Reduced use of intravenous atropine in atrial fibrillation pulsed field ablation commencing from the right pulmonary veins

Background Pulsed field ablation (PFA) is a novel, non-thermal ablation modality that selectively targets myocardial tissue using electroporation, minimizing collateral injury to adjacent structures such as the oesophagus, phrenic nerve, and pulmonary veins. It has demonstrated high efficacy and safety in treating both paroxysmal and persistent atrial fibrillation (AF). However, vagal reflexes—manifesting as sinus bradycardia, atrioventricular block, or transient asystole—are frequently observed during energy delivery, particularly when ablation begins at the left pulmonary veins (LPV), which are anatomically closer to parasympathetic ganglia. To mitigate these responses, intravenous atropine is routinely administered prophylactically in LPV-first procedures. The need for atropine when ablation begins at the right pulmonary veins (RPV), where ganglionated plexi are less concentrated, remains uncertain. Objective This single-centre study aimed to evaluate the necessity of atropine in patients undergoing RPV-first PFA and to compare atropine use and procedural outcomes with previously reported LPV-first protocols. Methods We retrospectively analysed 410 consecutive PFA procedures performed between August 2023 and October 2025. Patients were grouped by ablation initiation site: LPV-first (all received atropine prophylactically) and RPV-first (atropine given only for significant vagal response). Baseline demographics, comorbidities, atropine use, and procedural parameters were reviewed and compared. Results Among the RPV-first cohort (n=98), only 15 patients (15.3%) required atropine due to vagal response, significantly lower than the 78% reported in LPV-first procedures. Patients not requiring atropine had higher prevalence of diabetes and dyslipidemia (p=0.036 and p=0.049, respectively), and experienced shorter procedure and fluoroscopy times (p=0.023 and p=0.014). No procedural complications or sustained conduction disturbances occurred. All patients achieved successful pulmonary vein isolation. Conclusion RPV-first PFA substantially reduces the need for atropine while maintaining procedural safety and efficiency. By avoiding unnecessary pharmacologic intervention, this approach streamlines workflow, minimizes vagal reflexes, and represents a safer and more efficient strategy for both paroxysmal and persistent AF ablation.