https://doi.org/10.1007/s00392-024-02526-y
1Universitätsklinikum Hamburg-Eppendorf Universitäres Herzzentrum Hamburg, Deutschland; 2Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie mit Schwerpunkt Elektrophysiologie Hamburg, Deutschland; 3Universitätsklinikum Hamburg-Eppendorf Klinik für Intensivmedizin Hamburg, Deutschland; 4Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland
Background:
Atrial fibrillation (AF) is known to be associated and complicate acute heart failure (HF) and cardiogenic shock. The complex interaction between both diseases can complicate clinical treatment, since both conditions can cause aggravation of one another. Mechanical circulatory support (MCS) is often used to treat patients in cardiogenic shock, however the role of rhythm control when AF is present is unclear.
The case:
A 59-year-old male patient was admitted for radiofrequency ablation to persistent atrial fibrillation in an outside hospital. During the final cardioversion, part of the radiofrequency ablation procedure, the patient experienced ventricular fibrillation, necessitating immediate resuscitation. After a prolonged stay in the intensive care unit (ICU), the patient was transferred to another facility for rehabilitation but developed pneumogenic sepsis with worsening respiratory symptoms indicative of acute respiratory distress syndrome (ARDS) soon after.
After transfer to our hospital, we observed a combined cardiogenic shock with severe lung disease which necessitated the implantation of veno-arterial-venous extracorporeal membrane oxygenation (ECMO).
Upon admission, the patient presented with AF and rapid ventricular rate (RVR) while on ECMO, significantly reduced ejection fraction, paradoxical septal movement, and a dilated right ventricle. The patient also had peripheral edema and a high oxygen demand. To address this, we initiated a high-dose diuretic therapy with furosemide and an inotropic therapy with levosimendan.
However, AF with RVR persisted, so an antiarrhythmic therapy with intravenous amiodarone was established. This led to a conversion to a sinus rhythm and improvement of HF symptoms. The ejection fraction improved to approximately 40-45%, allowing a reduction in ECMO flow rates and oxygen requirement on both ECMO and the ventilator, leading to the explanation of the arterial cannula.
Shortly after, we observed recurrent episodes of AF with AVR, despite amiodarone, which led to reduced left and right ventricular contractile function and increased oxygen demand under veno-venous ECMO. Given the limited options for optimization beyond antiarrhythmic therapy, we decided to pursue an AF ablation. Due to the critical hemodynamic situation, we opted for a Pulsed-Field-Ablation (PFA) of the pulmonary veins to keep procedural times as short as possible. Using the Farapulse system, we were able to perform re-isolation of right-sided pulmonary veins. No complications during and after the procedure were observed. After the PFA ablation, the patient continued to exhibit sinus rhythm, and left ventricular contractile function improved, allowing for explanation of the VV-ECMO system. An echocardiographic assessment three weeks post-ablation demonstrated improved cardiac function and maintained sinus rhythm.
Discussion:
Arrhythmia-induced cardiomyopathy is an underrepresented entity of non-ischemic cardiomyopathy with HF. This case illustrates the complexities of treating patients with acute HF and AF, including the challenging weaning process from MCS. Our experience highlights the importance of the fast, efficient and safe PFA energy source for ablation in critically ill patients.