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Review
. 2024 Dec 7;45(46):4887-4901.
doi: 10.1093/eurheartj/ehae656.

Atrioventricular node ablation for atrial fibrillation in the era of conduction system pacing

Jacqueline Joza  1 , Haran Burri  2 , Jason G Andrade  3 , Dominik Linz  4 , Kenneth A Ellenbogen  5 , Kevin Vernooy  4
Affiliations
Review

Atrioventricular node ablation for atrial fibrillation in the era of conduction system pacing

Jacqueline Joza et al. Eur Heart J. .

Abstract

Despite key advances in catheter-based treatments, the management of persistent atrial fibrillation (AF) remains a therapeutic challenge in a significant subset of patients. While success rates have improved with repeat AF ablation procedures and the concurrent use of antiarrhythmic drugs, the likelihood of maintaining sinus rhythm during long-term follow-up is still limited. Atrioventricular node ablation (AVNA) has returned as a valuable treatment option given the recent developments in cardiac pacing. With the advent of conduction system pacing, AVNA has seen a revival where pacing-induced cardiomyopathy after AVNA is felt to be overcome. This review will discuss the role of permanent pacemaker implantation and AVNA for AF management in this new era of conduction system pacing. Specifically, this review will discuss the haemodynamic consequences of AF and the mechanisms through which 'pace-and-ablate therapy' enhances outcomes, analyse historical and more recent literature across various pacing methods, and work to identify patient groups that may benefit from earlier implementation of this approach.

Keywords: Atrial fibrillation; Atrioventricular node ablation; Catheter ablation; Conduction system pacing.

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Figures

Graphical Abstract
Graphical Abstract
The mechanisms through which the pace-and-ablate strategy influences the hemodynamic effects of atrial fibrillation.
Figure 1
Figure 1
Radar plot indicating the overall risk of efficacy and safety endpoints from the different atrial fibrillation management strategies. It illustrates that with the exception of recurrences, pace-and-ablate strategy for atrial fibrillation has a good efficacy and safety profile. See permission letter from Professor Zeyi Cheng for Figure 1.
Figure 2
Figure 2
Pacing modalities in patients undergoing atrioventricular node ablation: right ventiricular pacing, his bundle pacing, left bundle branch pacing, and biventricular pacing. See permission letter from Professor Glikson Figure 2.
Figure 3
Figure 3
An illustration of a patient who developed polymorphic ventricular fibrillation 1 day after atrioventricular node ablation when the cardiac resynchronization therapy-D device was programmed to a lower rate of 55 b.p.m. post-atrioventricular node ablation. The patient suffered seven ICD shocks in the nights following atrioventricular node ablation
Figure 4
Figure 4
Patient selection factors influencing decision for a pace-and-ablate strategy
See this image and copyright information in PMC

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