Anesthetic management for pulsed field ablation in a patient with Eisenmenger syndrome using general anesthesia with spontaneous ventilation: a case report

Abstract Background Drug-refractory atrial tachyarrhythmia is an important precipitating factor for recurrent heart failure decompensation in patients with Eisenmenger syndrome (ES). Although percutaneous pulsed field ablation (PFA) represents a potential therapeutic option for arrhythmia management, its application in this population is challenging due to the substantial anesthetic risks associated with severe pulmonary hypertension, right ventricular dysfunction, and profound hypoxemia. Case presentation We report the case of a 48-year-old male with ES and chronic heart failure who presented with recurrent, drug-refractory atrial flutter/fibrillation. Given concerns regarding hemodynamic deterioration during positive pressure ventilation, general anesthesia with spontaneous ventilation supported by a laryngeal mask airway was selected. The PFA was successfully completed without intraoperative hemodynamic instability. The patient was transferred to the ward with supplemental oxygen support. However, despite successful arrhythmia ablation and favorable intraprocedural physiology, he developed progressive heart failure and multiorgan dysfunction and died 20 days after the procedure. Conclusion The safe implementation of PFA relies on absolute immobility and stable hemodynamics. An anesthesia strategy utilizing general anesthesia with a laryngeal mask airway and spontaneous ventilation avoids the deleterious effects of positive intrathoracic pressure on right ventricular preload, allowing the PFA procedure to be completed with stable physiology and acute rhythm control.