LAA Occluder device impeding PFA ablation of an anterior mitral line: a case report about the role of a dual energy source

Background Pulsed field ablation and percutaneous closure of the left atrial appendage are increasingly used in patients with atrial fibrillation. Interaction between this form of energy and metallic structures in the heart are an emerging problem. We first report a LAAC limiting PFA using a novel dual energy ablation catheter, solved by switching for the classic radiofrequency ablation. Case summary An 85-year-old woman with HFpEF and a history of persistent atrial fibrillation (status post PVI 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 pulsed-field ablation (PFA) lesion toward the LAAC, the generator repeatedly aborted applications due to invalid impedance values near the device—despite the device having been in place for three years. Switching to radiofrequency energy on the same catheter allowed the line to be completed successfully, achieving bidirectional block and tachycardia non-inducibility. Discussion Interaction between PFA and metallic cardiac devices may limit catheter ablation, problem that can be solved by technologies that allow to switch for radiofrequency sources. Dual energy technologies may be therefore preferred in patients with LAAC devices.