Congenital Cardiac Anesthesia Society
A Section of the Society for Pediatric Anesthesia.

EXPLANATION

During catheter ablation procedures, the choice of ventilation strategy can influence the degree of respiratory motion within the thorax, which affects catheter stability and catheter–tissue contact. ^¹˒³˒⁴ Reducing respiratory excursion may improve mapping accuracy and lesion formation during ablations. ^¹˒²

In adults undergoing atrial fibrillation ablation, high-frequency jet ventilation (HFJV) has been shown to decrease diaphragmatic and chest wall motion, resulting in improved catheter stability and shorter procedure times. ^¹˒² Several studies have also reported improved long-term arrhythmia-free survival following HFJV-guided atrial fibrillation ablation, although randomized evidence remains limited. These studies also often include other interventions such as steerable catheters or rapid pacing. ^¹˒² HFJV delivers very small tidal volumes (approximately 1–3 mL/kg) at very high respiratory rates (typically >60 breaths/min) using a high-pressure jet with passive exhalation.^¹˒² Because expired gas is not reliably returned through the anesthesia circuit, continuous end-tidal carbon dioxide monitoring is unreliable, necessitating periodic arterial blood gas analysis to assess ventilation and oxygenation.^¹˒² Potential complications include hypercarbia, hypoxemia, barotrauma, pneumothorax, dynamic hyperinflation (auto-PEEP), hemodynamic compromise, and airway mucosal injury related to inadequate humidification.^¹˒²

High-frequency low-tidal-volume ventilation (HFLTV) is an alternative strategy designed to minimize respiratory motion while utilizing a conventional anesthesia ventilator.^¹˒³ This technique employs lower tidal volumes than conventional ventilation combined with higher respiratory rates, although substantially lower than those used during HFJV.^³˒⁴ Because HFLTV is delivered using a standard anesthesia ventilator, continuous capnography is maintained and a dedicated jet ventilator is not required.^³

In pediatric electrophysiology procedures, HFLTV has been shown to improve catheter stability and catheter–tissue interaction compared with conventional ventilation.^³˒⁴HFLTV also maintains standard anesthetic monitoring while avoiding many of the logistical challenges associated with HFJV, including specialized equipment, interruption of continuous capnography, and the need for frequent arterial blood gas analysis.^¹˒³

Overall, both HFJV and HFLTV aim to minimize chest wall and diaphragmatic excursion to improve catheter stability during catheter ablation procedures.^¹˒²˒³ HFJV has the some supporting evidence in adult atrial fibrillation ablation, whereas emerging pediatric evidence suggests that HFLTV may provide similar procedural advantages while avoiding many of the practical limitations associated with jet ventilation.¹˒³˒⁴

HFJV has not been shown to improve hemodynamics and delivers low tidal volumes at high pressures, making answer choices A and C incorrect.

REFERENCES

1. Alvarez CK, Zweibel S, Stangle A. et al. Anesthetic Considerations in the Electrophysiology Laboratory: A Comprehensive Review. J Cardiothorac Vasc Anesth. 2022. https://doi.org/10.1053/j.jvca.2022.10.013

2. Babapoor-Farrokhran S, Alzubi J, Port Z, Khraisha O, Mainigi SK. Utility of High-frequency Jet Ventilation in Atrial Fibrillation Ablation. J Innov Card Rhythm Manag. 2021 Jul 15;12(7):4590-4593. doi: 10.19102/icrm.2021.120708.

3. Çirkinoğlu GG, Şahinkaya HH, Öksüz S, et al. High-Frequency Low-Tidal Volume Ventilation and Catheter-Tissue Interaction During Pediatric Radiofrequency Ablation: A Prospective Observational Study. J Cardiothorac Vasc Anesth. 2026 Jul;40(7):2069-2075. doi: 10.1053/j.jvca.2026.03.022.

4. Janson CM, Ceresnak SR, Choi JM, et al. A Prospective Assessment of Optimal Mechanical Ventilation Parameters for Pediatric Catheter Ablation. Pediatr Cardiol. 2019 Jan;40(1):126-132. doi: 10.1007/s00246-018-1968-7.