General anesthesia/deep sedation versus conscious sedation for atrial fibrillation ablation outcomes: a systematic review and meta-analysis

Introduction: Catheter ablation is a widely utilized treatment for symptomatic atrial fibrillation (AF), performed under general anesthesia (GA), deep sedation (DS), or conscious sedation (CS). However, the optimal anesthetic strategy remains controversial. Methods: We systematically searched PubMed, clinicaltrials.gov, Web of Science, Cochrane Library, and Embase databases for relevant studies. The primary outcome was defined as AF recurrence after catheter ablation, with secondary outcomes including procedural parameters (procedure time, ablation time, fluoroscopy time), acute procedural success rates, and complication rates. Mediation analysis was performed to explore electrophysiological mechanisms. Results: A total of 17 studies involving 12 484 patients demonstrated that GA or DS significantly reduced AF recurrence after ablation compared with CS [risk ratio (RR) 0.86, 95% confidence interval (CI), 0.82–0.91; very low certainty of evidence]. The reduction in AF recurrence with GA and DS was consistent across AF subtypes and long-term follow-up duration. While ablation time was slightly shorter with GA and DS, procedure time, fluoroscopy time, complications, and acute success rates were similar between groups. Mediation analysis further indicated that the benefit of GA is mediated by reduced pulmonary vein (PV) reconnection and dormant conduction. Conclusion: GA is recommended for radiofrequency ablation to improve long-term success, supported by its mechanistic benefits. While current evidence does not support DS as an equivalent alternative to GA for radiofrequency ablation, anesthetic strategy for cryoballoon ablation can be individualized.