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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 40-44

Hypnotic communication in interventional electrophysiology procedures in the COVID-19 period


1 Department of Cardiology, Santa Maria del Carmine Hospital, Rovereto (TN), Italy
2 Santa Maria del Carmine Hospital, Rovereto (TN), Italy

Date of Submission21-Apr-2021
Date of Acceptance23-May-2021
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Massimiliano Maines
Department of Cardiology, Santa Maria del Carmine Hospital, Corso Verona 4, 38068, Rovereto (TN)
Italy
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/hm.hm_28_21

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  Abstract 


Background: Hypnotic communication is a validated technique for reducing procedural anxiety and pain. The aim of our work was to evaluate the additional utility of hypnotic communication during catheter ablation procedures in the COVID-19 period. Materials and Methods: Sixteen consecutive patients undergoing electrophysiological study and catheter ablation underwent: 8 to standard sedation procedure (Group B) and 8 to this with the addition of hypnotic communication (Group A). In these two groups, we measured and compared preprocedure and intraprocedure anxiety, compliance to the procedure, perceived pain, use of drugs, the procedural time perceived by the patient compared to real time in minutes, and radiological exposure, using validated scales. Results: Hypnotic communication resulted in a significant reduction in anxiety during the procedure (Group A: 1.1 ± 0.6 vs. Group B: 3.4 ± 2; P = 0.003); better procedural compliance (Group A: 4.8 ± 0.5 vs. Group B: 3.7 ± 0.8; P = 0.002) and showed a trend toward a reduction in procedural pain (Group A: 2.4 ± 2 vs. Group B: 4.3 ± 1.8; P = 0.08) compared to standard sedation. Midazolam was not used in Group A, while an average of 3 ± 1.3 mg was used in Group B. The use of local anesthetic and Fentanest was comparable. The real procedural durations (Group A: 167.5 ± 30.1 vs. Group B: 150 ± 27.8 min; P = not significant) and perceived (Group A: 78.8 ± 15.5 vs. Group B: 86.3 ± 29.9 min; P = not significant) and the difference between these was also comparable. The radiological exposure was 74.4 ± 65.5 s in Group A and 118 ± 119 s in Group B (P = not significant). There were no complications in the two groups. Conclusions: Hypnotic communication as an additional strategy during electrophysiological interventional procedures has made possible to eliminate the use of midazolam and reduce anxiety during the procedure, but above all, it has improved the patient's compliance with the procedure compared to traditional sedation approach.

Keywords: COVID-19, hypnotic communication, interventional electrophysiology


How to cite this article:
Maines M, Peruzza F, Angheben C, Moggio P, Catanzariti D, Greco MD. Hypnotic communication in interventional electrophysiology procedures in the COVID-19 period. Heart Mind 2021;5:40-4

How to cite this URL:
Maines M, Peruzza F, Angheben C, Moggio P, Catanzariti D, Greco MD. Hypnotic communication in interventional electrophysiology procedures in the COVID-19 period. Heart Mind [serial online] 2021 [cited 2022 Oct 2];5:40-4. Available from: http://www.heartmindjournal.org/text.asp?2021/5/2/40/319652




  Introduction Top


Ablation of cardiac arrhythmias is a consolidated technique and is now the first choice therapy in patients with symptomatic supraventricular arrhythmias.[1],[2] In many centers like ours, the technique is performed with the use of nonfluoroscopic navigation systems that allow the catheters to be moved inside the patient's heart, significantly reducing the use of ionizing radiation.[3] These systems require the patient to sit still on the couch and have as regular breathing as possible during the procedure, and this situation is not always easy to achieve because the procedures are sometimes lengthy (about 2–3 h for atrial fibrillation),[4] and ablative therapy is generally carried out with the use of radiofrequency which especially in certain areas of the heart (for example, the posterior wall of the left atrium) can generate pain for the patient. Based on what has been said, pain control is crucial for the safety and effectiveness of the procedure.

Historically, the procedures have been carried out with the use of analgesic drugs for pain control and anxiolytics or narcotics to avoid patient movements and optimize the tolerability of the procedure. In many European centers, atrial fibrillation ablation is performed with an anesthetist in the room who intubates the patient, increasing the complexity and procedural costs.

A limitation of the patient's sedation is that the possibility of interacting with them is lost.

A technique that has been rediscovered in recent years to reduce anxiety and obtain analgesia during invasive procedures is hypnotic communication.[5],[6] The advantages of using hypnosis during electrophysiological procedures have recently been described in a reduced case series[7] and in a wider experience in the ablative procedures of atrial fibrillation.[8]

Hypnosis is both a modified, physiological, and dynamic state of consciousness and a doctor–patient relationship during which psychic, somatic, and visceral modifications are possible, by means of plastic monoideisms.[9]

A crucial point of hypnosis is therefore the doctor–patient relationship that is established in the interviews preceding the procedure. Since March 2020, the COVID-19 pandemic has radically changed the way we work.[10] With the restart, in July 2020, we reorganized the admissions for ablative procedures and PMK implants in day hospital (DH) and day surgery (DS). This has led to a change in the relationship between doctor and patient: the patient is called the day before the procedure to assess that all is well and to explain the examination, and sometimes, the first contact with the electrophysiologist who performs the procedure is in the morning, 5 min before the patient is brought into the room. The use of masks and the distancing between people has also made communication between doctor and patient more complex.

The aim of our work was to evaluate the usefulness of hypnotic communication in addition to the use of drugs for pain reduction compared to our standard patient sedation protocol, in a setting where the use of masks, physical distancing, and reduced communication times, in procedures performed in DH or DS with the patient admitted on the morning of the procedure have made it more difficult to create a relationship with the patient.


  Materials and Methods Top


Between July 2020 and September 2020, we enrolled 16 patients undergoing electrophysiological study and catheter ablation at the Santa Maria del Carmine hospital in Rovereto. The patients were consecutive in relation to the fact that MM was in the room shift as the first operator, as MM was the only doctor of the team with hypnosis skills, and they were between 16 and 70 years old. Patients were randomized 1:1; eight patients underwent electrophysiological study and catheter ablation with the use of hypnotic communication + midazolam as needed + local anesthesia + painkillers (fentanyl) (Group A) and were compared with another eight patients managed with a traditional protocol of midazolam at the need + local anesthesia + fentanyl (Group B). If they were to perform electrical cardioversion at the end of the procedure, a bolus of midazolam was used.

Patients undergoing atrial fibrillation ablation performed a transesophageal echocardiogram on the morning of the procedure to rule out the presence of thrombi in the left atrium.

The study was conducted in accordance with the protocol of good clinical practice and the principles of the Declaration of Helsinki. All patients signed informed consent before undergoing the procedure.

Ablation procedure

The ablation procedures were performed using CARTO 3 (Biosense Webster) or Ensite Precision (Abbott) nonfluoroscopic navigation systems, which allow for real-time viewing of electrophysiological catheters without the use of scopes.

Venous approaches used for the procedure were the right femoral veins and the right internal jugular vein for atrial fibrillation ablation procedures. The venous punctures were performed under ultrasound guidance. In the case of procedures in the left atrium, the transseptal puncture was performed under fluoroscopic monitoring after placing a catheter in the coronary sinus and one in the Hisian region as landmarks and evaluating the pressure through the tip of the transseptal needle.

Using dedicated catheters, the reconstruction of the chambers of interest was performed, in case of procedures in the left atrium for the ablation of atrial fibrillation, the reconstruction was superimposed on the magnetic resonance images.

The electrophysiological study was performed with a BARD polygraph. The ablation catheter was decided on the basis of the arrhythmia induced by the electrophysiological study or the type of procedure.

Management of antiarrhythmic and anticoagulant therapy

Antiarrhythmic therapy was stopped 48 h before the procedure (14 days before if amiodarone), and direct thrombin inhibitor ( direct-acting oral anticoagulants [DOAC]) therapy in patients undergoing atrial fibrillation ablation was not taken the day before the procedure and was resumed on the evening of procedure (during the procedure and up to 2 h before resuming the DOAC, the patient undergoing atrial fibrillation ablation was treated with sodium heparin infusion).

Hypnotic communication protocol

The day before admission to DH or DS, patients were contacted by a cardiologist to perform a remote telephone television and evaluate anamnesis, preprocedure instrumental tests performed, blood tests, COVID screening (absence of fever, cough, or respiratory symptoms), and the negativity of the SARS-CoV-2 swab. If the patient had a history of cognitive impairment or a psychiatric pathology, he was excluded from the study. During this television program, the procedure was also explained, and any questions or doubts of the patient were answered.

On the day of the procedure, the patient entered at 7:30 (first procedure) or 8:00 (second room procedure), was prepared with depilation and positioning of a peripheral venous access, had a brief interview with the MM room doctor, and signed the informed consent to the procedure.

Once in the room, the hypnotic communication procedure began, which took place according to the following points:

  • Evaluation of the understanding of the procedure, of the development, and of the purposes
  • The patient's attention was focused to dissociate him from the surrounding environment and noises (first by making him focus on an external stimulus and then with his eyes closed on an internal stimulus such as breathing)
  • The patient was invited to relax, concentrate on having a regular breath, and plastic monoideism was introduced inviting the patient to imagine being in a safe place where he could feel calm and relaxed, isolated from what was around him and introduced himself suggestions of analgesia in the femoral and possibly jugular puncture site
  • The hypnotic state was validated and punctures for venous accesses began
  • Subsequently, reinforcements and consolidations were carried out during the procedure
  • At the end of the procedure, the patient is deinduced.


The patient was then taken to the room and given a questionnaire to assess the state of anxiety before the procedure and during this (on a scale of 1–10), the perceived pain (on a scale of 1–10), the time perceived procedural, and postprocedure well-being. Furthermore, at the end of the procedure, a form was filled in with the procedural times, the drugs administered, compliance with the procedure, the outcome of the ablation, any complications, blood pressure, and heart rate monitoring.

Pain management protocol

During the femoral/jugular puncture, local anesthesia was performed with mepivacaine 2% 10–20 cc. At the time of ablation in Group A, ½ vial of intravenous fentanyl was administered as a slow bolus in the ablations of atrial fibrillation, with a dosage that was then increased based on the response obtained. In Group B, in addition to this drug, iv midazolam was used as needed in boluses to reduce the patient's anxiety and with a muscle relaxant effect.

End point of the study

The end point of the study was to evaluate hypnotic communication in addition to the use of drugs to reduce pain, in a setting, in which the relationship with the patient has limitations related to the COVID-19 pandemic emergency, compared to traditional sedation.

Parameters measured were preprocedure anxiety, intraprocedure, and pain perceived on a scale from 1 to 10; the procedural time perceived by the patient compared to the real time in minutes; the patient's compliance with the procedure assessed by the doctor on a scale of 1–5; the use of drugs (local anesthetics, sedatives, and pain relievers); some vital parameters measured before and after the procedure (blood pressure, heart rate, and oxygen saturation); and scan time in seconds and complications.

Statistic analysis

Continuous measures were expressed as mean and standard deviation, while categorical variables as absolute value and percentage. Comparison between Groups A and B was performed with Student's t-test for continuous variables.


  Results Top


A total of 16 patients were enrolled in the study: Eight in Group A and 8 in control Group B. The baseline and clinical characteristics of the population are summarized in [Table 1]. There were no significant differences between Group A and B.
Table 1: Demographic, clinical, and echocardiographic data and procedures performed

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There were no differences in the management of antiarrhythmic and anticoagulant therapy in the two groups.

Ablation was effective (nonreinduction for paroxysmal supraventricular tachycardias, interruption, and nonreinduction for atypical atrial flutter, suppression of extrasystole from the outflow tract in this case, and isolation of all pulmonary veins for patients undergoing ablation of atrial fibrillation) in all patients. There were no periprocedural complications in the two groups. Data on preprocedure, during procedure anxiety, perceived pain, perceived and actual duration of the procedure, and patient compliance are shown in [Table 2].
Table 2: Preprocedural anxiety, during procedure, perceived pain, perceived and actual duration of the procedure and patient compliance

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In Group A, communication support was judged very useful 4.6 ± 0.5 on a scale of 1–5.

In Group A, there were no postprocedure symptoms; in Group B, three patients had symptoms: two nausea regressed with metoclopramide 5 mg intravenously in 30 min and one patient mild chest pain (with repeatedly negative ultrasound and stable parameters).

Vital signs measured before and during the procedure did not differ between the two groups except for a lower post procedural heart rate in Group A [Table 3].
Table 3: Vital signs before and after the procedure

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There were no significant differences in procedural times and radiological exposure. The radiological exposure was 74.4 ± 65.5 s in Group A and 118 ± 119 s in Group B (P = not significant).

In Group A, no midazolam was used in any patient, and the use of fentanyl was less, although not significantly. The dose of local anesthetic used in the two groups was the same [Table 4].
Table 4: Use of drugs in the two groups

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  Discussion Top


In our experience, hypnotic communication used in an interventional context with little knowledge of the patient given the reduced preprocedural times due to the reorganization of hospitalizations in the COVID period (DH/DS) has made it possible to eliminate the use of midazolam and to reduce the anxiety during the procedure, but above all it improved the patient's compliance with the procedure compared to the traditional sedation approach (the difference in periprocedural compliance is probably due to the different procedural anxiety).

The latter is a very important fact because having a patient who remains still, with regular breathing can facilitate the interventional cardiologist during the procedure. The perception of the room climate was also better, more relaxed, even if this figure was not measured.

In the group, in which hypnotic communication was used, there was a trend toward pain reduction during the procedure, although not significant (P = 0.08); the lack of significance could be due to the small number of the sample or to a poor depth of the state of hypnosis. Furthermore, patients managed with hypnotic communication had fewer postprocedural symptoms (although the difference was not significant).

However, there were no differences in procedural duration, radiology exposure, and procedural success between the two groups. Interestingly, the implementation of hypnotic communication in the workflow of the procedure did not affect the procedural timing. It can be hypothesized that the absence of statistical difference in the total procedural time in the two groups may be due to the fact that the time spent on hypnotic communication can be balanced by the patient's better compliance during the procedure.

Limitations of the study

The main limitations of this study are the small number of patients and the fact that the procedures performed were partially different in the two groups. Procedural outcomes such as anxiety, pain perception, and perceived duration of the procedure are also subjective data, which may have been influenced by the fact that they were collected at the end of a successful procedure (albeit in both groups). Further randomized trials with a larger number of patients will be needed to confirm these results.


  Conclusions Top


Hypnotic communication as an additional strategy during electrophysiological interventional procedures has made it possible to eliminate the use of midazolam and reduce anxiety during the procedure, but above all it has improved the patient's compliance with the procedure compared to the traditional sedation approach even in a period with significant doctor–patient relationship limitations due to the COVID pandemic. Furthermore, procedural safety, success rate, and radiological exposure were not affected by hypnotic communication. The reduction in use of intravenous sedative therapy during electrophysiology procedures permit to reduce hospitalization time allowing to perform the procedures in Day-Hospital or Day-Surgery.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. ESC Scientific Document Group. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association of Cardio-Thoracic Surgery (EACTS). Eur Heart J 2021;42:373-498.  Back to cited text no. 1
    
2.
Brugada J, Katritsis DG, Arbelo E, Arribas F, Bax JJ, Blomström-Lundqvist C, et al. ESC Scientific Document Group. 2019 ESC Guidelines for the management of patients with supraventricular tachycardiaThe Task Force for the management of patients with supraventricular tachycardia of the European Society of Cardiology (ESC). Eur Heart J 2020;41:655-720.  Back to cited text no. 2
    
3.
Casella M, Dello Russo A, Pelargonio G, Del Greco M, Zingarini G, Piacenti M, et al. Near zerO fluoroscopic exPosure during catheter ablAtion of supRavenTricular arrhYthmias: The NO-PARTY multicentre randomized trial. Europace 2016;18:1565-72.  Back to cited text no. 3
    
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Stabile G, Scaglione M, del Greco M, De Ponti R, Bongiorni MG, Zoppo F, et al. Reduced fluoroscopy exposure during ablation of atrial fibrillation using a novel electroanatomical navigation system: A multicentre experience. Europace 2012;14:60-5.  Back to cited text no. 4
    
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Adachi T, Fujino H, Nakae A, Mashimo R, Sasaki J. A meta-analysis of hypnosis for chronic pain problems: A comparison between hypnosis, standard care, and other psychological interventions. Int J Clin Exp Hypn 2014;62:1-28.  Back to cited text no. 5
    
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Wobst AH. Hypnosis and surgery: Past, present, and future. Anesth Analg 2007;104:1199-208.  Back to cited text no. 6
    
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Barbero U, Ferraris F, Muro M, Budano C, Anselmino M, Gaita F. Hypnosis as an effective and inexpensive option to control pain in transcatheter ablation of cardiac arrhythmias. J Cardiovasc Med (Hagerstown) 2018;19:18-21.  Back to cited text no. 7
    
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Scaglione M, Battaglia A, Di Donna P, Peyracchia M, Bolzan B, Mazzucchi P, et al. Hypnotic communication for periprocedural analgesia during transcatheter ablation of atrial fibrillation. Int J Cardiol Heart Vasc 2019;24:100405.  Back to cited text no. 8
    
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Elkins GR, Barabasz AF, Council JR, Spiegel D. Advancing research and practice: The revised APA division 30 definition of hypnosis. Int J Clin Exp Hypn 2015;63:1-9.  Back to cited text no. 9
    
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Maines M, Zorzi A, Benetollo PP, Guarrera GM, Moz M, Manica A, et al. Short-term outcome associated with remote evaluation (telecardiology) of patients with cardiovascular diseases during the COVID-19 pandemic. Int J Cardiol Heart Vasc 2020;30:100625.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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