Laryngeal mask airway versus endotracheal intubation for airway management during pulsed field ablation of atrial fibrillation: a multicenter observational study
L D'angelo, S Bianchi, C Tondo, F Solimene, M Bertini, S Iacopino, A Rossillo, S Themistoclakis, M Casella, A Bisignani, M Schiavone, V Schillaci, A Di Cori, M Malacrida, A Dello RussoAbstract
Background
Endotracheal intubation (ETI) is the standard airway management technique during general anesthesia for atrial fibrillation (AF) ablation. The laryngeal mask airway (LMA) may offer advantages such as easier placement and reduced hemodynamic stress, but data on its feasibility, safety, and patient experience during pulsed field ablation (PFA) are limited.
Purpose
To compare the feasibility, safety, and patient-reported outcomes of LMA versus ETI as airway management strategies in AF ablation performed with the pentaspline Farapulse PFA system.
Methods
This multicenter observational study included all consecutive patients undergoing PFA-based AF ablation across 19 centers. The choice of airway management was left to the operator’s discretion. Procedures were categorized according to airway management technique (LMA or ETI). Post-procedurally, patient satisfaction was assessed using Likert scale questionnaires and visual analog scales. A composite sedation score was derived based on patient-reported pain, anxiety, and discomfort.
Results
A total of 928 patients were included, with ETI used in 817 (88.0%) and LMA in 111 (12.0%) procedures. Baseline characteristics were similar, except for higher body mass index (ETI: 27.4±5 vs LMA: 25.8±3, p=0.004) and greater prevalence of hypertension (51.7% vs 25.1%, p=0.001) in the ETI group. ETI procedures were associated with greater use of propofol (96.8% vs 88.3%, p<0.001), volatile anesthetics (48.7% vs 11.7%, p<0.001), and neuromuscular blockers (78.8% vs 42.3%, p<0.001). In contrast, LMA cases more frequently involved benzodiazepines (58.6% vs 42.6%, p=0.001), ketamine (24.3% vs 1.7%, p<0.001), and etomidate (9.0% vs 1.0%, p<0.001). Sedation scores demonstrated excellent procedural tolerance: 99.4% of patients reported no pain recall (ETI 99.5% vs LMA 98.2%, p=0.154), 98.4% reported no anxiety (98.7% vs 96.4%, p=0.093), and 99.2% reported no discomfort (99.1% vs 100%, p=1.00). A positive composite sedation score was achieved in 908 patients (97.8%), with no difference between ETI and LMA (98.0% vs 96.4%, p=0.285). Multivariate logistic regression showed no significant association between airway strategy and sedation quality (ETI vs LMA, OR=0.5, 95%CI: 0.2–1.6, p=0.270). During the post-awakening phase, patient-reported satisfaction favored LMA: mean dissatisfaction (0.9±6 vs 6.8±11, p<0.001), anxiety (1.5±10 vs 7.0±11, p<0.001), discomfort (0.4±4 vs 9.8±16, p<0.001), and pain (0.6±3 vs 7.2±11, p<0.001) were all significantly lower compared with ETI. Anesthesia-related complications occurred in 2 patients (0.2%), with no significant difference among groups (0.9% LMA vs 0.1% ETI, p=0.225).
Conclusion
In patients undergoing pulsed field ablation of atrial fibrillation, both ETI and LMA provided excellent procedural conditions and patient satisfaction. The use of LMA was feasible, safe, and associated with superior comfort and reduced post-procedural discomfort.