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BACKGROUND: Atrial fibrillation (AF) can be associated with acute heart failure (HF) and can complicate cardiogenic shock. The interaction between AF and HF is challenging, both diagnostically and therapeutically. While AF ablation has been shown to be beneficial in patients with HF, the role of interventional treatment of AF in acute HF remains largely unexplored.CASE SUMMARY: A 59-year-old male patient was admitted from an outside hospital after a prolonged intensive care stay developing acute respiratory failure with concomitant acute HF. Previously, the patient experienced a cardiogenic shock after a non-synchronized cardioversion that induced ventricular fibrillation at the end of an AF ablation procedure. After initial improvement, he was transferred to a rehabilitation hospital where he showed signs of respiratory failure and HF. Upon transfer to our hospital, a veno-arterial-venous extracorporeal membrane oxygenation (VAV-ECMO) device was implanted in addition to diuretic and inotropic therapy. While the respiratory function steadily improved, allowing de-escalation to a VV-ECMO device, recurrent episodes of AF with rapid ventricular rate were observed. This resulted in a severely reduced biventricular function despite antiarrhythmic therapy with amiodarone. We opted for pulsed field ablation (PFA) of the pulmonary veins, which finally enabled us to explant the ECMO system under sustained sinus rhythm and improved haemodynamics. An echocardiographic assessment 3 weeks post-ablation demonstrated improved cardiac function and maintained sinus rhythm.DISCUSSION: This case illustrates the complexities of treating patients with acute HF and AF. Our experience highlights the value of the fast, efficient, and safe PFA modality for ablation in critically ill patients.