A case report of simultaneous His pacemaker implantation and atrioventricular junction ablation following unsuccessful treatment of atrial fibrillation

Abstract

Background: Atrial fibrillation can contribute to heart failure. Frequently, rhythm control is unachievable. Atrioventricular (AV) junction ablation and pacemaker implantation remain to be a therapeutic option for rate control in atrial fibrillation. Interventricular asynchrony is a potential downside of right ventricular pacing. However, cardiac resynchronization therapy and His pacing restore physiological activation sequences of the ventricles.

Case summary: The reported patient had undergone several interventions to cure atrial fibrillation without sufficient rhythm control and experienced deleterious effects of recurrent arrhythmias. Finally, we decided to ablate the AV junction simultaneously with the implantation of a His bundle pacemaker. Atrioventricular junction ablation had to be repeated following conduction recurrence. A left-sided transaortic approach was required to create a permanent effect and to avoid distal lesions. His pacing was not affected by the AV junction ablation at all. The pre-existing widened QRS was normalized by His pacing, the patient became free of any complaints with full restoration of exertion capability.

Discussion: His pacing has the potential to contribute to a revival of the 'ablate-and-pace' concept for incurable atrial fibrillation by restoring physiological ventricular activation, thereby overcoming the particular drawbacks of continuous ventricular pacing. Atrioventricular junction ablation simultaneously with the pacemaker implantation procedure is safe and feasible. His pacing is at least an alternative for cardiac resynchronization therapy. The implantation procedure is sometimes challenging.

Keywords: AV junction ablation; Ablate-and-pace; Atrial fibrillation; Case report; His pacing.

Figure 1

Twelve-lead electrocardiogram; atrial flutter with 2:1 atrioventricular conduction, heart rate 120/min, and QRS widening with right precordial positivity. Calibrating rectangle: 200 ms, 1 mV (50 mm/s. sweep).

Figure 2

Twelve-lead electrocardiogram; sinus rhythm, narrow QRS complex with non-selective His bundle pacing. Calibrating rectangle: 200 ms, 1 mV (50 mm/s. sweep).

Figure 3

Fluoroscopy of atrioventricular junction ablation with right atrial (A), right ventricular (V), and His electrode (H) in place. C, ablation catheter tip.

Figure 4

Echocardiographic strain rate imaging of left ventricular regional wall movement demonstrates resynchronization with His bundle pacing.