Introduction
Catheter ablation is an increasingly used procedure to treat atrial fibrillation (AF)1. Recently, a novel non-thermal ablation modality, Pulse Field Ablation (PFA), has been introduced in clinical practice2,3. During PFA, electrical pulses are applied to the myocardium, inducing a destabilization of the cell membrane, and then leading to the formation of nanoscale pores that culminate in cell death; this phenomenon is called electroporation2,3. PFA is a cardio-selective ablation modality that avoids thermal source-related complications2-5.
AF is responsible for about a quarter of ischemic strokes1, and closure of the left atrial appendage (LAA) is an alternative non-pharmacologic anti-thrombotic strategy in patients who have contraindications to oral anticoagulants (OACs) or patients with thrombo-embolic events, despite adequate OAC after other plausible causes (e.g. carotid disease) have been excluded6-9.
The prophylactic use of cerebral protection systems to prevent ischemic stroke has been evaluated in patients undergoing transcatheter aortic valve replacement10. As of today, we are lacking data concerning the use of cerebral protection systems in patients undergoing catheter ablation of AF; however, a clinical trial is underway (NCT04685317). We present for the first time in Europe the case of a patient with persistent AF with multiple recurrences of ischemic stroke despite adequate therapy with OACs, who underwent transcatheter ablation by PFA (FARAPULSE™ PFA System, Boston Scientific) combined with simultaneous WATCHMAN FLXTM (Boston Scientific, Marlborough, MA) implant and prophylactic use of a cerebral protection system (SENTINELTM, Boston Scientific, Santa Rosa, CA).