Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Anesthetic considerations for electrophysiology, interventional cardiology, and transesophageal echocardiography procedures

Wendy L Gross, MD
Douglas C Shook, MD, FASE
Kathleen Evangelista, MS, CRNA
Section Editors
Jonathan B Mark, MD
Bradley P Knight, MD, FACC
Deputy Editor
Nancy A Nussmeier, MD, FAHA


Due to advances in technology in electrophysiology (EP), interventional cardiology, and transesophageal echocardiography (TEE) technology, complex interventional procedures that may require anesthesia care are usually performed in these specialized settings remote from the main operating rooms. Many patients requiring such procedures have severe cardiovascular disease or pulmonary comorbidity; thus, they are at high risk for oversedation and hemodynamic instability. Even relatively healthy patients may not tolerate remaining motionless during prolonged or painful interventional procedures. For these reasons, the number of cases that require monitored anesthesia care (MAC) or general anesthesia in these off-site settings has increased (eg, >50 percent of EP cases [1]). Given the special considerations and growing need, some institutions have a subspecialized anesthesia team dedicated to these settings.

This topic will review anesthetic management of adult patients undergoing procedures in EP, interventional cardiology, and TEE suites. Anesthetic considerations in other off-site settings (eg, magnetic resonance imaging [MRI], computed tomography [CT], gastrointestinal endoscopy) are reviewed in other topics. (See "Anesthesia for magnetic resonance imaging and computed tomography procedures" and "Anesthesia for gastrointestinal endoscopy in adults".)  


Multiple factors affect the selection of anesthetic technique, dosing of anesthetic and adjuvant agents, and whether invasive monitoring will be employed for electrophysiology (EP), interventional cardiology, or transesophageal echocardiography (TEE) procedures. Unique patient- or procedure-related considerations are discussed in advance with members of the interventional team [2]. (See "Operating room hazards and approaches to improve patient safety", section on 'Briefings'.)

Anesthetic challenges in off-site locations — Typically, EP, interventional cardiology, and TEE suites are remote from the main operating room (OR) area. Challenges for anesthesiologists in such off-site locations often include lack of standard anesthesia machines, monitors, supplies, or scavenging equipment for anesthetic gases. Additional time is required for transport of necessary items from a distant OR location, and subsequent setup and positioning of all equipment in the off-site location. Ensuring availability of well-located portable shields, lead aprons, thyroid collars, and eye protection for all anesthesia personnel is necessary for procedures with radiation risks. Another challenge is interdisciplinary communication, which may be hindered by lack of familiarity with the procedures and techniques planned by each specialist. Further discussion of challenges in remote locations is available elsewhere. (See "Anesthesia for magnetic resonance imaging and computed tomography procedures", section on 'Anesthetic challenges in remote locations' and "Anesthesia for magnetic resonance imaging and computed tomography procedures", section on 'Radiation risks'.)

Patient and procedure-related considerations — The following factors should be considered:

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Sep 2017. | This topic last updated: Oct 07, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Gaitan BD, Trentman TL, Fassett SL, et al. Sedation and analgesia in the cardiac electrophysiology laboratory: a national survey of electrophysiologists investigating the who, how, and why? J Cardiothorac Vasc Anesth 2011; 25:647.
  2. Gross WL. Editorial comment: integrated care and teamwork: the rashomon effect in cardiovascular medicine. A A Case Rep 2014; 3:116.
  3. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96:1004.
  4. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. www.asahq.org/Search.aspx?q=standards+basic+anesthetic+monitoring (Accessed on March 29, 2016).
  5. Checketts MR, Alladi R, Ferguson K, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2016; 71:85.
  6. Essandoh MK, Otey AJ, Abdel-Rasoul M, et al. Monitored Anesthesia Care for Subcutaneous Cardioverter-Defibrillator Implantation: A Single-Center Experience. J Cardiothorac Vasc Anesth 2016; 30:1228.
  7. Cho JS, Shim JK, Na S, et al. Improved sedation with dexmedetomidine-remifentanil compared with midazolam-remifentanil during catheter ablation of atrial fibrillation: a randomized, controlled trial. Europace 2014; 16:1000.
  8. Flowers, J . Fire safety in procedural areas. Journal of Radiology Nursing 2011; 31:13.
  9. Lischke V, Wilke HJ, Probst S, et al. Prolongation of the QT-interval during induction of anesthesia in patients with coronary artery disease. Acta Anaesthesiol Scand 1994; 38:144.
  10. Korpinen R, Saarnivaara L, Siren K. QT interval of the ECG, heart rate and arterial pressure during anaesthetic induction: comparative effects of alfentanil and esmolol. Acta Anaesthesiol Scand 1995; 39:809.
  11. Zaballos M, Jimeno C, Almendral J, et al. Cardiac electrophysiological effects of remifentanil: study in a closed-chest porcine model. Br J Anaesth 2009; 103:191.
  12. Michaloudis DG, Kanakoudis FS, Xatzikraniotis A, Bischiniotis TS. The effects of midazolam followed by administration of either vecuronium or atracurium on the QT interval in humans. Eur J Anaesthesiol 1995; 12:577.
  13. Erdil F, Demirbilek S, Begec Z, et al. Effects of propofol or etomidate on QT interval during electroconvulsive therapy. J ECT 2009; 25:174.
  14. Mitchell GF, Jeron A, Koren G. Measurement of heart rate and Q-T interval in the conscious mouse. Am J Physiol 1998; 274:H747.
  15. Michaloudis DG, Kanakoudis FS, Petrou AM, et al. The effects of midazolam or propofol followed by suxamethonium on the QT interval in humans. Eur J Anaesthesiol 1996; 13:364.
  16. Saarnivaara L, Klemola UM, Lindgren L, et al. QT interval of the ECG, heart rate and arterial pressure using propofol, methohexital or midazolam for induction of anaesthesia. Acta Anaesthesiol Scand 1990; 34:276.
  17. Saarnivaara L, Klemola UM, Lindgren L. QT interval of the ECG, heart rate and arterial pressure using five non-depolarizing muscle relaxants for intubation. Acta Anaesthesiol Scand 1988; 32:623.
  18. de Kam PJ, van Kuijk J, Prohn M, et al. Effects of sugammadex doses up to 32 mg/kg alone or in combination with rocuronium or vecuronium on QTc prolongation: a thorough QTc study. Clin Drug Investig 2010; 30:599.
  19. de Kam PJ, van Kuijk J, Smeets J, et al. Sugammadex is not associated with QT/QTc prolongation: methodology aspects of an intravenous moxifloxacin-controlled thorough QT study. Int J Clin Pharmacol Ther 2012; 50:595.
  20. Knudsen K, Beckman Suurküla M, Blomberg S, et al. Central nervous and cardiovascular effects of i.v. infusions of ropivacaine, bupivacaine and placebo in volunteers. Br J Anaesth 1997; 78:507.
  21. Owczuk R, Wujtewicz MA, Sawicka W, et al. The effect of intravenous lidocaine on QT changes during tracheal intubation. Anaesthesia 2008; 63:924.
  22. DeSouza G, Lewis MC, TerRiet MF. Severe bradycardia after remifentanil. Anesthesiology 1997; 87:1019.
  23. Gravlee GP, Ramsey FM, Roy RC, et al. Rapid administration of a narcotic and neuromuscular blocker: a hemodynamic comparison of fentanyl, sufentanil, pancuronium, and vecuronium. Anesth Analg 1988; 67:39.
  24. Galmén K, Harbut P, Freedman J, Jakobsson JG. High frequency jet ventilation for motion management during ablation procedures, a narrative review. Acta Anaesthesiol Scand 2017; 61:1066.
  25. Tung R, Boyle NG, Shivkumar K. Catheter ablation of ventricular tachycardia. Circulation 2010; 122:e389.
Topic Outline