Is the addition of dexmedetomidine to a ketamine-propofol combination in pediatric cardiac catheterization sedation useful?

Comparative Evaluation of Regain of Consciousness in Dexmedetomidine-Propofol versus Ketamine-Propofol in the Pediatric Cardiac Catheterization Procedure under Sedation using BIS Monitoring: A Randomized Prospective Study

BACKGROUND

Congenital heart diseases (CHDs) are not rare and often require an intervention at some point of time. Pediatric cardiac catheterization, a minimally invasive procedure, is performed to diagnose and to correct many cardiac abnormalities. Deep sedation with spontaneously breathing patients is the preferred technique for pediatric catheterization in the pediatric population. Therefore, the author aimed to find the best combination of drugs for pediatric cardiac catheterization procedures using dexmedetomidine-propofol (DP) and ketamine-propofol (KP).

MATERIALS AND METHODS

Cyanotic and acyanotic CHD children, weighing 5-20 kg and undergoing sedation for cardiac catheterization, were randomly assigned into two groups. DP group children received a bolus intravenous (IV) propofol at 1 mg/kg body weight followed by 1 mcg/kg dexmedetomidine over 10 minutes. KP group children received a bolus IV propofol 1 mg/kg followed by ketamine 1 mg/kg over 10 minutes. For maintenance in the DP group, propofol infusion at 1.5 to 2 mg/kg/h and dexmedetomidine at 0.5 mcg/kg/h was started. In the KP group, propofol infusion at 1.5 to 2 mg/kg/h and ketamine at 1 mg/kg/h was started as maintenance. The bispectral index (BIS) was monitored throughout the procedure, and the BIS value was maintained between 60 and 80. Propofol top of 1 mg/kg was administered when the BIS value became more than 80 or when the child moved during the femoral vessel puncture or when the child moved during the procedure.

RESULTS

The mean time for regain of consciousness was faster (P < 0.005) in the KP group (11.02 ± 11.98) compared to the DP group (21.62 ± 18.68). BIS was monitored throughout the procedure; BIS values were lower (P < 0.001) in the DP group (60.0 ± 11.1) as compared to the KP group (73.7 ± 5.6). The cumulative doses of propofol in the KP group and DP group were comparable. Total fentanyl consumptions in the intraoperative period in the KP group and DP group were comparable (P > 0.001). There was no difference in drug side effects between the groups.

CONCLUSION

The KP combination had fast and early recovery compared to the DP combination in children who underwent the cardiac catheterization procedure under sedation in children undergoing cardiac catheterization procedures requiring sedation.

Usefulness of deep sedation with intravenous dexmedetomidine and midazolam in cardiac catheterization procedures for pediatric patients

Background

Dexmedetomidine (DEX) is a highly selective alpha 2 receptor agonist that has the advantage of causing less respiratory depression than other sedative agents. We evaluated the add-on effects of DEX on sedation among pediatric patients who received midazolam and pentazocine during cardiac catheterization.

Methods

120 cardiac catheterization procedures in 110 patients under deep sedation at Department of Pediatrics, Kanazawa University Hospital from January 2013 to August 2018: 63 procedures without DEX (i.e., non-DEX group) and 57 procedures with DEX (i.e., DEX group). Intravenous midazolam and pentazocine were used in both groups, and DEX without an initial loading dose (0.6 μg/kg/h) was used in the DEX group. We retrospectively investigated complications during catheterization, doses of sedative agents, and changes in vital signs.

Results

Hypoxemia requiring oxygen administration during catheterization tended to be higher in the non-DEX group than in the DEX group (4.8% vs. 0%). Additional dose of midazolam was significantly lower in the DEX group (median [IQR]: 0.05 mg/kg [0-0.11]) than in the non-DEX group [0.09 mg/kg (0-0.23), p = 0.0288]. The additional dose of midazolam in the non-DEX group with hypoxemia was significantly higher than the dose used in the non-DEX group without hypoxemia. No case of bradycardia below the criteria for bradycardia occurred and no serious complications occurred in the DEX group.

Conclusion

The use of intravenous DEX in combination with midazolam and pentazocine in pediatric cardiac catheterization may reduce the need for an additional dose of midazolam and may contribute to the prevention of airway complications associated with respiratory depression caused by sedative agents.

The association between different anesthetic techniques and outcomes in patients undergoing transfemoral aortic valve replacement

Background

There is an increasing number of patients undergoing transfemoral aortic valve replacement (TAVR) with sedation. There is limited data assessing the efficacy and safety of the different types of sedative drugs. The objective was to compare two sedation techniques with regard to the need for vasoactive support, respiratory support, rate of conversion to general anesthesia (GA), common perioperative morbidities, intensive care unit (ICU) stay, and in-hospital mortality.

Methods

A retrospective chart review study conducted among patients who underwent TAVR at a specialized cardiac center between January 2016 and December 2019. Data collection included patient diagnosis, preoperative comorbidities, intraoperative outcomes, and postoperative outcomes.

Results

A total of 289 patients received local anesthesia; 210 received propofol infusion and 79 received a mixed propofol-ketamine infusion (Ketofol). The average age was 75.5 ± 8.9 years and 58.1% of the patients were females. Comparing propofol and ketofol groups, 31.2% and 34.2% of the patients required drug support, 7.6% and 6.3% required conversion to GA, 46.7% and 59.5% required respiratory support, respectively. These intraoperative outcomes were not significantly different between groups, P = 0.540, P = 0.707, and P = 0.105, respectively. In-hospital 30-day mortality in propofol and ketofol groups were 1.9% and 3.8%, respectively, P = 0.396. In both groups, the median post-procedure coronary care unit stay was 26 hours while post-procedure hospital stay was 3 days.

Conclusions

There were no significant differences in perioperative or postoperative outcomes in TAVR patients receiving either propofol or ketofol. Propofol infusion, either alone or with ketamine, is reliable and safe, with minimal side effects.

Safety and Efficacy of Ketamine-Fentanyl-Dexmedetomidine-Induced Anesthesia and Analgesia in Neonatal and Aged Rats

The efficiency of many anesthetic regimens is controversial, with side effects especially in the vulnerable children and old population. The study aimed to evaluate the safety and efficacy of low-dose combination of ketamine, fentanyl, and dexmedetomidine (KFD) for anesthesia and analgesia in the neonatal and elderly rats. KFD rapidly induced anesthesia and analgesia in either postnatal days 6 (P6) or 13 months (13M) old rats. Meanwhile, KFD administration had no adverse effects on the cardiovascular and respiratory systems. Compared with control group, there were no distinct morphologic changes in kidney, liver, and brain in KFD group. Moreover, administration of KFD had no influence on hepatic and renal function in rats of both ages. Furthermore, there was no obvious difference in cognitive function between control and KFD groups. These results indicated that the administration of KFD combination offered safe and efficient anesthesia. Collectively, our results suggest the potential implication of the KFD combination in anesthesia management.

Effects of Propofol, Dexmedetomidine, or Ketofol on Respiratory and Hemodynamic Profiles in Cardiac Patients Undergoing Transesophageal Echocardiography: A Prospective Randomized Study

OBJECTIVES

The authors aimed to evaluate sedation characteristics, as well as cardiorespiratory effects, of propofol, dexmedetomidine, and ketofol used for conscious sedation during transesophageal echocardiography (TEE).

DESIGN

Prospective double-blind randomized study.

SETTINGS

Tanta University hospitals.

PARTICIPANTS

Seventy-five participants with left-to-right shunt requiring diagnostic TEE interventions. Patients were randomized into three groups-P, Dex, and K-to receive propofol, dexmedetomidine, or ketofol, respectively.

MEASUREMENTS AND MAIN RESULTS

Time to reach targeted sedation level, duration of the procedure, recovery time, hemodynamic parameters, incidence of oxygen desaturation <90%, as well as the cardiologist's satisfaction were recorded. The time onset and offset of sedation, duration of TEE procedure, and the need for rescue propofol were significantly less in the P and K groups compared with group Dex (p value 0.000*, 0.003*, 0.000*, and 0.000* and effect size 0.39, 0.15, 0.21, and 0.34, respectively). Mean arterial pressure, heart rate, and cardiac output significantly decreased in groups P and Dex compared with either baseline or group K. Hypoxic events were more manifest in group P; whereas group K had better cardiologist's satisfaction than the other two groups.

CONCLUSIONS

In the TEE settings, the three agents were capable of attaining the targeted sedation levels , with propofol and ketofol having a faster onset and recovery times compared with dexmedetomidine. Even though dexmedetomidine and ketofol provided a more stable respiratory profile than propofol, ketofol was favorable in providing fewer hemodynamic alterations with better satisfaction scores than both propofol and dexmedetomidine.

Dexmedetomidine Is an Equal Cost Alternative to Propofol in Transcatheter Aortic Valve Replacement, With Equivalent In-Hospital and 30-Day Outcomes

OBJECTIVE

Transcatheter aortic valve replacement (TAVR) with monitored anesthesia care (MAC) is well-tolerated and is growing in popularity. Differences in outcomes based on anesthetic agent choice with MAC has received less attention. The authors sought to determine whether differences in outcomes and cost exist based on whether patients receive dexmedetomidine or propofol when undergoing TAVR with MAC.

DESIGN

Retrospective cohort study.

SETTING

The Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.

PARTICIPANTS

The study comprised 161 patients who underwent TAVR with MAC between May 2014 and March 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A propofol-only (n = 58) group and dexmedetomidine-only (n = 103) group were identified. No differences in in-hospital mortality or complication rate were identified when evaluating for stroke, transfusion, new arrhythmia, cardiac arrest, or bleeding and vascular complications (p > 0.05, all). Thirty-day outcomes were also equivalent, with no differences in mortality, stroke, vascular complication, new arrhythmia, or myocardial infarction (p > 0.05, all). The average amount of epinephrine, norepinephrine, or phenylephrine used intraoperatively was not significantly different. Overall median hospitalization costs were equivalent ($57,554.31 with dexmedetomidine v $58,538.08 with propofol, p = 0.97).

CONCLUSIONS

There were no significant differences in in-hospital outcomes, 30-day outcomes, or total cost of the patient's hospitalization, based on the use of dexmedetomidine versus propofol in patients undergoing TAVR.

Effect of dexmedetomidine on pulmonary artery pressure in children with congenital heart disease and pulmonary hypertension

Background:

This study was undertaken to determine the effects of dexmedetomidine on pulmonary artery pressure (PAP) in children with congenital heart disease (CHD) and pulmonary hypertension (PH) undergoing cardiac catheterization with and without a planned intervention during monitored anesthetic care using midazolam and ketamine.

Materials and Methods:

Children (<18 years) with known CHD and PH who were scheduled for cardiac catheterization and interventional procedures were included in the study. The procedures were performed under monitored anesthesia. After obtaining baseline PAPs, an intravenous (IV) infusion of dexmedetomidine (1 μg/kg) was given for over 10 min. During infusion, heart rate (HR), blood pressure (BP), respiratory rate (RR), and peripheral arterial oxygen saturation (SPO₂) were recorded every 2 min until completion of dexmedetomidine infusion, 15 min later, and when the procedure was completed. In addition, pulmonary artery systolic and diastolic pressures, and mean pulmonary artery pressure (MPAP) were recorded and the pulmonary artery systolic pressure (PASP)/systolic blood pressure (BP) ratio was calculated.

Results:

All children tolerated the procedure without adverse events. The HR decreased significantly over time during dexmedetomidine infusion. The changes in systemic systolic BP and PAPs were not significantly different from the baseline value at all points of measurement as was the ratio between the systolic pulmonary artery and systolic systemic BPs.

Conclusions:

Administration of dexmedetomidine in a dose of 1 μg/kg over 10 min did not significantly alter the PAP in children with CHD and PH. There was a decrease in the HR that was not clinically significant. The children tolerated dexmedetomidine without adverse events.

A non-randomized controlled study of total intravenous anesthesia regimens for magnetic resonance imaging studies in children

BACKGROUND AND AIMS

We studied the efficacy and safety of different total intravenous anesthesia used for pediatric magnetic resonance imaging (MRI).

MATERIAL AND METHODS

Children of 1-7 years age (n = 88), undergoing MRI received a loading dose of dexmedetomidine 1 μg/kg over 10 min, ketamine 1 mg/kg, and propofol 1 mg/kg in sequence. University of Michigan Sedation Scale (UMSS) of 3 was considered an acceptable level for starting the scan. Rescue ketamine 0.25-0.5 mg/kg was given if UMSS remained <3. After the loading dose of drugs, some children attained UMSS = 4 or progressive decline in heart rate, therefore, did not receive any infusion. The rest received either dexmedetomidine (0.7 μg/kg/h) (n = 35) or propofol (3 mg/kg/h) (n = 38) infusion for maintenance. Ketamine 0.25 mg/kg was used as rescue. Sedation failure was considered if either there was inability to complete the scan at the pre-set infusion rate, or there was need for >3 ketamine boluses or serious adverse events occurred. Statistical Package for Social Sciences 20 was used for analysis.

RESULTS

Initiation of scan was 100% successful with median induction time of 10 min. Maintenance of sedation was successful in 100% with dexmedetomidine and 97.4% with propofol infusion. Recovery time (25 min v/s 30 min), discharge time (35 min v/s 60 min), and total care duration (80 min v/s 105 min) were significantly less with propofol as compared to dexmedetomidine (P = 0.002, 0.000, and 0.000, respectively). There were no significant adverse events observed.

CONCLUSION

Dexmedetomidine 1μg/kg, ketamine 1 mg/kg, and propofol 1 mg/kg provide good conditions for initiation of MRI. Although dexmedetomidine at 0.7μg/kg/h and propofol at 3 mg/kg/h are safe and effective for maintenance, propofol provides faster recovery.

Low-dose dexmedetomidine as an adjuvant to propofol infusion for children in MRI: A double-cohort study

INTRODUCTION

Propofol is an effective sedative for magnetic resonance imaging. Nevertheless, it may cause hemodynamic and respiratory complications in a dose dependent fashion. We investigated the role of low-dose dexmedetomidine (0.5 μg/kg) as an adjuvant to propofol sedation for children undergoing magnetic resonance imaging. We hypothesized that dexmedetomidine would decrease the propofol dose required, airway complications, and hemodynamic instability.

METHODS

We performed a retrospective chart review of patients' age of 1 month to 20 years. Children were divided into 2 groups; group P received only propofol; group D + P received intravenous bolus of dexmedetomidine (0.5 μg/kg) and propofol.

RESULTS

We reviewed 172 children in P and 129 in D + P (dexmedetomidine dose, median: 0.50 μg/kg (IQR: 0.45-0.62). An additional dexmedetomidine bolus was given to 17 children for sedation lasting longer than 2 hours. Total propofol dose (μg/kg/min) was significantly higher in group P than D + P; 215.0 (182.6-253.8) vs 147.6 (127.5-180.9); Median Diff = -67.8; 95%CI = -80.6, -54.9; P < .0001. There was no difference in recovery time (minutes); P: 28 (17-39) vs D + P: 27 (18-41); Median Diff = -1; 95%CI = -6.0, 4.0; P = .694. The need for airway support was significantly greater in P compared to D + P; 15/172 vs 3/129; OR = 0.25; 95%CI = 0.07 to 0.90; P = .02 (2-sample proportions test). Mean arterial pressure was significantly lower in P compared to D + P across time over 60 minutes after induction (coef = -0.06, 95%CI = -0.11, -0.02, P = .004).

DISCUSSION & CONCLUSION

A low-dose bolus of dexmedetomidine (0.5 μg/kg) used as an adjuvant can decrease the propofol requirement for children undergoing sedation for magnetic resonance imaging. This may decrease the need for airway support and contribute to improved hemodynamic stability without prolonging recovery time.

Propofol versus Ketofol for Sedation of Pediatric Patients Undergoing Transcatheter Pulmonary Valve Implantation: A Double-blind Randomized Study

OBJECTIVE

The study was done to compare propofol and ketofol for sedation of pediatric patients scheduled for elective pulmonary valve implantation in a catheterization laboratory.

DESIGN

This was a double-blind randomized study.

SETTING

This study was conducted in Prince Sultan Cardiac Centre, Saudi Arabia.

PATIENTS AND METHODS

The study included 60 pediatric patients with pulmonary regurge undergoing pulmonary valve implantation.

INTERVENTION

The study included sixty patients, classified into two groups (n = 30). Group A: Propofol was administered as a bolus dose (1-2 mg/kg) and then a continuous infusion of 50-100 μg/kg/min titrated as needed. Group B: Ketofol was administered 1-2 mg/kg and then infusion of 20-60 μg/kg/min. The medication was prepared by the nursing staff and given to anesthetist blindly.

MEASUREMENTS

The monitors included heart rate, mean arterial blood pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, fentanyl dose, antiemetic medications, and Aldrete score.

MAIN RESULTS

The comparison of heart rate, mean arterial pressure, respiratory rate, temperature, SPO2and PaCO2, Michigan Sedation Score, and Aldrete score were insignificant (P > 0.05). The total fentanyl increased in Group A more than Group B (P = 0.045). The required antiemetic drugs increased in Group A patients more than Group B (P = 0.020). The durations of full recovery and in the postanesthesia care unit were longer in Group A than Group B (P = 0.013, P < 0.001, respectively).

CONCLUSION

The use of propofol and ketofol is safe and effective for sedation of pediatric patients undergoing pulmonary valve implantation in a catheterization laboratory. However, ketofol has many advantages more than the propofol. Ketofol has a rapid onset of sedation, a rapid recovery time, decreased incidence of nausea and vomiting and leads to rapid discharge of patients from the postanesthesia care unit.

Dexmedetomidine-propofol vs ketamine-propofol anaesthesia in paediatric and young adult patients undergoing device closure procedures in cardiac catheterisation laboratory: An open label randomised trial

Background and Aims:

Several drug combinations have been tried in patients with acyanotic congenital heart disease (ACHD) undergoing transcatheter device closure in the cardiac catheterisation laboratory (CCL). Adequate sedation, analgesia, akinesia, cardiorespiratory stability, and prompt recovery are key requirements. Ketamine with propofol is used for this purpose. Dexmedetomidine carries a shorter recovery time. This study compared dexmedetomidine–propofol (DP) with ketamine–propofol (KP) in patients in the CCL.

Methods:

This was an open label randomised trial at a CCL over a 2-year period from August 2012 to August 2014. Fifty-six paediatric and 44 young adults with ACHD underwent device closure and were randomised to receive DP or KP. The primary outcome studied was time to regain full consciousness, airway and motor recovery.

Results:

Baseline characteristics were similar in the study groups. In the DP arm as compared to the KP arm, the time to recovery of consciousness (mean ± SD) was significantly faster in both paediatric patients [30 ± 15 vs. 58 ± 13 min (P < 0.001)] and in young adult patients [22 ± 10 vs. 35 ± 12 min (P < 0.001)]. There was significantly faster motor recovery also (mean ± SD) [paediatric: 25 ± 05 vs. 40 ± 14 (P < 0.001); young adult: 10 ± 05 vs. 22 ± 10 min (P < 0.001)].

Conclusion:

Procedural anaesthesia with DP in paediatric and young adult patients with ACHD undergoing device closure in the CCL resulted in faster recovery of consciousness and motor recovery compared to KP.

Ketamine-induced apoptosis in the mouse cerebral cortex follows similar characteristic of physiological apoptosis and can be regulated by neuronal activity

The effects of general anesthetics on inducing neuronal apoptosis during early brain development are well-documented. However, since physiological apoptosis also occurs during this developmental window, it is important to determine whether anesthesia-induced apoptosis targets the same cell population as physiological apoptosis or different cell types altogether. To provide an adequate plane of surgery, ketamine was co-administered with dexmedetomidine. The apoptotic neurons in the mouse primary somatosensory cortex (S1) were quantitated by immunohistochemistry. To explore the effect of neural activity on ketamine-induced apoptosis, the approaches of Designer Receptors Exclusively Activated by Designer Drugs (DREADDs) and an environmental enrichment (EE) were performed. Ketamine-induced apoptosis in S1 is most prominent at postnatal days 5 and 7 (P5 – P7), and becomes insignificant by P12. Physiological and ketamine-induced apoptosis follow similar developmental patterns, mostly comprised of layer V pyramidal neurons at P5 and shifting to mostly layer II to IV GABAergic neurons by P9. Changes in neuronal activity induced by the DREADD system bidirectionally regulated the pattern of ketamine-induced apoptosis, with reduced activity inducing increased apoptosis and shifting the lamination pattern to a more immature form. Importantly, rearing mice in an EE significantly reduced the magnitude of ketamine-induced apoptosis and shifted its developmental pattern to a more mature form. Together, these results demonstrate that lamination pattern and cell-type dependent vulnerability to ketamine-induced apoptosis follow the physiological apoptosis pattern and are age- and activity-dependent. Naturally elevating neuronal activity is a possible method for reducing the adverse effects of general anesthesia.

Effects of medetomidine and its active enantiomer dexmedetomidine on N-demethylation of ketamine in canines determined in vitro using enantioselective capillary electrophoresis

Cytochrome P450 (CYP) enzymes catalyze the metabolism of both, the analgesic and anesthetic drug ketamine and the α₂ -adrenergic receptor-agonist medetomidine that is used for sedation and analgesia. As racemic medetomidine or its active enantiomer dexmedetomidine are often coadministered with racemic or S-ketamine in animals and dexmedetomidine together with S- or racemic ketamine in humans, drug-drug interactions are likely to occur and have to be characterized. Enantioselective CE with highly sulfated γ-cyclodextrin as chiral selector was employed for analyzing in vitro (i) the kinetics of the N-demethylation of ketamine mediated by canine CYP3A12 and (ii) interactions occurring with racemic medetomidine and dexmedetomidine during coincubation with ketamine and canine liver microsomes (CLM), canine CYP3A12, human liver microsomes (HLM), and human CYP3A4. For CYP3A12 without an inhibitor, Michaelis-Menten kinetics was determined for the single enantiomers of ketamine and substrate inhibition kinetics for racemic ketamine. Racemic medetomidine and dexmedetomidine showed an inhibition of the N-demethylation reaction in the studied canine enzyme systems. Racemic medetomidine is the stronger inhibitor for CLM, whereas there is no difference for CYP3A12. For CLM and CYP3A12, the inhibition of dexmedetomidine is stronger for the R- compared to the S-enantiomer of ketamine, a stereoselectivity that is not observed for CYP3A4. Induction is observed at a low dexmedetomidine concentration with CYP3A4 but not with CYP3A12, CLM, and HLM. Based on these results, S-ketamine combined with dexmedetomidine should be the best option for canines. The enantioselective CE assay with highly sulfated γ-cyclodextrin as chiral selector is an effective tool for determining kinetic and inhibition parameters of metabolic pathways.

Dexmedetomidine decreases the requirement of ketamine and propofol during burns debridement and dressings

Background and Aims:

Dexmedetomidine (Dex), a highly selective α₂-adrenoreceptor agonist, is used for sedation management in various clinical settings and shows anaesthetic-sparing effect. Our aim was to study the effects of Dex on requirements of propofol, ketamine, and intraoperative haemodynamic variations during burns debridement and dressing changes, and compare its effectiveness and safety with combination of ketamine and propofol.

Methods:

Sixty adult patients posted for elective debridement and dressing were included in the study. Thirty patients received Dex (intramuscular)(IM) 1 μg/kg, 1 h before shifting to the operation theatre while the other thirty did not. Anaesthesia was induced with propofol and ketamine followed by adjusted infusion to achieve a Ramsay Sedation Scale score (RSS) of six in all patients. Intraoperatively haemodynamic parameters were recorded at regular intervals of 5, 15, 30, 45, and 60 min. The mean data between the groups were compared by unpaired t test and medians by Mann-Whitney U test. Within group analysis was performed by using repeated measures ANOVA. P < 0.05 was considered significant.

Results:

The dose requirement of ketamine and propofol in Dex group was significantly lower when compared to control group (100.5 ± 17.58 mg vs. 231.5 ± 60.39 mg (P < 0.0001) and 127.7 ± 15.47 mg vs. 254 ± 59.22 mg (P < 0.0001) respectively). Additionally, recovery time was lower in the Dex group as compared to the control group, 9.57 ± 1.50 min vs. 11.53 ± 2.56 min (P = 0.0006). Haemodynamic variations were also significantly lower in the Dex group as compared to the control group.

Conclusion:

Dexmedetomidine (1 μg/kg IM) reduced the requirement of propofol and ketamine, with more stable intraoperative haemodynamics.

Percutaneous closure of atrial septal defects in spontaneously breathing children under deep sedation: a feasible and safe concept

Interventional cardiac catheterization in children and adolescents is traditionally performed with the patient under general anesthesia and endotracheal intubation. However, percutaneous closure of atrial septum defect (ASD) without general anaesthesia is currently being attempted in a growing number of children. The study objective was to evaluate the success and complication rate of percutaneous ASD closure in spontaneously breathing children under deep sedation. Retrospective single centre cohort study of consecutive children undergoing percutaneous ASD closure at a tertiary care pediatric cardiology centre. Transesophageal echocardiography (TEE) and percutaneous ASD closure were performed with the patient under deep sedation with intravenous bolus of midazolam and ketamine for induction and propofol continuous infusion for maintenance of sedation in spontaneously breathing children. One hundred and ninety-seven patients (median age 6.1 years [minimum 0.5; maximum 18.8]) underwent TEE and ASD balloon sizing. Percutaneous ASD closure was attempted in 174 patients (88 %), and device implantation was performed successfully in 92 %. To achieve sufficient deep sedation, patients received a median ketamine dose of 2.7 mg/kg (0.3; 7) followed by a median propofol continuous infusion rate of 5 mg/kg/h (1.1; 10.7). There were no major cardiorespiratory complications associated with deep sedation, and only two patients (1 %) required endotracheal intubation due to bronchial obstruction immediately after induction of sedation. Seventeen patients (8 %) had minor respiratory complications and required frequent oral suctioning or temporary bag-mask ventilation. TEE and percutaneous ASD closure can be performed safely and successfully under deep sedation in spontaneously breathing children of all ages.