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Cardiac electrophysiology and conduction pathway ablation

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Invasive cardiac electrophysiological (EP) testing and transcatheter ablation are new methods available for the diagnosis and treatment of complex dysrhythmias. The purpose of this review is to familiarize anaesthetists with these procedures. The information presented combines a literature review with the authors’ experience. This article reviews normal cardiac conduction, tachycardia pathogenesis, principles of cardiac EP study and techniques of conduction pathway ablation. The anaesthetic considerations, including the choice of anaesthetic agent, monitoring problems, drug interactions, special methods ofdysrhythmia termination in the EP lab, and complications specific to these procedures, are detailed. Balanced general anaesthesia or monitored anaesthesia care (MAC) sedation with benzodiazepines, propofol and narcotics are acceptable. Several conclusions can be drawn: transcatheter ablation is an effective treatment for many reentry tachycardias; anaesthetic assistance for this procedure will increasingly be needed; anaesthesia can easily be provided without influencing accurate EP testing; overdrive pacing is the method of choice for terminating tachydysrhythmias in the EP lab.


Les tests d’électrophysiologie (EP) invasive et l’ablation transcathétérisme cardiaque représentent des nouvelles méthodes de diagnostic et de traitement des arythmies complexes. Cet article vise à familiariser les anesthésistes avec ces interventions par l’association d’une revue de la littérature à l’expérience des auteurs. On y passe en revue la conduction cardiaque normale, la pathogénèse des tachycardies, les principes d’investigation EP et les techniques d’ablation des voies de conduction. Les considérations anesthésiques dont le choix des agents, le monitorage et ses problèmes, les interactions pharmacologiques, les principales méthodes d’arrêt des arythmie en laboratoire d’EP et les complications spécifiques à ces interventions sont abordés. L’anesthésie générale équilibrée ou la sédation monitorée avec les benzodiazépines, propofol et opiacés sont appropriées. On peut tirer plusieurs conclusions: l’ablation transcathétérisme est une traitement efficace pour plusieurs tachyarythmies de réentrée; on aura de plus en besoin de l’assistance des anesthésistes pour cette intervention; l’anesthésie elle-même n’interfère pas nécessairement avec les épreuves EP; l’entraînement électrosystolique rapide est la méthode de choix pour mettre fin aux tachydysrythmies en laboratoire d’EP


  1. 1

    Scheinman MM, Laks MM, DiMarco J, Plumb V. Current role of catheter ablative procedures in patients with cardiac arrhythmias: a report for health professionals from the subcommittee on electrocardiography and electrophysiology, American Heart Association. Circulation 1991; 83: 2146–53.

  2. 2

    Schienman MM. Interventional electrophysiology: catheter ablation for patients with cardiac arrhythmias. Cardiol Clin 1986; 4: 543–9.

  3. 3

    Boineau JP, Canavan TE, Schuessler RB, Cain ME, Corr PB, Cox JL. Demonstration of a widely distributed atrial pacemaker complex in the human heart. Circulation 1988; 77: 1221–37.

  4. 4

    Boineau JP, Schuessler RB, Canavan TE, Corr PB, Cain ME, Cox JL. The human atrial pacemaker complex. J Electrocardiol 1989; 22: 189–97.

  5. 5

    Becker AE, Anderson RH, Durrer D, Wellens HJJ. The anatomical substrates of Wolff-Parkinson-White syndrome. A clinicopathologic correlation in seven patients. Circulation 1978; 57: 870–9.

  6. 6

    Wellens HJ, Atie J, Penn OC, Gorgels AP, Brugada P, Smeets JL. Diagnosis and treatment of patients with accessory pathways. Cardiol Clin 1990; 8: 503–21.

  7. 7

    Wellens HJ, Brugada P, Penn OC. The management of pre-excitation syndromes. JAMA 1987; 257: 2325–33.

  8. 8

    Fisch C. Clinical electrophysiological studies and the Wolff-Parkinson-White pattern. Circulation 1990; 82: 1872–3.

  9. 9

    Schuger CD, Steinman RT, Meissner MD, Mosteller RD, Lehmann MH. Clinical management of patients with atrioventricular nodal reentrant tachycardia. Cardiol Clin 1990; 8: 491–501.

  10. 10

    Kasanuki H, Ohnishi S, Tanaka E, Hirosawa K. Mechanism and prediction of sudden cardiac death in arrhythmia patients using electrophysiological studies. Jpn Circ J 1989; 53: 1565–70.

  11. 11

    Gomes JA, Hariman RJ, Kang PS, Showdry IH. Sustained symptomatic sinus node reentrant tachycardia: incidence, clinical significance, electrophysiologic observations and the effects of antiarrhythmic agents. J Am Coll Cardiol 1985; 5: 45–57.

  12. 12

    Cambell RF. Mapping of ventricular arrhythmias. Cardiol Clin 1986; 4: 497–505.

  13. 13

    Allee JL, Bosnjak ZJ. Mechanisms for candiac dysrhythmias during anesthesia. Anesthesiology 1990; 72: 347–74.

  14. 14

    Pralila MG, Pratilas V. Anesthetic agents and cardiac electromechanical activity. Anesthesiology 1978; 49: 338–60.

  15. 15

    Irish CL, Murkin JM, Guiraudon GM. Anaesthetic management for surgical cryoablation of accessory conducting pathways: a review and report of 181 cases. Can J Anaesth 1988; 35: 634–40.

  16. 16

    Bosnjak ZJ, Kampine JP. Effects of halothane, enflurane, and isoflurane on the SA node. Anesthesiology 1983; 58: 314–21.

  17. 17

    Marshall BE, Longnecher DE. General Anesthetics.In: Gilman AG, Rall TW, Nies AS, Taylor P. The Pharmacological Basis of Therapeutics. 8th ed. New York, Permagon, 1990: 285–310.

  18. 18

    Lazlo A, Polk S, Allee JL, Kampine JP, Bosnjak ZJ. Anesthetics and automaticity in latent pacemaker fibers: I. Effects of halothane, enflurane, and isoflurane on automaticity and recovery of automaticity from overdrive suppression in Purkinje fibers derived from canine hearts. Anesthesiology 1991; 75: 98–105.

  19. 19

    Riley DC, Schmeling WT, Al-Wathiqui MH, Kampine JP, Warltier DC. Prolongation of the QT interval by volatile anesthetics in chronically instrumented dog. Anesth Analg 1988; 67: 741–9.

  20. 20

    Denniss AR, Richards DA, Taylor AT, Uther JB. Halothane anesthesia reduces inducibility of ventricular tachyarrhythmias in chronic canine myocardial infarction. Basic Res Cardiol 1989; 84: 5–12.

  21. 21

    Deutsch N, Hantler CB, Tait AR, Uprichard A, Schork MA, Knight PR. Suppression of ventricular arrhythmias by volatile anesthetics in a canine model of chronic myocardial infarction. Anesthesiology 1990; 72: 1012–21.

  22. 22

    Atlee JL III, Yeager TS. Electrophysiologic assessment of the effects of enflurane, halothane, and isoflurane on properties affecting supraventricular re-entry in chronically instrumented dogs. Anesthesiology 1989; 71: 941–52.

  23. 23

    Atlee JL III, Alexander SC. Halothane effects on conductivity of the AV node and His-Purkinje system in the dog. Anesth Analg 1977; 56: 378–86.

  24. 24

    Eger EI II, Smith NT, Stoelting RK, Cullen DJ, Kadis LB, Whitcher CE. Cardiovascular effects of halothane in man. Anesthesiology 1970; 2: 396–409.

  25. 25

    Lynch C III, Vogel S, Sperelakis N. Halothane depression of myocardial slow action potentials. Anesthesiology 1981; 55: 360–8.

  26. 26

    Polic S, Atlee JL III, Laslo A, Kampine JP, Bosnjak ZJ. Anesthetics and automaticity in latent pacemaker fibers: II. Effects of halothane and epinephrine or norepinephrine on automaticity of dominant and subsidiary atrial pacemakers in the canine heart. Anesthesiology 1991; 75: 298–304.

  27. 27

    Reynolds AK. On the mechanism of myocardial sensitization to catecholamines by hydrocarbon anesthetics. Can J Physiol Pharmacol 1984; 62: 183–98.

  28. 28

    Maze M, Smith CM. Identification of receptor mechanism mediating epinephrine-induced arrhythmias during halothane anesthesia in the dog. Anesthesiology 1983; 59: 322–6.

  29. 29

    Gallagher JD, McClernan CA. The effects of halothane on ventricular tachycardia in intact dogs. Anesthesiology 1991; 75: 866–75.

  30. 30

    Calverley RK, Smith NT, Prys-Roberts C, Eger EI II, Jones CW. Cardiovascular effects of enflurane anesthesia during controlled ventilation in man. Anesth Analg 1978; 57: 619–28.

  31. 31

    Hief C, Borggrefe M, Chen X, et al. Effects of enflurane on inducibility of ventricular tachycardia. Am J Cardiol 1991; 68: 609–13.

  32. 32

    Blitt CD, Raessler KL, Wightman MA, Groves BM, Wall CL, Geha DG. Atrioventricular conduction in dogs during anesthesia with isoflurane. Anesthesiology 1979; 50: 210–2.

  33. 33

    Skovsted P, Sapthavichaikul S. The effects of isoflurane on arterial pressure, pulse rate, autonomic nervous system activity, and barostatic reflexes. Can Anaesth Soc J 1977; 24: 304–14.

  34. 34

    Weiskopf RB, Holmes MA, Rampil IJ, et al. Cardiovascular safety and actions of high concentrations of 1–653 and isoflurane in swine. Anesthesiology 1989; 70: 793–8.

  35. 35

    Eisele JH, Smith NT. Cardiovascular effects of 40 percent nitrous oxide in man. Anesth Analg 1972; 51: 956–63.

  36. 36

    Smith NT, Eger EI II, Stoelting RK, Whayne TF, Cullen D, Kadis LB. The cardiovascular and sympathomimetic responses to the addition of nitrous oxide to halothane in man. Anesthesiology 1970; 32: 410–21.

  37. 37

    Lampe GH, Donegan JD, Rupp SM, et al. Nitrous oxide and epinephrine-induced arrhythmias. Anesth Analg 1990; 71: 602–5.

  38. 38

    Harrah MD, Way WL, Katzung BG. The interaction of dtubocurarine with antiarrhythmic drugs. Anesthesiology 1970; 33: 406–10.

  39. 39

    Hardy PAJ. Atracurium and bradycardia (Letter). Anaesthesia 1985; 40: 504–5.

  40. 40

    Cozanitis DA, Lindgren L, Rosenberg PH. Bradycardia in patients receiving atracurium or vecuronium in conditions of low vagal stimulation. Anaesthesia 1989; 44: 303–5.

  41. 41

    Gautret B, Schmitt H. Cardiac slowing induced by peripheral K opiate receptors in rats. Eur J Pharmacol 1984; 102: 159–63.

  42. 42

    Maryniak JK, Bishop VA. Sinus arrest after alfentanil (Letter). Br J Anaesth 1987; 59: 390–1.

  43. 43

    Sebel PS, Bovill JG, van der Haven A. Cardiovascular effects of alfentanil anaesthesia. Br J Anaesth 1982; 54: 1185–90.

  44. 44

    Schmeling WT, Bernstein JS, Vucins EJ. Persistent bradycardia with episodic sinus arrest after sufentanil and vecuronium administration — successful treatment with isoproterenol. Journal of Cardiothoracic Anesthesia 1990; 4: 89–94.

  45. 45

    Pruett JK, Blair JR, Adams RJ. Cellular and subcellular actions of opioids in the heart.In: Estafanous FG. Opioids in Anesthesia. Butterworth-Heinemann, Boston. 1991.

  46. 46

    Blair JR, Pruett JK, Introna RPS, Adams RJ, Baiser JS. Cardiac electrophysiologic effects of fentanyl and sufentanil in canine cardiac Purkinje fibers. Anesthesiology 1989; 71: 565–70.

  47. 47

    Dashwood MR, Spyer KM. Autoradiographic localization of alpha-adrenoreceptors, muscarinic acetylcholine receptors and opiate receptors in the heart. Eur J Pharmacol 1986; 127: 279–82.

  48. 48

    Blair JR, Pruett JK, Crumrine RS. Prolongation of QT interval in association with the administration of large doses of opiates (Letter). Anesthesiology 1987; 67: 442–3.

  49. 49

    Helgesen KG, Refsum H. Arrhythmogenic, antiarrhythmic and inotropic properties of opioids. Effects of piritramide, pethidine and morphine compared on heart muscle isolated from rats. Pharmacology 1987; 35: 121–9.

  50. 50

    Gómez-Arnau J, Márquez-Montes J, Avello F. Fentanyl and droperidol effects on the refractoriness of the accessory pathway in the Wolff-Parkinson-White syndrome. Anesthesiology 1983; 58: 307–13.

  51. 51

    Sebel PS, Lowdon JD. Propofol: a new intravenous anesthetic. Anesthesiology 1989; 71: 260–77.

  52. 52

    Turtle MJ, Cullen P, Prys-Roberts C, Coates D, Monk CR, Faroqui MH. Dose requirements for propofol by infusion during nitrous oxide anaesthesia in man. II. Patients premedicated with lorazepam. Br J Anaesth 1987; 59: 283–7.

  53. 53

    Thompson SJ, Yate PM. Bradycardia after propofol infusion (Letter). Anaesthesia 1987; 42: 430.

  54. 54

    Colson P, Barlet H, Roquefeuill B, Eledjam JJ. Mechanism of propofol bradycardia (Letter). Anesth Analg 1988; 67: 906–7.

  55. 55

    Guise PA. Asystole following propofol and fentanyl in an anxious patient. Anaesth Intensive Care 1991; 19: 116–7.

  56. 56

    Dorrington KL. Asystole with convulsion following a subanaesthetic dose of propofol plus fentanyl. Anaesthesia. 1989; 44: 658–9.

  57. 57

    Ebert TJ, Muzi M, Berens R, Goff D, Kampine JP. Sympathetic responses to induction of anesthesia in humans with propofol or etomidate. Anesthesiology 1992; 76: 725–33.

  58. 58

    Munoz R, Goldberg ME, Cantillo J, Subramoni J, Nemiroff MS. Perioperative arrhythmias with a propofol-based anesthetic. J Clin Anesth 1991; 3: 149–52.

  59. 59

    Kamibayashi T, Hayashi Y, Sumikawa K, Yamatodani A, Kawabata K, Yoshiya I. Enhancement by propofol of epinephrine-induced arrhythmias in dogs. Anesthesiology 1991; 75: 1035–40.

  60. 60

    Cullen PM, Turtle M, Prys-Roberts C, Way WL, Dye J. Effect of propofol anesthesia on baroreflex activity in humans. Anesth Analg 1987; 66: 1115–20.

  61. 61

    Lucas WJ, Maccioli GA, Mueller RA. Advances in oral anti-arrhythmic therapy: implications for the anaesthetist. Can J Anaesth 1990; 37: 94–101.

  62. 62

    Vaughn Williams EM. A classification of antiarrhythmic actions reassessed after a decade of new drugs. J Clin Pharmacol 1984; 24: 129–47.

  63. 63

    Liberman BA, Teasdale SJ. Anaesthesia and amiodarone. Can Anaesth Soc J 1985; 32: 629–38.

  64. 64

    Satz AK, Stoelting RK, Gibbs PS. Intraoperative pulmonary edema in a patient being treated with amiodarone. Anesth Analg 1991; 73: 821–3.

  65. 65

    Kay GN, Epstine AE, Kirklin JK, Diethelm AS, Graybar G, Plumb VJ. Fatal postoperative amiodarone pulmonary toxicity. Am J Cardiol 1988; 62: 490–2.

  66. 66

    Gallagher JD. The electrophysiologic effects of amiodarone and halothane on canine Purkinje fibers. Anesthesiology 1991; 75: 106–12.

  67. 67

    Singh SN, Lazin A, Cohen A, Johnson M, Fletcher RD. Sotalol-induced Torsades des pointes successfully treated with hemodialysis after failure of conventional therapy. Am Heart J 1991; 121:601–2.

  68. 68

    Trappe HJ, Klein H, Lichtlen P. Sotalol in patients with life-threatening ventricular tachyarrhythmias. Cardiovasc Drugs Ther 1990; 4: 1425–32.

  69. 69

    Gallagher JD, Gessman LJ, Moura P, Klerns D. Electrophysiologic effects of halothane and quinidine on canine Purkinje fibers: evidence for a synergistic interaction. Anesthesiology 1986; 65: 278–85.

  70. 70

    Hernandez M, Reder RF, Marinchak RA, Rials SJ, Kowey PR. Propafenone for malignant ventricular arrhythmia: an analysis of the literature. Am Heart J 1991; 121: 1178–84.

  71. 71

    Podrid PJ, Lampert S, Graboys TB, Blatt CM, Lown B. Aggravation of arrhythmias by antiarrhythmic drugs — incidence and predictors. Am J Cardiol 1987; 59: 38E-44E.

  72. 72

    Ruskin JN, McGovem B, Garan H, DiMarco JP, Kelly E. Antiarrhythmic drugs: a possible cause of out-of-hospital cardiac arrest. N Engl J Med 1983; 309: 1302–6.

  73. 73

    Levine JH, Morganroth J, Kadish AH. Mechanisms and risk factors for proarrhythmia with type 1a compared with 1c antiarrhythmic drug therapy. Circulation 1989; 80: 1063–9.

  74. 74

    Pratt CM, Moye LA. The cardiac arrhythmia suppression trial: background, interim results and implications. Am J Cardiol 1990; 65: 20B-29B.

  75. 75

    Scheinman MM. Nonpharmacological treatment of lifethreatening cardiac arrhythmias. Am Heart J 1987; 114: 1291–8.

  76. 76

    Davis MJ, Mews GC, Cope GD. Transvenous ablation of atrioventricular conduction for refractory or malignant supraventricular arrhythmias. Aust N Z J Med 1984; 14: 479–86.

  77. 77

    Scheinman MM, Morady F, Hess DS, Gonzalez R. Catheter-induced ablation of the atrioventricular junction to control refractory supraventricular arrhythmia. JAMA 1982; 248: 851–5.

  78. 78

    Gallagher JJ, Svenson RH, Kasell JH, et al. Catheter technique for closed-chest ablation of the atrioventricular conduction system: a therapeutic alternative for the treatment of refractory supraventricular tachycardia. N Engl J Med 1982; 306: 194–200.

  79. 79

    Westveer DC, Nelson T, Stewart JR, Thornton EP, Gordon S, Timmis GC. Sequelae of left ventricular electrical endocardial ablation. J Am Coll Cardiol 1985; 5: 956–62.

  80. 80

    Chapman PD, Klopfenstein S, Troup PJ, Brooks HL. Evaluation of a percutaneous catheter technique for ablation of ventricular tachycardia in a canine model. Am Heart J 1985; 110: 1–8.

  81. 81

    Langberg JJ, Chin MC, Rosenqvist M, et al. Catheter ablation of the atrioventricular junction with radiofrequency energy. Circulation 1989; 80: 1527–35.

  82. 82

    Scheinman MM. Interventional electrophysiology: catheter ablation for patients with cardiac arrhythmias. Cardiol Clinics 1986; 4: 543–50.

  83. 83

    Scheinman MM. Catheter techniques for ablation of supraventricular tachycardia (Editorial). N Engl J Med 1989; 320:460–1.

  84. 84

    Warin J-F, Haissaguerre M, Lemetayer P, Guillem J-P, Blanchot P. Catheter ablation of accessory pathways with a direct approach: results in 35 patients. Circulation 1988; 78:800–15.

  85. 85

    Jackman WM, Beckman KJ, McClelland JH, et al. Treatment of supraventricular tachycardia due to atrioventricular nodal reentry by radiofrequency catheter ablation of slow-pathway conduction. N Engl J Med 1992; 327: 313–9.

  86. 86

    Poser RF, Podrid PJ, Lombardi F, Lown B. Aggravation of arrhythmia induced with antiarrhythmic drugs during electrophysiologic testing. Am Heart J 1985; 110: 9–16.

  87. 87

    Jones RM, Broadbent MP, Adams AP. Anaesthetic considerations in patients with paroxysmal supraventricular tachycardia. A review and report of cases. Anaesthesia 1984; 39: 307–13.

  88. 88

    Sadowsky AR, Moyers JR. Anesthetic management of Wolff-Parkinson-White syndrome. Anesthesiology 1979; 51: 553–6.

  89. 89

    Van der Starre PJA. Wolff-Parkinson-White syndrome during anesthesia. Anesthesiology 1978; 48: 369–72.

  90. 90

    Galletly DC, Short TG. Total intravenous anaesthesia using propofol infusion: 50 consecutive cases. Anaesth Intensive Care 1988; 16: 150–7.

  91. 91

    Guidelines for cardiopulmonary resuscitation and emergency cardiac care. JAMA 1992; 268: 2171–302.

  92. 92

    Akhtar. Management of ventricular tachyarrhythmias. Part I JAMA 1982; 24: 671–4.

  93. 93

    Platia EV. Management of Cardiac Arrhythmias. Philadelphia, JB Lippincott, 1987.

  94. 94

    Lehmann MH, Saksena S. Implantable cardioverter defibrillators in cardiovascular practice: report of the Policy Conference of the North American Society of Pacing and Electrophysiology. NASPE Policy Conference Committee. PACE Pacing Clin Electrophysiol 1991; 14: 969–79.

  95. 95

    Canessa R, Lenta G, Urzua J, Dagnino J, Concha M. Anesthesia for elective cardioversion: a comparison of four anesthetic agents. J Cardiothorac Vasc Anesth 1991; 5: 566–8.

  96. 96

    Lechleitner P, Genser N, Mitterschiffihaler G, Dienstl F. Propofol for direct current cardioversion in cardiac risk patients. Eur Heart J 1991; 12: 813–7.

  97. 97

    Fennelly ME, Powell H, Galletly DC, Whitwam JG. Midazolam sedation reversed with flumazenil for cardioversion. Br J Anaesth 1992; 68: 303–5.

  98. 98

    Evans GT Jr, Scheinman MM, Zipes DP, et al. The Percutaneous Cardiac Mapping and Ablation Registry: final summary of results. PACE Pacing Clin Electrophysiol 1988; 11: 1621–6.

  99. 99

    Hartzler GO, Giorgi LV, Diehl AM, Hamaker WR. Right coronary spasm complicating electrode catheter ablation of a right lateral accessory pathway. J Am Coll Cardiol 1985; 6: 250–3.

  100. 100

    Fisher JD, Brodman R, Kim SG, et al. Attempted nonsurgical electrical ablation of accessory pathways via the coronary sinus in the Wolfe-Parkinson-White syndrome. J Am Coll Cardiol 1984; 4: 685–94.

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Renwick, J., Kerr, C., McTaggart, R. et al. Cardiac electrophysiology and conduction pathway ablation. Can J Anaesth 40, 1053–1064 (1993). https://doi.org/10.1007/BF03009477

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Key words

  • Anaesthesia: cardiovascular
  • Heart: arrhythmia, electrocardiography