Feasibility and safety of etomidate based deep sedation protocol for pulsed field electroporation in atrial fibrillation ablation

Abstract Background Pulsed field electroporation represents an emerging ablation modality for the treatment of atrial fibrillation. Unlike thermal techniques, it necessitates the use of deep sedation. Propofol is frequently administered as the primary sedative agent; however, it is associated with a risk of significant hypotension and respiratory depression. Etomidate constitutes a potential alternative that may facilitate the performance of these procedures while minimizing such adverse effects. Purpose To evaluate the feasibility and safety of atrial fibrillation ablation procedures using pulsed field ablation with etomidate as the primary agent for deep sedation. Methods This retrospective, single-center observational study included patients with paroxysmal or persistent atrial fibrillation who underwent catheter ablation using pulsed field electroporation between December 2024 and October 2025 at our University Hospital. All ablations were performed with a pentaspline catheter and deep sedation was achieved with combination of midazolam, fentanyl, and etomidate. Feasibility was defined as successful completion of the planned lesion set—pulmonary vein isolation alone or in combination with additional posterior wall or superior vena cava ablation—using etomidate without propofol. Results A total of 132 patients were included (mean age 64.0 ± 9.2 years; 61.4% male), with paroxysmal and persistent AF (49.2% vs. 50.8%, p=0.602), preserved left ventricular ejection fraction (55.9 ± 10.7%), and enlarged left atrium (LAVI 43.7 ± 10.0 ml/m²). The mean procedure duration was 53.6 ± 18.5 minutes, and the mean fluoroscopy time was 11.2 ± 4.7 minutes. Pulmonary vein isolation was successful in all patients (100%), and posterior wall ablation was performed in 56.8% and SVC isolation in 41.7% of patients. Etomidate was administered in all procedures (mean dose 24.6 ± 7.0 mg) for deep sedation, with no use of propofol. Following ablation, flumazenil (mean dose 3.0 ± 1.8 ml) was administered to ensure prompt awakening. No cases of respiratory depression requiring assisted ventilation or hypotension requiring vasopressors occurred. Two postprocedural complications were observed: one aspiration pneumonia and one case of pulmonary edema, as detailed in Table 1. Conclusions Etomidate is effective for deep sedation in pulsed field ablation procedures for atrial fibrillation, demonstrating both feasibility and a favorable safety profile.Procedural characteristics