Remifentanil-Based Conscious Sedation for Pulsed Field Ablation of Atrial Fibrillation

Background Pulsed field ablation (PFA) has emerged as an effective and safe technology for pulmonary vein isolation (PVI) in patients with atrial fibrillation (AF). However, procedure-related skeletal muscle activation has led many centers to favor deep sedation or general anesthesia. Data on conscious sedation during PFA remain limited. Objective To compare the feasibility, tolerability, and procedural characteristics of a standardized conscious-sedation protocol during PVI using PFA or cryoballoon ablation (CBA). Methods We analyzed 200 consecutive patients undergoing first-time PVI for symptomatic AF, including 100 treated with PFA using the FARAPULSE/FARAWAVE system and 100 with CBA. All procedures were performed using an intended conscious-sedation strategy with continuous remifentanil infusion, low-dose midazolam, and intermittent propofol boluses. Procedural characteristics, sedation requirements, patient-reported outcomes, and in-hospital safety events were prospectively evaluated. Results Remifentanil requirements were modestly higher during PFA (0.058±0.04 vs. 0.037±0.02 μg/kg/min; P<0.001), whereas propofol requirements were comparable between groups (0.6±0.6 vs. 0.6±0.35 mg/kg; P=0.20). Despite higher remifentanil requirements, pain scores, procedural recall, and hemodynamic parameters were comparable between groups, whereas satisfaction with sedation was nominally higher with PFA. No patient required airway intervention, vasoactive medication, or conversion to general anesthesia. Procedure duration was shorter with PFA than with CBA (63±23 vs. 73±21 min; P<0.001). Conclusion PFA using the FARAPULSE/FARAWAVE system can be performed safely and effectively using the same remifentanil-based conscious-sedation workflow as CBA. Although PFA was associated with modestly higher analgesic requirements, hypnotic exposure remained low and comparable between groups, while patient-reported outcomes, procedural tolerance, safety, and procedural efficiency remained favorable.