Pulsed field ablation of refractory alternating atrial fibrillation and atrial flutter using Impella CP in a patient with cardiogenic shock: a case report.

Background: Supraventricular tachycardia (SVT) can lead to cardiogenic shock, particularly in patients with severely impaired left ventricular function. Acute management typically includes electrical cardioversion combined with antiarrhythmic drugs to restore sinus rhythm. In cases of therapy-resistant SVT, atrioventricular nodal ablation may be considered, although this results in permanent pacemaker dependency. Definitive treatments, such as atrial fibrillation (AF) or atrial flutter (AFLUT) ablation, which could potentially avoid pacemaker implantation, are seldom pursued in such critical settings, despite advancements in therapeutic efficacy. Case summary: We present the case of a 79-year-old male with ischaemic cardiomyopathy and advanced heart failure, admitted with cardiogenic shock and regular narrow-complex tachycardia. Initial attempts at electrical cardioversion combined with pharmacological rhythm control provided only temporary success, followed by recurrent episodes of alternating AF and AFLUT. This prompted the decision to perform pulmonary vein isolation (PVI) and posterior wall isolation (PWI) using pulsed field ablation (PFA), supported by the Impella CP device for mechanical circulatory support. The procedure, guided by the CARTO 3 electroanatomic mapping system, successfully achieved PVI and PWI with restoration of sinus rhythm. Following the procedure, the patient's haemodynamics stabilized, and sinus rhythm was maintained, along with significant improvement in left ventricular function. Discussion: This case underscores the feasibility of PFA-assisted PVI and PWI with Impella CP in the management of acute AF/AFLUT-induced cardiogenic shock. It highlights the role of mechanical circulatory support in enabling successful SVT ablation in haemodynamically unstable patients, offering an alternative to atrioventricular node ablation in critical situations.