Sedation and anaesthesia in pulsed-field ablation for atrial fibrillation: mechanisms, procedural requirements, and real-world practice

Pulsed-field ablation (PFA) has rapidly emerged as an important energy source for atrial fibrillation ablation, offering tissue selectivity and procedural efficiency while introducing specific anaesthetic and sedation requirements. This narrative review examines the rationale for anaesthesia and sedation during PFA, the mechanisms underlying pain, involuntary movement, and neuromuscular stimulation, and the implications of catheter design, waveform characteristics, and patient-related factors for peri-procedural management. Available evidence indicates that both deep sedation and general anaesthesia can provide safe and effective procedural conditions when supported by appropriate monitoring, airway rescue capability, and experienced multidisciplinary teams. Deep sedation may offer advantages in workflow, recovery, and patient-centred care, particularly for standard pulmonary vein isolation procedures using contemporary biphasic systems with reduced muscle activation, whereas general anaesthesia remains appropriate for complex procedures, patients with substantial comorbidity, or settings in which complete immobility and airway control are essential. Current real-world practice is highly heterogeneous across regions and institutions, reflecting differences in regulations, staffing models, procedural complexity, and local expertise rather than a universally accepted standard. Overall, anaesthetic strategy in PFA should be individualised according to patient risk profile, expected procedural demands, and device-specific stimulation burden. Further prospective comparative studies are needed to define optimal sedation depth, standardise monitoring and outcome measures, and clarify how emerging technologies may enable lighter yet still effective sedation pathways.