Cardiol Res

Cardiology Research, ISSN 1923-2829 print, 1923-2837 online, Open Access

Article copyright, the authors; Journal compilation copyright, Cardiol Res and Elmer Press Inc

Journal website https://www.cardiologyres.org

Case Report

Volume 14, Number 1, February 2023, pages 86-90

Remimazolam as the Primary Agent for Sedation During Cardiac Catheterization in Three Patients With Comorbid Cardiac Conduction Abnormalities

**Table 1.** Clinical Patient Data and Remimazolam Dosing
Concurrent medications and doses	Procedure and diagnosis	Treatment	Outcomes and follow-up
ECG: electrocardiogram; AICD: automatic implantable cardiac defibrillator; PACU: post-anesthesia care unit; RBBB: right bundle branch block.
Furosemide 20 mg q. AM. Mycophenolate 720 mg BID. Omeprazole 20 mg q. day. Trimethorpirim-sulfamethoxazole 160 mg q. MWF. Tacrolimus 3.5 mg BID. Tadalafil 20 mg q. day. Drosprenone 4 mg q. day. Valganciclovir 400 mg q. day. Insulin pump - regular insulin.	Cardiac catheterization and myocardial biopsy. ECG with new onset second degree (Mobitz type I) heart block. Echocardiogram with depressed myocardial function and moderate size pericardial effusion with no tamponade. Mostly posterior and around the right atrium. History of cardiomyopathy, status post heart transplantation and AICD placement.	Sedation initiated with remimazolam bolus (4 mg) followed by a remimazolam infusion at 20 µg/kg/min. The infusion was supplemented by four bolus doses of ketamine (10 mg each). After 45 min, the infusion was decreased to 15 µg/kg/min for 30 min, then to 10 µg/kg/min for 15 min followed by 5 µg/kg/min for 15 min. There were no adverse intraoperative events during the 120-min procedure.	PACU recovery for 58 min. Uncomplicated postoperative course. Postoperative echocardiogram showed resolution of diastolic dysfunction and decreased ventricular filling pressures. Repeat endomyocardial biopsy performed one month later with similar sedation regimen.
Metoprolol 25 mg q. day. Lisinopril 5 mg day. Furosemide 20 mg q. day. Ferrous sulfate 325 mg q. day. Aspirin 81 mg q. day. Nicotine transdermal patch.	AICD battery change. Complete heart block with no ventricular escape rhythm, status post placement of epicardial dual chamber pacemaker and AICD. Rhythm was sinus with ventricular pacing with RBBB. History of Ebstein’s anomaly status post tricuspid valve replacement.	Premedication with midazolam (2 mg). Sedation initiated with a remimazolam bolus (2.5 mg) followed by a remimazolam infusion at 10 µg/kg/min for 15 min. The remimazolam infusion was increased to 15 µg/kg/min for 15 min and then decreased to 10 µg/kg/min for the remainder of the procedure (45 min). Supplemental sedation included four bolus doses of fentanyl (25 µg each) and one bolus dose of propofol (10 mg) prior to infiltration of the surgical site with local anesthetic by the cardiologist. There were no adverse intraoperative events during the 72-min procedure.	Uncomplicated postoperative course with discharge from PACU in 25 min. Successful replacement of a dual-chamber cardioverter defibrillator. The pacing and sensing threshold were satisfactory.
Buprenorphine 8 mg BID. Omeprazole 40 mg q. day. Metoprolol 25 mg BID. Aspirin 81 mg q. day. Cariprazine 0.2 mg q. day. Gabapentin 600 mg TID. Venlafaxine 75 mg BID.	AICD battery change. History of sick sinus syndrome, RBBB, tetralogy of Fallot status post repair.	Sedation initiated with a remimazolam bolus (2.5 mg) followed by a remimazolam infusion at 10 µg/kg/min. After 15 min, the infusion was increased to 15 µg/kg/min for 30 min and then decreased to 10 µg/kg/min for the remainder of the case. Supplemental sedation included three bolus doses of fentanyl (25 µg) and one bolus dose of propofol (10 mg).	PACU recovery for 36 min. Uncomplicated postoperative course with discharge from PACU in 36 min.

Table 1. Clinical Patient Data and Remimazolam Dosing

Concurrent medications and doses

Procedure and diagnosis

Treatment

Outcomes and follow-up

ECG: electrocardiogram; AICD: automatic implantable cardiac defibrillator; PACU: post-anesthesia care unit; RBBB: right bundle branch block.

Furosemide 20 mg q. AM. Mycophenolate 720 mg BID. Omeprazole 20 mg q. day. Trimethorpirim-sulfamethoxazole 160 mg q. MWF. Tacrolimus 3.5 mg BID. Tadalafil 20 mg q. day. Drosprenone 4 mg q. day. Valganciclovir 400 mg q. day. Insulin pump - regular insulin.

Cardiac catheterization and myocardial biopsy. ECG with new onset second degree (Mobitz type I) heart block. Echocardiogram with depressed myocardial function and moderate size pericardial effusion with no tamponade. Mostly posterior and around the right atrium. History of cardiomyopathy, status post heart transplantation and AICD placement.

Sedation initiated with remimazolam bolus (4 mg) followed by a remimazolam infusion at 20 µg/kg/min. The infusion was supplemented by four bolus doses of ketamine (10 mg each). After 45 min, the infusion was decreased to 15 µg/kg/min for 30 min, then to 10 µg/kg/min for 15 min followed by 5 µg/kg/min for 15 min. There were no adverse intraoperative events during the 120-min procedure.

PACU recovery for 58 min. Uncomplicated postoperative course. Postoperative echocardiogram showed resolution of diastolic dysfunction and decreased ventricular filling pressures. Repeat endomyocardial biopsy performed one month later with similar sedation regimen.

Metoprolol 25 mg q. day. Lisinopril 5 mg day. Furosemide 20 mg q. day. Ferrous sulfate 325 mg q. day. Aspirin 81 mg q. day. Nicotine transdermal patch.

AICD battery change. Complete heart block with no ventricular escape rhythm, status post placement of epicardial dual chamber pacemaker and AICD. Rhythm was sinus with ventricular pacing with RBBB. History of Ebstein’s anomaly status post tricuspid valve replacement.

Premedication with midazolam (2 mg). Sedation initiated with a remimazolam bolus (2.5 mg) followed by a remimazolam infusion at 10 µg/kg/min for 15 min. The remimazolam infusion was increased to 15 µg/kg/min for 15 min and then decreased to 10 µg/kg/min for the remainder of the procedure (45 min). Supplemental sedation included four bolus doses of fentanyl (25 µg each) and one bolus dose of propofol (10 mg) prior to infiltration of the surgical site with local anesthetic by the cardiologist. There were no adverse intraoperative events during the 72-min procedure.

Uncomplicated postoperative course with discharge from PACU in 25 min. Successful replacement of a dual-chamber cardioverter defibrillator. The pacing and sensing threshold were satisfactory.

Buprenorphine 8 mg BID. Omeprazole 40 mg q. day. Metoprolol 25 mg BID. Aspirin 81 mg q. day. Cariprazine 0.2 mg q. day. Gabapentin 600 mg TID. Venlafaxine 75 mg BID.

AICD battery change. History of sick sinus syndrome, RBBB, tetralogy of Fallot status post repair.

Sedation initiated with a remimazolam bolus (2.5 mg) followed by a remimazolam infusion at 10 µg/kg/min. After 15 min, the infusion was increased to 15 µg/kg/min for 30 min and then decreased to 10 µg/kg/min for the remainder of the case. Supplemental sedation included three bolus doses of fentanyl (25 µg) and one bolus dose of propofol (10 mg).

PACU recovery for 36 min. Uncomplicated postoperative course with discharge from PACU in 36 min.