A comparison of feasibility and safety of three propofol sedation strategies for pulsed field ablation for atrial fibrillation

Abstract Background Pulsed field ablation (PFA) is an emerging ablation modality for atrial fibrillation (AF) ablation. However, the treatment is painful and adequate sedation of patients during treatment is imperative. Purpose Our aim was to compare feasibility and safety of deep sedation (DS) administrated by electrophysiology (EP) staff, DS administrated by an anaesthesia nurse, and general anaesthesia (GA) during PFA for AF ablation. Methods In this multi-center study that included all Danish electrophysiology (EP) centers performing PFA, we reviewed consecutive procedural data from 1106 patients undergoing first-time catheter ablation for AF with PFA technique from July 2021 – January 2024. In addition to PVI, 47 (4%) patients had a cavotricuspid isthmus block (CTIB) and 61 (6%) patients had posterior wall isolation. DS was defined as sedation without assisted ventilation. EP-led DS (EP-DS) was defined as sedation with propofol and fentanyl administrated by EP staff. Anaesthesia-led DS (AN-DS) was defined as sedation with propofol, midazolam and remifentanil administrated by anaesthesia nurse. Patients in the GA group were endotracheal intubated and monitored by anaesthesia staff. Sedation strategy was selected according to the guidelines of each EP center. Analysis of variance (ANOVA) was used to assess statistical differences. A p-value 0.05 was considered statistically significant. Results Of 1106 patients, 500 (45%) patients underwent EP-DS (age 63 ±10 yrs, 62% male, BMI 27±4 kg/m2, procedure time 53±16 min), 172 (16%) patients underwent AN-DS (age 62 ±10 yrs, 71% male, 27±12 kg/m2, procedure time 52±25 min), and 434 (39%) patients underwent GA (age 63 ±11 yrs, 55% male, BMI 27±5 kg/m2, procedure time 62 ±25 min). Overall, sedation complications were few (figure 1) and no procedures were abandoned due to adverse effects of sedation. In the EP-DS group the anaesthesiologist (AN) was unexpectedly called for back-up in 1 (0.2%) patient due to hypotension during the procedure, however, the procedure was completed in DS. In the AN-DS group the anaesthesiologist was called due to desaturation in 1 patient (0.6%), however, intubation was not necessary. One patient was unplanned intubated due to tamponade (0.6%). In the GA group, no peri-procedural sedation complications occurred. One patient (0.2%) had haemoptysis after GA due to a scratch in the trachea verified by an otorhinolaryngologist. Overall, 1 patient (GA group) had right-sided phrenic nerve paralysis that spontaneously remitted. Post-procedural, 5 (1%) patients in EP-DS group, 3 (2%) patients in AN-DS group and 15 (3%) patients in the GA group were treated with antibiotics for pneumonia within 30 days after the procedure (p=0.03). Conclusion Our study demonstrates that deep sedation administrated by EP staff or anaesthesia nurse during PFA for AF is feasible and safe as compared to GA.Peri-procedural complications during PFA