Position: Supine
Time: 2-4 hours (long)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Minimal (1-3)
Maintenance Paralytic: Yes
Lead: Yes

Approach – GETT and paralytics to start. Case is very similar to A-fib ablation as far a general set up.

Bite block – A strong suggestion is to place a soft bite block after induction to protect against tongue/lip/tooth injuries during cardio versions.

Arterial Line – standard for these cases to monitor for tamponade/hemodynamic instability. Hemodynamics can be very labile due to intermittent pacing and the general condition of the typical patient. Art lines can be difficult to place. If proving to be impossible, the surgeon may place an arterial line in the femoral artery. ACTs will be routinely taken via the arterial line.

Paralytics – Some surgeons do not allow paralytics after intubation. This allows phrenic nerve mapping. If paralytics are still on board, you may need to reverse. In other cases, surgeons are ok with maintenance paralytics – so ask!

Heparin – given at regular intervals based on the ACT value. The surgeon will tell you the dose.

Cardioversion – There may be multiple cardioversions during the case. Typically this doesn’t warrant any particular action but to closely watch vitals.

Protamine – At the end of the case, Protamine will be used to reverse the heparin. The amount is usually specified by the surgeon. Give SLOWLY.

Vascular perforation – high risk in these cases. If this is suspected, an emergency thoracotomy may be indicated. Most of these procedures are done in a hybrid procedure room/cath lab. This is to facilitate an emergency thoracotomy without delay.

If tamponade occurs – avoid the use of phenylephrine to correct pressures. Use ephedrine or epinephrine. If absolutely necessary, the venous introducers at the groin can be utilized to give fluids. Protamine will be used to reverse the heparin (1 mg/100 u of Heparin previously administered. Give SLOWLY). Blood removed via pericardiocentesis will be reinjected via the femoral line. If bleeding persists (doesn’t clot) an emergency repair of the perforation will have to be performed.

Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

Fluoroscopy / Xray (general considerations): Have lead aprons and thyroid shields available. Alternatively, distancing yourself 3 to 6 feet will reduce scatter radiation to 0.1% to 0.025% respectively. Occupational maximum exposure to radiation should be limited to a maximum average of 20 Sv (joules per kilogram – otherwise known as the Sievert/Sv) per year over a 5 year period. Limits should never exceed 50 Sv in a single year.

Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.

When PVCs become to frequent, causing palpitations, SOB, or chest pain, cardiac ablation may be necessary for the patient to resume normal activity. Often times multiple PVCs can lead to sustained ventricular tachycardia and can become a life threatening situation leading to the need for a pacemaker/defibrillator.

PVC suppression with catheter ablation becomes necessary in such situations to prevent recurrent sudden cardiac arrest and defibrillator shocks from the cardioverter implant (if the patient has one).