Open Journal of Anesthesiology, 2013, 3, 349-352 Published Online October 2013 ( 349
Anaesthesia Management for Ablation Therapy in Post
Heart Transplant Arrhythmia*
Sunisa Prapaitrakool, Daniel Tom Bainbridge, Ronit Lavi#
Department of Anaesthesia and Perioperative Medicine, London Health Science Centre, University of Western Ontario, London,
Received April 30th, 2013; revised June 1st, 2013; accepted July 15th, 2013
Copyright © 2013 Sunisa Prapaitrakool et al. This is an open access article distributed under the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
In this case series we describe the anaesthetic management of atrial ablation for arrhythmia in three post heart transplant
patients. These patients provide a unique challenge to the anaesthesiologist, as heart physiology, end organs effects,
procedural related factors should all be part of the specific anaesthetic plan tailored for each patient individually. The
different anaesthetic techniques applied, and procedure related complications are evaluated. Anaesthetic management,
procedural related difficulties, pharmacologic aspects, and possible associated complication s are reviewed .
Keywords: Ablation; Heart Transplant; Arrhythmia
1. Introduction
Heart transplantation has become a therapeutic option fo r
a variety of end-stage heart diseases with over 2000 cases
performed annually in the United States and approxi-
mately 3500 cases worldwide [1]. As a result of an in-
creasing number of patients surviving cardiac transplan-
tation and the relatively high incidence of atrial arrhyth-
mias in these patients, ablation procedures under anaes-
thesia may be required [2,3]. Percutaneous catheter abla-
tion is done with applying electrical triggers around the
pulmonary vein ostia in order to accomplish pulmonary
vein isolation using radiofrequency current. Radiofre-
quency ablation applies high-frequency, low-voltage
electrical energy to the endocardium via a catheter-based
electrode that leads to resistive thermal injury and sub-
sequent coagulative necrosis of the tissue, thereby block-
ing reentrant electrical circuits causing atrial fibrillation
[4]. Other reports have focused on the mechanism for
atrial flutter post heart transplantation and potential ther-
apy from cardiology perspective [5,6]. In this report we
will focus on Anaesthesia management for ablation ther-
apy in post heart transplant arrhythmia.
The transplanted he art physiology is different, and can
complicate anaesthetic management. Therefore, anaes-
thesiologists should be aware of particular problems and
risks associated with ablation procedures in this unique
group of patients. We present three cases of atrial abla-
tion due to arrhythmia after heart transplantation and
discuss the anaesthetic considerations for these proce-
2. Case Report
Written informed consent was obtained from all patients.
2.1. Case #1
A 47-year-old man received a cardiac transplantation due
to sarcoid cardiomyopathy 6 years before the ablation
procedure with a biatrial technique. He presented with
recurrent episodes of atrial fibrillation refractory to both
medical treatment and multiple cardioversion attempts.
He developed renal compromise with a slightly increase
in creatinine after the transplant. His current immuno-
suppressants were cyclosporine and mycophenolate mo-
fetil. Electrophysiologic (EP) studies and radiofrequency
ablation were done twice in the last 2 years.
The first EP study showed supraventricular tachycar-
dia (SVT) from Wolff-Parkinson-White syndrome. The
patient received sedation with both a propofol and fen-
tanyl infusion which was well tolerated for the first 90
minutes. It was then converted to a general anaesthetia
using a laryngeal mask airway, and sevoflurane to pro-
vide adequate level of anaesthesia for the next 100 min-
*The authors declare no financial support or conflict of interest.
#Corresponding author.
Copyright © 2013 SciRes. OJAnes
Anaesthesia Management for Ablation Therapy in Post Heart Transplant Arrhythmia
utes of the procedure.
The second EP study revealed atrial fibrillation origi-
nating from the recipients’ atrial cuff. Conscious sedation
was conducted with sufentanil and midazolam during the
procedure, which last ed over 4 ho u rs.
The ablation procedures were done successfully with-
out any complications.
2.2. Case #2
A 65-year-old received a cardiac transplant due to end
stage rheumatic valvular cardiomyopathy 13 years b efore
the ablation procedure with a biatrial technique. He pre-
sented with refractory atrial flutter. His current medica-
tions included cyclosporine, azathioprine, prednisolone,
diltiazem, atorvastatin, and furosemide. EP studies and
ablation showed peri-mitral flutter. The procedure was
performed under sedation with midazolam and fentanyl
with an anesthetic time of 145 minutes. The procedure
was done successfully, however the patient received 2
liters of normal saline as ablation catheter irrigation fluid
and developed orthopnea, and pulmonary edema after the
procedure which improved with intravenous furosemide.
2.3. Case #3
A 49-year-old man received his heart transplant 24 years
ago due to idiopathic cardiomyopathy by the biatrial
technique. He developed paroxysmal rapid atrial flutter
and underwent multiple cardioversions with medical
treatment during the last 2 years, however his atrial flut-
ter was refractory to those treatments and required an
ablation procedure. His post transplant course was com-
plicated by progressive renal failure and hypertension.
The EP study and pulmonary vein ablation were done
using the transseptal approach under Transesophageal
Echocardiography (TEE) which was technically very
difficult. The patient received general anesthesia with an
endotracheal tube, invasive intra-arterial monitoring and
maintaining the activated clotting time (ACT) > 300. As
the procedure concluded, and the lines were taken out,
the AV node was injured, and complete heart block oc-
curred. The patient did not respond to atropine and had to
be paced. The anaesthetic duration was over 6 hours.
3. Discussion
Cardiac arrhythmias are frequently encountered after
heart transplantation. Previous studies demonstrated that
about a quarter of these patients developed SVT attrib-
uted to macro-reentrant tachycardia, and about 4% un-
derwent EP studies [2,3]. Anesthesia for ablation proce-
dures in these patients mandate several considerations
including transplant technique used, interventional cardi-
ology procedure performed, and particular complications
common to post transplan t patients.
All three patients described had biatrial anastomosis
which altered heart anatomy and predisposed the atrium
to various re-entrant arrhythmias [7]. The third patient
who received heart transplant for the longest time in the
series (24 years before the ablation procedure) encoun-
tered a lot of technical difficulty during the lengthy pro-
cedure which is probably due to a combination of cardiac
fibrosis and complicated anatomy.
The specific considerations for patients undergoing
interventional cardiology procedures include pain man-
agement and increased incidence of complications. Pain
caused by the procedure is of variable intensity due to
radiofrequency ablation that generates heat and causes
tissue damage [8]. An 8-mm-tip ablation catheter is gen-
erally used at our institution, power (20 - 50 Watt) and
temperature use is limited to 50˚C, however power up to
100 Watt and temperature up to 65˚C may be required.
Post heart transplant patients, may have minimal pain
due to neuronal denervation. Periprocedural complica-
tions are usually related to mechanical trauma or the use
of radiofrequency power. This includes pericardial effu-
sion, cardiac tamponade, thromboembolism, persistent
defect of the inter atrial septum, aortic perforation, atrial
perforation, atrio-esophageal fistula, acute coronary ar-
tery occlusion (circumflex artery), phrenic nerve injury,
air emboli, periesophageal vagal injury, catheter entrap-
ment in the mitral valve, dysrrhythmia, and complete
heart block. An atrio-esophageal fistula is a rare but po-
tentially fatal complication, and may manifest weeks
after the ablation procedure [9]. If trans septal puncture is
expected, TEE may enhance safety by allowing monitor-
ing of catheter positioning as well as evaluation of com-
plications [10,11]. Anticoagulant and ACT monitoring is
crucial. Esophageal temperature monitoring may help
reduce thermal injury from ablation [9].
Cardiac denervation causes impaired autonomic regu-
latory mechanism, delayed stress response, loss of vagal
tone resulting in a resting heart rate of 90 - 100 per min-
ute and alterations to demands for increased cardiac out-
put. Therefore, maintenance of adequate preload is cru-
cial. Coronary atherosclerosis will be accelerated (silent
ischemia is likely). Renervation of the transplanted heart
may occur, but to an unknown extent. The first patient,
who underwent transplant 6 years before, had the atrial
fibrillation originating from the receipient’s atrial cuff
which dem onstra ted t he occ urren ce of renervation.
Immunosuppression is usually maintained with the
three-drug regimen which includes cyclosporine, azathio-
prine and corticosteroids is common (tacrolimus and
mycophenolate mofetil may replace cyclosporine and
azathioprine, respectively). Frequent consequences of
immunosuppressants include hypertension and renal im-
pairment, which may affect choices of anesthetic agents,
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Anaesthesia Management for Ablation Therapy in Post Heart Transplant Arrhythmia 351
and are associated with tacrolimus and cyclosporine.
Steroids can commonly cause hyperlipidemia and osteo-
porosis whereas Azathioprine frequently causes bone
marrow suppression. Other infrequent complications
include malignancy, gastrointestinal biliary disease, pan-
creatitis and peptic ulcer disease [10].
Drugs that act indirectly on the heart via either sym-
pathetic or parasympathetic nervous system (ephedrine,
atropine) will be ineffective. Drugs with a mixture of
direct and indirect effects (digoxin, norepinephrine, and
neostigmine) will exhibit only their direct effects. Agents
with direct cardiac effects (epinephrine, isoproterenol)
are more reliable.
Providing anesthesia for a high risk patien t in a hostile
environment outside of the operating room mandates
careful assessment of the patient and meticulous ar-
rangements for any possible complication and emergen-
cies. Preoperative assessment should focus on graft func-
tion and end organs function, especially those that might
be compromised by the long standing immunosuppres-
sive therapy and possible dysfunction of the transplanted
heart. Ablation procedures in a transplanted heart are
technically challenging due to altered heart anatomy,
intra thoracic position, and cardiac fibrosis which may
increase the incidence of life threatening complications.
Transcutaneous pacing and a defibrillator should be pre-
pared as well as emergency resuscitation measures.
Procedures performed on the right side of the heart are
usually less complicated than left sided procedures,
which mandate inter-atrial septal puncture. For ablation
within the right side of the heart, conscious sedation with
adequate analgesia is adequate to ensure calm and pain
free status without compromising the airway. However
the expected long duration of the procedure in these pa-
tients may influence the anaesthetic choice. When deeper
level of anesthesia or a prolonged procedure is required,
laryngeal mask airway or intratracheal tube may be used.
If TEE is required, deeper general anesthesia with se-
cured airway with an endotracheal tube is mandatory.
In conclusion, the management of heart transplanted
patients undergoing atrial ablation procedures includes a
thorough history and physical examination, understand-
ing of the procedure type, the transplanted heart anatomy
and the heart and end organs function. Furthermore, spe-
cial considerations should be addressed for management
of high risk patients outside of the operating room in a
remote location, lengthy procedures associated with
technical difficulties, management of possible complica-
tions, and considerations in altered medications pharma-
cology. The anaesthetic plan shou ld be tailored individu-
ally, and in collaboration with the cardiologists in order
to provide the appropriate anaesthetic technique for the
specific patient according to the planed intervention.
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