Conscious sedation with cardiologist-managed midazolam, fentanyl and ketamine during pulsed field ablation: comparison with anesthesiologist-administered propofol
C Martignani, A Spadotto, M Ziacchi, A Angeletti, G Massaro, L Bartoli, M BiffiAbstract
Background
Deep sedation with propofol ensures patient immobility during AF ablation but frequently induces hypotension and requires anesthesiologist supervision. Conscious sedation combining midazolam, fentanyl, and ketamine, managed by the electrophysiology team, may provide a practical, hemodynamically stable, and resource-efficient alternative for high-volume centers performing pulsed field ablation (PFA).
Methods
We prospectively included 238 consecutive patients undergoing PFA under cardiologist-managed conscious sedation using titrated doses of midazolam (median 3 mg), fentanyl (0.1 mg), and ketamine (0.25–0.5 mg/kg). A comparison group of 50 patients received anesthesiologist-administered propofol sedation. Hemodynamic stability, oxygen saturation, procedure duration, and patient comfort were recorded. Adverse events and need for anesthesiologic intervention were assessed. All patients were monitored continuously and recovered under direct supervision in the electrophysiology suite.
Results
All procedures were successfully completed without conversion to general anesthesia. Mean arterial pressure remained stable in the cardiologist-managed group (ΔMAP −4 ± 7 mmHg) but fell significantly with propofol (ΔMAP −18 ± 10 mmHg, p<0.001). No relevant desaturation or airway intervention occurred in either group. Mean procedure time was shorter under conscious sedation (59 ± 12 vs 77 ± 13 minutes, p<0.001), mainly due to the absence of hypotension-related interruptions. Comfort scores were excellent in both groups (92% vs 95%, ns). No major complications, delayed recovery, or procedure cancellations occurred.
Conclusion
Cardiologist-managed conscious sedation with midazolam, fentanyl, and ketamine ensures safety, comfort, and superior hemodynamic stability compared with anesthesiologist-administered propofol. This protocol allows full procedural control by the electrophysiology team, minimizes hypotension-related delays, and optimizes workflow efficiency in modern AF ablation practice.