Catheter ablation of atrial fibrillation on Impella support in a patient
with refractory cardiogenic shock due to tachycardia mediated
Background Impella support during Posterior Vein Isolation/Posterior
Wall Isolation (PVI/PWI) in the setting of persistent cardiogenic shock
due to refractory atrial fibrillation with rapid ventricular response
(AF/RVR), to the best of our knowledge, has not been reported in the
literature. Case A 61-year-old male trucker was admitted with acute
HFrEF with AF/RVR 130 – 150 bpm. EF was 20% with global hypokinesis.
He was diuresed and cardioverted to sinus rhythm and a QTc of 532 msec.
He reverted to AF/RVR in less than 24 hours and requiring amiodarone
drip but was discontinued due to severe intolerance. Subsequently, he
developed cardiogenic shock, worsening cardiorenal syndrome, and shock
liver requiring continuous renal replacement therapy (CRRT) in the CCU.
Inotropes and vasopressors were contraindicated. AV node ablation was
refused because he wanted to return to truck driving. Right heart
catheterization showed PASP 53, PADP 38, and PCWP 37 with RAP 28mmHg.
Coronary angiogram was normal. An Impella device was inserted, with P6
support at 3.4 L/min cardiac output. PVI with cryoablation, PWI, and
anterior mitral isthmus ablation was successful with RFA. There was a
complete exit block 30 mins after ablation. Normal sinus rhythm was
restored after cardioversion. Echocardiography 48 hours later revealed
improvement in EF from 10% to 40% in sinus rhythm. Follow up six
months in the clinic showed EF recovery to 62%. Conclusion This case
report demonstrates that in patients with refractory atrial fibrillation
causing cardiogenic shock, PVI/PWI, while on Impella support, could be a
good treatment option.