Sedation and anaesthesia in pulsed-field ablation for atrial fibrillation: mechanisms, procedural requirements, and real-world practice.
11 affiliations
- 1Department of Cardiology, General Regional Hospital 'F. Miulli', Acquaviva delle Fonti, Bari, Italy.
- 2Department of Medicine, LUM University, Casamassima, Bari, Italy.
- 3Department of Electrophysiology, Alfried Krupp Hospital, Essen, Germany.
- 4Department of Medicine, Witten/Herdecke University, Witten, Germany.
- 5Department of Arrhythmology and Electrophysiology, Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy.
- 6Department of Cardiology, University Heart & Vascular Center Hamburg, Hamburg-Eppendorf, Hamburg, Germany.
- 7German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck, Hamburg, Germany.
- 8Department of Anaesthesia and Critical Care, University Hospitals Coventry and Warwickshire, UK.
- 9Division of Electrophysiology, Department of Cardiology, Copenhagen Heart Center Rigshospitalet-Gentofte Hospital, Copenhagen, Denmark.
- 10Department of Electrophysiology, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany.
- 11Department of Clinical Affairs, AF Solution, Boston Scientific, Viale Forlanini 23, Milan 20134, Italy.
Abstract
Pulsed-field ablation (PFA) has rapidly emerged as an important energy source for atrial fibrillation ablation, offering tissue selectivity and procedural efficiency while introducing specific anaesthetic and sedation requirements. This narrative review examines the rationale for anaesthesia and sedation during PFA, the mechanisms underlying pain, involuntary movement, and neuromuscular stimulation, and the implications of catheter design, waveform characteristics, and patient-related factors for peri-procedural management. Available evidence indicates that both deep sedation and general anaesthesia can provide safe and effective procedural conditions when supported by appropriate monitoring, airway rescue capability, and experienced multidisciplinary teams. Deep sedation may offer advantages in workflow, recovery, and patient-centred care, particularly for standard pulmonary vein isolation procedures using contemporary biphasic systems with reduced muscle activation, whereas general anaesthesia remains appropriate for complex procedures, patients with substantial comorbidity, or settings in which complete immobility and airway control are essential. Current real-world practice is highly heterogeneous across regions and institutions, reflecting differences in regulations, staffing models, procedural complexity, and local expertise rather than a universally accepted standard. Overall, anaesthetic strategy in PFA should be individualised according to patient risk profile, expected procedural demands, and device-specific stimulation burden. Further prospective comparative studies are needed to define optimal sedation depth, standardise monitoring and outcome measures, and clarify how emerging technologies may enable lighter yet still effective sedation pathways.
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BibTeX
@article{monaco2026sedation,
title = {{Sedation and anaesthesia in pulsed-field ablation for atrial fibrillation: mechanisms, procedural requirements, and real-world practice.}},
author = {Antonio Di Monaco and Massimo Grimaldi and Stefan Hartl and Saverio Iacopino and Andreas Metzner and Usman Puar and Martin H Ruwald and Vanessa Sciacca and Philipp Sommer and Nadica Trajkovska and Maura Casciola and Maurizio Malacrida and Kars Neven},
journal = {Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology},
year = {2026},
month = oct,
doi = {10.1093/europace/euag127},
url = {https://europepmc.org/article/MED/42905911},
note = {CC BY},
}
RIS
TY - JOUR
TI - Sedation and anaesthesia in pulsed-field ablation for atrial fibrillation: mechanisms, procedural requirements, and real-world practice.
AU - Antonio Di Monaco
AU - Massimo Grimaldi
AU - Stefan Hartl
AU - Saverio Iacopino
AU - Andreas Metzner
AU - Usman Puar
AU - Martin H Ruwald
AU - Vanessa Sciacca
AU - Philipp Sommer
AU - Nadica Trajkovska
AU - Maura Casciola
AU - Maurizio Malacrida
AU - Kars Neven
PY - 2026
DA - 2026/10/01
JO - Europace : European pacing, arrhythmias, and cardiac electrophysiology : journal of the working groups on cardiac pacing, arrhythmias, and cardiac cellular electrophysiology of the European Society of Cardiology
DO - 10.1093/europace/euag127
UR - https://europepmc.org/article/MED/42905911
AB - Pulsed-field ablation (PFA) has rapidly emerged as an important energy source for atrial fibrillation ablation, offering tissue selectivity and procedural efficiency while introducing specific anaesthetic and sedation requirements. This narrative review examines the rationale for anaesthesia and sedation during PFA, the mechanisms underlying pain, involuntary movement, and neuromuscular stimulation, and the implications of catheter design, waveform characteristics, and patient-related factors for peri-procedural management. Available evidence indicates that both deep sedation and general anaesthesia can provide safe and effective procedural conditions when supported by appropriate monitoring, airway rescue capability, and experienced multidisciplinary teams. Deep sedation may offer advantages in workflow, recovery, and patient-centred care, particularly for standard pulmonary vein isolation procedures using contemporary biphasic systems with reduced muscle activation, whereas general anaesthesia remains appropriate for complex procedures, patients with substantial comorbidity, or settings in which complete immobility and airway control are essential. Current real-world practice is highly heterogeneous across regions and institutions, reflecting differences in regulations, staffing models, procedural complexity, and local expertise rather than a universally accepted standard. Overall, anaesthetic strategy in PFA should be individualised according to patient risk profile, expected procedural demands, and device-specific stimulation burden. Further prospective comparative studies are needed to define optimal sedation depth, standardise monitoring and outcome measures, and clarify how emerging technologies may enable lighter yet still effective sedation pathways.
SN - 1099-5129
SN - 1532-2092
ER -