1st year Electrophysiology Fellow UT Houston, Texas Houston, Texas, United States
Disclosure(s):
Kirtivardhan Vashistha, MD: No financial relationships to disclose
Background: Atrial fibrillation can precipitate cardiogenic shock in advanced cardiomyopathy. Catheter ablation improves outcomes in heart failure populations (CASTLE-AF), may benefit end-stage disease awaiting advanced therapies (CASTLE-HTx); however, its role in active shock is unclear. This case demonstrates feasibility of pulse field ablation in critically ill patients on mechanical circulatory support.
Methods: A 76-year-old woman with vascular comorbidities presented with acute decompensated heart failure and AF with RVR. Evaluation revealed severe biventricular dysfunction and progressive cardiogenic shock with a cardiac index of 1.3 L/min/m², prompting placement of an Impella CP device. Despite intravenous antiarrhythmic therapy and multiple transesophageal echocardiography–guided cardioversion attempts, AF persisted with ongoing hemodynamic compromise. Brief ventricular arrhythmias occurred following pharmacologic rhythm control attempts and were rapidly stabilized. Given refractory AF and continued shock physiology, urgent catheter ablation was pursued. Using the FARAPULSE PFA system with EnSite X electroanatomic mapping, pulmonary vein isolation and adjunctive left atrial substrate modification were successfully performed while on Impella support. Patient converted to sinus rhythm while delivering lesions in the left atrium. Intermittent electromagnetic interference related to the Impella was observed but did not preclude effective mapping or ablation. An atypical atrial flutter was induced on electrophysiologic testing and it was mapped to the Perimitral area. This rhythm was successfully terminated into normal sinus rhythm while creating an anterior mitral line with the PFA catheter. Durable pulmonary vein isolation, posterior wall and mitral line block was confirmed on remapping.
Outcome: Following ablation, the patient maintained stable sinus rhythm with significant hemodynamic improvement, allowing Impella explantation and discontinuation of temporary pacing. She was transitioned to oral antiarrhythmic therapy and discharged in stable condition to rehabilitation.
Conclusion: This case demonstrates that PFA-guided AF ablation is a feasible bailout strategy in cardiogenic shock due to refractory AF, even with temporary MCS. Building on CASTLE-AF and CASTLE-HTx, it supports expanding role for rhythm control in advanced heart failure patients, with PFA’s rapid, safe lesion delivery advantageous in high-risk populations.
