Monitored anesthesia care versus general anesthesia for balloon-in-basket pulsed-field ablation of atrial fibrillation: an age-matched analysis of procedural timing and acute procedural outcomes

Abstract Background General anesthesia (GA) has been the preferred sedation strategy for atrial fibrillation (AF) catheter ablation in the United States, in part because pulsed-field ablation (PFA) systems cause skeletal muscle stimulation and discomfort that can be poorly tolerated under lighter sedation. A recently introduced balloon-in-basket (BiB) PFA system (VOLT) has been reported to produce less muscle stimulation and pain, potentially allowing Monitored Anesthesia Care (MAC) instead of GA. Whether MAC offers procedural efficiency advantages without compromising ablation efficacy in this context has not been well characterized. Objective To compare procedural timing, ablation efficacy, and safety between MAC and GA in patients undergoing BiB PFA (VOLT) for AF, using an age-matched design. Methods We retrospectively analyzed 39 consecutive MAC cases and a pool of 83 GA cases undergoing VOLT BiB PFA from a two-site electrophysiology registry. Each MAC patient was matched 1:1 to the nearest age available GA patient yielding 39 age-matched controls. Six different time intervals were collected: total room time, pre-procedure setup time, core procedure time, post-procedure turnover time, transseptal-to-left atrial (LA) sheath-out (dwell) time, and ablation catheter dwell time. Total ablation lesions delivered, acute procedural success (isolation of all four pulmonary veins), and procedural complications were also compared. Group comparisons were then made. In addition, EP laboratory facility cost savings and scheduling opportunity cost associated with the observed difference in total room time, using published EP/procedural-suite per-minute cost estimates were also determined. Results Total room time (103.5 ± 20.0 vs. 126.2 ± 33.1 min; p = 0.0004), pre-procedure setup time (33.4 ± 10.0 vs. 50.3 ± 28.0 min; p = 0.0007), and post-procedure turnover time (14.8 ± 9.3 vs. 21.4 ± 8.3 min; p = 0.0030) were significantly shorter with MAC. Core procedure time (55.3 ± 20.5 vs. 55.3 ± 23.9 min), transseptal-to-LA-sheath-out time (34.2 ± 12.9 vs. 35.7 ± 18.5 min) did not differ significantly between groups (both p ≥ 0.62). Ablation catheter dwell time was modestly longer with MAC (27.7 ± 11.9 vs. 24.2 ± 15.5 min; p = 0.036). Total ablation lesions delivered (17.6 ± 5.1 vs. 18.8 ± 7.2, p = 0.68) and acute procedural success (39/39 [100%] vs. 39/39 [100%]) were similar between MAC and GA, with no procedural complications in either group. One MAC case (2.6%) was converted to general anesthesia interprocedurally for coughing attributed to airway secretions. Applying published EP/procedural-suite per-minute cost estimates ($29–$60/minute) to the observed 22.7-min reduction in total room time, MAC was associated with an estimated $658–$1,362 in facility cost savings per case, with potential opportunity cost benefit for additional case scheduling. Conclusion In an age-matched cohort undergoing BiB PFA (VOLT) for AF, MAC was associated with shorter total room time, pre-procedure setup time, and post-procedure turnover time than GA, with no difference in ablation lesion delivery, acute success, or complications. Anesthesia related time savings with MAC appear concentrated in room logistics rather than the ablation procedure itself, with no detectable difference in acute procedural outcomes in this small cohort, supporting MAC as a reasonable alternative to GA for BiB PFA.