Multi-Domain Symptom Resolution Following Pulsed Field Ablation in Arrhythmogenic Right Ventricular Cardiomyopathy

Background. Chronic high-burden cardiac arrhythmia is associated with neurocognitive and psychological sequelae independent of overt stroke. Proposed mechanisms include altered cerebral perfusion and sustained autonomic and allostatic stress. Psychological stress can itself destabilize ventricular electrophysiology in susceptible patients, and arrhythmogenic right ventricular cardiomyopathy (ARVC) can show marked catecholamine sensitivity, suggesting a potentially bidirectional heart–brain interaction. The inner ear and vestibular apparatus, supplied by the labyrinthine artery, a functional end-artery, may be similarly vulnerable to hemodynamic disturbance. These mechanisms have generally been studied in isolation. Case presentation. A man with ARVC experienced a decade of progressive multi-arrhythmia disease, including medication-refractory premature ventricular contractions, sustained ventricular tachycardia with appropriate ICD shocks, and paroxysmal atrial fibrillation. Seven electrophysiology procedures were undertaken between August 2017 and December 2024: five completed catheter ablations, one procedure aborted before ablation, and one diagnostic study at which an ICD was implanted. His history before the arrhythmia included major physical trauma in 2002, about a year of post-injury opioid addiction with withdrawal, and depression treated with psychiatric medication from age eighteen; an early diagnosis of bipolar disorder was later left open to question. During the arrhythmia decade he developed a progressive multi-domain symptom cluster: brain fog, impaired long-term memory encoding, executive dysfunction, emotional dysregulation, worsening depression and anxiety, constant high-pitched tinnitus with aural fullness, intermittent vertigo, cardiac hypervigilance, and social withdrawal, all while maintaining high-achieving professional performance. On December 9, 2024, the seventh procedure, an off-label pulsed field ablation of the ventricular substrate, reduced total arrhythmia burden from approximately 11% to less than 0.1% of beats. Tinnitus stopped within days; aural fullness and cognitive, affective, vestibular, and hypervigilance symptoms resolved or improved markedly within weeks. The same weeks also brought discontinuation of the prior cardiac medication regimen, a change of job, and residential treatment for alcohol and cannabis use. In follow-up, isolated arrhythmias returned within the year, and the patient has had three collapses and a prolonged supraventricular tachycardia. Conclusion. The near-simultaneous resolution of cognitive, affective, auditory, vestibular, and hypervigilance symptoms after a rhythm-restoring intervention is consistent with, though it cannot prove, a dominant cardiac maintaining driver operating through hemodynamic perturbation and interruption of a bidirectional cardioneural amplification loop. Concurrent changes in medication, work, and substance use mean the procedure's share of the recovery cannot be isolated. This case does not establish that psychological stress caused ARVC or accelerated structural progression. It supports prospective multi-domain measurement of autonomic, psychological, cognitive, auditory, and vestibular outcomes before and after rhythm-restoring interventions, and a cost-utility evaluation of earlier intervention that counts those outcomes alongside arrhythmia burden.