# A case report of cardiogenic shock due to tachycardic atrial fibrillation: a life-saving catheter ablation for atrial fibrillation and prone position during veno-arterial extracorporeal membrane oxygenation

## TL;DR

A 71-year-old man with severe heart failure and pneumonia was successfully treated with catheter ablation and prone positioning during VA-ECMO.

## Contribution

Demonstrates the effectiveness of catheter ablation and prone positioning in VA-ECMO for tachycardia-induced cardiomyopathy.

## Key findings

- Prone positioning during VA-ECMO improved respiratory status without causing complications.
- Radiofrequency catheter ablation successfully converted tachycardic AF to sinus rhythm.
- LVEF improved from 20% to 55% after treatment.

## Abstract

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is vital for acute cardio-respiratory failure, but challenges persist sometimes in weaning. Prone positioning, beneficial in veno-venous extracorporeal oxygenation (VV-ECMO), is generally avoided in VA-ECMO patients because of the risks such as bleeding from the catheter insertion site and dislodging of the perfusion cannula or tracheal tube.

A 71-year-old male with paroxysmal atrial fibrillation (AF) presented with dyspnoea. Chest computed tomography (CT) and echocardiogram revealed severe pneumonia and decreased cardiac function [left ventricular ejection fraction (LVEF) 20%]. The patient was diagnosed with heart failure complicated by severe pneumonia. Despite treatment, respiratory and circulatory status deteriorated, necessitating a VA-ECMO. Chest CT showed collapsed lungs, especially on the dorsal side. Thus, prone positioning was initiated under VA-ECMO with attention to potential complications associated with the postural change. Then, his respiratory status was improved dramatically. However, the haemodynamic status could not be probably because of tachycardic AF. Electrical cardioversions failed to maintain sinus rhythm, and heart rate was not adequately controlled. We decided to perform radiofrequency catheter ablation of tachycardic AF under VA-ECMO. Pulmonary vein isolation and conduction block line in the cavo-tricuspid isthmus were made and converted to sinus rhythm, enabling weaning of VA-ECMO. The primary cause of the heart failure was considered to be tachycardia-induced cardiomyopathy, as the LVEF improved to 55%.

Radiofrequency catheter ablation for AF can be effective even in case of cardio-respiratory failure necessitating VA-ECMO. Furthermore, prone positioning can be performed not only in VV-ECMO but also in VA-ECMO.