Efficacy and safety of conscious/deep sedation versus general anesthesia in pulsed field ablation for atrial fibrillation: a systematic review and meta-analysis

Background Pulsed field ablation (PFA) has emerged as a promising therapy for atrial fibrillation. While general anesthesia (GA) is the standard to ensure catheter stability, using conscious or deep sedation (CS/DS) to streamline workflows is gaining interest. However, whether CS/DS provides comparable safety and efficacy to GA remains controversial and has lacked systematic evaluation. Objectives To compare the clinical efficacy and safety of PFA for atrial fibrillation under GA vs. CS/DS. Methods A literature search was conducted in PubMed, Cochrane Library, and Embase from inception to April 9, 2026. Studies were selected using predefined inclusion and exclusion criteria. The comparison of GA and CS/DS during PFA focused on the following clinical outcomes: procedural time, left atrial dwell time, fluoroscopy time, pulmonary vein isolation (PVI) success rate, and adverse event incidence. Heterogeneity was assessed with the I² statistic and Cochran's Q test; sensitivity analysis was performed if heterogeneity was high. Publication bias was evaluated using funnel plots and Egger's test. Results Ten studies involving 3,692 atrial fibrillation patients were included. Compared to GA, CS/DS significantly shortened overall procedural time (WMD: −7.73 min, random-effects; 95% CI: −14.17 to −1.29; P = 0.019). However, there were no significant differences between the groups in left atrial dwell time (WMD: −2.59 min, random-effects; 95% CI: −9.74 to 4.57), fluoroscopy time (WMD: −2.52 min, random-effects; 95% CI: −5.31 to 0.28), acute PVI success (RR: 1.00, fixed-effects; 95% CI: 0.98 to 1.03), or major adverse events (RR: 1.57, fixed-effects; 95% CI: 0.81 to 3.05). CS/DS showed a borderline trend toward fewer minor adverse events (RR: 0.61, fixed-effects; 95% CI: 0.37 to 1.01; P = 0.053). Conclusion In PFA for AF, CS/DS was associated with reduced overall procedural time compared with GA, while maintaining comparable acute PVI success rates and safety profiles. However, large-scale randomized controlled trials are still needed to confirm these findings. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/view/CRD420251165071 , identifier (CRD420251165071).