Incidence of cough reflex and vagal response among various pulsed field ablation systems: a multicenter registry study

Background and aims: Cough reflex and vagal reflex–induced bradycardia are important to predict and prevent prior to PFA to ensure procedural safety and efficacy. However, no studies have yet investigated differences in their incidence among the various PFA systems. We aimed to evaluate the incidence, predictors, and system-specific differences of cough reflex and vagal response during PFA in a large multicenter cohort. Methods: Data from 1715 patients undergoing PFA using either PulseSelect, Farapulse, or Varipulse systems at 13 centers were analyzed. Cough reflex was defined as any episode requiring procedure interruption or physical restraint, while a vagal response was defined as sinus arrest or atrioventricular block lasting ≥ 5 s. Results: Pulmonary vein isolation was achieved in all patients except for one case. Complications were rare and did not differ significantly among the PFA systems. Cough reflex occurred in 49.3% of patients, most frequently in the left superior pulmonary vein. Compared with Farapulse, the risk of cough reflex was higher with PulseSelect (odds ratio [OR] 1.648, 95% confidence interval [CI] 1.321–2.057) and Varipulse (OR 1.645, 95% CI 1.019–2.657). Patient-related factors such as male sex, asthma, heart failure, and hypertension increased the risk, whereas general anesthesia significantly reduced it (OR 0.236, 95% CI 0.174–0.318). Vagal response occurred in 15.2% of patients, with no significant differences among the PFA systems, and the sequence of pulmonary vein isolation did not affect its occurrence. Prophylactic atropine reduced the risk of vagal response. Conclusion: Cough reflex may vary across PFA systems, while vagal response may remain consistent.