSC and NACS groups. Median pre-operative curvature of the IVCS cohort was 55 degrees (IQR=43.75-76.25) whereas the NACS curvature was 45 degrees (IQR=45-60). There was a 100% procedural success rate with no intra-operative concerns leading to the abortion of the procedure or conversion to general anesthetic. At six-week post-operative follow up, all patients had functional curvature. 100% of patients in the IVCS and NACS cohorts reported that they would recommend CS to others. Additionally, 95% (19/20; CI95=75.3%-99.0%) of those undergoing IVCS and 93.3% (14/15; CI95=70.2-98.8%) of the NACS cohort would choose CS over general anesthetic if they had to undergo the same surgery again. Sedation choice did not differ between CS groups (p=1.0). Most patients reported no pain pre-operatively (IVCS:[18/20]; NACS:[13/15]; p=1.0), peri-operatively (IVCS:[16/20]; NACS:[13/15]; p=0.68), or immediately post-operatively (IVCS:[14/20]; NACS:[14/15]; p=0.20). Two-hour post-operative pain did not differ between groups (p=0.89). Median two-hour post-operative IVCS pain was 2.5 (IQR=0-5.0) whereas median NACS pain was 3.0 (IQR=1.5-3.0). Conclusions Penile plication is exceptionally well tolerated when completed under either anesthesiologist administered intravenous conscious sedation or nursing administered conscious sedation. Most patients would choose conscious sedation over general anesthetic for the procedure in the future and all would recommend conscious sedation to others. Self-reported pain did not differ between groups and most patients reported no pain pre-, peri-, or immediately post-operatively. These results suggest that penile plication surgery can be completed in an outpatient setting under conscious sedation administered by trained nursing staff, which is expected to decrease costs, risks and wait-times of the procedure. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

A comparison of conscious sedation and local anesthesia for thrombectomy in acute ischemic stroke: a multicenter study.

Ischemic cerebrovascular disease (ICVD) is a serious health problem in which brain tissue suffers from hypoxic damage due to obstruction in cerebral vessels. Mechanical thrombectomy is a commonly used method in the treatment of these patients. However, the effects of local anesthesia (LA) and conscious sedation (CS) during thrombectomy are still unclear. We evaluated whether there was a relationship between the two anesthesia regimens in terms of 90-day modified Rankin Scale (mRS) scores. In this study, a retrospective observational study was conducted to evaluate the effects of LA and CS used during mechanical thrombectomy in four comprehensive stroke centers among ICVD patients. Patients were divided into the LA group and the CS group. Statistical analysis was performed before and after 1:1 matching under propensity score matching (PSM) analysis. The primary outcome measure was an mRS score of 0-2 at 90 days. Secondary outcomes were procedure times, recanalization rates, symptomatic and asymptomatic hemorrhage rates, and procedural complications. A total of 193 patients (118 patients with LA and 75 patients with CS) were included in the final analysis before PSM. After 1:1 PSM, 98 patients-49 patients from each group-were included in the study. There was no difference in clinical outcomes between the LA- and CS-applied groups (p = 0.543). When blood pressure (BP) values at follow-up after endovascular treatment (EVT) were compared, the lowest systolic and lowest diastolic BP were found to be lower in the CS group (p = 0.001 and p = 0.009). There was no significant difference between the two groups in terms of recanalization rates, symptomatic intracranial hemorrhage (sICH) rates, 90-day mRS, and procedure-related complication rates (p = 0.617, p = 0.274, p = 0.543, and p = 1.000). This study did not reveal the superiority of CS applied during EVT on 90-day mRS, sICH, recanalization rates, or procedural complications. However, the risk of developing hypotension during the CS application was found to be high.

Factors affecting the dosimetry of high-dose rate intracavitary brachytherapy in cervical cancer

Abstract Background: Intracavitary brachytherapy (ICBT) is essential in managing locally advanced cervical cancer. Brachytherapy as a modality has the advantage of a higher dose to the tumour with a dose fall off at the periphery as per the inverse square law. The dose per fraction is much higher than external beam radiotherapy. So proper application and dosimetry are of paramount importance to reduce late toxicity. Methods: A retrospective analysis of 69 patients who underwent three ICBT applications of 7 Gray in each fraction was done. The factors under consideration were the type of pain management (spinal anaesthesia (SA) versus conscious sedation (CS)), the initial size of the disease (bulky and non-bulky) and subsequent fractions (first fraction versus third fraction). The dosimetric parameters analysed were the doses received by points A, B and P and that of the critical organs (bladder, rectum and sigmoid colon). Results: The dose received by critical organs was comparable concerning all the factors under consideration. The dose to point P on the left side was significantly lower in the CS group than in the SA group (p-value = 0·031). Also, the dose to point P on the right side was significantly lower in the third fraction compared with the first fraction (p-value = 0·016). Conclusions: ICBT under spinal anaesthesia resulted in a higher dose to the pelvic wall. The initial size of the tumour or the subsequent fractions does not significantly affect the dose received by critical organs.

General anesthesia enhances lesion quality and ablation efficiency of circumferential pulmonary vein isolation.

Pulmonary vein isolation (PVI) is the cornerstone of atrial fibrillation (AF) ablation. General anesthesia (GA) resolves the problem of pain intolerability and provides regular respiratory mode which might improve the catheter maneuverability of AF ablation. This study aims to compare the procedural performance of PVI under GA versus conscious sedation (CS) from multiple perspectives. A total of 36 consecutive patients undergoing first AF ablation under GA were enrolled in GA group. Another 109 patients receiving AF ablation under CS in the same period were selected as the control group. After propensity score matching, 29 matched pairs with similar baseline characteristics were available for further analysis. The AIFV (using AI to analyze the raw data from CARTO3 system) system was used to evaluate six procedural parameters in each PVI procedure. Compared with CS, PVI under GA had a significantly shorter total PVI time (51.4 min vs. 67.8 min; p = .003) and higher radiofrequency ratio (62.6% vs. 55.8%; p = .032). The number of gaps (1.0 vs. 3.0; p < .001) and the rate of break point were significantly lower in the GA group. GA was also associated with a higher effective ablation-index ratio (87.5% vs. 74.1%; p < .001) and effective force-over-time ratio (85.3% vs. 69.2%; p = .001). After a medium follow-up time of 24 months, 12/29 (41.4%) patients in the CS group and 6/29 (20.7%) patients in the GA group suffered from AF recurrence (p = .156). GA improves the lesion quality and procedural efficiency of PVI from multiple perspectives evaluated by the AIFV system.

Catheter ablation in general anesthesia reduces atrial fibrillation recurrence regardless of atrial fibrillation type

Abstract Background Treatment with catheter ablation (CA) as rhythm control is increasingly used in atrial fibrillation (AF). Short-term AF recurrence after first-time CA varies from 10-30% in paroxysmal AF (PAF) and up to 50% in persistent AF (PeAF). Strategies to optimize outcome is still an ongoing challenge. Whether the sedation strategy, conscious sedation (CS) or general anesthesia (GA), has any impact on AF recurrence has yet to be determined. Currently no guidelines are available regarding sedation strategy. Objective To investigate the impact of sedation strategy in CA for PAF and PeAF on AF recurrence. Method This nationwide retrospective registry study was conducted using large real-life data from Danish mandatory registries. All patients above 18 years, that underwent CA for AF from January 1st 2010 to December 31st 2018, were identified and included at the date of ablation. Exposure of interest was type of anesthesia, and patients were stratified into CS or GA. Primary endpoint was recurrent AF after a 3-months blanking period, defined by a composite endpoint of first-reached endpoint of either use of antiarrhythmic drugs (AAD), AF-admission, electrical cardioversions or AF re-ablation. 5-year risk of recurrent AF was examined by the Aalen-Johansen estimator, taking the competing risk of death into account. Subgroup analysis of PAF and PeAF was performed. Results The study cohort consisted of 6,423 patients with first-time CA. 3,958 patients with PAF and 2,465 patients with PeAF. 5,058 patients underwent the procedure in CS, and 1,365 in GA. 5-year cumulative incidence of recurrent AF was higher in the CS group for both PAF and PeAF with 49,3% and 58,9% respectively, compared to 39,0% for PAF and 46,2% for PeAF in the GA group (Figure 1). A total of 3,242 patients reached the primary endpoint. Admissions for AF was the predominant endpoint for both CS and GA (1323, 42,0%). When subdivided into PAF and PeAF, admission for AF was still the predominant endpoint (Table 1). Conclusion Reduction of AF recurrence after CA is a continuing challenge. This study shows that the sedation strategy is important, and that the risk of recurrence is significantly lower for CA performed in GA. Subgroup analysis of PAF and PeAF, shows that regardless of AF type, recurrence rates are significantly lower in the GA group.Figure 1Table 1

Abstract 058: General anesthesia versus conscious sedation during endovascular thrombectomy for distal vessel occlusions

Introduction Choice of anesthesia for endovascular thrombectomy in large vessel occlusion of the anterior circulation has been well studied, although practice patterns may still be variable. Anesthesia choice for distal vessel occlusions (DVO) presents unique challenges, however. General anesthesia (GA) may offer advantages over conscious sedation (CS) due to reduced patient movement facilitating catheter navigation, but concerns persist about potential delays and hypotension impacting collateral circulation. In our study, we aim to explore this question further. Methods In our prospectively maintained stroke registry from December 2014 to July 2023, we identified patients with DMVO defined as M2, M3, M4 occlusion, ACA occlusion, and PCA occlusion, who underwent MT for AIS. We compared patients who received CS to those who GA. Our primary outcome measures were length of procedure defined as time from entering angiography suite until final recanalization, access time to recanalization, CS to GA conversion rate, number of passes to reach TICI2b or better and first pass effect. Our secondary outcomes were length of stay, and modified Rankin Scale (mRS) at 5 days, 30 days, and 90 days. Results Total of 290 patients with DVO were identified, the median age was 73 (IQR 19). Of these, 86 patients (29.7%) underwent GA, and 200 (69.0%) received CS. CS to GA conversion was required in 36 patients (12.4%). Females accounted for 47.5% of the CS group and 38.4% of the GA group. No significant differences were found between the two groups in the racial and gender composition (p&gt;0.1). The mean admission NIHSS was significantly higher in the GA group (16.86) compared to the CS group (12.44) as was the rate of IV thrombolysis in the CS (36.2%) group compared to GA (31.4%) group (p&lt;0.01). The type of anesthesia used was not influenced by the laterality of the stroke in the middle cerebral artery territory (left vs right) (χ²=0.39, p=0.53). After adjusting for age, sex, IV thrombolysis, and admission NIHSS, CS usage did not result in an increase in procedural time (β=1.3, p=0.83). Furthermore, CS had no significant effect on the total number of passes (β=‐0.15, p=0.53), nor did it influence the likelihood of achieving first‐pass recanalization (β=0.28, p=0.48). No associations were found between CS use and the modified Rankin Scale (mRS) at 5 days (β=0.17, p=0.65), 30 days (β=0.22, p=0.75), or 90 days (β=0.15, p=0.67). Likewise, the length of stay in the hospital (β=1.71, p=0.77) was not significantly affected by the use of CS. Conclusion In our analysis of DMVO, the use of CS during thrombectomy appeared to be safe and feasible and comparable to GA with regards to procedural length, number of passes, and rate of first pass recanalization. Similarly, the type of anesthesia did not have an impact on clinical outcome. Further studies are needed to build on these findings and inform optimal management strategies.

Impact of general anesthesia on ablation catheter stability during pulmonary vein isolation based on a novel measurement approach

Catheter ablation for atrial fibrillation (AF) during pulmonary vein isolation (PVI) is performed under general anesthesia (GA) or conscious sedation (CS). GA during PVI may improve treatment outcomes by improving catheter stability. However, the magnitude of GA-derived catheter stability compared with that of CS is unclear. We directly assessed catheter movement and determined the impact of GA compared with that of CS on ablation catheter stability during PVI. Patients who underwent initial ablation using the EnSite Precision™ mapping system were recruited and divided into two groups (GA and CS groups). The two groups were compared for ablation catheter stability during PVI based on the distance traveled by the catheter distal tip per second, clinical periprocedural characteristics, and periprocedural complications. Among 69 consecutively admitted patients, data of 30 patients (17 in the GA group and 13 in the CS group) and the distance traveled per second by the catheter on 148,976 points/patient were evaluated. The GA group had a significantly smaller catheter tip travel distance than the CS group (0.92 [0.82‒1.16] vs. 1.25 [1.14‒1.38], p = 0.01). Therefore, GA during PVI for AF provides greater catheter stability than CS and will contribute to more accessible and safer PVI procedures.

The Functional Prognosis of Rescue Conscious Sedation During Mechanical Thrombectomy on Patients with Acute Anterior Circulation Ischemic Stroke: A Single-Center Retrospective Study.

Basedonreal-worldcase data, this study intends to explore and analyze the impact of rescue conscious sedation (CS) on the clinical outcomes of patients with anterior circulation acute ischemic stroke (AIS) receiving mechanical thrombectomy (MT). This retrospective study enrolled patientswith anterior circulation AIS who received MT and were treated with eithersingle local anesthesia (LA) or rescue CS during MT between January 2018 and October 2021. We used univariate and multivariate logistic regression methods to compare the impact of LA and CS on the clinical outcomes of patients with AIS who received MT, including the mRS at90days, the incidence of poststroke pneumonia (PSP), the incidence of symptomatic intracranial cerebral hemorrhage (sICH), and the mortality rate. We reviewed 314 patient cases with AIS who received MT. Of all patients, 164met our search criteria. Eighty-nine patients received LA, and 75 patients received rescue CS. There was no significant difference between the two groups in the 90-day good prognosis (45.3% vs. 51.7%, p = 0.418) and mortality (17.3% vs. 22.5%, p = 0.414). Compared with the LA group, the incidence of postoperative pneumonia in the rescue CS group (44% vs. 25.8%, p = 0.015) was more significant. Multivariate stepwise logistic regression analysis revealed that intraoperative remedial CS was independently associated with PSP following MT. Inasubgroup analysis, rescue CS wasfoundto significantly increase the incidence of PSP in patients with dysphagia (OR = 7.307, 95% CI 2.144-24.906, p = 0.001). AstheseverityoftheNational Institutes of Health Stroke Scale (NIHSS)increased, intraoperative rescue CS wasfoundtoincrease the risk of PSP (OR = 1.155, 95% CI 1.034-1.290, p = 0.011) by 5.1% compared to that of LA (OR = 1.104, 95% CI 1.013-1.204, p = 0.024). Compared to LA, rescue CS during MT doesnotsignificantly improve the 90days of good prognosis and reduce the incidence of sICH and mortality in patients with anterior circulation AIS. However, it has a significantlyincreased risk of poststroke pneumonia (PSP), particularly in patients with dysphagia.