Anaesthesia for Pulsed Field Ablation Procedures

Catheter ablation is a well-established approach for rhythm control in patients with various types of cardiac arrhythmias. In recent years, pulsed field ablation (PFA) has emerged as a promising non-thermal alternative to conventional thermal ablation techniques such as radiofrequency (RF) and cryoablation.^1–4

Unlike thermal methods, which rely on heat or cold to destroy cardiac tissue, PFA operates via irreversible electroporation. This technique uses ultra-fast, high-intensity electric fields to create microscopic pores in myocardial cell membranes, leading to cell death within seconds.¹

One of PFA’s most notable features is its tissue selectivity. Since different tissues respond uniquely to electric fields, PFA can target myocardial cells specifically, while sparing surrounding structures such as the oesophagus, phrenic nerve and blood vessels.^5,6

Preclinical studies have shown no significant pulmonary vein stenosis, minimal or no phrenic nerve damage and – most importantly – no oesophageal injury, indicating a major safety advantage over thermal ablation.^7,8 Although the latest data found PFA to be safe and fast in terms of outcome, no differences have been observed in terms of pulmonary vein isolation.⁹

Anaesthesia management plays a crucial role in the success and tolerability of PFA. While it has a shorter duration than RF or cryoablation procedures, PFA induces intense skeletal muscle contractions that are often painful and typically require deep sedation or even general anaesthesia (GA).^10,11 While some centres have reported safe and effective use of propofol-based deep sedation, this approach still requires continuous monitoring by trained personnel – a resource not universally available.^10,11

Limited access to anaesthesia may play a role in preventing the adoption of PFA in some countries. Additionally, a variety of protocols are in use, depending on the individual country’s regulations. In some countries, propofol must be administered only by anaesthesia personnel, while this is not a requirement in others. Therefore, anaesthesia considerations go beyond clinical factors and become logistical and systemic challenges in the real-world implementation of this novel technology (Figure 1).

Anaesthesia Considerations

As previously described, PFA enables selective myocardial ablation through non-thermal mechanisms, offering safety advantages that also affect anaesthesia management. However, this novel technology also presents specific challenges in regards to anaesthesia.

Anaesthetic choice is pivotal to procedural success, directly influencing patient safety, comfort and workflow efficiency. Despite growing clinical experience with PFA (and ablation systems based on thermal energy), a standardised sedation protocol for electrophysiology (EP) procedures, including PFA, based on evidence and consensus, has not yet been established.¹²

This results in substantial variability in clinical practice, depending on the centre, the treating team and individual patient factors.¹²

Local Anaesthesia

Although the use of solely local anaesthesia is common in certain electrophysiological procedures, it is considered insufficient in the context of PFA. The discomfort caused by the electrical pulses and the potential for skeletal muscle contractions generally make purely local anaesthesia impractical.

This is reflected in sedation strategies described in recent studies: neither Grimaldi et al. nor Iacopino et al. employed local anaesthesia as the sole approach in their work.^11,12 Instead, targeted deep sedation protocols using midazolam, dexmedetomidine, remifentanil or ketamine were applied – sometimes with and sometimes without the direct involvement of an anaesthesiologist.^11–13

This suggests that local anaesthesia alone cannot be considered a feasible option for PFA. Owing to the unpredictable responses to pulsed electrical energy and the need for effective control of pain and muscle reactions, its use remains highly limited.

Deep Sedation

Deep sedation – whether propofol-based or using agents, such as midazolam, dexmedetomidine, ketamine or remifentanil, can provide reliable analgesia and amnesia while preserving spontaneous breathing.^2,14 It is increasingly favoured in PFA procedures for maintaining procedural stability and enhancing patient comfort without the need for intubation. When implemented using structured protocols and trained personnel, deep sedation is a safe and effective alternative to GA, even in non-operating room environments.^12,15

Propofol

Because of its rapid onset and short half-life, propofol is well-suited for high-output EP labs. However, its use requires careful monitoring because of its respiratory depressant effects. When applied under structured protocols, propofol can be administered safely outside traditional operating rooms.¹⁵

Propofol causes a dose-related depression of the sinus node and His-Purkinje conduction, with the most notable haemodynamic effects including hypotension and bradycardia.¹⁶ Nonetheless, its pharmacokinetic profile is particularly attractive, and rapid metabolism via multiple cytochrome P450 isoforms renders propofol less dependent on renal or hepatic clearance than midazolam.¹⁷

A large-scale study by Galuszka et al. evaluated a deep sedation protocol combining midazolam, fentanyl and propofol in >1,000 patients undergoing pulmonary vein isolation with PFA, cryoballoon or RF ablation.¹⁵ Sedation was delivered by the trained nursing staff under electrophysiologist supervision. Conversion to GA was rare (0.23% in PFA cases) and sedation-related adverse events were minimal. These findings confirm that propofol-based sedation is both safe and efficient when delivered by well-trained staff following standardised protocols.

Non-propofol Approaches

In response to concerns about respiratory depression, alternative deep sedation protocols that exclude propofol are also in clinical use.

For example, Grimaldi et al. used a regimen of midazolam, dexamethasone, ondansetron, dexmedetomidine and remifentanil to maintain spontaneous respiration while achieving adequate sedation depth.¹¹ Validated monitoring tools, such as the Patient State Index (PSI), the Richmond Agitation-Sedation Scale and a visual analogue scale, were used to titrate sedation. The EEG-based SedLine system (Masimo) enabled continuous real-time assessment. No patients required intubation and no sedation-related complications occurred. Post-procedural patient satisfaction was consistently high.

Both propofol-based and non-propofol sedation strategies demonstrate favourable safety and efficacy profiles. The choice should be based on institutional resources, provider expertise and individual patient characteristics. When executed with standardised protocols and experienced teams, deep sedation not only matches the safety of GA in PFA but also may offer workflow and resource advantages in many clinical settings.

General Anaesthesia

GA continues to be a widely used and well-established approach in EP, particularly for more complex or prolonged ablation procedures, as well as for patients with significant comorbidities or a high BMI.¹⁸ In such cases, the use of muscle relaxants during GA allows for better control of respiratory movements, which enhances catheter stability and the quality of 3D electroanatomical mapping – especially when using systems sensitive to motion artefacts.

Findings from Rillig et al. indicate that acute procedural success rates under GA are comparable to those achieved under deep sedation.¹⁹ However, one key outcome of their study was that lab occupancy time was significantly longer in patients receiving GA, suggesting that, while GA may offer certain procedural advantages, it is also associated with greater logistical and resource demands. These challenges may be particularly relevant in high-volume centres with limited anaesthesia support.

Despite these considerations, GA remains a routine approach in many institutions, especially those with dedicated anaesthesiology teams.

A survey conducted by the European Heart Rhythm Association and analysed by Iliodromitis et al. found that 24% of respondents routinely performed AF ablations, including PFA, under GA.²⁰ However, the majority (66%) preferred conscious or deep sedation and only 10% reported using local anaesthesia alone. This variation reflects diverse institutional practices, shaped by available infrastructure, staffing and national healthcare policies.

According to Hicks et al., GA offers additional advantages in the EP lab beyond sedation itself.¹⁸ It supports comprehensive control of anticoagulation, haemodynamic stability and airway protection, and enables a rapid response to rare but serious complications such as cardiac perforation or pericardial tamponade. However, many EP labs are physically separated from main operating rooms, so administering GA in these settings requires appropriate equipment, personnel and procedural planning.

With the increasing adoption of novel ablation technologies such as PFA, the question of optimal sedation strategy is gaining importance.

While GA can improve procedural precision through controlled ventilation and reduced motion, recent evidence from Rillig et al. suggests that deep sedation can provide comparable outcomes in appropriately selected patients with proper monitoring.¹⁹ Moreover, lab occupancy times were shorter under deep sedation – an important advantage for centres with high procedural volumes. Complications such as pericardial tamponade or airway issues were rare across both approaches, and conversion from deep sedation to GA occurred only in isolated cases, typically in patients with severe obesity and challenging airway anatomy.

In summary, GA continues to play a critical role in the safe and effective execution of AF ablation, particularly in high-risk and complex cases. However, emerging evidence supports deep sedation as a viable, efficient and resource-conscious alternative in selected patient populations.

In the context of rising procedural demands and limited resources, deep sedation may help streamline workflows and optimise the use of EP lab capacity.

Table 1 gives a summary of anaesthetic strategies applied during PFA procedures, including their advantages and limitations, as well as representative clinical studies.

Discussion

Anaesthetic Management

PFA introduces unique anaesthetic considerations that differ significantly from those encountered with conventional thermal ablation techniques such as RF or cryoablation.¹¹

A primary challenge lies in the involuntary skeletal muscle contractions caused by high-voltage electrical pulses. These abrupt and sometimes forceful muscle movements can be distressing for patients and, if sedation is inadequate, may lead to catheter dislodgement or reduced procedural stability.¹¹

Another key consideration is the need to balance adequate sedation with procedural efficiency. PFA is characterised by its short procedural duration and high patient throughput, making fast-acting and easily reversible sedation protocols particularly important.² However, the implementation of such protocols can be complicated by institutional differences in staffing, resources and national regulations – especially regarding the use of the agents such as propofol and dexmedetomidine, which in some countries may be administered only by licensed anaesthesiologists.²

Patient psychology plays a critical role in procedural success, influencing sedation depth and overall cooperation. Anxiety, fear and an insufficient understanding of the procedure can influence both sedation depth and patient cooperation. Pre-procedural education, along with clear and empathetic communication, might help reduce emotional distress and potentially lower the need for sedatives.

Additionally, the level of experience within the clinical team regarding both sedation practices and PFA technology plays a crucial role in ensuring safety and maintaining workflow efficiency. Because of this, many centres have adopted hybrid care models in which specially trained EP nurses manage sedation under the supervision of an anaesthesiologist. A notable approach within this framework is nurse-administered propofol sedation. Within this model, propofol administration is delegated to qualified nursing staff, while the physician retains full medical responsibility for the indication, dosing and overall management of the sedation process.²¹ Such interprofessional models enhance procedural efficiency and expand treatment capacity – an increasingly important factor in high-volume EP centres experiencing resource limitations.

Sedation: Monitoring and Safety

Although PFA significantly reduces many of the risks associated with traditional thermal ablation, it introduces challenges related to sedation, airway management and intraoperative stability.

Maximising the safety and effectiveness of PFA relies on a combination of innovative technology and structured patient management, supported by an interdisciplinary team approach. Adequate monitoring is essential to ensure patient safety and the successful outcome of the procedure.

Standard Monitoring

During PFA procedures, the following monitoring measures are considered essential: continuous ECG monitoring, non-invasive or invasive blood pressure measurement, and pulse oximetry (SpO₂) in patients under deep sedation to enable the early detection of hypoventilation.^12,18

Some centres also employ automated sedation tracking systems that integrate vital signs, drug dosages and real-time alarms. These systems help identify instability early and support proactive, safe clinical decision-making.

Continuous EEG-based monitoring of sedation depth may be recommended in some cases. A study by Grimaldi et al. involved the use of the SedLine system, which employs the PSI – a validated parameter to objectively assess sedation depth. PSI monitoring helps to prevent both over- and undersedation, thereby enhancing patient safety during ablation.¹¹

Airway Management

Deep sedation with spontaneous respiration is commonly used during PFA. Nonetheless, the depth of sedation must be individually adjusted based on the patient’s clinical condition and the expected duration of the procedure.22

A structured airway management plan is essential, particularly in patients with obesity, known obstructive sleep apnoea, anticipated difficult airways, longer procedure times or when phrenic nerve stimulation is planned, since neuromuscular blockers should be avoided or reversed in such cases.²²

Supplemental oxygen via nasal cannulae or high-flow systems improves safety during prolonged sedation.²²

Airway protection must be ensured, including readiness for a laryngeal mask airway or endotracheal intubation, even though the conversion rate from sedation to general anaesthesia is low (<5%).²²

Sedation: Complications

Despite the safety advantages of PFA, sedation-related complications remain a major concern. Potential adverse events include airway obstruction and hypoventilation, hypoxia and hypercapnia, haemodynamic instability and patient movement during critical phases of ablation.¹⁵ To effectively prevent and manage these issues, EP labs must implement safety protocols equivalent to those used in operating rooms, particularly when deep sedation is administered without the continuous presence of an anaesthesiologist.¹⁵

Key safety strategies include pre-procedure checklists for structured risk assessment, including the evaluation of sedation and airway-related risks, as well as clearly defined emergency protocols for managing airway compromise, cardiovascular collapse or adverse drug reactions.¹⁵

Post-procedural monitoring should focus on haemodynamic stability, respiratory function and puncture sites. Strict anticoagulation management is essential to prevent vascular complications such as retroperitoneal haematomas or thromboembolic events.¹⁵

Although PFA is associated with significantly lower rates of thermal tissue damage and less injury to surrounding structures than thermal ablation techniques, complications related to sedation and anaesthesia remain clinically relevant and require proactive, structured management.

Galuszka et al. demonstrated that the incidence of airway-related complications under deep sedation was significantly reduced when staff were specifically trained in airway rescue techniques, particularly in centres without continuous anaesthesiology coverage.¹⁵

Moreover, well-trained personnel can respond effectively to even serious complications such as pericardial tamponade. Therefore, regular training and interdisciplinary emergency simulations are essential to optimally prepare the entire team for critical events and to sustainably improve patient safety in the EP lab.

Future Perspectives

The continued evolution of PFA is driving the need for both standardised and personalised strategies in anaesthesia and procedural management. The overarching goal is to improve patient safety, streamline workflows and facilitate broad, global adoption of this promising technology.

Standardisation

As demonstrated in the Advent study, PFA has shown non-inferiority compared to thermal ablation with regard to efficacy and safety, including comparable rates of serious adverse events.²² Such findings, together with upcoming consensus guidelines, would pave the way for standardised clinical protocols that can be applied across centres and ablation systems. Furthermore, systematic registry data and meta-analyses will be essential for comparing sedation strategies objectively and for establishing evidence-based best practices.²³

Personalisation

As procedural complexity increases and patient populations become more heterogeneous, individualised sedation approaches are gaining relevance.

In future, validated risk scores and predictive models may support making the decision between deep sedation and GA, enabling more personalised and patient-centred anaesthesia management.

Technological Innovation

Technological advances in catheter design, mapping systems and non-fluoroscopic navigation have the potential to reduce procedure times and the required depth of sedation. Although current fluoroscopy times with PFA are longer than with thermal ablation, this gap is expected to narrow as operator experience increases.²³

Artificial intelligence (AI) may soon support real-time monitoring and risk prediction in the EP lab, although further clinical validation is required.

Teams and Training

In high-volume or resource-limited centres, expanding the roles of trained EP staff in sedation monitoring – under physician supervision – can enhance capacity and safety.

Simulation-based training and certification programmes for non-anaesthesiology practitioners are under discussion and may become crucial where continuous anaesthesia presence is not feasible.

It is also essential that anaesthesia teams understand PFA-specific risks, such as extracardiac muscle stimulation and vagal responses.^24,25

Data-driven Sedation Control

While still in development, AI-driven algorithms could help dynamically adjust sedation depth and detect instability early – potentially as part of remote supervision models.

The increasing availability of large-scale clinical data makes it feasible to build adaptive, evidence-based sedation protocols tailored to individual risk profiles, comorbidities and procedural characteristics.

Conclusion

The future of anaesthesia in PFA lies in the integration of technological innovation, clinical standardisation and individualised patient management.

While PFA already offers a high level of procedural safety and effectiveness, its full potential can be realised only through an interdisciplinary, flexible and evidence-based approach.