array:23 [ "pii" => "S234119292100086X" "issn" => "23411929" "doi" => "10.1016/j.redare.2021.01.001" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1278" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2021" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:309-37" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935621000517" "issn" => "00349356" "doi" => "10.1016/j.redar.2021.01.001" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1278" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Rev Esp Anestesiol Reanim. 2021;68:309-37" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo especial</span>" "titulo" => "Documento de consenso para la Sedación en procedimientos de intervencionismo en Cardiología" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309" "paginaFinal" => "337" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Consensus document for anaesthesiologist-assisted sedation in interventional cardiology procedures" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1356 "Ancho" => 1142 "Tamanyo" => 137103 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cardioversión eléctrica con choque bifásico.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. Martinez-Dolz, A. Pajares, M. López-Cantero, J. Osca, J.L. Díez, P. Paniagua, P. Argente, E. Arana, C. Alonso, T. Rodriguez, R. Vicente, M. Anguita, J. Alvarez" "autores" => array:14 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "Martinez-Dolz" ] 1 => array:2 [ "nombre" => "A." "apellidos" => "Pajares" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "López-Cantero" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Osca" ] 4 => array:2 [ "nombre" => "J.L." "apellidos" => "Díez" ] 5 => array:2 [ "nombre" => "P." "apellidos" => "Paniagua" ] 6 => array:2 [ "nombre" => "P." "apellidos" => "Argente" ] 7 => array:2 [ "nombre" => "E." "apellidos" => "Arana" ] 8 => array:2 [ "nombre" => "C." "apellidos" => "Alonso" ] 9 => array:2 [ "nombre" => "T." "apellidos" => "Rodriguez" ] 10 => array:2 [ "nombre" => "R." "apellidos" => "Vicente" ] 11 => array:2 [ "nombre" => "M." "apellidos" => "Anguita" ] 12 => array:2 [ "nombre" => "J." "apellidos" => "Alvarez" ] 13 => array:1 [ "colaborador" => "Grupo de trabajo de Sedación tutelada en procedimientos de intervencionismo en Cardiología de la Sociedad Española de Anestesia, Reanimación y Terapéutica del dolor (SEDAR) y de la Sociedad Española de Cardiología (SEC)" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S234119292100086X" "doi" => "10.1016/j.redare.2021.01.001" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S234119292100086X?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935621000517?idApp=UINPBA00004N" "url" => "/00349356/0000006800000006/v1_202106040545/S0034935621000517/v1_202106040545/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192921000871" "issn" => "23411929" "doi" => "10.1016/j.redare.2020.11.004" "estado" => "S300" "fechaPublicacion" => "2021-06-01" "aid" => "1269" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2021;68:338-45" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "The role of ultrasound guided serratus plane block on chronic neuropathic pain after breast surgery in cancer patient" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "338" "paginaFinal" => "345" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Papel del bloqueo ecoguiado del plano del músculo serrato en el dolor neuropático crónico tras una cirugía de mama en una paciente de cáncer" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1150 "Ancho" => 1207 "Tamanyo" => 131134 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">SPB technique: the needle is inserted at the level of the 5th rib until it reaches the deep plane of the serratus anterior muscle.</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LA: local anaesthetic.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M.J. dos Santos Rodrigues da Silva, M.L.N. Ferreira, M. Fernandez Gacio, M.L.C. Miranda, Ana Agrelo" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M.J." "apellidos" => "dos Santos Rodrigues da Silva" ] 1 => array:2 [ "nombre" => "M.L.N." "apellidos" => "Ferreira" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Fernandez Gacio" ] 3 => array:2 [ "nombre" => "M.L.C." "apellidos" => "Miranda" ] 4 => array:2 [ "nombre" => "Ana" "apellidos" => "Agrelo" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935620303248" "doi" => "10.1016/j.redar.2020.11.012" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935620303248?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192921000871?idApp=UINPBA00004N" "url" => "/23411929/0000006800000006/v1_202106271045/S2341192921000871/v1_202106271045/en/main.assets" ] "en" => array:18 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Special article</span>" "titulo" => "Consensus document for anaesthesiologist-assisted sedation in interventional cardiology procedures" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "309" "paginaFinal" => "337" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "L. Martinez-Dolz, A. Pajares, M. López-Cantero, J. Osca, J.L. Díez, P. Paniagua, P. Argente, E. Arana, C. Alonso, T. Rodriguez, R. Vicente, M. Anguita, J. Alvarez" "autores" => array:14 [ 0 => array:4 [ "nombre" => "L." "apellidos" => "Martinez-Dolz" "email" => array:1 [ 0 => "luismartinezdolz@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Pajares" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "López-Cantero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "J." "apellidos" => "Osca" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "J.L." "apellidos" => "Díez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 5 => array:3 [ "nombre" => "P." "apellidos" => "Paniagua" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 6 => array:3 [ "nombre" => "P." "apellidos" => "Argente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "E." "apellidos" => "Arana" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] 8 => array:3 [ "nombre" => "C." "apellidos" => "Alonso" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 9 => array:3 [ "nombre" => "T." "apellidos" => "Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">h</span>" "identificador" => "aff0040" ] ] ] 10 => array:3 [ "nombre" => "R." "apellidos" => "Vicente" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 11 => array:3 [ "nombre" => "M." "apellidos" => "Anguita" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">i</span>" "identificador" => "aff0045" ] ] ] 12 => array:3 [ "nombre" => "J." "apellidos" => "Alvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">j</span>" "identificador" => "aff0050" ] ] ] 13 => array:2 [ "colaborador" => "Working Group on Tutored Sedation in Interventional Procedures in Cardiology of the Spanish Society of Anesthesia Resuscitation and Therapeutic of Pain SEDAR and of the Spanish Society of Cardiology SEC" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">◊</span>" "identificador" => "fn0005" ] ] ] ] "afiliaciones" => array:10 [ 0 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, IIS La Fe, CIBERCV, Valencia, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Arritmias, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Hemodinámica, Servicio de Cardiología del Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Unidad de Arritmias, Servicio de Cardiología, Hospital Virgen del Rocío, Sevilla, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Unidad de Arritmias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Unidad de Hemodinámica, Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Servicio de Cardiología, Hospital Reina Sofía de Córdoba, Córdoba, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Anestesia y Reanimación, Complejo Hospitalario Universitario de Santiago, Universidad de Santiago, Santiago de Compostela, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Documento de consenso para la Sedación en procedimientos de intervencionismo en Cardiología" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1699 "Ancho" => 2953 "Tamanyo" => 485669 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Point-by-point radiofrequency ablation.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The field of interventional cardiology – both catheterisation and electrophysiology – has grown dramatically in recent years. Interventions in this specialty are often complex and non-deferrable, performed on patients with a considerable risk of complications due to their underlying disease or comorbidities, and require different levels of sedation that is not always administered in compliance with patient safety recommendations. Anaesthesiology services need to oversee and manage these procedures, but must adapt their protocols to the hospital’s operational structure. In hospitals with a cath or electrophysiology lab, efficiency and safety will be maximised if anaesthesiologists personally administer sedation in high risk cases and supervise the work of a nurse sedationist in other procedures. In this consensus document, we put forward a series of essential, practical, up-to-date evidence-based recommendations intended to establish sedation standards for all medical professionals involved in these care processes. The document is divided into 3 sections: the first presents the most relevant information for anaesthesiologists involved in interventional cardiology procedures that currently require sedation, including a brief description of the procedure, its objective, the general characteristics of patients in whom it is indicated, the success rate, complications and how to treat them, and the usual care circuits for both elective and urgent procedures. The second sections presents a comprehensive overview of the sedation procedure, including the pre-procedural assessment, the pharmacology of the drugs used, the acquisition and maintenance of minimum technical skills, periprocedural monitoring, the most frequent sedation-related complications and how to treat them, and recovery and discharge criteria. Finally, the third section addresses sedation-related issues in interventional procedures by degrees of complexity.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Interventional cardiology procedures that require sedation</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Electrical cardioversion</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Description and objectives</span><p id="par0010" class="elsevierStylePara elsevierViewall">Electrical cardioversion (ECV) is performed to restore sinus rhythm in patients with cardiac arrhythmias, especially atrial fibrillation (AF) and atrial flutter. In this procedure, a synchronized electrical current is delivered between two electrodes placed on the thorax. The shock depolarises the myocardium, thus interrupting the tachycardia and allowing the sinus node to resume control of the heart rhythm<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. Although the ECV procedure itself is usually very short, it requires sedation and analgesia due to the pain caused by the electric shock.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">General patient characteristics</span><p id="par0015" class="elsevierStylePara elsevierViewall">The procedure is indicated in patients with persistent AF and atrial flutter. The characteristics of patients who undergo ECV are, therefore, the same as those of patients with AF. The mean age of patients in the Spanish REVERSE registry was 63 ± 11 years. The most common comorbidities in patients with AF are: arterial hypertension, diabetes mellitus, sleep apnoea syndrome, overweight, thyroid dysfunction and structural heart disease, such as valvular heart disease and cardiomyopathy.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Outcomes</span><p id="par0020" class="elsevierStylePara elsevierViewall">The success rate of ECV is estimated to be as high as 90%. Biphasic device are reportedly more effective, defibrillate at lower energies with less risk of thermal injuries to the skin, and are now routinely used in clinical practice (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Randomized studies have reported global efficacy rates of 94% for biphasic compared with 79% for monophasic cardioversion. Since the maximum energy deliverable is fixed, the intensity of the current that reaches the heart is mainly determined by thoracic impedance. Some factors that can modify thoracic impedance and therefore the effectiveness of ECV are the size and position of the electrodes, the distance between them, and the electrode-skin interface. The position most frequently recommended is anterolateral, in which one of the electrodes is placed on the upper right margin of the sternum just below the right clavicle and the other on the left mid-axillary line. Some studies have suggested that the anteroposterior position (parasternal and below the left scapula) is more effective; however, other have not confirmed this finding. The electrode-skin interface can also affect the effectiveness of ECV, insofar as good contact between the electrode and the skin reduces transthoracic impedance and increases the effectiveness of the shock. This is why manual administration of the shock can be more effective than using adhesive electrodes. Another important factor is the duration of the arrhythmia. The highest efficacy rates (98%) have been reported in patients with AF lasting less than 1 year, with rates falling to 50% in patient with AF lasting more than 5 years.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">In patients with pacemakers or defibrillators, the electrodes should be placed at least 15 cm away from the pulse generator to avoid damage from the electric current. ECV will rarely affect the performance of these devices, although changes in pacing and sensing thresholds have been reported. Nevertheless, pacemaker parameters should be checked after ECV.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Treatment with antiarrhythmic drugs (amiodarone, sotalol, vernakalant, flecainide, or propafenone) prior to ECV can facilitate reversion to sinus rhythm and prevent the recurrence of arrhythmia. The most widely used drug is amiodarone, which should be started 2−3 weeks before ECV.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Procedure-related complications</span><p id="par0035" class="elsevierStylePara elsevierViewall">Although there are very few complications related to ECV, the following have been reported:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">Induction of ventricular arrhythmia if the electric shock is not synchronised with the QRS.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">Thromboembolic events (1%–7%) in patients with inadequate anticoagulation.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">Bradyarrhythmia: more than 25% of patients present bradycardia immediately after ECV. This is usually transient, and is probably related to atrial “stunning”, previous antiarrhythmic treatment, and the effect of sedation. It can also be a manifestation of previously undetected sinus dysfunction.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Myocardial dysfunction and acute lung oedema: this should be considered in patients with significant underlying ventricular dysfunction.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Transient hypotension.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Burns to the skin as a result of the application of electric current.</p></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Standard patient care circuits</span><p id="par0070" class="elsevierStylePara elsevierViewall">In haemodynamically stable patients, ECV is usually an elective, outpatient procedure. Anticoagulation therapy must be started at least 3 weeks before ECV and patients must fast before the procedure. During ECV, blood pressure, heart rate and pulse oximetry must be monitored. Given the short duration of the procedure, patients recover quickly and can be discharged within a few hours.</p><p id="par0075" class="elsevierStylePara elsevierViewall">In some situations, urgent or emergency ECV is required. This can occur, for example, in patients with ventricular or supraventricular arrhythmias and poor haemodynamic tolerance, or in cases in which anti-arrhythmia therapy itself causes arterial hypotension and rules out pharmacotherapy management. In these cases, if the arrhythmia involves AF lasting ≥ 48 h or of indeterminate duration and the patient is not anticoagulated, anticoagulation should be started as soon as possible and transoesophageal echocardiography, if available, should be considered to rule out the presence of a thrombus in the left atrial appendage. However, urgent cases must be evaluated individually.</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ablation of common or typical atrial flutter</span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Description and objectives</span><p id="par0080" class="elsevierStylePara elsevierViewall">Common atrial flutter is a reentrant tachycardia of the right atrium that can be treated most effectively with catheter ablation. The aim of ablation of common or typical atrial flutter is to interrupt the reentry circuit in the slow conduction zone located at the level of the cavotricuspid isthmus<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. The procedure consists, therefore, of linear ablation along the cavotricuspid isthmus to achieve a bidirectional conduction block. Diagnostic catheters are inserted into the heart, usually via the right femoral vein, and positioned at the level of the coronary sinus and in the lateral wall of the right atrium close to the isthmus and the ablation catheter (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Cavotricuspid isthmus ablation can be performed with the patient in atrial flutter or sinus rhythm. When the patient is in atrial flutter, catheter placement will allow the electrophysician to verify that the activation sequence in the right atrium is compatible with common flutter (activation is counter clockwise in 90% of cases and clockwise in 10%), and to perform pacing manoeuvres to confirm isthmus-dependent flutter. If the patient presents in the electrophysiology laboratory in sinus rhythm, the cavotricuspid isthmus is ablated while one of the diagnostic catheters close to the cavotricuspid isthmus stimulates the right atrium.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0085" class="elsevierStylePara elsevierViewall">Cavotricuspid isthmus ablation can be painful, so at this stage of the procedure it is usually necessary to increase the patient’s analgesia and sedation. However, ablation itself is usually brief (6−15 min), although this can vary depending on the anatomy of the patient and the thickness of the muscle fibres at this level. Total procedure time can range from 45 to 90 min. The procedure is usually performed under local anaesthesia and conscious sedation, which is usually deepened at the time of ablation.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">General patient characteristics</span><p id="par0090" class="elsevierStylePara elsevierViewall">Atrial flutter frequently occurs in combination with AF. According to reports, up to 56% of patients with typical atrial flutter also present AF, and these patients therefore share similar clinical characteristics. The average age is around 66 ± 8 years, and the most frequent comorbidities are: HBP, heart failure, diabetes mellitus, chronic obstructive pulmonary disease, ischaemic heart disease and other structural heart diseases (valvular heart disease, cardiomyopathy, congenital heart disease, etc.).</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Outcomes</span><p id="par0095" class="elsevierStylePara elsevierViewall">According to the Spanish Catheter Ablation Registry, 3425 such procedures were performed in 2018, with a success rate of 94%.</p><p id="par0100" class="elsevierStylePara elsevierViewall">The recurrence rate is only 5%–10%<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a>. The same procedure is performed to treat recurrence, although re-ablation of the cavotricuspid isthmus is usually faster as it simply involves identifying the conduction gap in the previous ablation line.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Procedure-related complications</span><p id="par0105" class="elsevierStylePara elsevierViewall">Ablation of common atrial flutter is usually a safe procedure with a complication rate of around 0.7%; the most frequent complications are vascular (52%). Other less frequent complications are: pericardial effusion, atrioventricular block, cerebrovascular accident or myocardial infarction.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Standard patient care circuits</span><p id="par0110" class="elsevierStylePara elsevierViewall">Ablation of common atrial flutter is nearly always an elective procedure that can be performed on an outpatient basis. Patients are usually anticoagulated prior to the procedure. Anticoagulation is managed at the discretion of the clinician - some do not suspend anticoagulation, while others will suspend it 1 or 2 days beforehand. Heparinisation is not usually required, except in some patients with mechanical valve prostheses. Patients should rest for 6 h after the procedure, and can then be discharged home.</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Ablation of atrial fibrillation</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Description and objectives</span><p id="par0115" class="elsevierStylePara elsevierViewall">AF is the most common cardiac arrhythmia. It affects 1%–2% of the general population, and according to data from the National Registry of Cardiac Arrhythmia Ablation, has been the most common target of ablation in Spain since 2017<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5,6</span></a>.</p><p id="par0120" class="elsevierStylePara elsevierViewall">The aim of AF ablation is pulmonary vein isolation, which can be performed using variations of 2 basic techniques: point-by-point radiofrequency ablation using electroanatomic mapping systems (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>), or balloon catheter ablation (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). In both cases, catheters are inserted into the left atrium through 1 or 2 transseptal punctures. Transseptal catheterization is one of the main causes of complications in AF ablation<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0125" class="elsevierStylePara elsevierViewall">Balloon catheters use cryo energy or laser energy, and radiofrequency balloon catheters will soon be available. Irrespective of the balloon catheter used, the technique involves inflating the balloon in the ostium of the pulmonary veins and delivering energy around the junction of the pulmonary veins until they are isolated. Isolation is confirmed by placing a multipolar catheter inside the ablated vein. Ablation ends when all pulmonary veins have been isolated. The procedure lasts between 90 and 120 min.</p><p id="par0130" class="elsevierStylePara elsevierViewall">Ablation of AF using radiofrequency catheters must be guided by electroanatomic mapping (EAM) systems, which provide a 3-D view of the left atrium and pulmonary veins. Ablation is performed by creating point-by-point radiofrequency lesions around the junction of the 2 ipsilateral pulmonary veins and sometimes in the carina until electrical isolation is achieved. In this technique, multipolar diagnostic catheters are also used to confirm electrical isolation of the pulmonary vein, and the procedure ends when all pulmonary veins have been isolated. The procedure lasts between 120 and 180 min.</p><p id="par0135" class="elsevierStylePara elsevierViewall">More extensive ablation is sometimes required in patients with persistent AF. In these cases, pulmonary vein isolation is combined with fractionated atrial electrogram ablation, additional ablation lines, ablation of rotors identified by other tests, or ablation of low voltage areas identified during electroanatomic mapping. The effectiveness of extended ablation has not been clearly demonstrated, but it is indicated in some patients with persistent AF<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. In these cases, ablation can last 240 min.</p><p id="par0140" class="elsevierStylePara elsevierViewall">The technique used is important from the point of view of anaesthesia. Mapping techniques maximise anatomical precision, but require total patient immobility. Ablation with radiofrequency catheters is painful during RF energy delivery, particularly when ablation involves the posterior wall of the left atrium. For this reason, point-by-point radiofrequency ablation of AF requires a deeper level of sedation and anaesthesia. Balloon catheter ablation does not require mapping systems, is less time-consuming and generally less painful, and can therefore be performed with lighter sedation or anaesthesia. During balloon catheter ablation of the right pulmonary veins, right diaphragmatic activity should be monitored by stimulating the right phrenic nerve. Ablation must be interrupted as soon a diaphragmatic mobility decreases. This is an important factor to consider when choosing the anaesthetic technique, since diaphragmatic monitoring cannot be performed when muscle relaxants are used.</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">General patient characteristics</span><p id="par0145" class="elsevierStylePara elsevierViewall">AF can be secondary to structural heart disease in more than 70% of cases, and is the ultimate arrhythmic manifestation of a variety of cardiac pathologies. The most common cause of AF is myocardial infarction, and it is usually associated with high blood pressure and ischaemic heart disease. Other comorbidities frequently associated with AF are obesity, diabetes mellitus, heart failure, chronic obstructive pulmonary disease, and other structural heart diseases (valvular heart disease, cardiomyopathy, congenital heart disease, etc.)<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a>.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Patients undergoing ablation of AF, however, do not necessarily present these comorbidities, and instead often present paroxysmal AF or persistent AF not associated with any structural heart disease or other factors classically associated with AF.</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Outcomes</span><p id="par0155" class="elsevierStylePara elsevierViewall">Ablation of AF is particularly successful in patients with paroxysmal AF, in whom arrhythmia-free survival rates can be as high as 70%–80% after 1 or 2 interventions. Patients with persistent AF, however, belong to a more heterogeneous group, and ablation outcomes will depend on several factors, such as the presence of structural heart disease, duration of AF, atrial fibrosis, etc. Arrhythmia-free survival rates of between 50% and 70% with 1 or more interventions have been reported in the literature<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a>.</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Procedure-related complications</span><p id="par0160" class="elsevierStylePara elsevierViewall">The most common peri-procedural complications associated with ablation of AF are related to thromboembolic events (stroke, transient ischemic attack or other embolisms) and the management of anticoagulation therapy (vascular complications, cardiac tamponade and other haemorrhagic events). Thromboembolic risk is highest during and immediately after ablation, since the procedure itself promotes a prothrombotic state even in patients with previous low thromboembolic risk. Therefore, anticoagulation therapy is one of the cornerstones of patient management before, during and after ablation for AF<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>. The aim of anticoagulation therapy is to minimise thromboembolic complications without excessively increasing ablation-related bleeding complications<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0165" class="elsevierStylePara elsevierViewall">The current guidelines of the North American and European scientific societies recommend 3 weeks of anticoagulation therapy prior to ablation in patients with AF lasting over 48 h or of uncertain duration. Furthermore, clinical practice guidelines do not recommend anticoagulation therapy in patients with low thromboembolic risk (CHA2DS2-VASc = 0)<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a>. In many cases, therefore, ablation is performed without prior anticoagulation, except in patients who, despite having a low risk, present AF lasting over 48 h or of uncertain duration.</p><p id="par0170" class="elsevierStylePara elsevierViewall">The current clinical practice guidelines for AF<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> and the expert consensus statement (HRS/EHRA/ECAS/APHRS/SOLAECE)<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> on ablation of AF recommend:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">□</span><p id="par0175" class="elsevierStylePara elsevierViewall">Preoperative management:</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">In patients receiving a vitamin K antagonist: do not suspend anticoagulation, and perform the procedure if the INR is between 2 and 3.5.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">In patients receiving direct acting oral anticoagulants (DOAC): do not suspend anticoagulation. In the case of a once-daily dose, the DOAC must be taken the day before, preferably the night before. In the case of a twice-daily dose, the DOAC can be taken immediately before ablation, although the patient can also suspend the morning dose on the day of ablation.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">In all patients, anticoagulation should restart 3−5 h after the end of the procedure, unless absolutely contraindicated.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">□</span><p id="par0195" class="elsevierStylePara elsevierViewall">Management during ablation:</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">Administer heparin in all patients immediately before or after transseptal catheterisation to achieve an ACT greater than 300 s throughout ablation.</p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">Patients not anticoagulated prior to ablation, usually with a CHA2DS2-VASc = 0, should be anticoagulated during the procedure to achieve the same target (ACT > 300 s).</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">□</span><p id="par0210" class="elsevierStylePara elsevierViewall">Post-ablation management:</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">Patients with no prior indication for chronic anticoagulation (CHA2DS2-VASc = 0) must receive oral anticoagulants for 2 months after ablation, starting 3−5 h after the end of the procedure.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Patients with a prior indication for chronic anticoagulation (CHA2DS2-VASc ≥ 2) must continue with anticoagulant treatment indefinitely.</p></li></ul></p><p id="par0225" class="elsevierStylePara elsevierViewall">Another relatively frequent complication is pericardial effusion. This has an incidence of around 1%, and is related to transseptal access and anticoagulant treatment. Management is conservative in most cases and may require pericardiocentesis, which is usually performed in the electrophysiology laboratory by the electrophysiologist as soon as pericardial effusion is detected.</p><p id="par0230" class="elsevierStylePara elsevierViewall">A rare but potentially deadly complication is atrioesophageal fistula, which can form a few days after ablation. To prevent this complication, oesophageal temperature is monitored during ablation using an oesophageal thermometer. If oesophageal temperature increases, the application of radiofrequency at that point must be interrupted. Patients are also given proton pump inhibitors, usually 80 mg of iv pantoprazole at the start of ablation followed by oral treatment for 1 month after ablation<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>.</p><p id="par0235" class="elsevierStylePara elsevierViewall">Complications can also arise during femoral access, and can be avoided by using ultrasound-guided femoral line placement.</p><p id="par0240" class="elsevierStylePara elsevierViewall">Finally, balloon catheter ablation is associated with a risk of around 2% of right diaphragmatic paralysis, which is usually reversible. As mentioned above, this complication can be avoided by stimulating the right phrenic nerve during right-vein ablation to monitor diaphragmatic activity.</p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Standard patient care circuits</span><p id="par0245" class="elsevierStylePara elsevierViewall">Ablation of AF is an elective procedure and can be performed on an outpatient basis in most cases. As mentioned above, correct anticoagulation management is essential to prevent ablation-related thromboembolic complications. After ablation, patients must observe bed rest for a number of hours, usually until the morning after the procedure.</p></span></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Ablation of atypical atrial flutter</span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Description and objectives</span><p id="par0250" class="elsevierStylePara elsevierViewall">Atypical flutter is a macroreentrant arrhythmia in which an electrical impulse rotates around a circuit that, unlike common flutter, does not include the cavo tricuspid isthmus. Atypical flutter, therefore, can arise in either the right or left atrium. Some rare cases of atypical flutter involving both atria have been described<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>.</p><p id="par0255" class="elsevierStylePara elsevierViewall">Atypical flutter is one of the least addressed arrhythmic substrates in Spain<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> and is most commonly found in the context of prior ablation of AF, congenital heart disease, valvular heart disease, and prior atriotomy<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0260" class="elsevierStylePara elsevierViewall">Ablation requires the use of several diagnostic catheters and an EAM system to define the location of the flutter circuit and design the necessary ablation. The aim of ablation is to create an ablation line that interrupts the flutter circuit. The choice of the ablation line depends on several factors, such as the location of the circuit, potential anatomical barriers (valve rings, veins, etc.), prosthetic structures such as patches, or areas of fibrosis. Therefore, left flutter ablation is more complex than common flutter ablation and cannot be standardized in the same way.</p><p id="par0265" class="elsevierStylePara elsevierViewall">Ablation of atypical flutter can be combined with AF ablation, since patients frequently suffer from both arrhythmic pathologies.</p><p id="par0270" class="elsevierStylePara elsevierViewall">The duration of the procedure depends on several factors, including the location of the flutter, the presence of congenital anomalies, or the complexity of the ablation circuit itself, but usually lasts 240 min, or longer for more complex cases.</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Outcomes</span><p id="par0275" class="elsevierStylePara elsevierViewall">The success rate of ablation is estimated at around 70%<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. However, recurrence occurs in around 54% of cases, according to some studies<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>.</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Procedure-related complications</span><p id="par0280" class="elsevierStylePara elsevierViewall">Complications are rare, with an incidence of just 3.5%. The most common are vascular access problems, pericardial effusion, and thromboembolic events. Regarding thrombosis, it is important to note that according to clinical practice guidelines the indication for anticoagulation in atrial flutter is similar to that in AF. This recommendation also applies to ablation of atypical atrial flutter, particular when located in the left atrium<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,7</span></a>.</p></span></span><span id="sec0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Ablation of ventricular tachycardia</span><span id="sec0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Description and objectives</span><p id="par0285" class="elsevierStylePara elsevierViewall">Ventricular tachycardia (VT) usually occurs in patients with structural heart disease, although it can also occur without associated heart disease (idiopathic ventricular tachycardias). When performed in patients with structural heart disease, ablation of VT usually requires sedation or anaesthesia<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a>.</p><p id="par0290" class="elsevierStylePara elsevierViewall">In most cases, VT in patients with structural heart disease is a reentrant arrhythmia that appears in the vicinity of eschar or a scar, usually the result of a prior myocardial infarction. However, ventricular scarring is also associated with dilated cardiomyopathy (with fibrosis usually involving the septum or the inferolateral wall), sarcoidosis, arrhythmogenic dysplasia, Chagas disease, and scars secondary to cardiac surgery to treat, for example, tetralogy of Fallot or other congenital heart diseases. Areas of scarring or fibrosis can produce reentry-vulnerable zones in which conduction is slow or disrupted. VT circuits (reentrant circuit) are located within or on the periphery of these fibrotic zones. VT circuits are usually located in the left ventricular endocardium, although they can also appear in the epicardium (typically in arrhythmogenic right ventricular dysplasia) or in the right ventricular endocardium<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>.</p><p id="par0295" class="elsevierStylePara elsevierViewall">Patients with VT and structural heart disease are usually treated with an implantable cardioverter defibrillator (ICD), a strategy that has proven effectiveness in reducing the risk of sudden cardiac death. ICDs, however, do not prevent VT recurrence, and patients may have arrhythmic recurrences that the ICD treats with shock or antitachycardia pacing<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a>. Ablation of VT is usually indicated in patients with ICD and arrhythmic recurrence<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a>.</p><p id="par0300" class="elsevierStylePara elsevierViewall">The aim of ablation is to interrupt the VT circuit by applying radiofrequency lesions at critical points, usually within the scar tissue. EAM systems are essential in VT ablation, since they reconstruct the ventricular anatomy and scar tissue where the VT circuit is located. Anatomical reconstruction of the scar together with characteristic local electrogram patterns allow the operator to identify the critical ablation targets in the VT circuit<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,14</span></a>. A multipolar catheter is used in addition to the ablation catheter to aid in the three-dimensional reconstruction of the cardiac chamber and to detect scars and VT circuits.</p><p id="par0305" class="elsevierStylePara elsevierViewall">Mapping and ablation can be performed during VT or in sinus rhythm. Ablation during VT may depend on the patient's haemodynamic tolerance, and VT will often need to be interrupted by shocks when haemodynamic changes are observed. In patients with haemodynamically unstable VT, ablation is performed in sinus rhythm once pathological zones potentially involved in the VT circuit have been identified (substrate ablation).</p><p id="par0310" class="elsevierStylePara elsevierViewall">In patients with right ventricular VT (less frequent), the catheter is inserted through the femoral vein. However, in left VTs the target site can be reached through the femoral artery (retrograde approach) or through transseptal catheterization (antegrade approach). Some epicardial VT ablations require epicardial access. Access to the pericardium is often achieved with a subxiphoid, transpericardial puncture. Radiofrequency ablation in the epicardium is restricted by the presence of the coronary arteries. This can be resolved by performing coronary angiography before starting epicardial ablation<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,14</span></a>.</p><p id="par0315" class="elsevierStylePara elsevierViewall">As catheter manipulation in the left ventricle and radiofrequency lesions can promote thrombogenesis, anticoagulants are routinely administered during VT ablation. As in ablation of AF, intravenous heparin is used to achieve a target ACT of >300 s.</p><p id="par0320" class="elsevierStylePara elsevierViewall">Patients with VT associated with structural heart disease frequently present with severe left ventricular systolic dysfunction. This can cause hemodynamic instability that interferes with the ablation procedure. In these cases, the use of haemodynamic support devices facilitates ablation<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12,14</span></a>.</p><p id="par0325" class="elsevierStylePara elsevierViewall">Ablation of VT in patients with structural heart disease is usually a lengthy procedure lasting from 180 to 300 min.</p></span><span id="sec0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Outcomes</span><p id="par0330" class="elsevierStylePara elsevierViewall">Ablation of VT is effective in reducing VT recurrence, the rate of ICD shocks to correct arrhythmia, and can improve survival in the event of electrical storm<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a>. Ablation of VT has an overall success rate of between 60% and 77% in ischaemic patients and 35%–65% in patients with dilated cardiomyopathy<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a>. The Spanish Catheter Ablation Registry shows an 84.1% success rate in ablation of ischaemic VT<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. Recurrence of VT after ablation in patients with structural heart disease is associated with an increased risk of mortality.</p></span><span id="sec0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Procedure-related complications</span><p id="par0335" class="elsevierStylePara elsevierViewall">Ablation of VT carries a high risk of complications, the most common being vascular access problems, cardiac perforation, cardiac tamponade, thromboembolism, and even mortality. In a national registry that included VT ablation data from more than 4600 patients, 6.9% presented vascular complications, 4.2% cardiac complications, 0.5% neurological complications; the hospital mortality rate was 1.6 %<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a>. The Spanish Ablation Registry of 2018 reports a complication rate of 6.5% and a mortality rate of 0.4%<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>.</p><p id="par0340" class="elsevierStylePara elsevierViewall">Some complications are specific to epicardial access, such as phrenic nerve injury, coronary lesions (which can be avoided by performing coronary angiography during the procedure), liver laceration or haematoma, and right ventricle injury.</p><p id="par0345" class="elsevierStylePara elsevierViewall">Ablation of VT can be associated with progressive pump failure and low cardiac output in patients with more advanced heart failure. These procedures are usually lengthy, and interventions involving ablation of multiple, wide-spread scars can last over 5 h.</p></span><span id="sec0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Standard patient care circuits</span><p id="par0350" class="elsevierStylePara elsevierViewall">Ablation of VT associated with structural heart disease is nearly always an urgent procedure performed in patients admitted for VT, who are often already admitted to the Cardiology Intensive Care Unit. The most urgent indication of VT ablation is electrical storm, which is associated with severe deterioration of the patient's clinical status. VT ablation is sometimes elective, and can be performed with a minimal hospital stay.</p><p id="par0355" class="elsevierStylePara elsevierViewall">After ablation, the patient remains in hospital for 24 h or more depending on their clinical status and complications. VT ablation can be associated with severe haemodynamic deterioration that requires haemodynamic support systems. This will lengthen hospital stay.</p></span></span><span id="sec0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Implantation and removal of cardiac electronic devices</span><span id="sec0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0155">Description and objectives</span><p id="par0360" class="elsevierStylePara elsevierViewall">Implantable cardiac electronic devices are designed to treat cardiac arrhythmias in certain patients. Pacemakers (PM) are implanted to treat bradyarrhythmia and ICDs are used to treat tachyarrhythmia. Conventional intravenous devices consist of a pulse generator, which is usually placed in the subclavicular region, and one or more intravenous leads that are attached to the myocardium. Other technologies include leadless PMs and subcutaneous ICDs; neither of these devices use intravenous leads, and are implanted using a different technique than that used in conventional systems (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><p id="par0365" class="elsevierStylePara elsevierViewall">Before implantation, the indication for the procedure, the type of intervention to be performed and the risks involved (see below) must be explained to the patient and their written consent must be obtained. Monitoring starts before the procedure (pulse oximetry, blood pressure and electrocardiography), and in the case of ICD implants or special circumstances, cutaneous defibrillator/pacing electrodes will be needed. A peripheral line is placed to administer prophylactic antibiotics, analgesia/sedation, and to perform venography if difficulties are encountered during insertion of intravenous leads. For this reason, the peripheral line is usually located in the arm ipsilateral to the implant.</p><p id="par0370" class="elsevierStylePara elsevierViewall">Before the procedure, temporary pacing in patients at risk of asystole during implantation should be considered. For example, in many patients scheduled for PM implantation arrive in the operating room with a temporary pacing device to treat severe bradycardia/asystole. The access route for temporary pacing should be located at a suitable distance from the site of implantation of the permanent device.</p><p id="par0375" class="elsevierStylePara elsevierViewall">Many patients are given oral anticoagulation prior to the procedure (mainly for AF, but also for valve prostheses or other pathologies). Although in other surgeries it is common practice to suspend anticoagulation or bridge with heparin, bleeding during implantation of cardiac electronic devices in patients taking oral anticoagulants is minor and easily controlled, being less severe than with bridging therapies. Therefore, in patients with high thrombotic risk, current guidelines recommend performing implantation under controlled oral anticoagulation<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a>.</p></span><span id="sec0160" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0160">Implantation technique</span><span id="sec0165" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0165">Conventional technique</span><p id="par0380" class="elsevierStylePara elsevierViewall">Cardiac electronic device implantation is generally well tolerated and is usually performed under conscious sedation with analgesia.</p><p id="par0385" class="elsevierStylePara elsevierViewall">After preparing the surgical field, the puncture site and area around the incision made to create the generator pocket are infiltrated with local anaesthetic. The left side is usually preferred because the angle between the subclavian and innominate veins is less acute than on the right side, making it easier to manipulate the lead. Venous access is obtained using the Seldinger technique (subclavian or axillary) or dissection (cephalic vein), preferably creating a puncture for each lead to be implanted. Following this, a subclavicular incision is made to create a prepectoral (subcutaneous) pocket for the PM/ICD pulse generator. In some cases (for cosmetic reasons or in patients with insufficient subcutaneous tissue) a deeper pocket is made in the submuscular plane.</p><p id="par0390" class="elsevierStylePara elsevierViewall">Depending on the type of pacing required, 1 (in the right ventricle, single chamber system), 2 (additional atrial lead, bicameral system) or 3 (additional left ventricular lead through the coronary sinus, tricameral system) leads will be implanted under fluoroscopic guidance. The only difference between PM and ICD implantation is that the right ventricular lead is thicker in the latter due to the shocking coil(s), and the generator is larger (8−10 ml in PMs vs. >30 ml in ICSs). After checking the performance of the device, the leads are fixed and connected to the pulse generator, and the pocket is closed in layers.</p><p id="par0395" class="elsevierStylePara elsevierViewall">Although modern devices do not require defibrillation testing at the end of implantation, it can be necessary in some cases (right implants, some cardiomyopathies, etc.). Testing is also performed to check the working status of the defibrillation system if, for example, a shock has not corrected tachycardia, or the generator does not respond correctly to a sensed event. To do this, the programmer is set to induce ventricular fibrillation and the device’s response to sensing is tested by delivering a shock lower than the energy ultimately programmed (defibrillation margin, usually >10 J difference). The patient must be anaesthetised during the test because the situation and the shock from the device are uncomfortable, and a rescue external defibrillator must be available in case the test fails.</p><p id="par0400" class="elsevierStylePara elsevierViewall">Replacing the pulse generator due to battery depletion simply involves opening the pocket and exchanging the device. There is no need to replace the existing leads unless they have failed, in which case new leads must be placed following the same procedure used during primary implantation. Surplus leads are either abandoned or removed.</p><p id="par0405" class="elsevierStylePara elsevierViewall">The average duration of a standard implantation procedure is between 30 and 45 min for a single chamber device and up to 90 (p<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25–75</span></a> 65−120) min for a 3-chamber device<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>. Standard replacement procedures usually last around 30 min.</p></span><span id="sec0170" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0170">Leadless pacemakers</span><p id="par0410" class="elsevierStylePara elsevierViewall">A leadless pacemaker, currently only available for single chamber pacing, is a miniature device (volume 0.8 ml) placed in the right ventricle (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>). The device is implanted using a deflectable catheter and a 27 Fr sheath that is inserted in the femoral vein and advanced into the heart via the inferior vena cava. The device is then released in the midseptal area or apical septum of the right ventricle. The puncture site is closed with a provisional suture and local compression.</p><elsevierMultimedia ident="fig0030"></elsevierMultimedia><p id="par0415" class="elsevierStylePara elsevierViewall">The procedure lasts 26 min on average, and is successfully implanted in > 99% of patients<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a>.</p></span><span id="sec0175" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0175">Subcutaneous ICD</span><p id="par0420" class="elsevierStylePara elsevierViewall">This device is not inserted intravenously, thus eliminating IV-related complications (mainly, infection, venous occlusion, and lead failure). This type of ICD consists of a pulse generator that is implanted subcutaneously on the left side of the chest, and a subcutaneous lead containing the shocking coil and ring electrode that is tunnelled to the parasternal area. The procedure is performed using anatomical landmarks instead of fluoroscopy. Defibrillation testing is currently required during implantation of a subcutaneous ICD. As implantation requires greater manipulation, it is usually more painful than a conventional procedure, but has a similar duration of around 60 min.</p></span><span id="sec0180" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0180">Other procedures</span><p id="par0425" class="elsevierStylePara elsevierViewall">With longer survival rates and technological advances, it is increasingly common for a patient to undergo reoperation to upgrade their existing device due to changes in their initial indication for pacing/defibrillation. This usually involves changing to a more complex pacing mode (from a single or dual chamber to a 3-chamber device) and/or from a PM to an ICD. These procedures are usually more time consuming than primary implantation and are associated with a higher rate of complications due to the need to adapt the generator pocket to another device and implant new leads. Currently, 28% of cardiac resynchronization procedure involve upgrading an existing device<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a>.</p><p id="par0430" class="elsevierStylePara elsevierViewall">Transvenous lead extraction is a complex procedure that deserves special mention. Although the indications for extraction have increased as the procedure has improved technically, systemic infection, venous occlusion, and problems arising from abandoned leads are the most common, and are supported by the strongest clinical evidence. This type of procedure requires specific training and material, and is usually performed specialized electrophysiologists or cardiac surgeons. In clinical practice, the procedure is performed under general anaesthesia with invasive hemodynamic monitoring and a central line. Major vascular complications occur in around 1%–2% and require immediate surgical intervention. For this reason, hospitals performing this procedure must have on-call cardiac surgeons and specialists in haemodynamic management<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a>.</p></span></span><span id="sec0185" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0185">General patient characteristics</span><p id="par0435" class="elsevierStylePara elsevierViewall">PM and ICD populations differ in terms of profile. Severe conduction disorders and symptomatic bradyarrhythmia are the main indication for PM implantation, and usually occur in elderly patients<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a>. For example, in the 2018 Spanish PaceMaker registry<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a>, the most common cause of implantation was atrioventricular block (60%), followed by sinus dysfunction (30%) and slow AF (12%). The mean age at implantation was 78 years (85% of patients older than 70 years), and 60% were men. Comorbidities were mostly age-related, and ejection fraction was preserved in most patients. Most of the procedures were primary implants (77%) with dual-chamber devices (62%).</p><p id="par0440" class="elsevierStylePara elsevierViewall">ICD implantation is performed in patients with heart disease and risk of sudden cardiac death, either for primary (prophylactic) or secondary (after a serious arrhythmic event) prevention<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a>; currently, 62% of all implants are for primary prevention. In the Spanish ICD registry<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a>, mean age at implantation is 62.6 years, with a predominance of men (>80%). Ventricular dysfunction and a high New York Heart Association (NYHA) functional class are the factors most related to sudden cardiac death. Therefore, >80% of patients have some degree of left ventricular dysfunction (46% severe dysfunction) and the majority are NYHA functional class II to III. Chronic ischaemic heart disease is the most common aetiology (54%), followed by idiopathic dilated cardiomyopathy (25.6%). Patients with other pathologies, such as congenital heart disease (24%), hypertrophic cardiomyopathy or channelopathies, form special populations, either due to their anatomical complexity or their young age.</p><p id="par0445" class="elsevierStylePara elsevierViewall">Cardiac resynchronization therapy devices are intended to treat heart failure, and are therefore implanted in special populations with a predominance of severe ventricular dysfunction and an advanced functional class. The procedure also tends to be longer, thereby increasing the risk of haemodynamic instability.</p></span><span id="sec0190" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0190">Procedure-related complications</span><p id="par0450" class="elsevierStylePara elsevierViewall">Modern devices are not free from complications (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). The incidence of some type of complication, according to various registers, is 5%–10% in the first months and approximately an additional 10% in the long term<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>. Early complications (first months) are directly related to surgical manipulation, and include haematoma (accumulation of blood in the pulse generator pocket), pneumothorax (depending on the chosen access route), cardiac perforation/tamponade (rare with modern leads), or lead displacement. Generally speaking, the more complex the device, the greater the likelihood of complications, with the highest risk occurring in patients with 3-chamber ICDs.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0455" class="elsevierStylePara elsevierViewall">Late complications include device failure (mainly due to lead deterioration) and infection. Although some individual factors can increase the risk of infection, the complexity of the device (ICDs or 3-chamber devices), the presence of previous haematoma, early reoperation, and the number of replacements performed are the main determinants of long-term infection.</p></span><span id="sec0195" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0195">Standard patient care circuits</span><p id="par0460" class="elsevierStylePara elsevierViewall">Cardiac electronic devices do not require major technical resources, and can be performed in either an operating room or cath lab (mainly electrophysiology). Implantation in electrophysiology labs is associated with a lower rate of complications, hospital admissions and costs, and is now, therefore, the standard of care. Most PM implantations are scheduled procedures. In the case of patients admitted for symptomatic bradyarrhythmia, irrespective of whether or not they are dependent on drugs or temporary stimulation, implantation should be performed as soon as possible to reduce complications, although the procedure is rarely performed in the emergency department.</p><p id="par0465" class="elsevierStylePara elsevierViewall">ICD implantation requires the presence of an electrophysiologist, so most procedures are performed in electrophysiology labs<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a>. The procedure is always scheduled, even when indicated for secondary prevention, since the patient must be stable and the goal of treatment is hospital discharge.</p><p id="par0470" class="elsevierStylePara elsevierViewall">Most patients only require a 24 -h hospital stay after PM or ICD implantation, and the procedure is now often performed on an out-patient basis, particularly in the case of ICD implants for primary prevention, replacement surgery, and other outpatient requirements.</p></span></span><span id="sec0200" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0200">Transcatheter aortic valve replacement (TAVR)</span><span id="sec0205" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0205">Description and objectives</span><p id="par0475" class="elsevierStylePara elsevierViewall">TAVR involves catheter-guided implantation of a biological prosthetic valve. The first-choice approach is through the femoral artery. The subclavian or transaxillary approach can also be used, but the transapical, transaortic, or transcarotid approach is rare. TAVR is performed to alleviate the signs and symptoms of aortic valve stenosis, and may improve survival in patients who are not candidates for surgery, or who are at greater risk of surgical complications.</p></span><span id="sec0210" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0210">General patient characteristics</span><p id="par0480" class="elsevierStylePara elsevierViewall">Clinical practice guidelines in patients with valvular heart disease<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> clearly recommend early treatment in all symptomatic patients with severe aortic stenosis. These guidelines recommend TAVR, preferably with transfemoral access, over aortic valve replacement (AVR) in patients with high or intermediate surgical risk, particularly in patients aged over 75 years. TAVR, therefore, is generally performed in elderly patients in whom frailty and comorbidities are common. Two recently published studies have shown that in aortic stenosis patients with low risk for surgery transfemoral TAVR has a similar <a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">26</span></a> or even more favourable<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> prognosis in the first year of follow-up than surgical valve replacement. The likelihood of TAVR being extended to include low-risk groups, especially elderly patients, shows the importance of planning to minimise the incidence of complications and optimize their management. In any event, the final decision on whether to perform TAVR or AVR should be made by consensus of a Heart Team made up of, at least, clinical cardiologists, haemodynamic cardiologists, surgeons and anaesthesiologists, with the mandatory participation of the patient.</p></span><span id="sec0215" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0215">Outcomes</span><p id="par0485" class="elsevierStylePara elsevierViewall">TAVR has proven efficacy and safety compared to surgery in several clinical trials analysing the entire spectrum of surgical risk<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26–29</span></a>. In these trials, a clear improvement in functional class was obtained, with a post-TAVR 30-day mortality rate of between 3.4% in high-risk patients and 0.4% in low-risk patients. The rate of complications has also been significantly reduced following further development of the technique.</p></span><span id="sec0220" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0220">Procedure-related complications</span><p id="par0490" class="elsevierStylePara elsevierViewall">The rate of serious TAVR-related complications have now been significantly reduced, and the need for urgent surgery (vascular or cardiac) is now less than 1% in Spain<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a>. <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the potential TAVR-related complications, the recommended prevention or treatment, and the published incidence<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31–38</span></a>.</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0225" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0225">Standard patient care circuits</span><p id="par0495" class="elsevierStylePara elsevierViewall">The TAVR care circuit involves several steps that can be divided into 3 stages: pre-TAVR or patient selection; TAVR; and post-TAVR or follow-up.</p><p id="par0500" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">pre-TAVR phase</span>, the severity of the aortic stenosis is evaluated. The study of choice, according to clinical practice guidelines, is transthoracic echocardiography<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a>. A detailed assessment is also made of the patient’s functional class, comorbidities, degree of frailty, and cognitive status. TAVR is contraindicated in patients that are extremely frail or exhibit cognitive impairment. If TAVI is indicated, CT angiography should be performed to evaluate the patient’s peripheral vascular anatomy and choose the access route. CT angiography is also used to measure the aortic valve annulus and explore the anatomy of both the aortic root and the heart in order to choose the best prothesis model and size<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">39</span></a>. Once the patient has been scheduled for TAVR, they must be evaluated by the Anaesthesia Service.</p><p id="par0505" class="elsevierStylePara elsevierViewall">The TAVR procedure is usually performed in the cath lab. This setting is associated with a lower rate of complications, hospital admissions and costs compared to the operating room<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">40</span></a>. The cath lab must be fully equipped to perform the technique, administer sedation or general anaesthesia, if required, and immediately treat any complications. The latest techniques are associated with few complications, and are performed under conscious sedation in most hospitals<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">41</span></a>.</p><p id="par0510" class="elsevierStylePara elsevierViewall">In the <span class="elsevierStyleItalic">post-TAVR phase</span> patients should ideally be transferred to a room with monitoring equipment and nurse surveillance. They can then be transferred to the ward 2 or 3 h after the procedure. Once on the cardiology ward, they should be telemonitored for 24–48 h to detect early signs of bradyarrhythmia. If there are no complications, the patient can be discharged at 48 h.</p></span></span><span id="sec0230" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0230">Left atrial appendage occlusion</span><span id="sec0235" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0235">Description and objectives</span><p id="par0515" class="elsevierStylePara elsevierViewall">The left appendage is an embryological remnant that is the site of thrombi in > 90% of patients with nonvalvular AF. In recent years, percutaneous occlusion of the left atrial appendage has become an alternative treatment strategy for patients with atrial fibrillation who are at risk for thromboembolic events and contraindicated for anticoagulants<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">42–45</span></a>.</p><p id="par0520" class="elsevierStylePara elsevierViewall">Percutaneous occlusion of the left atrial appendage is performed both under general anaesthesia and conscious sedation, depending on each hospital’s care protocol. The procedure is guided by transesophageal echocardiography (TEE), although intracardiac echocardiography (ICE) is preferred in some hospitals, based on their clinical experience. The introducer is inserted into the femoral vein and advanced to the heart, where a transseptal puncture is performed in the inferoposterior portion of the fossa ovale, following which 100 IU/kg sodium heparin is administered, unless contraindicated. Then, a guidewire is advanced into the left superior pulmonary vein and the transseptal introducer is exchanged for the delivery catheter. After removing the introducer and guidewire, a pigtail catheter is advanced into the left appendage under fluoroscopic visualization. The left appendage is evaluated to determine the size of the occluder. The occluder is placed in position and checked for stability, sealing of the left appendage, and major leaks. If everything is satisfactory, it is released, the delivery catheter and introducer are removed, and the venous puncture site is closed.</p></span><span id="sec0240" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0240">General patient characteristics</span><p id="par0525" class="elsevierStylePara elsevierViewall">According to the latest European clinical practice guidelines for the management of AF, left atrial appendage occlusion is recommended in patients with AF and a contraindication for long-term anticoagulation (recommendation class IIb, level of evidence B)<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">46</span></a>. Similarly, the latest ACC/AHA/HRS guidelines recommend left atrial appendage occlusion in patients with AF and high risk of stroke (IIb class of recommendation)<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a>.</p></span></span><span id="sec0245" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0245">Outcomes</span><p id="par0530" class="elsevierStylePara elsevierViewall">Success rates range from 90.9% to 100%, depending on the study consulted<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>. However, if the procedure is unsuccessful (transseptal puncture in a position other than inferoposterior, occluder malpositioning, intra-procedural complications, etc.) a second percutaneous left atrial appendage occlusion procedure can be considered.</p><span id="sec0250" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0250">Procedure-related complications</span><p id="par0535" class="elsevierStylePara elsevierViewall">Complications that may arise during the procedure include:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0540" class="elsevierStylePara elsevierViewall">Pericardial effusion and/or cardiac tamponade. Transseptal puncture or even perforation of a cardiac structure can cause pericardial effusion. If the effusion is mild to moderate and is not accompanied by signs compatible with cardiac tamponade, it can be treated conservatively. If it is severe or produces signs compatible with cardiac tamponade, pericardiocentesis should be performed (percutaneously in most cases). Surgical drainage should be reserved for cases where percutaneous drainage is infeasible or unsuccessful.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0545" class="elsevierStylePara elsevierViewall">Occluder embolization. This is a rare (less than 2%) though serious complication that can arise if the occluder is unstable or incorrectly positioned in the appendage. It can be prevented by following all the steps recommended in each occluder to check stability once the device has been deployed inside the left atrial appendage.</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0550" class="elsevierStylePara elsevierViewall">Stroke/TIA. This complication has to be considered in any interventional procedure. It is prevented by optimal heparinization, and monitoring ACT every 20−30 min to achieve a target of >300.</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0555" class="elsevierStylePara elsevierViewall">Bleeding complications.</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0560" class="elsevierStylePara elsevierViewall">Death. Intraprocedural mortality in left atrial appendage closure has only been reported in 0%–1% of cases<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">47</span></a>.</p></li></ul></p></span><span id="sec0255" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0255">Standard patient care circuits</span><p id="par0565" class="elsevierStylePara elsevierViewall">Percutaneous left atrial appendage occlusion is mainly an elective procedure. However, emergency occlusion can be required in patients admitted for pathologies that absolutely contraindicate the use of anticoagulants; for example, in the case of serious or life-threatening bleeding secondary to anticoagulant treatment, and whenever it is important to ensure thromboembolic prevention prior to hospital discharge.</p></span></span></span><span id="sec0260" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0260">General aspects of sedation in interventional cardiology</span><span id="sec0265" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0265">Types of sedation. Levels of sedation and anaesthesia</span><p id="par0570" class="elsevierStylePara elsevierViewall">Sedation is defined as the neurological state produced by a drug or other medium to calm a patient or induce sleep. There are several validated ways of defining and evaluating levels of sedation. Clinicians have traditionally used the modified 5-level version of the Ramsay Scale, where level 1 corresponds to the awake patient and level 5 corresponds to general anaesthesia<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">48,49</span></a>. It is sometimes difficult to establish the differences between levels of sedation, but it is clear that the greater the depth of sedation, the greater the risk of life-threatening adverse events that require immediate, appropriate management. Therefore, administering deeper levels of sedation requires specific knowledge and technical skills that are usually only mastered by anaesthesiologists.</p><p id="par0575" class="elsevierStylePara elsevierViewall">The latest clinical guidelines from the American Society of Anesthesia (ASA)<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">50</span></a> divides the continuum of states ranging from sedation to general anaesthesia into 4 phases that are described below (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0580" class="elsevierStylePara elsevierViewall">Anaesthesiologist-assisted sedation is performed by an officially qualified nurse sedationist. The procedure is supervised by an on-call anaesthesiologist who is present in the area, can communicate directly with the sedationist, and is immediately available. These team members should only be involved in administering sedation.<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">a</span><p id="par0585" class="elsevierStylePara elsevierViewall">Minimal sedation (anxiolysis):</p></li></ul></p><p id="par0590" class="elsevierStylePara elsevierViewall">Anxiolysis is a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, airway reflexes and ventilatory and cardiovascular functions are not affected.<ul class="elsevierStyleList" id="lis0025"><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">b</span><p id="par0595" class="elsevierStylePara elsevierViewall">Moderate sedation/analgesia (conscious sedation):</p></li></ul></p><p id="par0600" class="elsevierStylePara elsevierViewall">Moderate sedation/analgesia is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway when spontaneous ventilation is adequate. Cardiovascular function is usually maintained.</p><p id="par0605" class="elsevierStylePara elsevierViewall">Moderate sedation/analgesia provides patient tolerance of unpleasant or prolonged procedures through relief of anxiety, discomfort, and/or pain. Reaching a deeper level of sedation than intended can be associated with cardiac or respiratory depression that must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or death. Inadequate sedation or analgesia can result in undue patient discomfort or patient injury, lack of cooperation, or adverse physiological or psychological responses to stress.</p><p id="par0610" class="elsevierStylePara elsevierViewall">The appropriate choice of agents and techniques for moderate sedation/analgesia is dependent on the experience, training, and preference of the individual practitioner, requirements or constraints imposed by the patient’s clinical status or the type of procedure, and the risk of producing a deeper level of sedation than anticipated.</p><p id="par0615" class="elsevierStylePara elsevierViewall">For moderate sedation, this implies the ability to manage a compromised airway or hypoventilation and support cardiovascular function in patients who require advanced cardiopulmonary resuscitation (CPR).<ul class="elsevierStyleList" id="lis0030"><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">c</span><p id="par0620" class="elsevierStylePara elsevierViewall">Deep sedation/analgesia:</p></li></ul></p><p id="par0625" class="elsevierStylePara elsevierViewall">Deep sedation/analgesia is characterized by a drug-induced decreased level of consciousness during which the patient is not easily aroused, but responds after repeated or painful stimulation. Reflex withdrawal from a painful stimulus is not considered a purposeful response.</p><p id="par0630" class="elsevierStylePara elsevierViewall">The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be insufficient. Cardiovascular function is usually maintained.<ul class="elsevierStyleList" id="lis0035"><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">d</span><p id="par0635" class="elsevierStylePara elsevierViewall">General anaesthesia:</p></li></ul></p><p id="par0640" class="elsevierStylePara elsevierViewall">General anaesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assistance in maintaining a patent airway and positive pressure ventilation or even administration of a neuromuscular relaxant to improve ventilation may be required. Cardiovascular function may be impaired.</p><p id="par0645" class="elsevierStylePara elsevierViewall">Because sedation is a continuum, it is not always possible to predict how a patient will respond. In conclusion, interventional cardiology procedures that are expected to require deeper sedation than anxiolysis should be attended by an anaesthesiologist, since respiratory and consequently cardiac problems can occur at levels deeper than conscious sedation.</p><p id="par0650" class="elsevierStylePara elsevierViewall">Healthcare workers assisting the anaesthesiologist during sedation must in turn be able to detect and warn of progression to deeper levels of sedation so that the changes or measures needed to reverse this process can be applied.</p></span><span id="sec0270" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0270">Pre-procedure anaesthesia assessment</span><p id="par0655" class="elsevierStylePara elsevierViewall">All patients must undergo a pre-procedural anaesthesiology evaluation in order to reduce the risk of sedation-related complications<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>.</p><p id="par0660" class="elsevierStylePara elsevierViewall">Some observational studies have identified certain comorbidities that may cause or predispose patients to develop problems during the administration of moderate sedation/analgesia.</p><p id="par0665" class="elsevierStylePara elsevierViewall">These risk conditions include extreme ages, ASA III or higher and respiratory disease<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">52</span></a>, obstructive sleep apnoea<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>, chronic respiratory failure, obesity<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">54</span></a>, allergies, antipsychotic therapy<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">55</span></a>, history of gastric bypass surgery, patients with behavioural or attention disorders, or cardiovascular disorders<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>, history of chronic benzodiazepine use<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">55,56</span></a>, urgent admission<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>, prior respiratory support<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>, and transfer from a critical care unit to perform the procedure<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">53</span></a>.</p></span><span id="sec0275" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0275">Pre-procedural assessment of cardiac patients</span><p id="par0670" class="elsevierStylePara elsevierViewall">Pre-procedural assessment should include the following:</p><p id="par0675" class="elsevierStylePara elsevierViewall">Review previous medical records and interview the patient or family to identify<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">51</span></a>:<ul class="elsevierStyleList" id="lis0040"><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">□</span><p id="par0680" class="elsevierStylePara elsevierViewall">Cardiac history: NYHA classification, interventions performed, baseline status, Euroscore II<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">57,58</span></a>, assess frailty in elderly patients<a class="elsevierStyleCrossRefs" href="#bib0295"><span class="elsevierStyleSup">59–61</span></a>.</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">□</span><p id="par0685" class="elsevierStylePara elsevierViewall">Abnormalities of the major organ systems (e.g., cardiac, renal, pulmonary, neurologic, sleep apnoea, metabolic, endocrine).</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">□</span><p id="par0690" class="elsevierStylePara elsevierViewall">Adverse experience with sedation/analgesia as well as regional and general anaesthesia.</p></li><li class="elsevierStyleListItem" id="lsti0145"><span class="elsevierStyleLabel">□</span><p id="par0695" class="elsevierStylePara elsevierViewall">History of difficult intubation.</p></li><li class="elsevierStyleListItem" id="lsti0150"><span class="elsevierStyleLabel">□</span><p id="par0700" class="elsevierStylePara elsevierViewall">Current medical treatment (need for drug adjustment), possible drug interactions, drug allergies or others.</p></li><li class="elsevierStyleListItem" id="lsti0155"><span class="elsevierStyleLabel">□</span><p id="par0705" class="elsevierStylePara elsevierViewall">History of tobacco, alcohol, or drug abuse.</p></li><li class="elsevierStyleListItem" id="lsti0160"><span class="elsevierStyleLabel">□</span><p id="par0710" class="elsevierStylePara elsevierViewall">Frequent or repeated exposure to pain relievers or anxiolytics.</p></li></ul></p><p id="par0715" class="elsevierStylePara elsevierViewall">Conduct a focused physical examination of the patient that includes vital signs, auscultation of the heart and lungs, and airway assessment.</p><p id="par0720" class="elsevierStylePara elsevierViewall">Review available laboratory test results and additional cardiac studies. Evaluate the results of these tests before starting sedation and establish the patient’s functional status with regard to dyspnoea and tolerance of exercise.</p><p id="par0725" class="elsevierStylePara elsevierViewall">Request informed consent for anaesthesia, informing the patient that sedation may have to be deepened to general anaesthesia.</p><p id="par0730" class="elsevierStylePara elsevierViewall">The pre-procedural assessment must be performed in advance to allow the patient to prepare for the procedure. The report will be valid for a limited period of time, depending on the patient’s ASA status (ASA I: 1 year; ASA II: 1 year-6 months; ASA III: 6−3 months; ASA IV: 3−1 month)<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">62</span></a>.</p><p id="par0735" class="elsevierStylePara elsevierViewall">Reassess the patient immediately before the procedure to identify any possible changes from their previous status.</p><p id="par0740" class="elsevierStylePara elsevierViewall">Warn of possible, though rare complications, and possible options, including postponement of treatment, if anaesthesia is unsuccessful. It is not necessary to describe every conceivable risk.</p><p id="par0745" class="elsevierStylePara elsevierViewall">By signing the informed consent form, the patient authorises the anaesthesia and confirms that they have understood the information provided. The informed consent must be in hard copy, and must be signed in the hospital by the patient. Informed consent can be waived if the patient is unable to provide explicit consent due to severe pain or altered mental status.</p><p id="par0750" class="elsevierStylePara elsevierViewall">The patient or legal guardian must be told how to prepare in the days or hours prior to the procedure (suspension or switch of medication, preoperative hygiene, fasting, etc.).</p></span><span id="sec0280" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0280">Types of patients and comorbidities</span><p id="par0755" class="elsevierStylePara elsevierViewall">The following comorbidities are high risk factors for the development of serious sedation/anaesthesia-related complications:</p><span id="sec0285" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0285">Severe cardiovascular disease (Level of evidence A, strong recommendation<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a>)</span><p id="par0760" class="elsevierStylePara elsevierViewall">Patients with cardiovascular disease must be carefully evaluated and optimized before the procedure. This involves a complete evaluation of their physical status and cardiac function, since the higher the NYHA grade (commonly used to classify patients with heart failure), the greater the anaesthetic risk. Some circumstances, such as emergency surgery and an invasive approach, increase the risk of complications during procedural sedation and analgesia (PSA).</p><p id="par0765" class="elsevierStylePara elsevierViewall">Cardiac risk scales are objective tools that can be used in the preoperative assessment to assess and predict individual risks in patients undergoing cardiac and non-cardiac procedures under PSA<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">63–66</span></a>.</p><p id="par0770" class="elsevierStylePara elsevierViewall">The anaesthesiologist plays an essential role in the case of patients with haemodynamic instability or severe cardiac dysfunction<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">71,72</span></a> undergoing the minor or major cardiac procedures described in the previous section, such as electrical cardioversion<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">67,68</span></a> implantation of defibrillators<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">69</span></a> or pacemakers,TAVR<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,70</span></a>, etc.</p></span><span id="sec0290" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0290">Documented risk of obstructive sleep apnoea (Level of evidence B, strong recommendation<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a>)</span><p id="par0775" class="elsevierStylePara elsevierViewall">Patients with obstructive sleep apnoea (OSA) are more vulnerable to drug-induced cardiopulmonary depression during deep sedation<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">73</span></a>. There are different ways to identify this type of patient, such as the Berlin <a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> and STOP-BANG<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> questionnaires. OSA should be identified during the pre-anaesthesia assessment (history of snoring or sleep apnoea). There is no evidence that low levels of sedation (anxiolysis and conscious sedation) are related to cardiopulmonary complications in this type of patient<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">76</span></a>.</p><p id="par0780" class="elsevierStylePara elsevierViewall">Management of OSA patients undergoing PSA requires thorough and appropriate understanding of the different pharmacological options available; minimal doses of hypnotics should be used and opioids should be avoided. Dexmedetomidine has been shown to be safe, and could be considered as an alternative to PSA in patients with documented OSA. In patient with severe OSA, the use of nasal continuous positive airway pressure (CPAP) might reduce the risk of post-procedural respiratory complications<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">77</span></a>.</p></span><span id="sec0295" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0295">Morbid obesity<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a> (BMI > 40 kg/m<span class="elsevierStyleSup">2</span>)</span><p id="par0785" class="elsevierStylePara elsevierViewall">Morbidly obese patients are at higher risk of respiratory complications during PSA for several reasons, the most important being: impaired function of respiratory muscles, reduced functional residual capacity, limitation of expiratory flow, increased oxygen consumption, increased production of carbon dioxide, increased work of breathing at rest, increased upper airway resistance with propensity for OSA, and the potential development of obesity–hypoventilation syndrome, followed by pulmonary hypertension and right heart failure<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">78</span></a>. Although BMI is a robust, simple clinical tool for assessing obesity, it over-estimates heavily muscled individuals. Central obesity is more strongly related to a higher risk of breathing impairment, which often worsens during PSA. As obese patients with OSA are more prone to airway obstruction, the Berlin<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">74</span></a> or STOP BANG<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">75</span></a> questionnaires are recommended to assess the severity of OSA and its association with airway obstruction.</p><p id="par0790" class="elsevierStylePara elsevierViewall">Practical recommendations in obese patients are<a class="elsevierStyleCrossRefs" href="#bib0395"><span class="elsevierStyleSup">79,80</span></a>:<ul class="elsevierStyleList" id="lis0045"><li class="elsevierStyleListItem" id="lsti0165"><span class="elsevierStyleLabel">□</span><p id="par0795" class="elsevierStylePara elsevierViewall">Avoid the supine position.</p></li><li class="elsevierStyleListItem" id="lsti0170"><span class="elsevierStyleLabel">□</span><p id="par0800" class="elsevierStylePara elsevierViewall">Place the patient in the beach chair position.</p></li><li class="elsevierStyleListItem" id="lsti0175"><span class="elsevierStyleLabel">□</span><p id="par0805" class="elsevierStylePara elsevierViewall">Endotracheal intubation is the default choice of airway management.</p></li><li class="elsevierStyleListItem" id="lsti0180"><span class="elsevierStyleLabel">□</span><p id="par0810" class="elsevierStylePara elsevierViewall">Avoid long-acting sedatives.</p></li><li class="elsevierStyleListItem" id="lsti0185"><span class="elsevierStyleLabel">□</span><p id="par0815" class="elsevierStylePara elsevierViewall">Avoid drugs with respiratory depressant effects on the breathing frequency and/or tidal volume.</p></li><li class="elsevierStyleListItem" id="lsti0190"><span class="elsevierStyleLabel">□</span><p id="par0820" class="elsevierStylePara elsevierViewall">Avoid drugs that induce or reinforce airway obstruction in non-intubated patients.</p></li></ul></p><p id="par0825" class="elsevierStylePara elsevierViewall">Sedation with propofol appears to be associated with respiratory complications, even when used by anaesthesiologists, so guidelines recommend remifentanil and dexmedetomidine (authorised by the European Medicines Agency) for tailored titration of sedation and analgesia with appropriate monitoring of breathing and depth of anaesthesia.</p></span><span id="sec0300" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0300">Chronic renal failure<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a> (Level of evidence B, weak recommendation)</span><p id="par0830" class="elsevierStylePara elsevierViewall">Chronic renal failure is defined as a glomerular filtration rate below 60 ml min for more than 3 months or K-DIGO grade 3A<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">81</span></a>.</p><p id="par0835" class="elsevierStylePara elsevierViewall">In these patients, the pathway of drug metabolism and elimination must be taken into account to avoid the cumulative effects of prolonged sedation/analgesia and overdose. This is particularly important in patients with end-stage renal failure in whom sedation must be maintained with continuous infusions during lengthy procedures<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a>.</p></span><span id="sec0305" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0305">Chronic liver failure (MELD ≥ 10)<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a> (Level of evidence A, weak recommendation)</span><p id="par0840" class="elsevierStylePara elsevierViewall">Hepatic dysfunction secondary to liver disease can significantly change the metabolism and pharmacokinetic properties of hypnotic drugs and the risk of sedation-related complications increases. There is evidence that the half-life of benzodiazepines is prolonged in these patients, and they therefore require more time to eliminate the effects of sedation than a healthy patient<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">83</span></a>. Propofol for sedation has the best safety profile in these patients<a class="elsevierStyleCrossRefs" href="#bib0420"><span class="elsevierStyleSup">84,85</span></a>.</p></span><span id="sec0310" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0310">Elderly patients (over 70 years)<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a> (Level of evidence A, strong recommendation)</span><p id="par0845" class="elsevierStylePara elsevierViewall">Studies performed in this age group suggest that sedation increases the risk of arterial hypotension, hypoxaemia, cardiac arrhythmias and aspiration due to age-related physiological changes<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">86</span></a>.</p><p id="par0850" class="elsevierStylePara elsevierViewall">It is also important to bear in mind that the onset of action of all anaesthetic drugs is much slower in elderly patients, and successive doses and continuous perfusion should be titrated accordingly. In lengthy procedures, dosage should be reduced by up to 30% to avoid overdose, post-procedure hypoxaemia, and hasten recovery<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">87</span></a>.</p></span><span id="sec0315" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0315">ASA III or IV<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a> (Level of evidence B, strong recommendation)</span><p id="par0855" class="elsevierStylePara elsevierViewall">High-risk (ASA III or higher) patients undergoing PSA have a higher risk of hypoxaemia due to hypoventilation, and require good clinical observation and monitoring. Monitoring respiratory function helps prevent respiratory depression associated with the procedure.</p><p id="par0860" class="elsevierStylePara elsevierViewall">All studies supporting this recommendation are based on sedation for gastrointestinal procedures. Given that these are usually less invasive than interventional cardiology procedures, a parallel can be drawn and they can be considered applicable to interventional cardiology<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">88</span></a>.</p><p id="par0865" class="elsevierStylePara elsevierViewall">Accordingly, and following the clinical guidelines of the European and American societies of anaesthesiologists (ESA and ASA), all seriously compromised or medically unstable patients, or those most likely to require sedation to the depth of general anaesthesia (no response to painful stimuli) cannot be included in protocols where sedation is administered by non-anaesthesia clinicians (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>). These patients, therefore, must follow the established care circuit.</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0320" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0320">Acquisition and maintenance of minimum technical skills by non-anaesthesiologists</span><p id="par0870" class="elsevierStylePara elsevierViewall">Although the role of the anaesthesiologist in PSA has been established in several clinical guidelines<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">89</span></a>, it is still questioned by some scientific societies and organizations<a class="elsevierStyleCrossRefs" href="#bib0450"><span class="elsevierStyleSup">90,91</span></a> that advocate the administration of fast-acting hypnotic drugs for PSAs by non-anaesthesiologists.</p><p id="par0875" class="elsevierStylePara elsevierViewall">The main problems encountered during and after PSA include hypoxaemia (40.2%), vomiting and/or aspiration (17.4%), arterial hypotension and/or haemodynamic instability (15.2%), apnoea (12.4%) and cardiac arrest.</p><p id="par0880" class="elsevierStylePara elsevierViewall">Although some complications are not fatal, if appropriate measures are not taken to reverse the situation they can easily lead to cardiac arrest, requiring CPR<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">92</span></a>. The recent introduction of patient safety recommendations published by the Spanish Anaesthesia and Recovery Safety Notification System (SENSAR, in its Spanish acronym)<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">93</span></a> in Europe and Spain has probably helped reduce these incidents in our setting.</p><p id="par0885" class="elsevierStylePara elsevierViewall">Both the ESA and the ASA address this issue in their clinical guidelines for sedation, and establish the minimum knowledge and skills required by non-anaesthesiologists and, ideally, by all personnel involved in the procedure<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51</span></a>. However, the US guidelines do not specifically address this type of sedations in cardiac procedures, and the European guidelines only mention them in passing. Obviously, each country has its own legal and regulatory requirements for certifying non-anaesthesiologists to administer sedation. However, there is a general consensus that this certificate must be granted together with the acquisition of the Basic Life Support Course Diploma, both endorsed by a competent body.</p><p id="par0890" class="elsevierStylePara elsevierViewall">According to the UK’s Royal College of Anaesthetists<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a>, the minimal requirements for the administration of PSA should include the following skills:<ul class="elsevierStyleList" id="lis0050"><li class="elsevierStyleListItem" id="lsti0195"><span class="elsevierStyleLabel">□</span><p id="par0895" class="elsevierStylePara elsevierViewall">Ability to appropriately perform pre-procedural clinical assessments including upper airway and comorbidities assessment).</p></li><li class="elsevierStyleListItem" id="lsti0200"><span class="elsevierStyleLabel">□</span><p id="par0900" class="elsevierStylePara elsevierViewall">Competence at intravenous cannulation.</p></li><li class="elsevierStyleListItem" id="lsti0205"><span class="elsevierStyleLabel">□</span><p id="par0905" class="elsevierStylePara elsevierViewall">Appropriate skills for rapid assessment (by direct clinical observation and monitoring) of adverse respiratory and haemodynamic events.</p></li><li class="elsevierStyleListItem" id="lsti0210"><span class="elsevierStyleLabel">□</span><p id="par0910" class="elsevierStylePara elsevierViewall">Management of different levels of sedation.</p></li><li class="elsevierStyleListItem" id="lsti0215"><span class="elsevierStyleLabel">□</span><p id="par0915" class="elsevierStylePara elsevierViewall">Advanced airway diagnosis management using different airway devices.</p></li><li class="elsevierStyleListItem" id="lsti0220"><span class="elsevierStyleLabel">□</span><p id="par0920" class="elsevierStylePara elsevierViewall">Diagnosis and management of respiratory and haemodynamic depression.</p></li><li class="elsevierStyleListItem" id="lsti0225"><span class="elsevierStyleLabel">□</span><p id="par0925" class="elsevierStylePara elsevierViewall">Detailed knowledge of the pharmacology of drugs used for PSA and for emergency management.</p></li><li class="elsevierStyleListItem" id="lsti0230"><span class="elsevierStyleLabel">□</span><p id="par0930" class="elsevierStylePara elsevierViewall">Certified competence in advanced life support and monitoring of the patient.</p></li><li class="elsevierStyleListItem" id="lsti0235"><span class="elsevierStyleLabel">□</span><p id="par0935" class="elsevierStylePara elsevierViewall">Ability to evaluate full recovery of consciousness from PSA (using the Aldrete scale).</p></li><li class="elsevierStyleListItem" id="lsti0240"><span class="elsevierStyleLabel">□</span><p id="par0940" class="elsevierStylePara elsevierViewall">Receive training in these skills in other anaesthesiologist-assisted clinical scenarios.</p></li><li class="elsevierStyleListItem" id="lsti0245"><span class="elsevierStyleLabel">□</span><p id="par0945" class="elsevierStylePara elsevierViewall">Establish the minimum number of procedures to guarantee learning.</p></li></ul></p><p id="par0950" class="elsevierStylePara elsevierViewall">Royal College recommendations to acquire certification<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">94</span></a>:<ul class="elsevierStyleList" id="lis0055"><li class="elsevierStyleListItem" id="lsti0250"><span class="elsevierStyleLabel">□</span><p id="par0955" class="elsevierStylePara elsevierViewall">The theoretical training should be assessed by a written formal exam (preferably with multiple choice questions) with a minimal pass score of 75%, and the performance of at least 200 procedures with airway management.</p></li></ul></p></span><span id="sec0325" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0325">Location: optimal setting, patient preparation, and general monitoring</span><p id="par0960" class="elsevierStylePara elsevierViewall">Therapeutic procedures should be carried out in the cath and cardiology labs available and equipped for this purpose. The presence of an anaesthesiologist to supervise sedation will maximise patient comfort and safety and improve the conditions in which the procedures are performed. Likewise, having an established, functional setting that compensates for the drawbacks of out-of-operating-room procedures is the key to patient safety and correct action to address any possible complications<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">95</span></a>. Therefore, these out-of-operating-room settings must meet the following criteria:<ul class="elsevierStyleList" id="lis0060"><li class="elsevierStyleListItem" id="lsti0255"><span class="elsevierStyleLabel">1</span><p id="par0965" class="elsevierStylePara elsevierViewall">The room must be large enough to allow the anaesthesiologist to see and have access to all the equipment.</p></li><li class="elsevierStyleListItem" id="lsti0260"><span class="elsevierStyleLabel">2</span><p id="par0970" class="elsevierStylePara elsevierViewall">Ideally, the room must have a multiposition operation table that allows the patient to be placed in a Trendelenburg position if required.</p></li><li class="elsevierStyleListItem" id="lsti0265"><span class="elsevierStyleLabel">3</span><p id="par0975" class="elsevierStylePara elsevierViewall">*It is essential to have a fully checked and ready-to-use anaesthesia machine and the corresponding haemodynamic and respiratory monitoring equipment.</p></li><li class="elsevierStyleListItem" id="lsti0270"><span class="elsevierStyleLabel">4</span><p id="par0980" class="elsevierStylePara elsevierViewall">Minimum monitoring should include noninvasive blood pressure (NIBP), electrocardiogram (ECG), anaesthetic depth monitoring (BIS/entropy), peripheral oxygen saturation (SpO<span class="elsevierStyleInf">2</span>), and capnography.</p></li><li class="elsevierStyleListItem" id="lsti0275"><span class="elsevierStyleLabel">5</span><p id="par0985" class="elsevierStylePara elsevierViewall">The anaesthesia cart should also function as an advanced CPR cart. It should be checked daily to ensure all the mandatory equipment is included, and any missing items should be replaced.</p></li><li class="elsevierStyleListItem" id="lsti0280"><span class="elsevierStyleLabel">6</span><p id="par0990" class="elsevierStylePara elsevierViewall">It is essential to have airway management devices available (laryngoscope, orotracheal tubes, external and laryngeal masks, etc.) and trained nursing personnel familiar with this material in case complications arise.</p></li><li class="elsevierStyleListItem" id="lsti0285"><span class="elsevierStyleLabel">7</span><p id="par0995" class="elsevierStylePara elsevierViewall">The emergency telephone numbers of the on-call anaesthesiologist, cardiac surgeon, and the blood bank must be visible to all members of the healthcare team.</p></li></ul></p><p id="par1000" class="elsevierStylePara elsevierViewall">The anaesthesia carts must be equipped with everything necessary to address and resolve an unforeseen difficult airway and its clinical impact, including immediate access to resuscitation equipment. Airway problems during sedation rapidly evolve to hypoxaemia-hypercapnia, which leads to cardiac arrest and a metabolic situation that will not respond adequately to advanced CPR manoeuvres until ventilation is achieved and acidosis resolved. Therefore, all healthcare workers must be aware of the urgency of these situations, and must have the minimum knowledge needed to provide basic help until additional staff have been located. SEDAR airway management algorithms should be followed<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">96</span></a> and anaesthesia carts must be equipped with the material recommended in these algorithms.</p><span id="sec0330" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0330">Anaesthesia cart equipment</span><p id="par1005" class="elsevierStylePara elsevierViewall">To minimise risks associated with administration errors, anaesthesia carts should be organised using the standardized medication cart design (place most frequently used and clinically important drugs in the front, remove irrelevant or rarely used drugs, separate drugs with similar names or appearance, use different brand names when stocking similar drugs). Carts should be stocked in accordance with current operating room safety standards and in consensus with the head cath lab nurse.</p><p id="par1010" class="elsevierStylePara elsevierViewall">The other team members (nurses and nursing assistants) must be informed of the contents, and should receive training in stocking and maintaining medication carts. The cart must be checked daily, and any missing drugs and other materials must be replaced after the scheduled intervention.</p></span><span id="sec0335" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0335">Pre-sedation fasting</span><p id="par1015" class="elsevierStylePara elsevierViewall">The latest studies show that long pre-operative fasting does not necessarily imply an empty stomach, but rather a stomach with a high acid content that can cause metabolic and electrolyte alterations and increase the risk of acid-aspiration pneumonia. Preoperative fluid fasting contributes to post-induction hypotension, dehydration, hypoglycaemia, and intense thirst and hunger that makes both children and adults irritable. This has led experts to redefine existing fasting recommendations in recent years<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">97</span></a>. Current recommendations for pre-sedation fasting are summarized in <a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>.</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par1020" class="elsevierStylePara elsevierViewall">Prophylactic use of antiemetics and/or prokinetics are not routinely recommended in patients with no risk of aspiration. Exceptions can be made in patients with concomitant diseases that can affect gastric emptying (obesity, diabetes mellitus, gastroesophageal reflux disease [GERD], hiatal hernia, ileus or intestinal obstruction, emergency surgery, and patients receiving enteral nutrition) and in patients with anticipated difficult airway (<a class="elsevierStyleCrossRef" href="#tbl0030">Table 6</a>). In the interests of patient safety, fasting times should be lengthened in these cases, the risk vs. benefit of delaying urgent procedures should be analysed, or other anaesthetic and airway management techniques should be considered. The therapeutic options for adjuvant therapy to reduce the risk of aspiration are summarized in <a class="elsevierStyleCrossRef" href="#tbl0035">Table 7</a>.</p><elsevierMultimedia ident="tbl0030"></elsevierMultimedia><elsevierMultimedia ident="tbl0035"></elsevierMultimedia></span><span id="sec0340" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0340">Monitoring</span><p id="par1025" class="elsevierStylePara elsevierViewall">Continuous visual observation of the patient, though basic, is the most essential level of monitoring during and after PSA. Most sedation-related complications can be avoided if they are detected and treated early; therefore, the patient must be monitored constantly by a staff member other than the practitioner administering sedation.</p><p id="par1030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Level of consciousness:</span> The level of sedation can change during the procedure (from conscious to moderate or deep sedation), and only direct visual surveillance and continuous monitoring of response to stimuli can detect these transitions. Certain scales can be used to objectively assess different levels of sedation (<a class="elsevierStyleCrossRef" href="#tbl0040">Table 8</a>: MOAAS scale).<ul class="elsevierStyleList" id="lis0065"><li class="elsevierStyleListItem" id="lsti0290"><span class="elsevierStyleLabel">a)</span><p id="par1035" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Non-invasive blood pressure and ECG:</span> Intermittent (5−10 min) determination of blood pressure and continuous ECG are mandatory. In structural interventional cardiology, <span class="elsevierStyleItalic">invasive blood pressure (IBP)</span> measurement through the arterial line is highly useful at key times of haemodynamic instability (anti-tachycardia pacing, prosthesis expansion, etc.).</p></li><li class="elsevierStyleListItem" id="lsti0295"><span class="elsevierStyleLabel">b)</span><p id="par1040" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Pulse oximetry (SpO<span class="elsevierStyleInf">2</span>):</span> This is a rapid, effective technique for detecting hypoxaemia, and must be used in all patients undergoing PSA. Ideally, a baseline determination should be performed with the patient breathing room air. Patients with a history of hypoxaemia should not undergo PSA without first clarifying and correcting the cause of hypoxaemia. The baseline value will also indicate the post-recovery target value. The audible heart rate alarm on the pulse oximeter must always be activated to provide real-time blood gas monitoring. Bear in mind that these measurements can be inaccurate during episodes of hypotension.</p></li><li class="elsevierStyleListItem" id="lsti0300"><span class="elsevierStyleLabel">c)</span><p id="par1045" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Capnography:</span> The most common PSA-related complication is respiratory depression and/or airway obstruction, so most experts recommend monitoring ventilation by observing chest movements. There is also a wide consensus to include capnography, a technique that is highly sensitive to episodes of apnoea and alveolar hypoventilation, for early detection of respiratory depression as standard monitoring in any moderate or deep sedation procedure [E: 1A].</p></li><li class="elsevierStyleListItem" id="lsti0305"><span class="elsevierStyleLabel">d)</span><p id="par1050" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">EEG Monitors (BIS):</span> Target-controlled infusion (TCI) to objectively measure the level of sedation can be considered in PSA procedures involving continuous infusion of propofol. There is no evidence that these monitors improve oxygenation and or the incidence of cardiopulmonary complications, but they are welcomed by both patients and clinicians because they allow more accurate titration of sedation drugs and reduce PSA duration.</p></li><li class="elsevierStyleListItem" id="lsti0310"><span class="elsevierStyleLabel">e)</span><p id="par1055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Transesophageal echocardiography (TEE):</span> Fluoroscopy imaging is adequate for most structural interventional cardiology procedures; however, TEE is standard in left atrial appendage occlusion and MitraClip placement. The use of TEE can be considered in some patients undergoing combined or complex procedures that can require general anaesthesia. It can also be considered during deep sedation; however, as it obstructs the airway it can increase the risk of aspiration and hypoventilation, and is uncomfortable for the patient.</p></li><li class="elsevierStyleListItem" id="lsti0315"><span class="elsevierStyleLabel">f)</span><p id="par1060" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">Regional cerebral O2 saturation (SrO<span class="elsevierStyleInf">2</span>):</span> SrO<span class="elsevierStyleInf">2</span> is useful in TAVR, which can cause cerebrovascular events; however, its sensitivity for detecting very focal strokes is very low. It is useful for detecting persistent perfusion alterations in larger brain territories in the context of low cardiac output. These alterations can have postoperative clinical repercussions.</p></li></ul></p><elsevierMultimedia ident="tbl0040"></elsevierMultimedia></span></span><span id="sec0345" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0345">Sedation pharmacology</span><p id="par1065" class="elsevierStylePara elsevierViewall">Sedationists (physicians and/or nurses) who administer anaesthetic or analgesic agents must have detailed knowledge of the pharmacological properties of each drug and of the potential risks of drug combinations in order to ensure they are titrated correctly<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">50,51,60</span></a>. It is essential to bear in mind that the expected effect can vary, so clinicians must remain vigilant to ensure the level of safety that each patient deserves.</p><p id="par1070" class="elsevierStylePara elsevierViewall">Generally speaking, a sedation agent will be optimal if it is correctly titrated to achieve and maintain an adequate level of sedation and analgesia, while avoiding overdose-related adverse effects or unforeseen adverse reactions due to individual variability or the use of drug combinations.</p><p id="par1075" class="elsevierStylePara elsevierViewall">Accordingly, the "ideal drug" for sedation is one that rapidly reaches target plasma levels, has a short duration of action, and a predictable half-life that is not affected by the particular clinical-metabolic context. In other words, it must be easily titrated, with a good haemodynamic and respiratory safety profile and no significant adverse effects. Since most anaesthetic drugs do not simultaneously meet both hypnotic and analgesic requirement, a combination of drugs is usually required. Therefore, practitioners in charge of administering these drugs must understand the principles of drug interactions in order to assess the risk-benefit of desired and undesired clinical effects.</p><p id="par1080" class="elsevierStylePara elsevierViewall">Guidelines recommend intravenous administration, because it has the highest bioavailability and therefore the most predictable pharmacokinetics compared to other options.</p><p id="par1085" class="elsevierStylePara elsevierViewall">It is important to distinguish between toxic effect and adverse effect. Toxicity usually refers to effects derived from an overdose and is, therefore, avoidable and undesirable; adverse effects are determined by the inherent pharmacokinetics of the drug at therapeutic doses, and are therefore predictable, expected and sometimes even desirable.</p><p id="par1090" class="elsevierStylePara elsevierViewall">The choice of the most appropriate anaesthetic regimen in each case will be based on the pathology to be treated, the degree of patient collaboration, and the characteristics of the procedure to be performed (duration, degree of immobility required, painful/pain-free, patient positioning, etc.). The quality of the sedation administered will depend on achieving a balance between efficacy and quality while ensuring intra-procedural patient comfort and safety<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">98,99</span></a>.</p><p id="par1095" class="elsevierStylePara elsevierViewall">The most widely used formula consists of a combination of benzodiazepines (BDZ) or propofol and opioids (<a class="elsevierStyleCrossRef" href="#tbl0045">Table 9</a>) administered in 1 or more boluses or in continuous target-controlled infusion. These synergies and new methods of administration increase patient comfort and allow the sedationist to closely monitor drug titration and post-procedural patient recovery. Another option that is gaining ground is dexmedetomidine, an alpha-2-agonist with sedative, anxiolytic and analgesic effects that does not cause respiratory depression and reduces the risk of delirium<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">100</span></a>. Dexmedetomidine-induced sedation differs from the level of sedation induced by other sedatives<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">70</span></a>, such as the GABA receptor agonist BDZ or propofol, since patients can open their eyes, respond to simple commands, and cooperate with the procedure under stimulation. However, when no stimulus is delivered, the patient falls asleep again and returns to the previous level of sedation. The respiratory pattern and EEG changes produced by dexmedetomidine are very similar to natural sleep<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">101</span></a>, and for this reason it is usually used in procedures that do not require deep sedation<a class="elsevierStyleCrossRefs" href="#bib0510"><span class="elsevierStyleSup">102,103</span></a>.</p><elsevierMultimedia ident="tbl0045"></elsevierMultimedia></span><span id="sec0350" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0350">Complications associated with PSA in interventional cardiology</span><p id="par1100" class="elsevierStylePara elsevierViewall">Complications associated with PSA in general include postoperative nausea and vomiting (PONV), airway obstruction, allergic reactions, and respiratory depression. In cardiological procedures in particular, PSA can cause arrhythmia, episodes of hypotension or hypertension, haematomas or pseudoaneurysms in vascular accesses, and other severe complications.</p><p id="par1105" class="elsevierStylePara elsevierViewall">PSA-related complications, though rare, can be serious. Vasoactive and antiarrhythmic drugs (ephedrine, atropine, amiodarone, adrenaline), a defibrillator or pacemaker, and all necessary blood products correctly typed and ordered in advance must be readily available. Antihistamines and corticosteroids should also be on hand to treat allergic reactions.</p><p id="par1110" class="elsevierStylePara elsevierViewall">The most serious problems stem from respiratory depression or airway obstruction, and include hypoxaemia (40.2%), aspiration (17.4%), apnoea (12.4%), and cardiac arrest. In addition, central (haemopericardium) and peripheral (vascular injury) bleeding can result in considerable morbidity and mortality<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">104</span></a>.</p><p id="par1115" class="elsevierStylePara elsevierViewall">Respiratory depression usually occurs only with deep sedation, and is due to overdosage or the combined effect of several drugs<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">82</span></a>. The patient will require ventilatory assistance and oxygenation until they have recovered spontaneous ventilation, and in some cases it is advisable to reverse the effect of sedative drugs. Bear in mind that one in 10–20 cases of intubation failure occurs outside the surgical area, and is associated with a mortality rate of 3%. "Can’t ventilate, can’t intubate" situations occur in 1 in every 60–100 of these cases. Airway obstruction results in hypoventilation; although the patient is awake enough to breathe, they will not be able to do so. Airway obstruction can be caused by tongue displacement, presence of foreign material, laryngospasm, or laryngeal oedema. If the patient develops hypoxaemia, significant hypoventilation, or apnoea during PSA<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">105</span></a>, a patent airway must be established (insert a Guedel airway, jaw thrust, remove TEE probe if applicable, etc.) and BDZ or opioid reversal agents must be given if there is suspicion of overdose and spontaneous ventilation is not achieved (<a class="elsevierStyleCrossRef" href="#tbl0050">Table 10</a>).</p><elsevierMultimedia ident="tbl0050"></elsevierMultimedia><p id="par1120" class="elsevierStylePara elsevierViewall">It is also important to be vigilant for possible allergic reactions, ranging from local reactions (skin rash) to anaphylactic shock with severe hypotension and bronchospasm in the most severe cases. These events are very serious and require emergency action with intubation, volume replacement and administration of hydrocortisone, antihistamines and adrenaline.</p><p id="par1125" class="elsevierStylePara elsevierViewall">All healthcare workers involved in PSAs must have the knowledge and skills required to detect and manage these emergencies and to secure the airway, restore respiratory function and manage shock until the situation is resolved or the appropriate care circuits for each clinical situation have been set in motion. The "International Committee for the Advancement of Procedural Sedation” has launched an initiative to standardise the registry of PSA-related complications with the aim of improving the quality of procedures and contributing to research<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">106</span></a>.</p></span><span id="sec0355" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0355">Post-procedure recovery</span><p id="par1130" class="elsevierStylePara elsevierViewall">Patients undergoing low-risk procedures that do not require hospital admission should be monitored and observed in a post-procedure recovery area for at least 30−60 min. Lack of intra-procedural stimulation coupled with delayed drug elimination may contribute to persistent sedation and cardiorespiratory depression during this period; therefore, constant visual observation by a trained nurse is essential. The Modified Aldrete Scale establishes the criteria for discharge to the hospital ward, PACU or ICU.</p><p id="par1135" class="elsevierStylePara elsevierViewall">In outpatients (Group I procedures) undergoing low risk procedures that do not require monitoring for complications, variables such as pain, ambulation, urinary output and oral tolerance are added to determine the suitability of discharge home<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">107</span></a> (Aldrete score > 18). Patients must be given written instructions and a telephone number they can call if they observe any warning signs.</p><p id="par1140" class="elsevierStylePara elsevierViewall">If the patient is hospitalized (Group II procedures and higher), the postoperative care circuits established for each type of pathology (PACU, Critical Care Unit, Intermediate Care Unit) must be followed. Each unit must implement postoperative management protocols, detailing the care circuits and pre-established admission times for each procedure.</p></span></span><span id="sec0360" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0360">General aspects of sedation in interventional cardiology</span><p id="par1145" class="elsevierStylePara elsevierViewall">Each procedure has its own technical characteristics and potential complications, and each will require a specific sedation technique. We have therefore divided the different procedures into groups according to the depth of sedation required and specific anaesthesiologic approach.</p><p id="par1150" class="elsevierStylePara elsevierViewall">Irrespective of the initial interventional approach and sedation chosen, inter-patient variations and technical and/or clinical complications can require the team to change the entire initial strategy, so constant monitoring and careful management of these complex patients is mandatory. <a class="elsevierStyleCrossRef" href="#tbl0055">Table 11</a> provides an overall summary of sedation levels, taking into account the specific considerations for each procedure described in this document. <a class="elsevierStyleCrossRef" href="#tbl0060">Table 12</a> outlines the different interventional procedures performed, the type and duration of sedation administered, potential sedation-related complications and special considerations to bear in mind.</p><elsevierMultimedia ident="tbl0055"></elsevierMultimedia><elsevierMultimedia ident="tbl0060"></elsevierMultimedia></span><span id="sec0365" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0365">Conflict of interests</span><p id="par1155" class="elsevierStylePara elsevierViewall">The authors have no conflict of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:3 [ "identificador" => "sec0010" "titulo" => "Interventional cardiology procedures that require sedation" "secciones" => array:9 [ 0 => array:3 [ "identificador" => "sec0015" "titulo" => "Electrical cardioversion" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Description and objectives" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "General patient characteristics" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Outcomes" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Procedure-related complications" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Standard patient care circuits" ] ] ] 1 => array:3 [ "identificador" => "sec0045" "titulo" => "Ablation of common or typical atrial flutter" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Description and objectives" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "General patient characteristics" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Outcomes" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Procedure-related complications" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Standard patient care circuits" ] ] ] 2 => array:3 [ "identificador" => "sec0075" "titulo" => "Ablation of atrial fibrillation" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0080" "titulo" => "Description and objectives" ] 1 => array:2 [ "identificador" => "sec0085" "titulo" => "General patient characteristics" ] 2 => array:2 [ "identificador" => "sec0090" "titulo" => "Outcomes" ] 3 => array:2 [ "identificador" => "sec0095" "titulo" => "Procedure-related complications" ] 4 => array:2 [ "identificador" => "sec0100" "titulo" => "Standard patient care circuits" ] ] ] 3 => array:3 [ "identificador" => "sec0105" "titulo" => "Ablation of atypical atrial flutter" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0110" "titulo" => "Description and objectives" ] 1 => array:2 [ "identificador" => "sec0115" "titulo" => "Outcomes" ] 2 => array:2 [ "identificador" => "sec0120" "titulo" => "Procedure-related complications" ] ] ] 4 => array:3 [ "identificador" => "sec0125" "titulo" => "Ablation of ventricular tachycardia" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0130" "titulo" => "Description and objectives" ] 1 => array:2 [ "identificador" => "sec0135" "titulo" => "Outcomes" ] 2 => array:2 [ "identificador" => "sec0140" "titulo" => "Procedure-related complications" ] 3 => array:2 [ "identificador" => "sec0145" "titulo" => "Standard patient care circuits" ] ] ] 5 => array:3 [ "identificador" => "sec0150" "titulo" => "Implantation and removal of cardiac electronic devices" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0155" "titulo" => "Description and objectives" ] 1 => array:3 [ "identificador" => "sec0160" "titulo" => "Implantation technique" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0165" "titulo" => "Conventional technique" ] 1 => array:2 [ "identificador" => "sec0170" "titulo" => "Leadless pacemakers" ] 2 => array:2 [ "identificador" => "sec0175" "titulo" => "Subcutaneous ICD" ] 3 => array:2 [ "identificador" => "sec0180" "titulo" => "Other procedures" ] ] ] 2 => array:2 [ "identificador" => "sec0185" "titulo" => "General patient characteristics" ] 3 => array:2 [ "identificador" => "sec0190" "titulo" => "Procedure-related complications" ] 4 => array:2 [ "identificador" => "sec0195" "titulo" => "Standard patient care circuits" ] ] ] 6 => array:3 [ "identificador" => "sec0200" "titulo" => "Transcatheter aortic valve replacement (TAVR)" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0205" "titulo" => "Description and objectives" ] 1 => array:2 [ "identificador" => "sec0210" "titulo" => "General patient characteristics" ] 2 => array:2 [ "identificador" => "sec0215" "titulo" => "Outcomes" ] 3 => array:2 [ "identificador" => "sec0220" "titulo" => "Procedure-related complications" ] 4 => array:2 [ "identificador" => "sec0225" "titulo" => "Standard patient care circuits" ] ] ] 7 => array:3 [ "identificador" => "sec0230" "titulo" => "Left atrial appendage occlusion" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0235" "titulo" => "Description and objectives" ] 1 => array:2 [ "identificador" => "sec0240" "titulo" => "General patient characteristics" ] ] ] 8 => array:3 [ "identificador" => "sec0245" "titulo" => "Outcomes" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0250" "titulo" => "Procedure-related complications" ] 1 => array:2 [ "identificador" => "sec0255" "titulo" => "Standard patient care circuits" ] ] ] ] ] 2 => array:3 [ "identificador" => "sec0260" "titulo" => "General aspects of sedation in interventional cardiology" "secciones" => array:9 [ 0 => array:2 [ "identificador" => "sec0265" "titulo" => "Types of sedation. Levels of sedation and anaesthesia" ] 1 => array:2 [ "identificador" => "sec0270" "titulo" => "Pre-procedure anaesthesia assessment" ] 2 => array:2 [ "identificador" => "sec0275" "titulo" => "Pre-procedural assessment of cardiac patients" ] 3 => array:3 [ "identificador" => "sec0280" "titulo" => "Types of patients and comorbidities" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0285" "titulo" => "Severe cardiovascular disease (Level of evidence A, strong recommendation)" ] 1 => array:2 [ "identificador" => "sec0290" "titulo" => "Documented risk of obstructive sleep apnoea (Level of evidence B, strong recommendation)" ] 2 => array:2 [ "identificador" => "sec0295" "titulo" => "Morbid obesity (BMI > 40 kg/m)" ] 3 => array:2 [ "identificador" => "sec0300" "titulo" => "Chronic renal failure (Level of evidence B, weak recommendation)" ] 4 => array:2 [ "identificador" => "sec0305" "titulo" => "Chronic liver failure (MELD ≥ 10) (Level of evidence A, weak recommendation)" ] 5 => array:2 [ "identificador" => "sec0310" "titulo" => "Elderly patients (over 70 years) (Level of evidence A, strong recommendation)" ] 6 => array:2 [ "identificador" => "sec0315" "titulo" => "ASA III or IV (Level of evidence B, strong recommendation)" ] ] ] 4 => array:2 [ "identificador" => "sec0320" "titulo" => "Acquisition and maintenance of minimum technical skills by non-anaesthesiologists" ] 5 => array:3 [ "identificador" => "sec0325" "titulo" => "Location: optimal setting, patient preparation, and general monitoring" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0330" "titulo" => "Anaesthesia cart equipment" ] 1 => array:2 [ "identificador" => "sec0335" "titulo" => "Pre-sedation fasting" ] 2 => array:2 [ "identificador" => "sec0340" "titulo" => "Monitoring" ] ] ] 6 => array:2 [ "identificador" => "sec0345" "titulo" => "Sedation pharmacology" ] 7 => array:2 [ "identificador" => "sec0350" "titulo" => "Complications associated with PSA in interventional cardiology" ] 8 => array:2 [ "identificador" => "sec0355" "titulo" => "Post-procedure recovery" ] ] ] 3 => array:2 [ "identificador" => "sec0360" "titulo" => "General aspects of sedation in interventional cardiology" ] 4 => array:2 [ "identificador" => "sec0365" "titulo" => "Conflict of interests" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-02-21" "fechaAceptado" => "2021-01-11" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0055">Please cite this article as: Martinez-Dolz L, Pajares A, López-Cantero M, Osca J, Díez JL, Paniagua P, et al. Documento de consenso para la Sedación en procedimientos de intervencionismo en Cardiología. Rev Esp Anestesiol Reanim. 2021;68:309–337.</p>" ] 1 => array:3 [ "etiqueta" => "◊" "nota" => "<p class="elsevierStyleNotepara" id="npar0060">More information on the components of the Working Group on Tutored Sedation in Interventional Procedures in Cardiology of the Spanish Society of Anesthesia, Resuscitation and Therapeutic of Pain (SEDAR) and of the Spanish Society of Cardiology (SEC) is available at <a class="elsevierStyleCrossRef" href="#sec0370">Appendix A</a>.</p>" "identificador" => "fn0005" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par1160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Technical aspects of interventional cardiology procedures. SEC Task Force:</span></p> <p id="par1165" class="elsevierStylePara elsevierViewall">Concepción Alonso Martín. Arrhythmia Unit Hospital de la Santa Creu i Sant Pau. Barcelona.</p> <p id="par1170" class="elsevierStylePara elsevierViewall">Joaquín Osca Asensi. Arrhythmia Unit Cardiology Service of the Hospital Universitari i Politècnic La Fe. IIS La Fe. Valencia.</p> <p id="par1175" class="elsevierStylePara elsevierViewall">Eduardo Arana Rueda. Arrhythmia Unit Cardiology Service of the Virgen del Rocío Hospital. Seville.</p> <p id="par1180" class="elsevierStylePara elsevierViewall">José Luis Díez Gil. Cath Lab. Cardiology Service of the Hospital Universitari i Politècnic La Fe. IIS La Fe. Valencia.</p> <p id="par1185" class="elsevierStylePara elsevierViewall">Tania Rodriguez Gabella. Cath Lab. Cardiology Service of the Virgen del Rocío Hospital. Valladolid.</p> <p id="par1190" class="elsevierStylePara elsevierViewall">Coordinators:</p> <p id="par1195" class="elsevierStylePara elsevierViewall">Dr. Luis Martínez Dolz. Cardiology Service of the Hospital Universitari i Politècnic La Fe. IIS La Fe. CIBERCV. Valencia.</p> <p id="par1200" class="elsevierStylePara elsevierViewall">Dr. Manuel Anguita. Cardiology Service Hospital Reina Sofía de Córdoba. SEC Chair.</p> <p id="par1205" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Specific aspects of sedation in interventional cardiology SEDAR Task Force:</span></p> <p id="par1210" class="elsevierStylePara elsevierViewall">Azucena Pajares Moncho. Anaesthesiology and Resuscitation Service of the Hospital Universitari i Politècnic La Fe. IIS La Fe. Valencia.</p> <p id="par1215" class="elsevierStylePara elsevierViewall">Marta López Cantero. Anaesthesiology and Resuscitation Service of the Hospital Universitari i Politècnic La Fe. IIS La Fe. Valencia.</p> <p id="par1220" class="elsevierStylePara elsevierViewall">Pilar Paniagua Iglesias. Anaesthesiology and Resuscitation Service. Hospital de la Santa Creu i Sant Pau. Barcelona.</p> <p id="par1225" class="elsevierStylePara elsevierViewall">Pilar Argente. Anaesthesiology and Resuscitation Service of the Hospital Universitari i Politècnic La Fe. (Valencia). IIS La Fe. Valencia.</p> <p id="par1230" class="elsevierStylePara elsevierViewall">Coordinators:</p> <p id="par1235" class="elsevierStylePara elsevierViewall">Rosario Vicente. Anaesthesiology and Resuscitation Service of the Hospital Universitari i Politècnic La Fe. (Valencia). IIS La Fe. Valencia.</p> <p id="par1240" class="elsevierStylePara elsevierViewall">Dr. Julián Alvarez. Head of the Anaesthesia and Resuscitation. Complejo Hospitalario Universitario de Santiago. Professor of the University of Santiago. SEDAR Chair. Santiago de Compostela.</p>" "etiqueta" => "Annex" "titulo" => "Authorship of the consensus document for Anaesthesiologist-Assisted Sedation in Interventional Cardiology" "identificador" => "sec0370" ] ] ] ] "multimedia" => array:18 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1356 "Ancho" => 1142 "Tamanyo" => 137103 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Biphasic cardioversion.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1223 "Ancho" => 2605 "Tamanyo" => 290058 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Cavotricuspid isthmus and catheter arrangement in ablation of typical atrial flutter.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1699 "Ancho" => 2953 "Tamanyo" => 485669 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Point-by-point radiofrequency ablation.</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1007 "Ancho" => 2576 "Tamanyo" => 192326 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Balloon catheter ablation (cryoballoon and laser balloon catheter).</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 903 "Ancho" => 2954 "Tamanyo" => 185980 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A) Single chamber ICD. Note the thicker lead with the shocking coil in the right ventricle (arrow). The pulse generator (lightening symbol) is larger than the PM generator (B and C). B) Dual chamber PM, with atrial lead in the right atrial appendage (white arrow) and ventricular lead in the septum of the right ventricle (black arrow). C) Three-chamber PM, with a lead in the apex of the right ventricle and in the lateral vein of the left ventricle through the coronary sinus.</p>" ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 954 "Ancho" => 2939 "Tamanyo" => 190892 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A and B) Subcutaneous ICD. The shocking coil is placed adjacent to the sternal, under the skin (black arrow). The pulse generator (lightening symbol) is located in the back. C) Leadless PM (black arrow) housed in the septum of the right ventricle. Not the right subclavian central catheter in a haemodialysis patient.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complication \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prevention/treatment \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Pneumothorax:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Overall 0.7% cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observation in small cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Varies according to access route (subclavian 1%–2% vs. axillary or cephalic <0.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chest tube drainage in larger cases \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Cardiac perforation:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>0.3−1% cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Most manifest as thoracic-pleuritic discomfort on follow-up. Lead repositioning with support from a cardiac surgeon \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Less frequent in septal vs. apical implants \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In the event of acute cardiac tamponade, drain and reposition the lead. Surgery in patients with active bleeding \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Acute tamponade during implantation is rare, and gives immediate signs of haemodynamic instability \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Haematoma:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>2%−4% cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optimal haemostasis during the intervention \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ecchymosis is common and has no clinical significance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conservative treatment in most cases. Intervention if large and associated with tension and active bleeding \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>The risk is multiplied with heparin bridging and with dual antiplatelet therapy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Perform controlled implants under dicoumarin or NOACs. Avoid dual antiplatelet therapy and heparins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Lead displacement:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>1.6%–4.4% cases \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Reoperation to reposition the lead \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>More common in the atrial lead \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Can be early or late (generally the first month after implantation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Infection:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Between 1% and 7%, increasing in parallel with the number of reoperations (replacements, device upgrade, complications, etc.) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Optimise aseptic technique \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Infection is usually limited to the pulse generator pocket \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intra-procedural antibiotic prophylaxis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Systemic infection is associated with significant mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Identify patients at risk: (fever prior to implantation, use of temporary pacemakers, diabetes, kidney disease, haematoma, reoperation) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Most infections are late (>1 month after implantation) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment: targeted antibiotic therapy; explanation of the entire pacemaker/ICD system is usually required \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Venous thrombosis:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Up to 5% of patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Most are asymptomatic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>May cause venous occlusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Oedema in the ipsilateral arm. Development of collateral circulation in chronic obstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640531.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Complications associated with the implantation of cardiac devices.</p>" ] ] 7 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0040" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">TAVR: transcatheter aortic prosthesis replacement.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Incidence (%) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prevention measures and/or treatment. \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Refs. \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">During vascular access:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5−8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ultrasound-guided puncture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,31,32</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Second vascular access leaving a protection guide wire \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Major bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ischaemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">While advancing the prosthesis through the aorta:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">31,32</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Perforation/dissection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">New advance and release systems \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Embolic protection devices (EPD) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Stent-related:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">28,30,33,34</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aortic annulus rupture \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5−1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Implant technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Prosthesis embolization \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Correct prosthesis size \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">EPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ventricular perforation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Manipulation of guide wires and electrocatheters \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Mitral valve injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Implantation technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Coronary obstruction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Preimplantation study \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Implantation technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Post-implantation complications:</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">27,30,36,37</span></a><span class="elsevierStyleSup">,</span><a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">38</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Pacemaker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Implantation technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Kidney injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Minimize contrast agent \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Endocarditis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Manipulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eliminate source of infection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Periprosthetic leaks (mod/sev) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Prosthesis design \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Implantation technique \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Leaflet thrombosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antiplatelet \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anticoagulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640529.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Complications related to TAVR.</p>" ] ] 8 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0045" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Minimal sedation (anxiolysis) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Moderate sedation (Conscious sedation) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Deep sedation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">General anaesthesia: \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Response \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Normal response to verbal commands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Purposeful response to verbal commands or tactile stimulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intentional response to repeated or painful stimulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unarousable, even with painful stimulus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Airway \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unaffected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adequate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">May be affected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Intervention often required \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spontaneous ventilation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unaffected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adequate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">May be inadequate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Often inadequate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiovascular function \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unaffected \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Usually maintained \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Usually maintained \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">May be impaired \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640525.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Levels of sedation and anaesthesia.</p>" ] ] 9 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0050" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Serious cardiovascular disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Documented risk of sleep apnoea (OSAS) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Morbid obesity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic kidney failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic liver failure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Elderly patient \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ASA III or > \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640532.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">High risk factors for the development of serious sedation/anaesthesia-related complications.</p>" ] ] 10 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0055" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adult patients</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 h clear liquids \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 h solid liquids \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pharmacological prophylaxis is not recommended in patients with no added risk factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Paediatric patients</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 h for clear liquids \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 h for breast milk \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 h for cow's milk and formula \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8 h for solid food \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enteral feeding</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gastric tube 8 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transpyloric tube 4 h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Jejunal tube or patient with orotracheal intubation does not require prior fasting \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640524.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Fasting time and pharmacological recommendations.</p>" ] ] 11 => array:8 [ "identificador" => "tbl0030" "etiqueta" => "Table 6" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0060" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">GERD: gastroesophageal reflux disease.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Patients and comorbidities that require sedation assessment and management by an anaesthesiologist \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Obesity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Diabetes mellitus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pregnant women \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">GERD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hiatus hernia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ileus or intestinal obstruction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Urgent procedures \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enteral feeding tubes \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640528.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Patients with risk factors for aspiration.</p>" ] ] 12 => array:8 [ "identificador" => "tbl0035" "etiqueta" => "Table 7" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0065" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Gastric stimulants</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Proven efficacy in reducing gastric volume \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Metoclopramide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Systematic use is not recommended in patients with no added risk factors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">H2 blockers</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Effective in reducing gastric volume and acidity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cimetidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insufficient evidence to assess their effect in routine administration</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ranitidine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Omeprazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lansoprazole \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Antiemetics</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Effective in reducing perioperative nausea and vomiting (PONV) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Droperidol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Routine use is not recommended \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ondansetron \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DUAL antiemetic therapy in patients with a history of PONV \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Anticholinergics</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Routine use is not recommended</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Atropine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scopolamine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><span class="elsevierStyleItalic">Antacids</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Routine use in patients with risk factors</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium citrate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sodium bicarbonate \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640526.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Pharmacological prophylaxis for aspiration.</p>" ] ] 13 => array:8 [ "identificador" => "tbl0040" "etiqueta" => "Table 8" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Response \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Score \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Agitated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Responds readily to name spoken in normal tone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lethargic response to name spoken in normal tone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Responds only after name is called loudly and/or repeatedly \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Responds only after painful stimulus or mild shaking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Does not respond after painful stimulus or mild shaking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No response after painful stimulus \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640530.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Modified sedation assessment scale.</p>" ] ] 14 => array:8 [ "identificador" => "tbl0045" "etiqueta" => "Table 9" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0075" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">COPD: chronic obstructive pulmonary disease; CKD: chronic kidney disease; IV: intravenous; IM: intramuscular.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sedation dose \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Half life \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Adverse effects \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Respiratory depression \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Midazolam \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.01−0.1 mg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1−4 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Accumulates in fatty tissue \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes, dose dependent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Muscle relaxant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BEWARE IN COPD AND CKD \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ketamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 mg/kg (IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">HBP, tachycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3−5 mg/kg (IM) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bronchodilator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypersalivation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dissociative state \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Propofol \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">100−300 mcg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cardiodepressant \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Vasodilator \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Antiemetic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fentanyl \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2−150 mcg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30−60 min IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bradycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1−2 h IM \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Remifentanil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.05−2 mcg/kg/min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3−10 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Muscle stiffness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Yes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dexmedetomidine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bolus 0.5−1 mcg/kg/h over 10 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bradycardia-hypotension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infusion of 0.2−0.7 mcg/kg/h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nausea \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thirst \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#tblfn0005">*</a>Naloxone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.5−1 mg/kg up to maximum 0.2 mg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30−45 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sympathetic stimulation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pulmonary oedema \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><a class="elsevierStyleCrossRef" href="#tblfn0010">**</a>Flumazenil \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1−5 mg/kg \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1 h \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Liver metabolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640522.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "*" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Opioid antagonist.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "**" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Benzodiazepine antagonist.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Sedative drugs.</p>" ] ] 15 => array:8 [ "identificador" => "tbl0050" "etiqueta" => "Table 10" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0080" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">PSA: procedural sedation and analgesia; TEE: transesophageal ultrasound.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Encourage or physically stimulate the patient to take deep breaths \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administer supplemental oxygen \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Perform jaw thrust to clear the airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Aspirate secretions \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Call for help (Code for emergency response plan) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Remove TEE probe, if applicable \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insert a Guedel airway \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deliver positive ventilation through a face mask if spontaneous ventilation is inadequate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">If the patient's ventilation and oxygenation are still inadequate, administer benzodiazepine or opioid antagonists (naloxone and/or flumazenil), if applicable. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Insert a laryngeal mask airway or endotracheal tube \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">After administering antagonists the patient should be kept under observation and monitored for a reasonable time to ensure that cardiorespiratory depression does not recur once the effect of the antagonist wears off. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640527.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Management sequence for respiratory complications in PSA.</p>" ] ] 16 => array:8 [ "identificador" => "tbl0055" "etiqueta" => "Table 11" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0085" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">cp: continuous perfusion; DEX: dexmedetomidine; ECV: electrical cardioversion; MDZ: midazolam; TIVA: total intravenous anaesthesia.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group 1 (Anxiolysis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• 3 mg MDZ ± 50 mcg fentanyl bolus \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group 2 (conscious sedation)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• 1−2 mg MDZ + cp 0.6 mg/kg/h DEX ± remifentanil 0.05 mcg/kg/min or 50/100 mcg fentanyl (bolus) before painful stage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• 2 mg MDZ + loading dose DEX 0.5 mcg/kg over 10′ + cp 0.7 mg/kg/h DEX ± 50/100 mcg fentanyl during painful stage \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• 1−2 mg MDZ + cp 1−2 mg/kg/h propofol \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group 3 (deep sedation)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• <span class="elsevierStyleItalic">Long duration:</span> 1−3 mg MDZ + cp propofol 1.5−4.5 mg/kg/h + 50/100 fentanyl prior to painful stage or cp 0.25−0.5 g/kg/min remifentanil \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• <span class="elsevierStyleItalic">Short duration (ECV):</span> 2−3 mg MDZ + bolus etomidate 0.1 mg/kg ± fentanyl 50 g \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Group 4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Balanced general anaesthesia or TIVA \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640523.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Sedation regimens.</p>" ] ] 17 => array:8 [ "identificador" => "tbl0060" "etiqueta" => "Table 12" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0090" "detalle" => "Table 1" "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">AF: atrial fibrillation; ECV: electrical cardioversion; ICD: implantable cardioverter defibrillator; TEE: transesophageal echocardiography; VT: ventricular tachycardia.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Procedure \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Type of sedation \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Duration \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Complications \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Special features \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ECV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep sedation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><5 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Minimal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Thromboembolism<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Transient sinus dysfunction (25%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ablation of typical atrial flutter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conscious sedation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">45−90 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Incidence: rare (0.7 %) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Conscious sedation can be deepened during the ablation phase (6−15 min) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Thromboembolism<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Generally performed under oral anticoagulation \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Vascular complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ablation of atypical atrial flutter \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep sedation/general anaesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Up to 240 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Incidence: up to 3.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Right atrial flutter: usually a simpler procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Vascular complications<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Left atrial flutter: generally more complex procedure that requires ACT > 300. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Thromboembolism<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Left atrial flutter: complications similar to AF ablation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ablation of atrial fibrillation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep sedation/general anaesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cryoablation < 120 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Incidence: between 3.5% and 4% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Because of the risk of diaphragmatic paralysis, diaphragm activity must be monitoring during balloon catheter procedures (avoid muscle relaxants) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Radiofrequency < 180 min<a class="elsevierStyleCrossRef" href="#tblfn0025"><span class="elsevierStyleSup">c</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Vascular complications<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Generally performed under oral anticoagulation, requires ACT > 300 s \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Extended procedures up to 240 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Thromboembolism<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Pericardial effusion (1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Diaphragmatic paralysis (<2%)<a class="elsevierStyleCrossRef" href="#tblfn0030"><span class="elsevierStyleSup">d</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Atrioesophageal fistula<a class="elsevierStyleCrossRef" href="#tblfn0035"><span class="elsevierStyleSup">e</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Mortality: < 0.1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ablation of ventricular tachycardia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Idiopathic VT: local anaesthesia ± anxiolysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Ventricular tachycardia in structural heart disease: complex procedure lasting between 180 and 300 min. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Procedure associated with more frequent and severe complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Some VT ablation procedures require epicardial access and coronary angiography. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">VT associated with structural heart disease: deep sedation/general anaesthesia<a class="elsevierStyleCrossRef" href="#tblfn0021"><span class="elsevierStyleSup">f</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Incidence: between 6.5% and 10% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Requires ACT > 300 s \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Vascular complications<a class="elsevierStyleCrossRef" href="#tblfn0020"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Thromboembolism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Pericardial effusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Haemodynamic impairment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Phrenic nerve injury \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Complications associated with epicardial access (liver injury) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Mortality: 0.4−1.5% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pacemaker and ICD implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local anaesthesia and anxiolysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Between 30 min (single chamber devices) and 120 min (three-chamber) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Early complications < 2 %–3 % (pneumothorax, cardiac perforation or haematoma) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• In patients receiving oral anticoagulants, maintaining anticoagulants should be prioritised over heparin bridging. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICD: occasionally deep sedation<a class="elsevierStyleCrossRef" href="#tblfn0040"><span class="elsevierStyleSup">g</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Late complications (electrode displacement, infection or venous thrombosis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Leadless pacemaker implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local anaesthesia and anxiolysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">30 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Complications < 1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The device is implanted through a 27 Fr catheter that is inserted in the femoral vein. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The most frequent are vascular lesions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• More serious complication: cardiac perforation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Subcutaneous ICD implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local anaesthesia and deep sedation<a class="elsevierStyleCrossRef" href="#tblfn0045"><span class="elsevierStyleSup">h</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">60 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Early complications < 2% (local haematoma, haemodynamic instability after defibrillation testing) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Defibrillation testing is performed at the end of the procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Pacemaker/ICD lead removal \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local anaesthesia and anxiolysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Variable, between 30 and 180 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Rare in simple procedures, <1% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• In the most complex cases, specific materials are used to extract the leads, such as dissection sheaths (electrosurgical or laser-assisted). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Deep sedation or general anaesthesia<a class="elsevierStyleCrossRef" href="#tblfn0050"><span class="elsevierStyleSup">i</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• In more complex procedures, major vascular complications may appear in 2% and mortality in 3%. \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• The procedure may require femoral access \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• In the most complex cases it is recommended to have a cardiac surgeon on call or access to an electrophysiologist/cardiac surgeon in hybrid operating rooms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Transcatheter aortic prosthesis replacement (TAVR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Conscious sedation and analgesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><90 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Vascular complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Should be performed in centres with a cardiac surgery unit \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Local anaesthesia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Cardiac tamponade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Need for urgent cardiac surgery (<1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Left atrial appendage occlusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">General anaesthesia or sedation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><60 min \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Vascular complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Usually guided by TEE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Intracavitary ultrasound or microTEE can also be used \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Cardiac tamponade \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">• Occluder embolization (<2%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2640521.png" ] ] ] "notaPie" => array:9 [ 0 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">If anticoagulation is inadequate.</p>" ] 1 => array:3 [ "identificador" => "tblfn0020" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0020">Vascular complications are the most frequent type of complication in these procedures.</p>" ] 2 => array:3 [ "identificador" => "tblfn0025" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Ablation of atrial fibrillation is performed to isolate the pulmonary veins. It is usually performed with a cryoballoon catheter or with point-by-point radiofrequency ablation. Laser balloon ablation is used less frequently, and has an intermediate duration. Various catheters that can speed up the ablation procedure are currently under development.</p>" ] 3 => array:3 [ "identificador" => "tblfn0030" "etiqueta" => "d" "nota" => "<p class="elsevierStyleNotepara" id="npar0030">In balloon catheter procedures (laser-assisted or cryoablation).</p>" ] 4 => array:3 [ "identificador" => "tblfn0035" "etiqueta" => "e" "nota" => "<p class="elsevierStyleNotepara" id="npar0035">An oesophageal thermometer is used to reduce risks.</p>" ] 5 => array:3 [ "identificador" => "tblfn0021" "etiqueta" => "f" "nota" => "<p class="elsevierStyleNotepara" id="npar0031">VT ablation in the context of structural heart disease can be performed under deep sedation when systolic dysfunction is less severe and the patient’s clinical status allows it. However, in patients with poorer clinical status, generally with a greater degree of left ventricular systolic dysfunction, general anaesthesia is recommended.</p>" ] 6 => array:3 [ "identificador" => "tblfn0040" "etiqueta" => "g" "nota" => "<p class="elsevierStyleNotepara" id="npar0040">Defibrillation testing the end of ICD implantation is not usually performed; however, when it is unavoidable, sedation should be deepened during induction of VF and verification of the effectiveness of the ICD to terminate the induced arrhythmia (the defibrillation test only lasts a few minutes).</p>" ] 7 => array:3 [ "identificador" => "tblfn0045" "etiqueta" => "h" "nota" => "<p class="elsevierStyleNotepara" id="npar0045">The procedure is more painful than the implantation of a conventional ICD, and defibrillation testing is mandatory after implantation. This requires deeper sedation, and some hospitals administer locoregional anaesthesia, such as serratus plane block.</p>" ] 8 => array:3 [ "identificador" => "tblfn0050" "etiqueta" => "i" "nota" => "<p class="elsevierStyleNotepara" id="npar0050">The complexity and risk of the procedure varies greatly, and depends on the time elapsed since implantation of surplus lead or the type of lead used (ICD leads are more difficult to remove). Newly implanted leads are easily removed and the procedure requires only local anaesthesia and anxiolysis; however, removal of leads implanted more than 10 years earlier, particularly ICD leads, usually require deep sedation or general anaesthesia.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Specific aspects of sedation in interventional cardiology.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:107 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cardioversion: past, present, and future" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIRCULATIONAHA.109.865535" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2009" "volumen" => "120" "paginaInicial" => "1623" "paginaFinal" => "1632" "link" => array:1 [ …1] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Electrical cardioversion" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.4103/0256-4947.51775" "Revista" => array:6 [ "tituloSerie" => "Ann Saudi Med" "fecha" => "2009" "volumen" => "29" "paginaInicial" => "201" "paginaFinal" => "206" "link" => array:1 [ …1] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Atrial flutter: an update" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2006" "volumen" => "59" "paginaInicial" => "816" "paginaFinal" => "831" "link" => array:1 [ …1] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spanish Catheter Ablation Registry. 17th Official Report of the Spanish Society of Cardiology Working Group on Electrophysiology and Arrhythmias (2017)" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rec.2018.07.014" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2018" "volumen" => "71" "paginaInicial" => "941" "paginaFinal" => "951" "link" => array:1 [ …1] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "XVIII Informe Oficial de la Sección de Electrofisiología yArritmias de la Sociedad Espa˜nola de Cardiología (2018)" "autores" => array:1 [ 0 => array:2 [ …2] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.rec.2015.08.006" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Cardiol" "fecha" => "2016" "volumen" => "68" "paginaInicial" => "1127" "paginaFinal" => "1137" "link" => array:1 [ …1] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0030" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:1 [ "titulo" => "Atrial fibrillation" ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:6 [ "editores" => "Z.F.Issa, J.M.Miller, D.P.E.Zipes" "titulo" => "Clinical arrhythmology and electrophysiology: a companion to Braunwald’s heart disease" "paginaInicial" => "421" "paginaFinal" => "548" "edicion" => "3a ed." 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Journal Information
Vol. 68. Issue 6.
Pages 309-337 (June - July 2021)
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Vol. 68. Issue 6.
Pages 309-337 (June - July 2021)
Special article
Consensus document for anaesthesiologist-assisted sedation in interventional cardiology procedures
Documento de consenso para la Sedación en procedimientos de intervencionismo en Cardiología
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7
L. Martinez-Dolza,
, A. Pajaresb, M. López-Canterob, J. Oscac, J.L. Díezd, P. Paniaguae, P. Argenteb, E. Aranaf, C. Alonsog, T. Rodriguezh, R. Vicenteb, M. Anguitai, J. Alvarezj, Working Group on Tutored Sedation in Interventional Procedures in Cardiology of the Spanish Society of Anesthesia Resuscitation and Therapeutic of Pain SEDAR and of the Spanish Society of Cardiology SEC ◊
Corresponding author
a Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, IIS La Fe, CIBERCV, Valencia, Spain
b Servicio de Anestesiología y Reanimación, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
c Unidad de Arritmias, Servicio de Cardiología, Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
d Unidad de Hemodinámica, Servicio de Cardiología del Hospital Universitari i Politècnic La Fe, IIS La Fe, Valencia, Spain
e Servicio de Anestesiología y Reanimación, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
f Unidad de Arritmias, Servicio de Cardiología, Hospital Virgen del Rocío, Sevilla, Spain
g Unidad de Arritmias, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
h Unidad de Hemodinámica, Servicio de Cardiología, Hospital Clínico de Valladolid, Valladolid, Spain
i Servicio de Cardiología, Hospital Reina Sofía de Córdoba, Córdoba, Spain
j Servicio de Anestesia y Reanimación, Complejo Hospitalario Universitario de Santiago, Universidad de Santiago, Santiago de Compostela, Spain
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Tables (12)
Table 2. Complications related to TAVR.
Table 3. Levels of sedation and anaesthesia.
Table 4. High risk factors for the development of serious sedation/anaesthesia-related complications.
Table 5. Fasting time and pharmacological recommendations.
Table 6. Patients with risk factors for aspiration.
Table 7. Pharmacological prophylaxis for aspiration.
Table 8. Modified sedation assessment scale.
Table 9. Sedative drugs.
Table 10. Management sequence for respiratory complications in PSA.
Table 11. Sedation regimens.
Table 12. Specific aspects of sedation in interventional cardiology.
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