Monitored Anesthesia Care without Endotracheal Intubation and General Anesthesia in Pulsed Field Atrial Fibrillation Ablation

Background Pulsed field ablation for atrial fibrillation offers shorter procedural times and improved safety compared with thermal ablation, but the optimal anesthesia strategy remains uncertain. Most centers in the United States use general anesthesia with endotracheal intubation, whereas monitored anesthesia care without endotracheal intubation may be a safe and efficient alternative. Objectives To compare procedural efficiency and safety between monitored anesthesia care and general anesthesia for pulsed field ablation. Methods Consecutive adults who underwent pulsed field ablation for atrial fibrillation between 2024 and 2025 at Marshfield Clinic Health System were included. The anesthesia approach was determined by operator preference. Procedural times, medication use, complications, and patient tolerance were recorded prospectively. Results Among 200 patients, 100 received monitored anesthesia care without endotracheal intubation and 100 received general anesthesia. The mean age was 67 years, 42 percent were female, and the mean body mass index was 33 kilograms per square meter. Monitored anesthesia care shortened case duration (77 vs 95 minutes; p < 0.001) and laboratory time (118 vs 153 minutes; p = 0.002) and required fewer adjunct medications (p < 0.001). Twenty-five procedures (25 percent) were challenging due to cough or motion but were all completed safely. Complications occurred in one monitored anesthesia care case and six general anesthesia cases (p = 0.054). Pulmonary vein isolation was achieved in all patients. Conclusions Monitored anesthesia care without endotracheal intubation was safe, efficient, and resource-sparing compared with general anesthesia for pulsed field atrial fibrillation ablation.