Background <p>The safety and tolerability of early invasive therapies for rapid atrial fibrillation in patients with cardiogenic shock is yet to be established.</p> Method <p>This retrospective study reviewed patients with diagnosis of atrial fibrillation and cardiogenic shock during the same hospital admission between 2019 and 2024. These patients were dependent on inotropes and/or mechanical circulatory support and received PVI or AVJ ablation with CRT implantation during the index hospitalization. Outcomes measured were procedural complications, post-procedural heart failure or Afib hospitalization, continued inotrope and/or mechanical circulatory dependence, mortality, and change in ejection fraction.</p> Results <p>Of 54 patients reviewed, 16 met the study criteria. At baseline, 94% (15/16) of patients were on inotropes for management of cardiogenic shock while 44% (7/16) were on mechanical circulatory support. There were minimal adverse events associated with invasive management of atrial fibrillation. There was a trend towards reduced dependence on inotropes and mechanical support post-procedure. There was a significant increase in ejection fraction from a baseline of 20% pre-procedure to an average of 36% post-procedure, with an increase in EF recorded in 80% of patients. There was one re-admission for heart failure and no re-admissions for atrial fibrillation at 6 months post-procedure.</p> Conclusion <p>Our study shows that among patients with atrial fibrillation and cardiogenic shock, invasive therapy with pulmonary vein isolation or AV node ablation and CRT implantation is safe and may be associated with improved survival, reduced need for continued hemodynamic support, reduced hospital readmission, and improvement in left ventricular ejection fraction.</p> Graphical Abstract <p></p>