Pulmonary vein isolation as the fifth column of heart failure therapy: a case report

Background: Heart failure (HF) and atrial fibrillation often coexist and exacerbate each other, creating a therapeutic challenge when both are present. This case presents a patient with suspected tachycardia-induced cardiomyopathy (TIC) progressing to cardiogenic shock, managed with guideline-directed medical therapy (GDMT) for HF and pulmonary vein isolation (PVI) as an additional therapeutic pillar. Case summary: atrial fibrillation and TIC leading to cardiogenic shock. As rhythm control was initially unsuccessful, mechanical circulatory support was required despite GDMT. A thorough diagnostic work-up was performed, excluding coronary artery disease and structural heart diseases as underlying HF causes, making TIC the most likely diagnosis. After rhythm stabilization was achieved, haemodynamic stabilization followed subsequently. Later on, the patient underwent successful PVI. At the 12-month follow-up, no AF recurrence occurred, and the patient presented with HF with improved ejection fraction. Conclusion: Treatment of HF with GDMT should be performed simultaneously and harmonized with rhythm and rate control. This case highlights the role of early rhythm control and the potential of left ventricular ejection fraction improvement after PVI in patients with TIC.