Po-02-106 general anesthesia versus conscious sedation with locoregional anesthesia in s-icd implantation: a monocentric retrospective analysis

In patients not requiring pacing, the subcutaneous implantable cardioverter-defibrillator (S-ICD) has emerged as a safe and effective alternative to the transvenous implantable cardioverter-defibrillator (TV-ICD) for the treatment of life-threatening ventricular arrhythmias. The S-ICD’s larger size requires a larger pocket for insertion and peri-procedural lead tunnelling carries high nociceptive potential, resulting historically in 65% of S-ICD implantations being performed under general anesthesia (GA). This study seeks to demonstrate that conscious sedation with locoregional anesthesia (CS-LA) is a safe and effective alternative to general anesthesia (GA) in S-ICD implantation. A total of 138 S-ICD implantations (90 under CS-LA) at our institution between 2013 and 2020 were studied The CS-LA technique was performed with conscious sedation, local anesthesia of the pocket and xyphoid incision sites, and post-procedural intercostal nerve blocade of the 4th to 7th intercostal spaces with a mixture of 10mL of 0.5% bupivacaine and 20mL of 2% lidocaine without epinephrine. Analgesic efficacy in the 24 post-operative hours was evaluated by Numerical Pain Rating Scale (NPRS) score and by total analgesic medication dosage received. Safety was evaluated by comparing the incidence of significant adverse events (AE): hypotension <80 mmHg or requiring vasopressors, bradycardia <40 bpm, or desaturation <90% for more than two minutes or requiring non-invasive ventilation maneuvers. Post-procedural pain at 15 minutes and at 24 hours was significantly less in the CS-LA group, with a difference of -0.90 (p=0.04) and -1.21 (p=0.004) respectively. Post-procedural opioid consumption was 10.64mg of per os morphine equivalents (p=0.046) lower than in the CS-LA group. No significant difference in the likelihood of at least one adverse event occurring was noted, with CS-LA demonstrating OR 1.95 (95% CI [0.86, 4.40], p=0.11) for at least one AE. Only one patient in the CS-LA arm required conversion to GA, due to excessive agitation during the procedure. S-ICD implantation under CS-LA was superior at 15 minutes and 24 hours to GA in terms of analgesic efficacy and post-procedural patient comfort. CS-LA’s safety profile was similar to GA, with no significantly increased risk of suffering at least one adverse event.