This special article represents the eighth installment in an annual Journal of Cardiothoracic and Vascular Anesthesia series highlighting key advances in cardiac electrophysiology relevant to cardiothoracic anesthesiologists. The authors extend their gratitude to Editor-in-Chief Dr. Kaplan, Associate Editor-in-Chief Dr. Augoustides, and the editorial board for the opportunity to contribute to this series. Rapid innovations in electrophysiology continue to reshape perioperative care and expand the anesthesiologist’s role. This 2025 update synthesizes developments in atrial fibrillation guidelines across major societies, emerging cardiac implantable electronic device technologies, and evolving evidence in pulsed field ablation, transcatheter left atrial appendage occlusion, and stereotactic arrhythmia radioablation. Advances in wearable technologies and artificial intelligence are also highlighted. Collectively, these developments underscore the anesthesiologist’s integral role within the multidisciplinary electrophysiology team.

Traditionally, transvenous implantable cardioverter-defibrillators (ICDs) have served as the cornerstone of sudden cardiac death treatment; however, transvenous implantable ICDs carry significant short- and long-term risks of complications associated with intravascular and intracardiac leads. Attempts to migrate from the transvenous components resulted in the development of the subcutaneous ICD, which successfully terminates life-threatening ventricular tachyarrhythmias. However, the subcutaneous ICD has limitations, including the need for higher defibrillation energy, a lack of bradycardic pacing, and a lack of antitachycardia pacing for terminating ventricular tachycardias. The Aurora Extravascular ICD (ICD, Medtronic, Minneapolis, MN) introduces a novel substernal lead placement and represents a notable advancement in the prevention of sudden cardiac death from ventricular tachyarrhythmias by integrating defibrillation therapy with short-term bradycardia and antitachycardia pacing capabilities without the need for transvenous leads. With the introduction of this novel device in clinical practice, anesthesiologists need to understand what makes the extravascular ICD system unique and how to manage it appropriately during the perioperative period.

The Impella 5.5 (Abiomed, Danvers, MA, USA) is the newest iteration of temporary left-ventricular assist devices in the Impella family of devices used for cardiogenic shock. While general guidelines for implantation of mechanical circulatory support devices are available, the authors aim to provide specific and detailed guidance for the Impella 5.5 for the practical application of intraoperative transesophageal echocardiography during placement and transthoracic and transesophageal echocardiography for device monitoring and management. Transesophageal echocardiography is paramount for preimplantation assessment of the right and left ventricles, possible shunt physiology, and valvular pathology. Its use is also helpful in ensuring appropriate device placement, initiating and modifying device settings, troubleshooting device placement, and diagnosing and managing complications.

We describe a 69-year-old man in septic shock undergoing an emergent endoscopic retrograde cholangiopancreatography (ERCP) whose narrow-complex supraventricular tachycardia (SVT, 180-200 bpm) persisted despite synchronized cardioversion, vagal maneuvers, adenosine, esmolol, and amiodarone. Changing vasopressors from norepinephrine to phenylephrine and angiotensin II aided in rate control. Noting transient reversion during maneuvers provoking vagal stimulation, when SVT reoccurred we titrated intravenous neostigmine in 0.5 to 1.0 mg increments (3.5 mg total), achieving a stable sinus rhythm at 80 bpm without adverse effects. This case illustrates neostigmine's value as an off-label vagomimetic rescue when guideline-directed therapies fail, and vagal stimulation appears beneficial. .

LEFT VENTRICULAR outflow tract obstruction (LVOTO) due to hypertrophic cardiomyopathy (HCM) can provoke cardiac arrest and death due to the impedance of systemic blood flow. When isolated to the basal-septal left ventricle, surgical myectomy improves the dynamics of blood flow in the LVOT by eliminating anterior displacement of the anterior mitral valve leaflet and improving myocardial and systemic blood flow and oxygen delivery. Additionally, with increased recognition of LVOTO, centers treating HCM have noted an increased incidence of patients referred with LVOTO with mild or no septal hypertrophy, with the etiologies being papillary muscle displacement or redundant chordae tendineae, which may also require surgical intervention.1-3 Rarely, patients with structural evidence concerning for LVOTO present for cardiac surgery for other indications without provocative testing. In this setting, the best strategies to determine the significance and guide surgical management are unclear. We present a case describing attempted intraoperative provocation of LVOTO in a patient with structural echocardiographic evidence of basal septal hypertrophy and redundant chordae tendineae suggestive of LVOTO undergoing coronary artery bypass to guide surgical decision-making. Patient consent was provided for this case report.

Background: Etomidate has minimal cardiovascular depressant effects at the cost of endogenous cortisol production suppression, whereas propofol has vasodilatory and myocardial depressant properties, which may be poorly tolerated in the cardiac surgical population. To offset the undesirable effects of propofol, ketamine can be co-administered to harness its cardiac stimulatory properties. Though etomidate is a more cardio-stable induction agent than propofol, its superiority over the combination of propofol and ketamine-colloquially known as "ketofol"-remains controversial. Methods: United States National Library of Medicine Database (MEDLINE) and Excerpta Medica Database (EMBASE) were searched for randomized controlled trials published since 2010 comparing etomidate and ketofol relative to propofol alone for induction of general anesthesia for coronary artery bypass grafting (CABG). Key data collected included post-induction nadir mean arterial pressure (MAP), heart rate, cardiac index, systemic vascular resistance (SVR), and serum cortisol levels at 24 hours postoperatively. Variables were compared by calculating a weighted mean difference (WMD) [95% confidence interval (CI)]. Results: This analysis included 15 studies (1125 patients). Anesthetic induction with etomidate was associated with a higher nadir MAP and SVR compared to ketofol during the peri-induction period by WMD 4.77 mmHg [95% CI 0.31, 9.23, P = 0.04] and 42.22 dynes/cm5 [95% CI 0.49-83.94, P = 0.05]. However, there was no difference in the frequency of needed boluses of vasopressors or fluids for peri-induction hypotension. Conclusions: Though etomidate appears to provide a superior hemodynamic profile compared to ketofol, both agents require similar degrees of clinical response to hypotension during the induction of CABG surgery patients.

This special article marks the seventh installment in an annual series featured in the Journal of Cardiothoracic and Vascular Anesthesia. The authors extend their gratitude to Editor-in-Chief Dr. Kaplan, Associate Editor-in-Chief Dr. Augoustides, and the editorial board for the opportunity to contribute to this series, which highlights key research in electrophysiology (EP) relevant to cardiothoracic and vascular anesthesiologists. This collection of articles explores evolving perioperative EP practices, including updated guidelines and therapies for atrial and ventricular fibrillation management, innovations in cardiovascular implantable devices and wearable technologies, and the integration of artificial intelligence into EP. Implications of these advancements on anesthetic management for patients undergoing EP procedures are discussed.

Failure to provide one-lung ventilation can prohibit minimally invasive thoracic surgeries. Strategies for one-lung ventilation include double-lumen endotracheal tubes or endobronchial blockers, but rarely both. Inability to provide lung isolation after double-lumen endotracheal tube placement requires troubleshooting and sometimes the use of extra equipment. This case describes using a unique Y-shaped endobronchial blocker placed through a left-sided double-lumen endotracheal tube after failure to achieve lung isolation with a double-lumen endotracheal tube alone.

The Aveir DR dual-chamber Leadless Pacemaker system (Abbott Laboratories) was recently approved by the US Food and Drug Administration and is heralded to be the next generation of leadless pacemakers. Earlier generations of leadless pacemakers could only provide single-chamber right ventricular pacing, limiting their application to a small subset of patients in whom pacemaker therapy is indicated. With the expansion of pacing therapy, the Aveir DR system expands availability of leadless pacing to more patients. Although there have been prior documented experiences with the earlier generation of leadless pacemakers, the addition of a second leadless pacemaker to provide dual-chamber pacing adds new complexities. It is essential to understand what makes the Aveir DR system unique if an anesthesiologist were to come across one perioperatively.

The presence of a tracheal bronchus, which is often incidentally discovered, complicates endotracheal intubation and lung isolation during thoracic surgery. Prior reports of successful right-sided lung isolation in the presence of tracheal bronchus required utilization of a double lumen tube. Although right-sided lung isolation was required in our case, due to other patient factors, it was determined that a double lumen tube of a suitable size would be unlikely to be placed safely and successfully. We describe the successful use of a Rüsch EZ-Blocker bronchial blocker in obtaining right-sided isolation in a patient with a difficult airway and tracheal bronchus.

A 53-year-old, 104- kg, 165- cm woman with nonischemic cardiomyopathy with a reduced ejection fraction of 30%-to-35% secondary to cardiac sarcoidosis was admitted for decompensated heart failure. She previously had a single-chamber implantable cardioverter-defibrillator (ICD) placed via a left pectoral approach for the primary prevention of sudden cardiac death. Considering that the patient was on maximally tolerable guideline-directed medical therapy for heart failure with reduced ejection fraction, and was not a candidate for cardiac resynchronization therapy, the decision was made to augment her systolic function with a cardiac rhythm management device.

Simulation-based training is an essential component in the education of transthoracic echocardiography (TTE). Nevertheless, current TTE teaching methods may be subject to certain limitations. Hence, the authors in this study aimed to invent a novel TTE training system employing three-dimensional (3D) printing technology to teach the basic principles and psychomotor skills of TTE imaging more intuitively and understandably. This training system comprises a 3D-printed ultrasound probe simulator and a sliceable heart model. The probe simulator incorporates a linear laser generator to enable the visualization of the projection of the ultrasound scan plane in a 3D space. By using the probe simulator in conjunction with the sliceable heart model or other commercially available anatomic models, trainees can attain a more comprehensive understanding of probe motion and related scan planes in TTE. Notably, the 3D-printed models are portable and low-cost, suggesting their potential utility in various clinical scenarios, particularly for just-in-time training.

Atrial fibrillation (AF) is the one of the most common arrhythmias seen clinically, with an estimated prevalence of more than 33 million cases worldwide.1Chugh SS Havmoeller R Narayanan K et al.Worldwide epidemiology of atrial fibrillation: A Global Burden of Disease 2010 Study.Circulation. 2014; 129: 837-847Crossref PubMed Scopus (3003) Google Scholar In a vulnerable atrial substrate, a rapid triggering event is able to initiate reentrant waves that lead to the formation of atrial fibrillation.2Iwasaki YK Nishida K Kato T Nattel S. Atrial fibrillation pathophysiology: Implications for management.Circulation. 2011; 124: 2264-2274Crossref PubMed Scopus (554) Google Scholar As time is spent in atrial fibrillation, atrial remodeling can lead to paroxysmal episodes that increase in frequency and duration, causing progression to more persistent AF subtypes, which are not only associated with a decrease in quality of life, but also may be more resistant to treatment; this leads to the saying “AF begets AF.”3Wijffels MC Kirchhof CJ Allessie MA. Atrial fibrillation begets atrial fibrillation. A study in awake chronically instrumented goats.Circulation. 1995; 92: 1954-1968Crossref PubMed Scopus (2945) Google Scholar,4Dudink EAMP Erküner Ö Berg J et al.The influence of progression of atrial fibrillation on quality of life: A report from the Euro Heart Survey.Europace. 2018; 20: 929-934Crossref PubMed Scopus (24) Google Scholar,5de Vos CB Pisters R Nieuwlaat R et al.Progression from paroxysmal to persistent atrial fibrillation clinical correlates and prognosis.J Am Coll Cardiol. 2010; 55: 725-731Crossref PubMed Scopus (482) Google Scholar Studies have shown that early rhythm control therapy is associated with a lower risk of adverse cardiovascular outcomes.6Kirchhof P Camm AJ Goette A et al.Early rhythm-control therapy in patients with atrial fibrillation.N Engl J Med. 2020; 383: 1305-1316Crossref PubMed Scopus (711) Google Scholar Given the procedural risks of catheter ablation and studies showing that catheter ablation, compared with medical therapy, does not significantly reduce the primary composite endpoint of death, disabling stroke, serious bleeding, or cardiac arrest, current guidelines recommend the use of antiarrhythmic medications as initial therapy for maintenance of sinus rhythm in symptomatic patients.7Packer DL Mark DB Robb RA et al.Effect of catheter ablation vs antiarrhythmic drug therapy on mortality, stroke, bleeding, and cardiac arrest among patients with atrial fibrillation: The CABANA randomized clinical trial.JAMA. 2019; 321: 1261-1274Crossref PubMed Scopus (745) Google Scholar,8Hindricks G Potpara T Dagres N et al.2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS): The task force for the diagnosis and management of atrial fibrillation of the European Society of Cardiology (ESC) developed with the special contribution of the European Heart Rhythm Association (EHRA) of the ESC.Eur Heart J. 2021; 42: 373-498Crossref PubMed Scopus (3688) Google Scholar,9January CT Wann LS Calkins H et al.2019 AHA/ACC/HRS focused update of the 2014 AHA/ACC/HRS guideline for the management of patients with atrial fibrillation: A report of the american college of cardiology/american heart association task force on clinical practice guidelines and the heart rhythm society.J Am Coll Cardiol. 2019; 74: 104-132Crossref PubMed Scopus (1124) Google Scholar In November 2022, the New England Journal of Medicine published the results of a 3-year follow-up conducted by Andrade et al. to the Early Aggressive Invasive Intervention for Atrial Fibrillation (EARLY AF) trial.10Andrade JG Deyell MW Macle L et al.Progression of atrial fibrillation after cryoablation or drug therapy.N Engl J Med. 2023; 388: 105-116Crossref PubMed Scopus (27) Google Scholar The EARLY AF trial was a multicenter, randomized trial with blinded endpoint adjudication, comparing the use of cryoballoon ablation to the use of antiarrhythmic drugs in the prevention of atrial fibrillation/tachycardia recurrence using continuous cardiac monitoring over the trial period. The trial was based out of 18 centers in Canada between January 2017 and December 2018, and enrolled 303 patients, with 154 randomly assigned to receive catheter ablation, and the remaining 149 patients received antiarrhythmic therapy. On initial report at one year, the primary endpoint was time to the first documented recurrence of any atrial tachyarrhythmia (atrial flutter/fibrillation/atrial tachycardia) after initiation of antiarrhythmic medication; or 91-to-365 days after catheter ablation (0-90 days is considered a blanking period, in which expert consensus from 2017 stated that any atrial tachyarrhythmias during this period are not to be considered for first clinical failure of the primary endpoint). At the end of the initial report, there was a significantly lower rate of atrial fibrillation recurrence with catheter cryoballoon ablation than with antiarrhythmic drug therapy.11Andrade JG Wells GA Deyell MW et al.Cryoablation or drug therapy for initial treatment of atrial fibrillation.N Engl J Med. 2021; 384: 305-315Crossref PubMed Scopus (267) Google Scholar In this current analysis at 3 years posttreatment, the primary endpoint was time to first occurrence of persistent atrial fibrillation (which was defined as an episode of continuous atrial tachyarrhythmia lasting ≥7 days, or lasting 46 hours-to-7 days but requiring cardioversion for termination). Over the 3-year period, 63 patients who were initially assigned to the antiarrhythmic medication arm underwent catheter ablation after documented arrhythmia recurrence, and 27 patients assigned to cryoballoon ablation. At the end of 3 years, initial treatment of paroxysmal atrial fibrillation with catheter cryoballoon ablation was associated with a lower incidence of persistent atrial fibrillation (hazard ratio 0.25; 95% CI 0.09-0.70) and recurrent atrial tachyarrhythmia than initial use of antiarrhythmic drugs (hazard ratio 0.51; 95% CI 0.38-0.67). Cryoballoon ablation also was associated with lower AF burden (time spent in AF) when compared to use of antiarrhythmic medications. Andrade et al. recognized this trial was performed with cryoballoon ablation, and that the outcomes may not be generalizable to other ablation techniques. However, if the reduction in time to AF and AF burden is essential for slowing down the progression of AF and cardiac remodelling, the use of radiofrequency ablation may be of benefit as well. Previous studies have shown that to there was no/minimal difference in time to first recurrence or AF burden.12Kuck KH Brugada J Fürnkranz A et al.Cryoballoon or radiofrequency ablation for paroxysmal atrial fibrillation.N Engl J Med. 2016; 374: 2235-2245Crossref PubMed Scopus (1135) Google Scholar,13Hoffmann E Straube F Wegscheider K et al.Outcomes of cryoballoon or radiofrequency ablation in symptomatic paroxysmal or persistent atrial fibrillation.Europace. 2019; 21: 1313-1324Crossref PubMed Scopus (58) Google Scholar,14Chen YH Lu ZY Xiang Y et al.Cryoablation vs. radiofrequency ablation for treatment of paroxysmal atrial fibrillation: A systematic review and meta-analysis.Europace. 2017; 19: 784-794Crossref PubMed Scopus (44) Google Scholar,15Andrade JG Champagne J Dubuc M et al.Cryoballoon or radiofrequency ablation for atrial fibrillation assessed by continuous monitoring: A randomized clinical trial.Circulation. 2019; 140: 1779-1788Crossref PubMed Scopus (277) Google Scholar In regard to catheter ablation therapy versus antiarrhythmic medication therapy, previous studies compared ablation therapy in patients in whom drug therapy already had failed, giving an edge to ablation therapy. Early intervention in patients with AF offers additional potential benefits besides the ones listed above. One benefit is the reduction in needing additional interventions to lower burden of arrythmia. It has been shown that patients with long-standing AF require repeat ablations to decrease the burden of arrythmias.18McCarthy PM Cox JL Kislitsina ON et al.Surgery and catheter ablation for atrial fibrillation: History, current practice, and future directions.J Clin Med. 2022; 11: 210Crossref Scopus (8) Google Scholar Additionally, repeat ablation is a predictor of complications of AF ablation.19Szegedi N Széplaki G Herczeg S et al.Repeat procedure is a new independent predictor of complications of atrial fibrillation ablation.Europace. 2019; 21: 732-737Crossref PubMed Scopus (21) Google Scholar There are several potential areas for future studies. A longer-term follow-up of patients in the EARLY AF trial could further show how early ablation can keep patients out of AF, as opposed to ablation being performed using current guidelines. The EARLY AF study patients had few coexisting conditions and were at low risk for progression of AF.10Andrade JG Deyell MW Macle L et al.Progression of atrial fibrillation after cryoablation or drug therapy.N Engl J Med. 2023; 388: 105-116Crossref PubMed Scopus (27) Google Scholar A potential study could be early catheter ablation against current ablation guidelines in patients with multiple comorbidities. Another potential future study can be to compare the need for additional ablation in patients who have catheter ablation as initial therapy versus the current guidelines. As perioperative physicians, we should be aware that patients with AF are at an increased risk of adverse effects when they present within the perioperative setting. Preoperative AF has been shown to be associated with increases in postoperative adverse effects in patients undergoing noncardiac surgery.20Prasada S Desai MY Saad M et al.Preoperative atrial fibrillation and cardiovascular outcomes after noncardiac surgery.J Am Coll Cardiol. 2022; 79: 2471-2485Crossref PubMed Scopus (3) Google Scholar Prasada et al. found that preexisting AF was associated independently with heart-failure hospitalization, postoperative motility, and stroke within 30 days of noncardiac surgery.20Prasada S Desai MY Saad M et al.Preoperative atrial fibrillation and cardiovascular outcomes after noncardiac surgery.J Am Coll Cardiol. 2022; 79: 2471-2485Crossref PubMed Scopus (3) Google Scholar These outcomes not only increase the burden on patients' quality of life, but also increase healthcare expenditures, especially as the prevalence of AF is projected to increase by 3-fold by 2050.21Morin DP Bernard ML Madias C et al.The state of the art: Atrial fibrillation epidemiology, prevention, and treatment.Mayo Clin Proc. 2016; 91: 1778-1810Abstract Full Text Full Text PDF PubMed Scopus (112) Google Scholar As early catheter ablation prevents AF disease progression and maintenance of sinus rhythm, it could help decrease the perioperative risks that the patients have. Although the current guidelines recommend medical therapy as the initial strategy for rhythm control, this shows the potential benefits of early catheter ablation as an alternative. It is time to consider catheter ablation as a first-line therapy for AF. There have been 2 other multicenter randomized studies, Cryo-FIRST and STOP AF FIRST, that compared cryoablation to antiarrhythmic drugs as first-line therapy, and they both showed similar results to the EARLY AF trial.16Kuniss M Pavlovic N Velagic V et al.Cryoballoon ablation vs. antiarrhythmic drugs: First-line therapy for patients with paroxysmal atrial fibrillation.Europace. 2021; 23: 1033-1041Crossref PubMed Scopus (59) Google Scholar,17Wazni OM Dandamudi G Sood N et al.Cryoballoon ablation as initial therapy for atrial fibrillation.N Engl J Med. 2021; 384: 316-324Crossref PubMed Scopus (225) Google Scholar The results of the trials continue to build the case for catheter ablation as a first-line treatment for AF. None.