Rapid atrial pacing in endovascular aneurysm repairs

[jwk]

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We have a new vascular surgeon that, among other things, will be doing endovascular thoracic aneurysm repairs. I've done tons of open AAA's, and a handful of thoracics, but endovascular repairs and grafts are new to us.

During deployment of the graft, this surgeon is requesting rapid atrial pacing (200/min) as a way to temporarily decrease cardiac output and aortic blood flow. The idea is that deploying the graft during a low-flow state enhances proper graft placement, avoiding a "windsock" effect as the graft opens. Pace>low flow>deploy graft>pace off>flow up. None of us had ever heard of this, much less done it, including our newer attendings with extensive cardiovascular experience. Have y'all heard of this, and are you doing it in your hospitals?

 

[lushmd]

Yes, we do it for TAVI/TAVR procedures. Basically as you described. Its quite brief (<1 min). The surgeon should give you advanced warning of when he/she plans to do this so that you can augment BP with phenylephrine (obviously, be judicious such that the BP isn't sky high afterwards).

 

[WholeLottaGame7]

We have a new vascular surgeon that, among other things, will be doing endovascular thoracic aneurysm repairs. I've done tons of open AAA's, and a handful of thoracics, but endovascular repairs and grafts are new to us.

During deployment of the graft, this surgeon is requesting rapid atrial pacing (200/min) as a way to temporarily decrease cardiac output and aortic blood flow. The idea is that deploying the graft during a low-flow state enhances proper graft placement, avoiding a "windsock" effect as the graft opens. Pace>low flow>deploy graft>pace off>flow up. None of us had ever heard of this, much less done it, including our newer attendings with extensive cardiovascular experience. Have y'all heard of this, and are you doing it in your hospitals?

Yes and yes.

The procedure itself went smoothly; what I remember most is the cardiologist at the end saying "while we're here..." and cardioverting the patient (a-fib at baseline, I think?). Except the underlying rhythm in this case was asystole so we ended up going to the unit with transvenous pacing wires. Patient did fine.

 

[btbam]

We have a new vascular surgeon that, among other things, will be doing endovascular thoracic aneurysm repairs. I've done tons of open AAA's, and a handful of thoracics, but endovascular repairs and grafts are new to us.

During deployment of the graft, this surgeon is requesting rapid atrial pacing (200/min) as a way to temporarily decrease cardiac output and aortic blood flow. The idea is that deploying the graft during a low-flow state enhances proper graft placement, avoiding a "windsock" effect as the graft opens. Pace>low flow>deploy graft>pace off>flow up. None of us had ever heard of this, much less done it, including our newer attendings with extensive cardiovascular experience. Have y'all heard of this, and are you doing it in your hospitals?

The n=1 I did last year, the surgeon had us give nitro while deploying the graft and asked us to have adenosine available...

 

[periopdoc]

It's a great way of improving success with these stents. In fellowship I did it primarily for placing endovascular aortic valves. The biggest hassle is figuring out who is responsible for floating and managing the pacing wire (cardiologist, anesthesiologist, surgeon) and which access point it is going to come from. I prefer the cardiologist does it from a femoral approach with the understanding that he needs to be immediately available throughout the procedure and in the OR for the actual stent deployment period.

I haven't done the rapid atrial pacing here, but I did fibrillate a heart for a procedure that we did with fem-fem bypass with a fibrillating heart. I just used a pacing Swan for that.

I don't have any particular advice for you other than to be reactive to the blood pressure after termination of the pacing rather than trying to guess what it is going to be and pre-treating. You are probably better than me at figuring out what the patient will need afterward, but I never could predict if the pressure was going to be too high, too low, or just right, so I would wait to see what happened and treat from there.

I do like to have external pads on in case defibrillation is necessary, and I have pressors and NTG in the room though not necessarily spiked/ drawn up. I am certain you already knew that though.

- pod

 

[imfrankie]

You could ask the doctor of nurse anesthesia what he/she would do in a "highly collaborative practice"

 

[gasp]

Yes, we do it for TAVI/TAVR procedures. Basically as you described. Its quite brief (<1 min). The surgeon should give you advanced warning of when he/she plans to do this so that you can augment BP with phenylephrine (obviously, be judicious such that the BP isn't sky high afterwards).

Sounds interesting, Never seen or heard of this before. Can't you just use adenosine by itself to decrease c.o. during deployment of the stent?

 

[ssmallz]

We used adenosine to achieve the same effect.....worked really well

 

[urge]

Yes, we do it for TAVI/TAVR procedures. Basically as you described. Its quite brief (<1 min). The surgeon should give you advanced warning of when he/she plans to do this so that you can augment BP with phenylephrine (obviously, be judicious such that the BP isn't sky high afterwards).

?????

Why would you want to do that?

Are you missing the point of rapid pacing?

 

[lushmd]

Perhaps I'm mistaken, but my understanding is that rapid atrial pacing is used to decrease forward flow/cardiac output and thus provide a relatively still surgical field. Hypotension is a (not strictly necessary) consequence of that.

 

[Oggg]

What ventricular rhythm do you get with atrial pacing at 200bpm? Wouldn't you get a sinus tachycardia of 200, and an increase in cardiac output due to HR increase? Or is it too fast for the ventricle, and you get a slow ventricular escape rhythm?

 

[psychbender]

What ventricular rhythm do you get with atrial pacing at 200bpm? Wouldn't you get a sinus tachycardia of 200, and an increase in cardiac output due to HR increase? Or is it too fast for the ventricle, and you get a slow ventricular escape rhythm?

There is poor ventricular filling at those high (atrial) paced rates, and thus, low stroke volume and cardiac output.

 

[Agast]

Yes, we do it for TAVI/TAVR procedures. Basically as you described. Its quite brief (<1 min). The surgeon should give you advanced warning of when he/she plans to do this so that you can augment BP with phenylephrine (obviously, be judicious such that the BP isn't sky high afterwards).

That's interesting, our surgeons give us advance warning specifically so that we do NOT treat the sudden hypotension with any additional phenylephrine - because the pacing is brief, and once they stop pacing the blood pressure returns to where it was before. Plus once the aortic valve graft is deployed, pressor use can exacerbate aortic insufficiency. I hate doing TAVRs, the patients are old and sick as sheet but they actually do go home POD #1...

 

[seinfeld]

Why do rapid atrial pacing, just do rapid RV pacing, much easier to float and more stable than atrial pacing. I actually think TAVRs are a pretty easy anesthetic despite how old and sick they are. I don't give any pressers for the rapid pacing, they usually recover quickly and when they don't i assume that something has gone wrong.

 

[B-Bone]

Why do rapid atrial pacing, just do rapid RV pacing, much easier to float and more stable than atrial pacing. I actually think TAVRs are a pretty easy anesthetic despite how old and sick they are. I don't give any pressers for the rapid pacing, they usually recover quickly and when they don't i assume that something has gone wrong.

This is what we did in residency for TAVI. Placed a pacing swan. Bascially creates standstill. Pressure goes virtually to nil for the duration of the pacing and recovers quickly, though not instantaneously. Pretty nerve-wracking the first few times, but once you get used to it, it's actually a pretty slick way to do it.

 

[periopdoc]

I did laugh a bit when I was asked to do RAP for a patient in A-Fib. Uh, yeah, I don't think that is going to make much difference.

I do get a little nervous about the idea of putting a patient into V-Tach/V-Fib when we aren't on pump.

- pod

 

[DrN2O]

What ventricular rhythm do you get with atrial pacing at 200bpm? Wouldn't you get a sinus tachycardia of 200, and an increase in cardiac output due to HR increase? Or is it too fast for the ventricle, and you get a slow ventricular escape rhythm?

I'm pretty sure that it's rapid VENTRICULAR pacing, at least for the TAVR. Not sure about this endovascular stuff. But atrial rate of 180-200bpm would still give you a decent pressure, like with AFIB.