LAA occluder device impeding pulsed field ablation of an anterior mitral line: a case report about the role of a dual energy source.

BACKGROUND: Pulsed field ablation (PFA) and percutaneous closure of the left atrial appendage are increasingly used in patients with atrial fibrillation. An interaction between this form of energy and metallic structures in the heart is an emerging problem. We first report a left atrial appendage closure (LAAC)-limiting PFA using a novel dual energy ablation catheter, solved by switching to the classic radiofrequency ablation.

CASE SUMMARY: An 85-year-old woman with heart failure with preserved ejection fraction and a history of persistent atrial fibrillation (status post pulmonary vein isolation in 2019, with a 25 mm Abbott Amulet LAAC implanted in 2023) presented with recurrent atrial tachycardia. During redo ablation, mapping revealed a macroreentrant circuit through an anterior left atrial low-voltage area. While extending a linear PFA lesion towards the LAAC, the generator repeatedly aborted applications due to invalid impedance values near the device-despite the device having been in place for 3 years. Switching to radiofrequency energy on the same catheter allowed the line to be completed successfully, achieving bidirectional block and tachycardia non-inducibility.

DISCUSSION: The interaction between PFA and metallic cardiac devices may limit catheter ablation, a problem that can be solved by technologies that allow for the switch to radiofrequency sources. Dual energy technologies may be therefore preferred in patients with LAAC devices.