Severe Hemolysis After Moderate-Dose Pulsed Field Application (48 Pulses) for Atrial Fibrillation/Flutter

BACKGROUND: Pulsed field ablation (PFA) has gained popularity for its cardiac selectivity; however, its hemolysis safety profiles are not well understood. CASE SUMMARY: A 69-year-old, African-American man underwent atrial fibrillation/flutter ablation with moderate-dose PFA (48 pulses) and developed significant near-dialysis oliguric acute kidney injury (AKI), requiring a prolonged hospital stay. DISCUSSION: Previous studies have noted an increased risk of hemolysis and AKI with higher PFA lesions, with 70 to 100 pulses being the historical thresholds. This case highlights that hemolysis and AKI could occur with much lower doses than previously considered safe. Universal preventive measures with empirical hydration and extended observation periods post-ablation (overnight stay) could be considered. Genetic factors that could possibly put African Americans at increased risk for hemolysis need to be explored. TAKE-HOME MESSAGES: Hemolysis can occur with any number of pulses with PFA. Pre-existing chronic kidney disease could be a risk factor for developing AKI.