Pulsed Field Ablation for Persistent Atrial Fibrillation with Atrioventricular Reentrant Tachycardia Under Tubeless General Anesthesia: A Case Report

Background: Radiofrequency ablation combined with left atrial appendage closure (LAAC) has long been used in the treatment of atrial fibrillation (AF). Pulsed field ablation (PFA) is now increasingly adopted due to its great precision and improved safety profile. This report presents a rare case of PFA performed for persistent AF and atrioventricular reentrant tachycardia (AVRT), along with LAAC, under non-intubated general anesthesia.

Case description: A 36-year-old male patient presented with a 10-year history of recurrent chest tightness and palpitations, which had worsened during the week prior to admission. He was diagnosed with dilated cardiomyopathy and atrial fibrillation four months ago and had a previous cerebral infarction, with a CHA₂DS₂-VASc score of 3 and a HAS-BLED score of 1. A one-stop procedure combining PFA and LAAC was planned. During ablation at the roof of the right superior pulmonary vein, AF converted to sinus rhythm and subsequently developed spontaneous tachycardia, suspected to be AVRT due to a left-sided accessory pathway near CS1-2. Therefore, ablation of the accessory pathway and mitral isthmus was performed, and atrioventricular separation and mitral isthmus block were confirmed. A total of 78 discharges were delivered throughout the procedure, and repeated high-frequency atrial stimulation did not induce atrial flutter or atrial fibrillation. LAAC was then completed as planned. Electrocardiogram (ECG) showed sinus rhythm, and echocardiography demonstrated improved cardiac remodeling at three-month follow-up.

Conclusions: AVRT is a type of supraventricular tachycardia caused by the presence of an accessory pathway due to congenital structural abnormalities. Our case reports a AVRT occurrence during PFA for AF and provides significant evidence that PFA is effective and safe for accessory pathway ablation during AF ablation.