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. 2025 Oct;68(7):1487-1495.
doi: 10.1007/s10840-025-02038-3. Epub 2025 Apr 7.

Long-term outcomes of pace-and-ablate strategy in patients with atrial fibrillation

Johan van Koll  1 , Madelon D E A Engels  1   2 , Jesse H J Rijks  1 , Madelon Salari  2 , Jelle Luijten  2 , Joost Lumens  3 , Vanessa P M van Empel  1 , Sjoerd W Westra  2 , Antonius M W van Stipdonk  1 , Theo A R Lankveld  1 , Sevasti M Chaldoupi  1 , Jacqueline Joza  4 , Rypko J Beukema  2 , Justin G L M Luermans  1 , Dominik K Linz  1 , Kevin Vernooy  5
Affiliations

Long-term outcomes of pace-and-ablate strategy in patients with atrial fibrillation

Johan van Koll et al. J Interv Card Electrophysiol. 2025 Oct.

Abstract

Background: The pace-and-ablate strategy is second -line therapy to obtain rate control in patients with persistent symptomatic atrial fibrillation (AF) when other treatment options fail. This study aims to evaluate long-term effects on clinical outcomes following pace-and-ablate strategy in AF patients.

Methods: This retrospective study includes patients who underwent successful pacemaker implantation (right ventricular pacing (RVP) or cardiac re-synchronization therapy (CRT)) followed by atrioventricular node ablation (AVNA) between 2010 and 2020. Patients were treated according to the prevailing guidelines. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization (HFH). Secondary endpoints were individual outcomes of all-cause mortality, HFH, and left-ventricular ejection fraction (LVEF) change.

Results: Two hundred ninety-eight patients were included, 162 undergoing RVP, and 136 receiving CRT, with a median follow-up of 5.8 years [4.1-8.0]. The primary endpoint occured in 47% of the RVP group and 49% of the CRT group (p = 0.206). All-cause mortality occurred in 36% of the RVP group and in 45% of the CRT group (p = 0.005). HFH occurred in 22% of the RVP group and in 15% of the CRT group (p = 0.328), with 17(10%) upgrades to CRT in the RVP group. Median LVEF in the RVP group remained stable (56% [49-60] to 53% [43-57]; p = 0.081), while it improved in the CRT group (31% [22-38] to 43% [32-51]; p < 0.001).

Conclusion: Mortality and HFH in patients with AF managed through a pace-and-ablate strategy are high. Reassuringly, LVEF deterioration requiring upgrade to CRT is uncommon in patients undergoing RVP with normal baseline LVEF before AVNA. CRT improves LVEF in patients with reduced LVEF before AVNA.

Keywords: Atrial fibrillation; Atrioventricular node ablation; Cardiac resynchronization therapy; Heart failure; Right ventricular pacing; Survival analysis.

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Conflict of interest statement

Declarations. Competing interests: J.v.K., M.E., J.R., M.S., S.W., A.S., T.L., R.B., D.L..: no conflicts to disclose; Jo.L. has a consultancy agreement with Medtronic (fees paid to institute); Jo.L. has received research grants from Medtronic (grants paid to institute); V.v.E. receives consultancy fees from Novartis, Janssen, Boehringer Ingelheim, Novonordisk (paid to institute) and received sponsoring/grants from Roche, Vifor Pharma, Boehringer Ingelheim, Astra Zeneca and Pfizer (paid to institute and not related to submitted work); J.J. has a research grant from Medtronic, consultant for Boston Scientific, Abbott, Medtronic; S.C. has a research grant and consultancy agreement with Biosense webster (paid to the institute). J.L. has a consultancy agreement and research grant from Medtronic, consultant for Abbott (all paid to the institute). KV: has research and educational grants and consultancy agreements with Medtronic, Abbott, Boston scientific, Philips and Biosense webster (all grants are paid to the institute).

Figures

Fig. 1
Fig. 1
A Kaplan–Meier survival curve of time to primary endpoint in total study population. B Kaplan–Meier survival curve of time to primary endpoint in patients with right ventricular pacing and cardiac resynchronization therapy. CRT, cardiac resynchronization therapy; HFH, heart failure hospitalization; RVP, right ventricular pacing
Fig. 2
Fig. 2
A Kaplan–Meier survival curve of time to all-cause mortality in total study population. B Kaplan–Meier survival curve of time to heart failure hospitalization in total study population. C Kaplan–Meier survival curve of time to all-cause mortality for patients with right ventricular pacing and cardiac resynchronization therapy. D Kaplan–Meier survival curve of time to heart failure hospitalization for patients with RVP or CRT. CRT, cardiac resynchronization therapy; HFH, heart failure hospitalization; RVP, right ventricular pacing
Fig. 3
Fig. 3
Echocardiography–Median left ventricular ejection fraction (%) with interquartile ranges at baseline and at follow-up in right ventricular pacing group and cardiac resynchronization therapy group. CRT, cardiac resynchronization therapy; FU, follow-up; LVEF, left ventricular ejection fraction; RVP, right ventricular pacing. The asterisk “*” indicates significant difference (p < 0.05)
See this image and copyright information in PMC

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