Pulsed field ablation for persistent atrial fibrillation with atrioventricular reentrant tachycardia under tubeless general anesthesia: a case report

Abstract

Background

Radiofrequency ablation (RFA) 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 AF 4 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 AF. LAAC was then completed as planned. Electrocardiogram (ECG) showed sinus rhythm, and echocardiography demonstrated improved cardiac remodeling at 3-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 an AVRT occurrence during PFA for AF and provides significant evidence that PFA is effective and safe for accessory pathway ablation during AF ablation.

Highlight box.

Key findings

• Pulsed field ablation (PFA) is an effective and safe alternative to radiofrequency ablation (RFA) for accessory pathway ablation during atrial fibrillation (AF) ablation.

• Adopting tubeless anesthesia in cardiovascular interventional surgery, patients may reduce their postoperative discomfort and achieve improved prognostic outcomes.

What is known and what is new?

• PFA has emerged as an effective and safe alternative for treating AF or atrioventricular reentrant tachycardia (AVRT).

• PFA is an alternative to RFA for accessory pathway ablation during AF ablation. Tubeless anesthesia in cardiovascular interventional surgery reduces their postoperative discomfort.

What is the implication, and what should change now?

• PFA is an effective and safe alternative for treating AF comorbid with AVRT. Tubeless anesthesia could be widely adopted in cardiovascular interventional surgery.

Introduction

Atrioventricular reentrant tachycardia (AVRT) is the most common tachyarrhythmia associated with pre-excitation syndrome, resulting from impulse conduction through an accessory pathway outside the normal atrioventricular conduction system. Radiofrequency ablation (RFA) has been widely used in the treatment of AF and AVRT. With advances in selectively targeting cardiac tissue, pulsed field ablation (PFA) has emerged as an effective and safe alternative for treating atrial fibrillation (AF) or AVRT (1,2). However, limited evidence exists regarding the efficacy and safety of PFA in patients with AF comorbid with AVRT (3). This case report presents a rare instance of PFA performed on persistent AF and AVRT, combined with left atrial appendage closure (LAAC), under a newly developed non-intubated general anesthesia technique that avoids intraoperative intubation and simplifies procedural steps (4). Our report provides valuable insights into alternative procedures for AF comorbid with AVRT, demonstrating the safety and effectiveness of PFA for AVRT during AF ablation and highlighting the efficiency and comfort of tubeless anesthesia. We present this article in accordance with the CARE reporting checklist (available at https://acr.amegroups.com/article/view/10.21037/acr-2026-0122/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

A 36-year-old male patient presented to The First Affiliated Hospital of Guangzhou Medical University on February 18, 2025, with complaints of recurrent chest tightness and palpitations lasting over 10 years, which had worsened and recurred one week prior. He was diagnosed 4 months ago at a hospital in Shanghai with dilated cardiomyopathy and AF and had a previous history of cerebral infarction. His medication regimen included dapagliflozin, sacubitril/valsartan, vericiguat, edoxaban, and metoprolol succinate sustained-release tablets. The cardiac physical examination revealed an irregular heart rhythm with varying intensity of the first heart sound. Cardiac ultrasound showed left atrial (LA) enlargement (anteroposterior diameter: 42 mm), abnormal left ventricular wall motion, and reduced left ventricular ejection fraction (EF: 37%). Moderate mitral and tricuspid regurgitation were also observed. A 12-lead electrocardiogram (ECG) indicated AF rhythm. A 24-hour Holter monitor detected one episode of AF lasting 1,407 minutes. His CHA₂DS₂-VASc score is 3 and HAS-BLED score is 1. He was unwilling to take long-term oral anticoagulants and strongly desired LAAC. Therefore, a combined PFA and LAAC procedure was planned.

The procedure was performed under tubeless general anesthesia, which means that no tracheal intubation or other artificial airway devices were used during the surgery. Instead, laryngeal mask anesthesia was employed to effectively maintain the patient's respiratory function while minimizing stimulation and damage to the airway. Following femoral venous puncture, a transseptal puncture was conducted under intracardiac echocardiography (ICE) guidance. No ST-segment elevation was observed in leads II, III, or aVF during the puncture. LA and pulmonary vein angiograms revealed no anatomical variations, confirming the anatomy of the pulmonary vein antrum. An adjustable PFA sheath was exchanged, flushed, and then inserted. Under fluoroscopic guidance, standard pulmonary vein isolation (PVI) was performed with 32 applications applied at the ostia and antrum of the superior and inferior pulmonary veins, as well as the roof and posterior wall—two applications per site, each lasting 2.5 seconds, at a voltage of ±2,000 V (Figure 1A,1B). During ablation at the roof of the right superior pulmonary vein, the intracardiac electrogram showed that AF converted to sinus rhythm, followed by spontaneous tachycardia ventriculoatrial (ventriculoatrial conduction at a 1:1 ration, earliest A wave in CS1-2, with AV fusion on CS1-2) (Figure 1C). A left-sided accessory pathway near CS1-2 was suspected, prompting ablation of the pathway and the mitral isthmus with three applications per site, each lasting 2.5 seconds, at a voltage of ±2,000 V (Figure 1D,1E). During the ablation of the mitral valve isthmus, nitroglycerin was administered, and it was observed that the ST segment remained unchanged. Verification confirmed ventriculoatrial dissociation and successful mitral isthmus block. A total of 78 applications were delivered. Repeated atrial high-rate stimulation did not induce atrial flutter or fibrillation, indicating successful ablation.

Figure 1.

Angiography during the operation. (A) The catheter is advanced into a basket configuration at the ostium of the pulmonary vein. (B) The catheter is positioned in a flower-like configuration anterior to the pulmonary vein. (C) The intracavitary electrocardiogram demonstrates atrioventricular reentrant tachycardia, with the earliest atrial activity observed at CS1-2 and atrioventricular fusion present on CS1-2. (D,E) The catheter is positioned in a flower-like configuration during ablation of the mitral isthmus. (F) LAA angiography reveals a chicken-wing morphology characterized by a small superior pouch, distal bilobation, and limited internal space. LAA, left atrial appendage.

The LAAC procedure proceeded as planned. The sheath was exchanged for a Boston Scientific LAA occluder delivery sheath. A pigtail catheter was advanced for LAA angiography (Figure 1F). The appendage was chicken-wing shaped, with an ostium diameter of 26.5 mm, a depth of 24 mm, a small superior pouch, and distal bilobation with limited internal space. A 31-mm WATCHMAN FLX device (Boston Scientific, USA) was selected, advanced to the LAA body, and deployed to form a FLX BALL. It was then positioned distally, and the sheath was withdrawn to fully deploy the device. ICE confirmed device positioning at the ostium, with minimal inferior shoulder exposure (less than one-third of the device length). A tug test demonstrated stable positioning with no residual flow, meeting PASS criteria. The device was released. Postoperative ECG showed normal sinus rhythm (Figure 2A-2C presents the preoperative ECG), and no discomfort or adverse events were reported. The patient was discharged four days after the procedure and was placed on oral edoxaban and amiodarone.

Figure 2.

Electrocardiogram. (A) The intracavitary electrocardiogram confirmed that no tachycardia was induced after multiple attempts at burst pacing. (B) Postoperative surface electrocardiogram demonstrated the restoration of sinus rhythm. (C) Preoperative surface electrocardiogram: atrial fibrillation.

At the 3-month follow-up, cardiac ultrasound showed a reduced left atrial anteroposterior diameter (Figure 3A), an increased left ventricular EF (Figure 3B), reduced mitral regurgitation (Figure 3C), and reduced tricuspid regurgitation (Figure 3D). Twenty-four-hour Holter monitoring confirmed sinus rhythm. LAA CT demonstrated complete endothelialization of the occluder with no residual flow (Figure 4), confirming the efficacy and safety of PFA for AF. Therefore, edoxaban was discontinued at the 3-month follow-up.

Figure 3.

Results of echocardiography before the operation and at the three-month follow-up. (A) Preoperative LA anteroposterior diameter: 42 mm (left); LA anteroposterior diameter at 3-month follow-up: 38 mm (right). (B) Preoperative left ventricular ejection fraction: 43% (left); left ventricular ejection fraction at 3-month follow-up: 64% (right). (C) Preoperative mitral regurgitation area: 4.91 cm2 (left); mitral regurgitation area at 3-month follow-up: 1.50 cm2 (right). (D) Preoperative tricuspid regurgitation area: 4.96 cm2 (left); tricuspid regurgitation area at 3-month follow-up: 0.50 cm2 (right). LA, left atrial.

Figure 4.

Re-examination of the LAA CT after 3 months showed complete endothelialization of the occluder with no residual flow. CT, computed tomography; LAA, left atrial appendage.

Discussion

In this case, the patient had a previous cerebral infarction, with a CHA₂DS₂-VASc score (stroke risk score for patients with non-valvular AF) of 3 and a HAS-BLED score of 1. Although the patient did not meet the criteria for high bleeding risk (HAS-BLED score ≥2) (5), he was unwilling to take oral anticoagulants long-term due to poor compliance and strongly desired LAAC. Therefore, the one-stop PFA combined with LAAC strategy was selected. Following eight standard applications of energy delivery to a single pulmonary vein during the procedure, we expanded the antral ablation area by performing clockwise rotation, counterclockwise rotation, deflecting and straightening the catheter. Additional ablation was often applied to the carina region, anterior-posterior overlap areas, the interpulmonary region, and the right superior antral area to improve long-term isolation success. During ablation at the roof of the right superior pulmonary vein, the patient developed spontaneous AVRT. EGM showed ventriculoatrial conduction at a 1:1 ratio, with the earliest A wave recorded at CS1-2 and atrioventricular fusion at CS1-2. A left-sided accessory pathway near CS1-2, consistent with the mitral isthmus pathway, was suspected. Ablation was performed in a petal-shaped pattern along the mitral isthmus. Post-ablation electrophysiological assessment confirmed successfully ablation of the left accessory pathway and repeated burst pacing failed to induce tachycardia. Patients with manifest accessory pathways (mAPs) have a higher propensity for AF compared to those with concealed accessory pathways (cAPs) (6). Previous studies have demonstrated outstanding efficacy and safety of PFA for either AF (7) or AVRT (3). Nevertheless, there have been no prior reports or studies evaluating the efficacy and safety of PFA for both AF and AVRT simultaneously. Therefore, our current case report provides valuable evidence that PFA is an effective and safe alternative to RFA for accessory pathway ablation during AF ablation.

Furthermore, this case has provided us with valuable experience. The patient underwent multiple dynamic ECG examinations both at our hospital and other facilities prior to surgery, and all results consistently showed AF without any electrocardiographic evidence of supraventricular tachycardia caused by an accessory pathway. Under these circumstances, AF ablation is typically performed first. Diagnostic electrophysiological studies are not routinely conducted before ablation. However, when AF occurs in a young patient without many risk factors, cardiovascular specialists should consider the possibility of an abnormal triggering pathway, which serves as a cautionary indicator in making an accurate diagnosis.

Additionally, the tubeless general anesthetic technique employed in this case is also noteworthy. With the trend toward minimally invasive cardiovascular interventions, the choice of anesthesia has an increasingly significant impact on the quality of postoperative recovery (8). Although traditional endotracheal intubation during general anesthesia ensures airway security, it can cause airway injury, hemodynamic fluctuations, and delayed recovery. The tubeless anesthetic technique, which preserves spontaneous respiration without endotracheal intubation, is an innovative approach that has demonstrated notable advantages in thoracic surgeries (e.g., thoracoscopic lung resection), including reduced airway trauma, shorter wake-up times, and fewer postoperative complications (9,10), based on the low-resistance ventilation mechanism. This case highlights the key implementation aspects and clinical value of the tubeless technique in cardiovascular interventions, confirming its safety and efficacy in selected procedures. With broader adoption of tubeless anesthesia in cardiovascular interventional surgery, patients may reduce their postoperative discomfort and achieve improved prognostic outcomes.

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. In addition, tubeless anesthesia in cardiovascular interventional surgery effectively reduces their postoperative discomfort, which could be widely adopted in cardiovascular interventional surgery.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.