Comparative analysis of anaesthesia modalities in pulmonary vein isolation: insights from a prospective multicentre registry

Abstract

Aims: Atrial fibrillation (AF), the most common sustained arrhythmia in adults, is increasing in prevalence globally. Catheter ablation (CA), particularly pulmonary vein isolation (PVI), is a key treatment option. Pulmonary vein isolation can be performed using different energy sources, including cryoballoon ablation (CBA), radiofrequency ablation (RFA), or pulse field ablation. Anaesthesia modalities for these procedures include general anaesthesia (GA), deep sedation (DS), and conscious sedation (CS). However, the optimal anaesthesia modality remains unclear, as previous studies have shown mixed outcomes. This study aims to compare the safety and efficacy of different anaesthesia modalities in PVI.

Methods and results: This prospective, multicentre study, based on the Israeli Catheter Ablation Registry, evaluated the impact of different anaesthesia modalities on procedural outcomes and safety in AF ablation. Data from 1002 patients who underwent PVI between January 2019 and December 2021 across 14 centres were analysed. Patients were stratified by anaesthesia modality-CS vs. GA, with the latter encompassing DS. Key outcomes, including AF recurrence, procedural complications, and success rates, were evaluated over a 24-month follow-up period. Additionally, a sensitivity analysis was performed for the subgroup of patients who underwent CBA. Of the 1002 patients, 53% received GA, 6.3% DS, and 40% CS, with CBA used in 84% of cases. Complete PVI was achieved in 91% of patients, with comparable success rates observed between CS and GA groups. No significant differences were found between CS and GA modalities in terms of AF recurrence rates at 12 months (15% vs. 16%) and 24 months (19.5% vs. 21.2%), or in 12-month rehospitalization rates (19.8% vs. 16.5%). Sensitivity analysis of the CBA subgroup yielded similar results, with no significant differences in AF recurrence, complications, or procedural duration between CS and GA modalities.

Conclusion: Conscious sedation is as safe and effective as general anaesthesia in AF ablation, particularly with cryoablation. The choice of anaesthesia appears to be driven by patient characteristics and institutional factors without affecting long-term outcomes such as AF recurrence or complication rates.

Keywords: AF recurrence; Conscious sedation; Cryoballoon ablation; General anaesthesia; Pulmonary vein isolation; Radiofrequency ablation.

Graphical Abstract

Figure 1

One-year cumulative risk incidence of atrial fibrillation recurrence stratified by anaesthesia modality. Kaplan–Meier survival curves depicting the 1-year cumulative risk of AF recurrence following PVI, stratified by anaesthesia modality. The upper curve represents general anaesthesia/deep sedation (GA/DS), while the lower curve shows conscious sedation (CS). The HR comparing GA to CS is 1.08 (95% CI: 0.78–1.49), with a P-value of 0.63, indicating no statistically significant difference in the risk of AF recurrence between the two groups. The lower panel shows the number of patients at risk over time for each group.

Figure 2

Subgroup analysis using multivariable cox proportional hazards model. Forest plot demonstrating the association between anaesthesia modality and AF recurrence for the entire cohort and separately for the subgroups: female sex, CBA, persistent AF, high-volume centre, and moderate-to-severe LA enlargement. The x-axis depicts HR with 95% CIs, while the y-axis represents the anaesthesia type across various subgroups. The analysis was adjusted for age, female sex, clinical HF, chronic obstructive pulmonary disease, prior CVA, LVEF, sPAP, AF duration, centre volume, and energy source. AF, atrial fibrillation; CVA, cerebrovascular accident; HR, hazard ratio; LA, left atrial; LVEF, left ventricular ejection fraction; sPAP, systolic pulmonary artery pressure.