Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Case Reports
. 2020 Oct;43(10):1205-1209.
doi: 10.1111/pace.14037. Epub 2020 Sep 4.

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

Kofi Osei  1 , Tuncay Taskesen  1 , Troy Hounshell  1 , Jason Meyers  1
Affiliations
Case Reports

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

Kofi Osei et al. Pacing Clin Electrophysiol. 2020 Oct.

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.

Keywords: Impella; atrial fibrillation; cardiogenic shock; catheter-ablation.

PubMed Disclaimer

References

REFERENCES

    1. Sohinki D, Ho J, Srinivasan N, Collins LJ, Obel OA. Outcomes after atrioventricular node ablation and biventricular pacing in patients with refractory atrial fibrillation and heart failure: a comparison between non-ischaemic and ischaemic cardiomyopathy. Europace. 2014;16:880-886.
    1. Tanaka R, Spinale FG, Crawford FA, Zile MR. Effect of chronic supraventricular tachycardia on left ventricular function and structure in newborn pigs. J Am Coll Cardiol. 1992;20:1650-1660.
    1. Wilson JR, Douglas P, Hickey WF, et al. Experimental congestive heart failure produced by rapid ventricular pacing in the dog: cardiac effects. Circulation. 1987;75:857-867.
    1. Martin CA, Lambiase PD. Pathophysiology, diagnosis and treatment of tachycardiomyopathy. Heart. 2017;103:1543-1552.
    1. Ha J-W, Oh JK. Therapeutic strategies for diastolic dysfunction: a clinical perspective. J Cardiovasc Ultrasound. 2009;17:86-95.

Publication types