Vagal Response and Cough Reflex During Atrial Fibrillation Ablation Under Deep Sedation: A Comparison Across Pulsed Field Ablation Systems

Background Pulsed field ablation (PFA) is increasingly used for atrial fibrillation (AF), but device‐specific autonomic and respiratory reflex responses remain insufficiently characterized. We aimed to compare vagal responses and cough reflexes among three commercially available PFA systems across individual pulmonary veins and the posterior wall. Methods This retrospective single‐center study included 200 consecutive patients who underwent AF ablation with FARAPULSE ( n = 83), PULSESELECT ( n = 83), or VARIPULSE ( n = 34). Vagal response was operationally defined as bradyarrhythmia requiring temporary back‐up pacing during energy delivery. Cough reflex was assessed intraprocedurally at the left superior pulmonary vein (LSPV), left inferior pulmonary vein (LIPV), right superior pulmonary vein (RSPV), right inferior pulmonary vein (RIPV), and posterior wall. Results Baseline characteristics were generally similar among groups, although heart failure and diabetes mellitus (DM) differed significantly. Overall vagal response rates did not differ among FARAPULSE, PULSESELECT, and VARIPULSE (61.4%, 67.5%, and 58.8%, respectively; p = 0.596). In contrast, overall cough reflex rates differed significantly (75.9%, 91.6%, and 55.9%; p < 0.001), driven by consistently higher rates with PULSESELECT. On logistic regression, male sex, body mass index, and use of PULSESELECT versus FARAPULSE were independently associated with cough reflex. Conclusions Cough reflex was most frequent with PULSESELECT, whereas no significant difference in vagal response was observed among platforms. Recognizing these differences may improve procedural planning, sedation strategy, and prophylactic management during PFA.