Anesthetic and Perioperative Considerations for Convergent Procedure for Atrial Fibrillation: A Retrospective Observational Cohort Study

Objective

To summarize anesthetic and perioperative considerations in patients undergoing the convergent procedure for atrial fibrillation (AF).

Design

Retrospective observational study.

Setting

A single quaternary teaching hospital.

Participants

Adult patients with AF undergoing the convergent procedure before January 2024.

Interventions

Retrospective chart review.

Measurements/Main Results

The study cohort comprised 40 patients, including 35 patients with persistent longstanding AF. The mean age was 64 (SD, 6) years, and 33 patients (83%) were male. Common comorbidities included obesity (n = 27; 68%), obstructive sleep apnea (n = 29; 73%), history of tachycardia-mediated cardiomyopathy (n = 10; 25%), and significant alcohol use (n = 10; 25%). Sixteen of the 40 patients (40%) had a history of prior endocardial ablation, and 37 patients (93%) had required a cardioversion in the past. In all, 39 patients (98%) were receiving anticoagulation, and 38 (95%) were on at least 1 antiarrhythmic medication prior to the procedure. All patients received general anesthesia, inhalational in 39 patients (98%) and total intravenous in 1 patient (3%), with regional analgesia adjuncts in 36 patients (88%). All patients required lung isolation, arterial line, central venous access, and transesophageal echocardiographic monitoring. While cardiopulmonary bypass (CPB) was on standby and ready to be initiated for every patient, only 3 patients (8%) required CPB (1 planned, 2 emergent). Thirty seven of the 40 patients (93%) were extubated in the operating room, and 11 patients (28%) required intensive care unit (ICU) admission (planned or unplanned). The median ICU and hospital length of stay were 1 day and 4 days, respectively.

Conclusions

This retrospective analysis of medical records showed that many patients with recurrent AF presenting for convergent procedure carry a burden of multiple comorbidities (eg, obesity, obstructive sleep apnea), and history of unsuccessful ablations. Multistage multidisciplinary convergent procedure might be lengthy and potentially complicated and requires meticulous preparation (eg, endotracheal intubation, lung isolation, advanced cardiac monitoring, central venous access) to ensure optimal outcomes. Anesthesiologists and perioperative physicians should tailor their approach to this multimorbid population while anticipating perioperative respiratory events, rapid hemodynamic shifts, blood loss, and the possibility of CPB.