High‐risk catheter ablation of refractory atrial fibrillation using Impella CP in a patient with cardiogenic shock

Abstract

Background: Impella CP support during Posterior Vein Isolation/Posterior Wall Isolation (PVI/PWI) in the setting of persistent cardiogenic shock from refractory atrial fibrillation with rapid ventricular response (AF/RVR), has not been reported in the literature to the best of our knowledge. Case: A 61-year-old male truck driver was admitted with acute HFrEF with AF/RVR 130-150. His EF was 20% with global hypokinesis. He was diuresed and cardioverted to sinus rhythm and had QTc of 532. He reverted to AF/RVR in less than 24 hours, requiring amiodarone drip. Shortly, amiodarone was discontinued because of intense anorexia, nausea, and vomiting. Class III and Class 1c agents were contraindicated due to prolonged QTc and cardiomyopathy. He developed cardiogenic shock, worsening cardiorenal syndrome, and shock liver requiring continuous renal replacement therapy (CRRT). Inotropes and vasopressors were contraindicated. AVN ablation was refused because he wanted to return to truck driving. EF dropped to 10%, and moderate RV dysfunction ensued. Right heart catheterization showed PASP 53, PADP 38, and PCWP 37 with RAP 28mmHg. Coronary angiogram was normal. An Impella device was inserted, and support was set to P6 with 3.4 L/min cardiac output. PVI with cryoablation, PWI, and anterior mitral isthmus ablation was successful. The adequacy of isolation was verified by demonstrating a complete exit block 30 mins after ablation. Normal sinus rhythm was restored after cardioversion. Echo 48 hours later revealed improvement in EF from 10% to 40% in sinus rhythm. Impella and CRRT were weaned. He was discharged on GDMT. Conclusion: There are no recommendations regarding PVI for AF/RVR on mechanical circulatory support (MCS). MCS assisted PVI/PWI may be the only resort to restore hemodynamic stability in cases where a pacemaker is not desirable. PVI/PWI is a lengthy procedure; the use of the Impella support for PVI/PWI in cardiogenic shock allows adequate time for exit block testing and PWI. The operator can do thorough mapping and ablation, knowing that the patient is receiving adjustable support based on hemodynamic demands. We had a good outcome; nevertheless, the potential pitfalls are unknown.