Prolonged transesophageal echocardiography during percutaneous closure of the left atrial appendage without general anesthesia: the utility of the Janus mask.
OBJECTIVE
Left atrial appendage (LAA) closure is an interventional procedure increasingly used to prevent stroke in patients with permanent atrial fibrillation and contraindications to anticoagulation therapy. As this procedure requires a relatively immobile patient and performance of continuous and prolonged transesophageal echocardiography (TEE), it is usually performed under general anesthesia. In this case series, we describe the feasibility of prolonged TEE for percutaneous LAA closure using a new noninvasive ventilation device that can avoid the need for endotracheal intubation and general anesthesia.


METHODS
Percutaneous LAA closure was performed under deep sedation in three elderly patients with permanent atrial fibrillation. Sedation was obtained with a combination of midazolam, propofol, and remifentanil. Continuous intraoperative TEE was performed through the port of the newly available Janus mask (Biomedical Srl; Florence, Italy), allowing for noninvasive ventilation (pressure support = 12-16 cm H2O; positive end-expiratory pressure = 7 cm H2O; FIO2 = 0.3) in these spontaneously breathing patients. The total procedure times ranged from 75-90 min. The patients reported excellent satisfaction with the sedation received in terms of discomfort experienced during the procedure, capacity to recall the procedure, and comfort with the mask. The operators also rated the procedural conditions as excellent.


CONCLUSIONS
Deep sedation with noninvasive ventilation may be a reasonable and safe alternative to general endotracheal anesthesia in patients requiring prolonged TEE for noninvasive cardiac procedures, including LAA closure.
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.|Vita-Salute San Raffaele University, Milan, Italy.
Alberto
A
Zangrillo
Arrhythmology and Electrophysiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Patrizio
P
Mazzone
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy. carmine.d.votta@virgilio.it.
Carmine D
CD
Votta
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
Nicola
N
Villari
Arrhythmology and Electrophysiology Unit, Cardio-Thoracic-Vascular Department, IRCCS San Raffaele Scientific Institute, Milan, Italy.
Paolo
P
Della Bella
Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
Fabrizio
F
Monaco
D000368:Aged; D000369:Aged, 80 and over; D000768:Anesthesia, General; D020517:Atrial Appendage / Q000601:surgery*; D001281:Atrial Fibrillation / Q000601:surgery*; D054810:Deep Sedation / Q000379:methods; D019560:Echocardiography, Three-Dimensional / Q000295:instrumentation / Q000379:methods; D017548:Echocardiography, Transesophageal / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D008397:Masks; D061646:Operative Time; D016896:Treatment Outcome