Pulsed-field ablation (PFA) offers myocardial selectivity and reduced procedural time compared with thermal ablation, but its adoption can be limited by the need for deep sedation or general anesthesia. The 2025 European Society of Cardiology (ESC) guidelines highlight the importance of optimizing sedation strategies to maintain safety and procedural efficiency.

A single-center retrospective study evaluated 58 consecutive patients (mean age 61 years; 81% men) who underwent atrial fibrillation ablation with PFA in 2024 using a ketamine-based sedation protocol. Sedation was managed directly by electrophysiologists with trained nurses and no active anesthesiologic support. Pain perception, anxiety, and procedural comfort were assessed up to 24 hours post-procedure, along with patient, nurse, and physician satisfaction. Safety outcomes included respiratory depression and hemodynamic instability.

All patients reported satisfactory pain control; only 7% described mild discomfort. Overall satisfaction exceeded 90/100 in 97% of patients, and all medical staff rated the protocol highly. Transient respiratory depression occurred in 9% of patients and was managed with airway maneuvers and supplemental oxygen, while transient hemodynamic effects occurred in 26% and resolved with fluids or ephedrine. No major complications occurred, and anesthesiologic intervention was unnecessary.

These findings suggest that ketamine-based sedation under spontaneous respiration can be safely implemented by electrophysiologists, offering an effective and resource-efficient approach to facilitate broader clinical adoption of pulsed-field ablation for atrial fibrillation.