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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. [ABSTRACT FROM AUTHOR]

Introduction and objective: His bundle pacing (HBP) could replace failed biventricular pacing (BVP) in guidelines (IIa Indication), but the high capture thresholds and backup lead pacing requirements limit its development. We assessed the efficacy and safety of HBP combined with atrioventricular node ablation (AVNA) for atrial fibrillation (AF) and compared with BVP and left bundle branch pacing (LBBP). Methods: We reviewed PubMed, Embase, Web of Science, and Cochrane Library databases on left ventricular ejection fraction (LVEF), New York Heart Association (NYHA) score, QRS duration (QRSd), and pacing threshold. Results: Thirteen studies included 1115 patients (639 with HBP, 338 with BVP, and 221 with LBBP). Compared with baseline, HBP improved LVEF (mean difference [MD]: 9.24 [6.10, 12.37]; p < 0.01), reduced NYHA score (MD: −1.12 [−1.34, −0.91]; p < 0.01), increased QRSd (MD: 10.08 [4.45, 15.70]; p < 0.01), and rose pacing threshold (MD: 0.16 [0.05, 0.26]; p < 0.01). HBP had comparable efficacy to BVP and LBBP and lower QRSd (p < 0.05). HBP had a lower success rate (85.97%) and more complications (16.1%). Conclusion: HBP combined with AVNA is effective for AF, despite having a lower success rate and more complications. Further trials are required to determine whether HBP is superior to BVP and LBBP. [ABSTRACT FROM AUTHOR]

Background: Atrioventricular node ablation (AVNA) with permanent pacing is an effective treatment of symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) prevents cardiac dyssynchrony associated with right ventricular pacing and could prevent worsening of heart failure (HF). Methods: In this retrospective monocentric study, all patients who received AVNA procedure with LBBAP were consecutively included. AVNA procedure data, electrical and echocardiographic parameters at 6 months, and clinical outcomes at 1 year were studied and compared to a matched cohort of patients who received AVNA procedure with conventional pacing between 2010 and 2023. Results: Seventy-five AVNA procedures associated with LBBAP were studied. AVNA in this context was feasible, with a success rate of 98.7% at first ablation, and safe without any complications. There was no threshold rise at follow-up. At 1 year, 6 (8%) patients were hospitalized for HF and 2 (2.7%) were deceased. Patients had a significant improvement in NYHA class and left ventricular ejection fraction (LVEF) (P ≤ 0.0001). When compared to a matched cohort of patients with AVNA and conventional pacing, AVNA data and pacing complications rates were similar. Patients with LBBAP had a better improvement of LVEF (+5.27 ± 9.62% vs. −0.48 ± 14%, P = 0.01), and a lower 1-year rate of composite outcome of hospitalization for HF or death (HR 0.39, 95% CI: 0.16–0.95, P = 0.037), significant on survival analysis (log-rank P-value = 0.03). Conclusion: AVNA with LBBAP in patients with symptomatic AF is feasible, safe, and efficient. Hospitalization for HF or death rate was significantly lower and LVEF improvement was greater. [ABSTRACT FROM AUTHOR]

Background Cardiac interventions may be challenging in patients with congenital cardiac abnormalities. This case reports cardiac resynchronization therapy pacemaker (CRT-P) implantation and single catheter ablation of atrioventricular node (AVN) with remote magnetic navigation (RMN) via peripheral vascular access in a patient with Kartagener's syndrome and permanent atrial fibrillation (AF). Case summary A 74-year-old male with situs inversus presented for treatment of permanent AF and severe heart failure. In echocardiography, left ventricular ejection fraction was 30%, and there was severe dyskinesia due to a left bundle branch block. After successful CRT-P implantation, we performed AVN ablation because biventricular (BiV) pacing was <75% despite maximal rate control medication. The ablation catheter was inserted from the right basilic vein, and no other catheters were used. Despite peripheral vascular access, manipulation of the ablation catheter with RMN was easy, and the ablation was successful. After the ablation, BiV pacing instantly increased to 100%, and left ventricular function and symptomatic status improved gradually. Conclusions Cardiac resynchronization therapy pacemaker implantation and RMN-guided single catheter ablation of the AVN in a patient with dextrocardia via peripheral vascular access was effective and safe. The use of RMN and peripheral vascular access may offer important advantages also in other patient groups. [ABSTRACT FROM AUTHOR]

Background There is emerging evidence for the potential utility of left bundle branch area pacing (LBBAP), as an alternative to conventional cardiac resynchronization therapy (CRT). The utility of right ventriculography by way of power injector to facilitate lead placement has not yet been reported in the literature. Case summary A 79-year-old female, with a background of poorly rate-controlled atrial fibrillation, presented with worsening dyspnoea. She had recently undergone single-chamber pacemaker insertion prior to an atrioventricular nodal (AVN) ablation, owing to failure in achieving successful CRT coronary sinus lead placement. She had clinical evidence of volume overload, and her electrocardiogram demonstrated right ventricular pacing. Echocardiography demonstrated left ventricular (LV) impairment, with an ejection fraction (EF) of 35%, and severe functional mitral regurgitation (MR). Her diagnosis was overall consistent with pacing-induced cardiomyopathy (PIC). In this patient, the use of right ventriculography, using power-injector-delivered contrast, successfully facilitated placement of an LBBAP lead, with confirmation of good threshold and sensing parameters. Following an upgrade to conduction system pacing, the patient recovered well. On recent follow-up, repeat echocardiography (24 months post initial presentation) demonstrated improved LV function (EF 45% from 35%) and only mild-to-moderate MR. Discussion In conclusion, we demonstrate the utility of right ventriculography to facilitate placement of an LBBAP lead, successfully treating a patient who developed PIC from chronic right ventricular pacing following AVN ablation. [ABSTRACT FROM AUTHOR]

With the advancement of pacing technologies, His-Purkinje conduction system pacing (HPCSP) has been increasingly recognized as superior to conventional right ventricular pacing (RVP) and biventricular pacing (BVP). This method is characterized by a series of strategies that either strengthen the native cardiac conduction system or fully preserve physical atrioventricular activation, ensuring optimal clinical outcomes. Treatment with HPCSP is divided into two pacing categories, His bundle pacing (HBP) and left bundle branch pacing (LBBP), and when combined with atrioventricular node ablation (AVNA), can significantly improve left ventricular (LV) function. It effectively prevents tachycardia and regulates ventricular rates, demonstrating its efficacy and safety across different QRS wave complex durations. Therefore, HPCSP combined with AVNA can alleviate symptoms and improve the quality of life in patients with persistent atrial fibrillation (AF) who are unresponsive to multiple radiofrequency ablation, particularly those with concomitant heart failure (HF) who are at risk of further deterioration. As a result, this “pace and ablate” strategy could become a first-line treatment for refractory AF. As a pacing modality, HBP faces challenges in achieving precise localization and tends to increase the pacing threshold. Thus, LBBP has emerged as a novel approach within HPCSP, offering lower thresholds, higher sensing amplitudes, and improved success rates, potentially making it a preferable alternative to HBP. Future large-scale, prospective, and randomized controlled studies are needed to evaluate patient selection and implantation technology, aiming to clarify the differential clinical outcomes between pacing modalities. [ABSTRACT FROM AUTHOR]

Background An atrioventricular node (AVN) ablation and permanent pacing have been previously reported as effective treatments for patients with atrial tachyarrhythmias. However single-ventricle patients requiring chronic ventricular pacing are at a higher risk of developing ventricular dysfunction and atrioventricular valve regurgitation. We report a case of successful AVN ablation in a 3-month-old infant with hypoplastic left heart syndrome and ectopic atrial tachycardia (EAT). Case summary A boy with hypoplastic left heart syndrome who had a refractory EAT resistant to various medications. At 2 months old, we performed an urgent radiofrequency (RF) catheter ablation of the EAT and the applications delivered at the cavo-atrial junction. Although it disappeared after the first catheter ablation for 2 weeks, it recurred on the next day after the diaphragm plication. At 3 months old and weighed 3.1 kg, we decided to perform an urgent AVN ablation of the EAT. The application was performed on the mid-septum of the tricuspid septum. A permanent pacemaker was implanted after the ablation. After the AVN ablation, the haemodynamics stabilized during the EAT. However, he died from a bacteraemia infection at 4 months. Discussion This patient received an AVN ablation due to failure to previous RF catheter ablation and was haemodynamically stable with the dual-chamber pacemaker. The AV block was successfully created by RF energy on the mid-septum of the tricuspid annulus in this hypoplastic left heart syndrome patient. Pathological findings exhibited that the compact AVN was totally ablated without damage to the tricuspid leaflets or coronary artery. [ABSTRACT FROM AUTHOR]

Background: Atrioventricular node (AVN) ablation is an effective treatment for atrial fibrillation (AF) with uncontrolled ventricular rates despite maximal pharmacological treatment. Intracardiac echocardiography (ICE) can help with visualizing structures, positioning catheters, and guiding the ablation procedure. We compared only fluoroscopy-guided and ICE-guided AVN ablation regarding patients with permanent AF. Methods: Sixty-two consecutive patients underwent AVN ablation were enrolled in our retrospective single-center study (ICE group: 28 patients, Standard group: 34 patients). Procedural data, acute and long-term success rate, and complications were analyzed. Results: ICE guidance for AVN ablation significantly reduced fluoroscopy time (0.30 [0.06; 0.85] min vs. 7.95 [3.23; 6.59] min, p < 0.01), first-to-last ablation time (4 [2; 16.3] min vs. 26.5 [2.3; 72.5] min, p = 0.02), and in-procedure time (40 [34; 55] min vs. 60 [45; 110], p = 0.02). There was no difference in either the total ablation time (199 [91; 436] s vs. 294 [110; 659] s, p = 0.22) or in total ablation energy (8272 [4004; 14,651] J vs. 6065 [2708; 16,406] J, p = 0.28). The acute success rate was similar (ICE: 100% vs. Standard: 94%, p = 0.49) between the groups. Conclusions: In our retrospective trial, ICE-guided AVN ablation reduced fluoroscopy time, procedure time, and first-to-last ablation time. There was no difference in ablation time, total ablation energy, acute and long-term success, and complication rate. [ABSTRACT FROM AUTHOR]

[Display omitted] • Left bundle branch area pacing provided better 1-year outcome than HBP. • Significant improvement in LVEF and NHYA class observed with both techniques. • These data may clarify the role of HBP vs LBBAP in the "ablate and pace" strategy. Pacemaker implantation combined with atrioventricular node ablation (AVNA) is a well-established strategy for uncontrolled atrial arrhythmias. Limited data are available regarding His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) in this setting. To compare the outcomes of HBP and LBBAP in patients undergoing pacemaker implantation combined with AVN in routine clinical practice. We prospectively included all patients who underwent AVNA after successful conduction system pacing (CSP) in two hospitals between September 2017 and May 2023. The primary outcome was the 1-year composite of first episode of heart failure hospitalization, symptomatic atrioventricular node reconduction requiring a second AVNA procedure, lead revision or death from any cause. A total of 164 patients underwent AVNA following successful CSP (68 HBP and 96 LBBAP). Mean pacemaker implantation and AVNA procedure times were shorter in the LBBAP group than the HBP group (46 ± 18 vs 59 ± 23 min; P < 0.001 and 31 ± 12 v s 43 ± 22 min, respectively; P < 0.001). Complete atrioventricular block was more frequently obtained in the LBBAP group (88/96 patients [92%] vs 54/68 patients [79%]; P = 0.04). One-year freedom from the composite outcome was more frequent in the LBBAP group (89.7% vs 72.9%; hazard ratio 0.32, 95% confidence interval 0.14 − 0.72; P = 0.01). The strategy was similarly effective in both groups with a significant improvement in NYHA class and left ventricular ejection fraction. A secondary pacing threshold elevation >1 V occurred only in the HBP group (11%). In this prospective, comparative study, LBBAP provided better 1-year outcomes than HBP. [ABSTRACT FROM AUTHOR]

Background: There is currently no particularly effective strategy for patients with persistent atrial fibrillation accompanying heart failure with preserved ejection fraction (HFpEF), especially with recurrent atrial fibrillation after ablation. In this study, we will evaluate a new treatment strategy for patients with persistent atrial fibrillation who had at least two attempts (≧2 times) of radio-frequency catheter ablation but experienced recurrence, and physiologic conduction was reconstructed after atrioventricular node ablation or drug therapy, to control the patient's ventricular rate to maintain a regular heart rhythm, which is called His–Purkinje conduction system pacing (HPCSP) with atrioventricular node ablation. Methods and results: This investigator-initiated, multicenter prospective randomized controlled trial aimed to recruit 296 randomized HFpEF patients with recurrent atrial fibrillation. All the enrolled patients were randomly assigned to the pacing group or the drug treatment group. The primary endpoint is differences in cardiovascular events and clinical composite endpoints (all-cause mortality) between patients in the HPCSP and drug-treated groups. Secondary endpoints included heart failure hospitalization, exercise capacity assessed by cardiopulmonary exercise tests, quality of life, echocardiogram parameters, 6-minute walk distance, NT-ProBNP, daily patient activity levels, and heart failure management report recorded by the CIED. It is planned to compete recruitment by the end of 2023 and report in 2025. Conclusions: The study aims to determine whether His–Purkinje conduction system pacing with atrioventricular node ablation can better improve patients' symptoms and quality of life, postpone the progression of heart failure, and reduce the rate of rehospitalization and mortality of patients with heart failure. Clinical trial registration number: ChiCTR1900027723, URL:http://www.chictr.org.cn/edit.aspx?pid=46128&htm=4 [ABSTRACT FROM AUTHOR]

The feasibility of the conduction system pacing combined with atrioventricular node ablation was demonstrated in patients with atrial fibrillation in whom rate control can’t be achieved with medication and heart failure.

Despite lack of concrete evidence, right ventricular thrombus is generally considered to be a contraindication for intracardiac lead placement. We present a case of successful placement of a right ventricular defibrillator lead and left bundle branch pacing lead and atrioventricular node ablation in a patient with chronic right ventricle thrombus.

Abstract Background Fast-conducting atrial fibrillation misinterpreted as ventricular tachycardia is the leading cause for inappropriate shocks in patients with implantable cardiac defibrillators (ICD). These inappropriate shocks are associated with significant morbidity and mortality and cause great discomfort and stress. Case presentation We report the case of a patient with ischemic cardiomyopathy, permanent atrial fibrillation, and a single-chamber DF-1 ICD implanted for the primary prevention of sudden cardiac death, who presented for multiple inappropriate internal shocks due to very fast-conducting atrial fibrillation, which was mislabeled as ventricular fibrillation by the ICD. Since the patient was under maximal atrioventricular nodal blocking medical therapy (beta-blockers and digitalis) and we didn`t find any reversible causes for the heart rate acceleration, we opted for rate control with atrioventricular node ablation. To counteract the risk of pacing-induced cardiomyopathy in this patient who would become totally pacemaker-dependent, we successfully performed left bundle branch area pacing. Because the patient`s ICD had a DF-1 connection and the battery had a long life remaining, we connected the physiological pacing lead to the IS-1 sense-pace port of the ICD. The 6-month follow-up showed an improvement in left ventricular function with no more inappropriate shocks. Conclusions Left bundle branch area pacing and atrioventricular node ablation in patients with an implantable single-chamber DF-1 defibrillator and fast-conducting permanent atrial fibrillation is a cost-efficient and very effective method to prevent and treat inappropriate shocks, avoiding the use of an additional dual-chamber or CRT-D device.

Background: Fast-conducting atrial fibrillation misinterpreted as ventricular tachycardia is the leading cause for inappropriate shocks in patients with implantable cardiac defibrillators (ICD). These inappropriate shocks are associated with significant morbidity and mortality and cause great discomfort and stress. Case presentation: We report the case of a patient with ischemic cardiomyopathy, permanent atrial fibrillation, and a single-chamber DF-1 ICD implanted for the primary prevention of sudden cardiac death, who presented for multiple inappropriate internal shocks due to very fast-conducting atrial fibrillation, which was mislabeled as ventricular fibrillation by the ICD. Since the patient was under maximal atrioventricular nodal blocking medical therapy (beta-blockers and digitalis) and we didn't find any reversible causes for the heart rate acceleration, we opted for rate control with atrioventricular node ablation. To counteract the risk of pacing-induced cardiomyopathy in this patient who would become totally pacemaker-dependent, we successfully performed left bundle branch area pacing. Because the patient's ICD had a DF-1 connection and the battery had a long life remaining, we connected the physiological pacing lead to the IS-1 sense-pace port of the ICD. The 6-month follow-up showed an improvement in left ventricular function with no more inappropriate shocks. Conclusions: Left bundle branch area pacing and atrioventricular node ablation in patients with an implantable single-chamber DF-1 defibrillator and fast-conducting permanent atrial fibrillation is a cost-efficient and very effective method to prevent and treat inappropriate shocks, avoiding the use of an additional dual-chamber or CRT-D device. [ABSTRACT FROM AUTHOR]

Background: Left bundle branch area pacing (LBBAP) has rapidly emerged as a promising modality of physiologic pacing and has demonstrated excellent lead stability. In this retrospective study, we evaluate whether this pacing modality can allow concomitant atrioventricular node (AVN) ablation and same-day dismissal. Methods: Twenty-four consecutive patients (female 63%, male 37%) with an average age of 78 ± 5 years were admitted for pacemaker (75%)/defibrillator (25%) implantations and concomitant AVN ablation. Device implantation with LBBAP was performed first, followed by concomitant AVN ablation through left axillary vein access to allow for quicker post-procedure ambulation. The patients were discharged on the same day after satisfactory post-ambulation device checks. Results: LBBAP was successful in 22 patients (92% in total, 20 patients had an LBBP and two patients had a likely LBBP), followed by AVN ablation from left axillary vein access (21/24, 88%). All patients had successful post-op chest x-rays, post-ambulation device checks, and were discharged on the same day. After a mean follow up of three months, no major complications occurred, such as LBBA lead dislodgement requiring a lead revision. The LBBA lead pacing parameters immediately after implantation vs. three-month follow up were a capture threshold of 0.8 ± 0.3 V@0.4 ms vs. 0.6 ± 0.3 V@0.4 ms, sensing 9.9 ± 3.9 mV vs. 10.4 ± 4.1 mV, and impedance of 710 ± 216 ohm vs. 544 ± 110 ohm. The QRS duration before and after AVN ablation was 117 ± 32 ms vs. 123 ± 14 ms. Mean LVEF before and three months after the implantation was 44 ± 14% vs. 46 ± 12%. Conclusion: LBBA pacing not only offers physiologic pacing, but also allows for a concomitant AVN ablation approach from the left axillary vein and safe same-day hospital dismissal. [ABSTRACT FROM AUTHOR]

Background: “Ablate and pace” strategy is a reasonable treatment option in refractory atrial fibrillation (AF) when sinus rhythm (SR) cannot be achieved with catheter ablation or pharmacological therapy. Atrioventricular node ablation (AVNA) combined with conduction system pacing (CSP), with left bundle branch pacing (LBBP) or His bundle pacing (HBP), is gaining recognition since it offers the most physiological activation of the left ventricle. However, the incidence of conversion to SR after AVNA with CSP is not known. The purpose of the investigation was to determine the incidence of spontaneous conversion to SR and its predicting factors in patients undergoing CSP and AVNA. Methods: Consecutive refractory symptomatic AF patients undergoing AVNA with CSP at our institution between June 2018 and December 2022 were retrospectively analyzed. Twelve lead electrocardiogram (ECG) recordings were analyzed at each outpatient follow-up visit. Echocardiographic and clinical parameters were assessed at baseline and six months after the implantation. Results: Sixty-eight patients (male 42.6%, age 71 ± 8 years, left ventricular ejection fraction 40 ± 15%) were included. Thirty-seven patients (54.4%) received HBP and 31 (45.6%) LBBP. During follow-up, spontaneous conversion to SR was registered in 6 patients (8.8%); 3 in the HBP group and 3 in the LBBP group. Baseline characteristics of patients who converted to SR did not differ from non-sinus rhythm (NSR) patients except for left atrial volume index (LAVI), which was significantly smaller in the SR group (45 mL/m² (41–51) vs. 60 mL/m² (52–75); p = 0.002). Multiple regression model confirmed an inverse association between LAVI and conversion to SR even after considering other clinically relevant covariates (odds ratio 1.273, p = 0.028). At follow-up, LAVI did not change in any group (SR: p = 0.345; NSR: p = 0.508). Improvement in New York Heart Association (NYHA) class was comparable in both groups. Conclusions: Spontaneous conversion to SR after AVNA combined with CSP is not uncommon, especially in patients with smaller left atria. Further studies are warranted to clarify which patients should be considered for initial dual-chamber device implantation to provide atrio-ventricular synchrony in case of SR restoration. [ABSTRACT FROM AUTHOR]

Background: Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome right ventricular pacing-induced dyssynchrony. In this study, the feasibility and safety of performing LBBAP and AV node ablation in a single procedure in the elderly was investigated. Methods: Consecutive patients with symptomatic AF referred for pace-and-ablate underwent the treatment in a single procedure. Data on procedure-related complications and lead stability were collected at regular follow-up at one day, ten days and six weeks after the procedure and continued every six months thereafter. Results: 25 patients (mean age 79.2 ± 4.2 years) were included and underwent successful LBBAP. In 22 (88%) patients, AV node ablation and LBBAP were performed in the same procedure. AV node ablation was postponed in two patients due to lead-stability concerns and in one patient on their own request. No complications related to the single-procedure approach were observed with no lead-stability issues at follow-up. Conclusions: LBBAP combined with AV node ablation in a single procedure is feasible and safe in elderly patients with symptomatic AF. [ABSTRACT FROM AUTHOR]

Abstract Background There is an ongoing debate on how cardiac resynchronization therapy (CRT) in the presence of total AV block affects atrial fibrillation (AF) episodes and symptoms in patients with AF. Methods Seventy‐five patients with symptomatic, drug and ablation refractory AF received, irrespective of their left ventricular ejection fraction (EF), either a CRT device and underwent subsequent atrioventricular node (AVN) ablation or already had a total AV block and underwent CRT upgrade. Long‐lasting AF episodes (>48 h), left ventricular ejection fraction (LVEF), left ventricular end‐diastolic diameter (LVEDD), left atrial diameter (LAD), NTproBNP levels, EHRA score, and NYHA class had been monitored on the follow‐up. Results The number of patients experiencing long‐lasting AF episodes (>48 h) and symptoms decreased significantly within 24 months after CRT implantation in the presence of total AV block (p

Background: “Ablate and pace” strategy is a reasonable treatment option in refractory atrial fibrillation (AF) when sinus rhythm (SR) cannot be achieved with catheter ablation or pharmacological therapy. Atrioventricular node ablation (AVNA) combined with conduction system pacing (CSP), with left bundle branch pacing (LBBP) or His bundle pacing (HBP), is gaining recognition since it offers the most physiological activation of the left ventricle. However, the incidence of conversion to SR after AVNA with CSP is not known. The purpose of the investigation was to determine the incidence of spontaneous conversion to SR and its predicting factors in patients undergoing CSP and AVNA. Methods: Consecutive refractory symptomatic AF patients undergoing AVNA with CSP at our institution between June 2018 and December 2022 were retrospectively analyzed. Twelve lead electrocardiogram (ECG) recordings were analyzed at each outpatient follow-up visit. Echocardiographic and clinical parameters were assessed at baseline and six months after the implantation. Results: Sixty-eight patients (male 42.6%, age 71 ± 8 years, left ventricular ejection fraction 40 ± 15%) were included. Thirty-seven patients (54.4%) received HBP and 31 (45.6%) LBBP. During follow-up, spontaneous conversion to SR was registered in 6 patients (8.8%); 3 in the HBP group and 3 in the LBBP group. Baseline characteristics of patients who converted to SR did not differ from non-sinus rhythm (NSR) patients except for left atrial volume index (LAVI), which was significantly smaller in the SR group (45 mL/m2 (41–51) vs. 60 mL/m2 (52–75); p = 0.002). Multiple regression model confirmed an inverse association between LAVI and conversion to SR even after considering other clinically relevant covariates (odds ratio 1.273, p = 0.028). At follow-up, LAVI did not change in any group (SR: p = 0.345; NSR: p = 0.508). Improvement in New York Heart Association (NYHA) class was comparable in both groups. Conclusions: Spontaneous conversion to SR after AVNA combined with CSP is not uncommon, especially in patients with smaller left atria. Further studies are warranted to clarify which patients should be considered for initial dual-chamber device implantation to provide atrio-ventricular synchrony in case of SR restoration.

Background: There is an ongoing debate on how cardiac resynchronization therapy (CRT) in the presence of total AV block affects atrial fibrillation (AF) episodes and symptoms in patients with AF. Methods: Seventy‐five patients with symptomatic, drug and ablation refractory AF received, irrespective of their left ventricular ejection fraction (EF), either a CRT device and underwent subsequent atrioventricular node (AVN) ablation or already had a total AV block and underwent CRT upgrade. Long‐lasting AF episodes (>48 h), left ventricular ejection fraction (LVEF), left ventricular end‐diastolic diameter (LVEDD), left atrial diameter (LAD), NTproBNP levels, EHRA score, and NYHA class had been monitored on the follow‐up. Results: The number of patients experiencing long‐lasting AF episodes (>48 h) and symptoms decreased significantly within 24 months after CRT implantation in the presence of total AV block (p <.001) from 57 (76%) to 25 (33.3%). Mean LAD decreased from 52 mm (IQR 48.0–56.0) to 48 mm (IQR 42.0–52.0, p <.001) and LVEDD from 54 mm (IQR 49.0–58.0) to 51 mm (IQR 46.5–54.0, p <.001). Conclusion: A combination of total AVN block and biventricular pacing markedly reduces long‐lasting AF episodes, symptoms, left atrial diameter, and left ventricular end‐diastolic diameter. [ABSTRACT FROM AUTHOR]

Atrioventricular node ablation (AVNA) and pacemaker (PM) is performed in symptomatic atrial fibrillation (AF) unresponsive to medical treatment and percutaneous ablation. This meta-analysis evaluated results after AVNA and PM. Primary and secondary endpoints were early/late overall/cardiac-related mortality and early/late postoperative complications. Meta-regression explored mortality and preoperative characteristics relation. We selected 93 studies with 11,340 patients: 9105 right ventricular (RV)-PM, and 2235 biventricular PM (cardiac resynchronization therapy, CRT). Malignant arrhythmia (2.5%), heart failure (2.4%), and lead dislodgement (2.0%) were most common periprocedural complications. Pooled estimated 30-day mortality was 1.08% (95%CI:0.65–1.77). At 19.9 months median follow-up (IQR: 10.3–34 months), rehospitalization (0.79%/month) and heart failure (0.48%/month) were the most frequent complications. Overall mortality incidence rate (IR) was 0.43%/month (95%CI:0.36–0.51), and cardiac death IR 0.27%/month (95%CI:0.22–0.32). No mortality determinants emerged in the AVNA CRT subgroup. AVNA RV-PM subgroup univariable meta-regression showed inverse relationship between age, ejection fraction (EF), and late cardiac death (Beta = −0.0709 ± 0.0272; p = 0.0092 and Beta = −0.0833 ± 0.0249; p = 0.0008). Coronary artery disease (CAD) was directly associated to follow-up overall/cardiac mortality at univariable (Beta = 0.0550 ± 0.0136, p < 0.0001; Beta = 0.0540 ± 0.0130, p < 0.0001) and multivariable (Beta = 0.0460 ± 0.0189, p = 0.152; Beta = 0.0378 ± 0.0192, p = 0.0491) meta-regression. Solid long-term evidence supporting AVNA and pace is lacking. Younger patients with reduced LVEF% have increased follow-up cardiac mortality after AVNA RV and may require CRT. Alternative strategies to maintain sinus rhythm and ventricular synchronism should be compared to AVNA to support future treatment strategies. [Display omitted] • Long-term follow-up data of ablate and pace to treat atrial fibrillation are lacking. • Ablate and pace carries a not trivial burden of early and late complications. • Age and LVEF are inversely related to follow-up mortality. • CRT reduces late cardiac mortality, but at higher costs and procedural complexity. • Prospective long-term studies for outcomes and alternative strategies in patients unresponsive to percutaneous ablation are warranted. [ABSTRACT FROM AUTHOR]

Objective: To review the relevant literature on the use of atrioventricular node ablation and pacing in patients with heart failure and atrial fibrillation. Methods: APubMed/MEDLINE and SCOPUS search was performed in order to assess the clinical outcomes of atrioventricular node ablation and pacemaker implantation, as well as the complications that may occur. Results: Several clinical trials, observational analyses and meta-analyses have shown that the “pace and ablate” strategy not only improves symptoms but also can enhance cardiac performance in patients with heart failure and atrial fibrillation. Although this procedure is effective and safe, some complications may occur including worsening of heart failure, permanent fibrillation, arrhythmias and sudden death. Regarding pacemaker implantation, cardiac resynchronization therapy is shown to be the optimal choice compared to right ventricle apical pacing. His bundle pacing is a promising alternative to cardiac resynchronization therapy and has shown beneficial effects, while left bundle branch pacing is an innovative modality. Conclusions: Atrioventricular node ablation and pacemaker implantation is shown to have beneficial effects on clinical outcomes of patients with atrial fibrillation ± heart failure who do not respond or are intolerant to medical treatment. Cardiac resynchronization therapy is the treatment of choice and His bundle pacing seems to be an effective alternative way of pacing in these patients.

IntroductionAtrial fibrillation (AF) is a prevalent arrhythmia that occurs in 2–4% of adults and poses a threat to human health. Thus, comparison of the efficacy and safety of therapies for AF is warranted. Here, we used network analysis to compare efficacy (arrhythmia recurrence and re-hospitalization) and safety (ischemic cerebral vascular events, all-cause mortality, and cardiovascular mortality) endpoints among five major therapies for AF.MethodsThe PubMed, Cochrane, and Embase databases were searched, and relevant literature was retrieved. Only studies that made comparisons among the therapies of interest and involved patients with AF were included. Pairwise comparisons and frequentist method (SUCRA plot) analyses were conducted.ResultsIn total, 62 studies were included in the pooled analysis. In pairwise comparisons, atrioventricular nodal ablation plus permanent pacemaker (AVN + PPM) was associated with a significantly higher risk of atrial arrhythmia recurrence than surgical ablation [odds ratio (OR): 23.82, 95% confidence interval (CI): 1.97–287.59, fixed-effect model; 3.82, 95% CI: 1.01–559.74, random-effects model]. Furthermore, radiofrequency ablation was associated with a significantly lower risk of cardiovascular mortality than medication in pairwise comparison (OR: 0.49, 95% CI: 0.29–0.83, fixed-effect model; OR: 0.49, 95% CI: 0.27–0.9, random-effects model). Frequentist analysis indicated that AVN + PPM had the best performance in reducing the risk of safety and efficacy endpoints.ConclusionNon-pharmaceutical therapies showed superior performance to traditional drug therapy in lowering the risk of safety and efficiency endpoint events. AVN + PPM performed best in reducing the risk of safety and efficacy endpoints.

Atrial fibrillation and heart failure frequently co-exist and the combination is associated with a worse prognosis than either condition alone. A number of pharmacological agents and invasive procedures have been shown to benefit this complex patient group. In this review, we compare different therapeutic approaches to atrial fibrillation and heart failure, including pharmacotherapy, left atrial catheter ablation and pace-and-ablate. Left atrial catheter ablation is an efficacious option for restoring sinus rhythm and is most likely to provide benefit to those in whom durable sinus rhythm can be expected, and whose life expectancy is not significantly reduced by other pathologies or advanced age. A pace-and-ablate approach, particularly with physiological pacing, may provide more benefit to those with low chance of maintaining sinus rhythm. Both invasive options generally outperform pharmacotherapy, although it is important to individualize the approach for each patient through shared decision-making. [ABSTRACT FROM AUTHOR]

Background: Response rates for cardiac resynchronization therapy (CRT) in patients without intrinsic left bundle-branch block (LBBB) morphology are poor.Objective: We sought to develop a nomogram model to predict response to CRT in patients without intrinsic LBBB.Methods: We searched electronic health records for patients without intrinsic LBBB who underwent CRT at Mayo Clinic. Logistic regression and Cox proportional hazards regression analysis were performed for the odds of response to CRT and risk of death, respectively. Results were used to develop the nomogram model.Results: 761 patients without intrinsic LBBB were identified. Six months after CRT, 47.8% of patients demonstrated improvement of left ventricular ejection fraction by more than 5%. The 1-, 3-, and 5-year survival rates were 95.9, 82.4, and 66.70%, respectively. Patients with CRT upgrade from pacemaker [odds ratio (OR), 1.67 (95% CI, 1.05–2.66)] or atrioventricular node (AVN) ablation [OR, 1.69 (95% CI, 1.09–2.64)] had a greater odds of CRT response than those patients who had new implant, or who did not undergo AVN ablation. Patients with right bundle-branch block had a low response rate (39.2%). Patients undergoing AVN ablation had a lower mortality rate than those without ablation [hazard ratio, 0.65 (95% CI, 0.46–0.91)]. Eight clinical variables were automatically selected to build a nomogram model and predict CRT response. The model had an area under the receiver operating characteristic curve of 0.71 (95% CI, 0.63–0.78).Conclusions: Among patients without intrinsic LBBB undergoing CRT, upgrade from pacemaker and AVN ablation were favorable factors in achieving CRT response and better long-term outcomes.

Background  The presence of a dilated coronary sinus (CS) assessed by transthoracic echocardiography (TTE) is highly suggestive of inferior or superior vena cava (SVC) anomalies, in the absence of a shunt. The most frequent finding is the persistence of a left superior vena cava (LSVC): well-known feature to electrophysiologists. Abnormal inferior vena cava (IVC) drainage is another cause of CS dilatation. Case summary  An 83-year-old woman presented with heart failure symptoms, atrial fibrillation with rapid ventricular rate, and a dilated CS assessed by TTE. Atrioventricular (AV) node ablation was considered given the poor efficacy of a rate control strategy. Cardiac computed tomography (CT) revealed a double SVC with an LSVC draining directly into the dilated CS. Single-lead pacemaker implantation was performed using a right-sided vascular access with no technical difficulties. An aborted AV node ablation procedure was due to the impossibility of getting to the right atrium. Fluoroscopy and CT imaging at second look analysis confirmed the diagnosis of an abnormal IVC with an agenesia of its supra-hepatic segment directly drained into the CS. Discussion  Our clinical case illustrates an unusual and rare double venous abnormality: both LSVC and IVC directly drained into the CS and were responsible for its massive dilatation. [ABSTRACT FROM AUTHOR]

Background: Pacemaker implantation combined with atrioventricular node ablation (AVNA) could be a practical choice for atrial fibrillation (AF) patients with heart failure (HF). Left bundle branch area pacing (LBBaP) has been widely reported. Objectives: To explore the safety and efficacy of LBBaP combined with AVNA in AF patients with HF. Methods and results: Fifty-six AF patients with HF attempted LBBaP and AVNA from January 2019 to December 2020. Standard LBBaP was achieved in forty-six patients, and another ten received left ventricular septal pacing (LVSP). The cardiac function indexes and pacemaker parameters were evaluated at baseline, and we conducted a 1-month and 1-year follow-up. Result: At the time of implantation and 1-month and 1-year follow-up, QRS duration of LVSP group was longer than that of LBBaP group. The pacemaker parameters remained stable in both the LBBaP and LVSP groups. At 1-month and 1-year follow-up after LBBaP and AVNA, left ventricular ejection fraction, left ventricular end-diastolic diameter, and NYHA classification continued to improve. Baseline left ventricular ejection fraction and QRS duration change at implantation can predict the magnitude of improvement of left ventricular ejection fraction at 1-year after LBBaP. Baseline right atrial left-right diameter, the degree of tricuspid regurgitation, and interventricular septum thickness may be the factors affecting the success of LBBaP. Conclusion: LBBaP combined with AVNA is safe and effective for patients with AF and HF. Baseline right atrial left-right diameter, the degree of tricuspid regurgitation, and interventricular septum thickness may be the factors affecting the success of LBBaP.

Introduction: In patients with uncontrolled atrial fibrillation, atrioventricular (AV) node ablation after permanent His bundle pacing (p‐HBP) could be a therapeutic option for heart rate (HR) control. We aimed to demonstrate the advantages of AV node ablation with p‐HBP, and to describe its effectiveness and safety. Methods: This descriptive observational study included patients with uncontrolled permanent atrial arrhythmias who were candidates for HR control (January 2019 to July 2020) and underwent p‐HBP and AV node ablation. Results: A total of 39 patients were included. The median left ventricular ejection fraction (LVEF) was 55% (45–60); 46.1% in NYHA class II and 43.6% in NYHA class III. p‐HBP was achieved in 92.3% (n = 36), and AV node ablation was successfully performed in all patients. The LVEF improved in patients with reduced LVEF (baseline, 35% [23.8–45.3%]; follow‐up, 40% [35–56.5%], p < 0.05); the NYHA class also showed improvement (baseline, 71.4% patients in class III and 7.1% in class II, and at follow‐up, 78.6% patients in class II and 14.3% in class I). In patients with previously normal LVEF, LVEF remained stable; nevertheless, a significant NYHA class improvement was observed (baseline, 63.6% class II and 31.8% class III patients; follow‐up, 54.5% class I and 45.5% class II patients). The His thresholds and lead parameter values did not significantly change during the follow‐up and remained stable. Conclusions: In patients with uncontrolled atrial arrhythmias who underwent AV node ablation after p‐HBP, the NYHA class improved and the LVEF increased in those with reduced baseline LVEF. The values of pacing parameters were acceptable and remained stable during the follow‐up. [ABSTRACT FROM AUTHOR]

Atrioventricular node (AVN) ablation for atrial fibrillation (AF) is commonly performed in the cardiac catheterization laboratory often requiring patient immobility for accurate anatomical mapping and ablation. 1 Anesthetic management for AVN ablation can be accomplished via multiple modalities such as total intravenous anesthesia and jet ventilation, or deep sedation and analgesia. 1 Deep sedation is typically accompanied by deleterious sequelae such as hypotension, apnea, and respiratory depression. 1,2 This presents a significant challenge for the anesthesia professional as maintaining hemodynamic and respiratory stability requires judicious management in this high-risk patient population. 1 The following is a case study presenting the anesthetic management of an obese patient with multiple cardiac and respiratory comorbidities. [ABSTRACT FROM AUTHOR]

Aims: Radiofrequency ablation (RFA) of the atrioventricular node (AVN) with His-bundle pacing (HBP) can cause rise in capture thresholds. Cryoablation (CRYO) may offer reversibility in case of threshold rise but has never been tested for AVN ablation in this setting. Our aim was to compare procedural characteristics and outcome of CRYO compared with RFA for AVN ablation in patients with HBP.Methods and Results: Forty-four patients with HBP underwent AVN ablation for an 'ablate and pace' indication. Cryoablation was performed in the first 22 patients and RFA in the following 22 patients. Procedural characteristics, success rates, and change in His capture thresholds were compared between groups. Distance from the ablation site to the His lead was measured using biplane fluoroscopy. Acute success was 100% with both strategies. Median procedural duration was significantly longer for CRYO {50 [interquartile range (IQR) 38-63] min} compared with RFA [36 (IQR, 30-41) min; P = 0.027]. An acute threshold rise of ≥1 V was observed in four CRYO (one complete loss of capture) and three RFA patients (P = 0.38), with all of the applications being within 6 mm of the His lead tip. During follow-up, nine patients had AVN re-conduction (six CRYO vs. three RFA; P = 0.58), but only four patients required a redo procedure (all CRYO; P = 0.09).Conclusion: Cryoablation does not offer any advantage over RFA for AVN ablation in patients with HBP and tended to require more redo procedures. If possible, a distance of ≥6 mm should be maintained from the His lead tip to avoid a rise in capture thresholds. [ABSTRACT FROM AUTHOR]

Introduction: Frequent right AQ4ventricular pacing (≥40%) with a transvenous pacemaker (TVP) is associated with the risk of pacing‐induced cardiomyopathy (PICM). Leadless pacemakers (LPs) have distinct physical and mechanical differences from TVP. The risk of PICM with LP is not known. To identify incidence, predictors, and long‐term outcomes of PICM in LP and TVP patients. Methods: The study comprised all pacemaker‐dependent patients with LP or TVP who had left ventricular ejection fraction (LVEF) of ≥50 from 2014 to 2019. The incidence of PICM (≥10% LVEF drop) was assessed with an echocardiogram. Predictors for PICM were identified using multivariate analysis. Long‐term outcomes after cardiac resynchronization (CRT) were assessed in both groups. Results: A total of 131 patients with TVP and 67 with LP comprised the study. All patients in the TVP group and the majority in the LP group underwent atrioventricular node ablation. The mean follow‐up duration in TVP and LP groups was 592 ± 549 and 817 ± 600 days, respectively. A total of 18 (13.7%) patients in TVP and 2 (3%) in LP developed PICM after a median duration of 254 (interquartile range: 470) days. The incidence of PICM was significantly higher with TVP compared with LP (p =.02). TVP as pacing modality was a positive (odds ratio [OR]: 1.07) while age was negative (OR: 0.94) predictor for PICM on multivariable analysis. Both patients in LP and all except two in the TVP group responded to CRT. Conclusion: Incidence of PICM is significantly lower with LP compared with TVP in pacemaker‐dependent patients. Age and TVP as pacing modality were predictors for PICM. [ABSTRACT FROM AUTHOR]

Recent publications have reported the feasibility of atrioventricular node ablation (AVNA) and concomitant His-bundle pacing guided by an electroanatomic tridimensional mapping system (ETMS). We report the case of a 65-year-old female patient in which zero fluoroscopy left bundle branch pacing and AVNA were performed guided just by ETMS. Optimal device functioning, electrical parameters stability, and correct lead location were observed 24 h and 30 days after the procedure. In selected cases, in which ionizing radiation is not recommended, this technique may represent an alternative for performing both interventions in the same procedure. < Learning objective: Left bundle branch pacing is a physiological form of ventricular pacing achievable with zero fluoroscopy, being a feasible alternative technique when fluoroscopy is not recommended.> [ABSTRACT FROM AUTHOR]

Background  Infective endocarditis with paravalvular abscess can be complicated by atrioventricular block (AVB), but junctional ectopic tachycardia (JET) has as yet never been described. Case summary  A 68-year-old male recently admitted with Staphylococcal aureus endocarditis of his aortic valve bioprosthesis, presented with a regular tachycardia at 240 b.p.m. with a pre-existent right bundle branch block pattern. Haemodynamic collapse necessitated electrical cardioversion, following which high-grade AVB was observed. Multiple recurrences of the same tachycardia required repeated electrical cardioversions and emergent electrophysiological study, which indicated JET. The tachycardia was unresponsive to overdrive pacing, adenosine and intravenous amiodarone, and external cardioversions. Radiofrequency catheter ablation of the atrioventricular node was performed emergently with interruption of the tachycardia. A temporary external pacemaker was implanted via a jugular route. The tachycardia recurred after 48 h at a slower rate, and the patient underwent redo ablation. Transoesophageal echocardiography revealed a pseudoaneurysm of the right sinus of Valsalva probably corresponding to an evacuated abscess. A permanent pacemaker was implanted after active infection had been ruled out. At 3 months of follow-up, the patient had complete AVB, without arrhythmia recurrence. Discussion  This is the first case report of JET complicating a paravalvular abscess of the aortic valve with concomitant AVB. Junctional ectopic tachycardia is very rare arrhythmia which is usually seen in children as a congenital arrhythmia or following surgical correction of paediatric heart disease. The differential diagnosis is discussed in detail in the article. [ABSTRACT FROM AUTHOR]

Aims: His-bundle pacing (HBP) combined with atrioventricular node (AVN) ablation has been demonstrated to be effective in patients with atrial fibrillation (AF) and heart failure (HF) during medium-term follow-up and there are limited data on the risk analysis of adverse prognosis in this population. In this study, we aimed to evaluate the long-term performance of HBP following AVN ablation in AF and HF.Methods and Results: From August 2012 to December 2017, consecutive AF patients with HF and narrow QRS who underwent AVN ablation and HBP were enrolled. The clinical and echocardiographic data, pacing parameters, all-cause mortality, and heart failure hospitalization (HFH) were tracked. A total of 94 patients were enrolled (age 70.1 ± 10.5 years; male 57.4%). Acute HBP were achieved in 89 (94.7%) patients with successful permanent HBP combined with AVN ablation in 81 (86.2%) patients. Left ventricular ejection fraction (LVEF) improved from 44.9 ± 14.9% at baseline to 57.6 ± 12.5% during a median follow-up of 3.0 (IQR: 2.0-4.4) years (P < 0.001). Heart failure hospitalization or all-cause mortality occurred in 21 (25.9%) patients. The LVEF ≤ 40%, pulmonary artery systolic pressure (PASP) ≥40 mmHg, or serum creatinine (Scr) ≥97 μmol/L at baseline was significantly associated with higher composite endpoint of HFH or death (P < 0.05). The His capture threshold was 1.0 ± 0.7 V/0.5 ms at implant and remained stable during follow-up.Conclusion: His-bundle pacing combined with AVN ablation was effective in patients with AF and drug-refectory HF. High PASP, high Scr, or low LVEF at baseline was independent predictors of composite endpoint of all-cause mortality or HFH. [ABSTRACT FROM AUTHOR]

Background: Atrioventricular node (AVN) ablation combined with His bundle pacing is an effective strategy for permanent atrial fibrillation (AF) with rapid ventricular rate refractory to pharmacological therapy. We aimed to access the feasibility and efficiency of His bundle pacing and AVN ablation guided by three‐dimensional (3‐D) mapping system throughout the procedure. Methods: Eighteen patients with permanent AF with refractory rate and symptoms were referred for His bundle pacing and AVN ablation guided by 3‐D mapping (CARTO3). Electroanatomic 3‐D mapping of the right atrium and right ventricle was performed by the ablation catheter with CARTO 3 system, followed by the visualization of the leads for implantation and AVN ablation. Results: Implantation of His bundle and ventricular leads and AVN ablation were achieved successfully with the help of 3‐D mapping in 17 patients. Selective His bundle pacing was achieved in five patients (29.4%), and the other (70.6%) were nonselective His bundle pacing. The mean procedure duration was 99.4 ± 16.4 minutes. The mean fluoroscopy time was 7.0 ± 2.6 minutes. The time spent on His lead implantation was 6.1 ± 3.2 minutes. One patient experienced AVN ablation from left side under aortic valves due to no effect of ablation in right atrium. Conclusion: His bundle pacing and AVN ablation guided by throughout real‐time 3‐D mapping system are of high‐efficiency and feasibility. [ABSTRACT FROM AUTHOR]

Background: Cardiac amyloidosis is a progressive infiltrative disease involving deposition of amyloid fibrils in the myocardium and cardiac conduction system that frequently manifests with heart failure (HF) and arrhythmias, most frequently atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT). Methods: We performed an observational retrospective study of patients with a diagnosis of cardiac amyloid who underwent catheter ablation at our institution between January 1, 2011 and December 1, 2018. Patient demographics, procedural characteristics, and outcomes were determined by manual chart review. Results: A total of 13 catheter ablations were performed over the study period in patients with cardiac amyloidosis, including 10 AT/AF/AFL ablations and three atrioventricular nodal ablations. Left ventricular ejection fraction was lower at the time of AV node ablation than catheter ablation of AT/AF/AFL (23% vs 40%, P =.003). Cardiac amyloid was diagnosed based on the results of preablation cardiac MRI results in the majority of patients (n = 7, 70%). The HV interval was prolonged at 60 ± 15 ms and did not differ significantly between AV nodal ablation patients and AT/AF/AFL ablation patients (69 ± 18 ms vs 57 ± 14 ms, P =.36). The majority of patients undergoing AT/AF/AFL ablation had persistent AF (n = 7, 70%) and NYHA class II (n = 5, 50%) or III (n = 5, 50%) HF symptoms, whereas patients undergoing AV node ablation were more likely to have class IV HF (n = 2, 66%, P =.014). Arrhythmia‐free survival in CA patients after catheter ablation of AT/AF/AFL was 40% at 1 year and 20% at 2 years. Conclusions: Catheter ablation of AT/AF/AFL may be a feasible strategy for appropriately selected patients with early to mid‐stage CA, whereas AV node ablation may be more appropriate in patients with advanced‐stage CA. [ABSTRACT FROM AUTHOR]

Atrial fibrillation and other atrial tachyarrhythmias are increasing with age and concomitant morbidity. First options in symptomatic patients are drug treatment and catheter ablation. Nevertheless, a considerable number of patients suffer from refractory atrial tachyarrhythmias despite treatment. Atrioventricular node ablation (AVNA) may be helpful in many of these patients. Therefore, we investigated AVNA patients with a long-term follow-up. We enrolled 82 patients with a follow-up longer than 1 year receiving AVNA for drug- and ablation-resistant atrial tachyarrhythmias (AA) in a retrospective manner. Mean follow-up duration was 48 ± 24 months. 50% of the patients initially received AVNA to optimize biventricular pacing in cardiac resynchronization therapy, the other 50% because of refractory symptomatic tachyarrhythmias. Persistent AV block was achieved in every patient. Symptom relief and patient satisfaction were high during follow-up. Due to system upgrades there were 63% of patients with a biventricular system during follow-up. In these patients, left-ventricular ejection fraction (LV-EF) increased by 7% (42–49%) after ablation. AVNA is effective in increasing biventricular pacing as well as for symptom relief in patients with refractory atrial tachyarrhythmias. AVNA should be considered as a valuable option in patients with refractory atrial tachyarrhythmias lacking other treatment options. [ABSTRACT FROM AUTHOR]

Background Persistent atrial fibrillation may lead to a higher probability of inappropriate shocks in heart failure patients with an implantable cardioverter‐defibrillator (ICD). The aim of this study was to evaluate the impact of His‐Purkinje conduction system pacing combined with atrioventricular node ablation in improving heart function and preventing inappropriate shock therapy in these patients. Methods and Results A total of 86 consecutive patients with persistent atrial fibrillation and heart failure who had indications for ICD implantation were enrolled from January 2010 to March 2018. His‐Purkinje conduction system pacing with ICD and atrioventricular node ablation was attempted in 55 patients, and the remaining patients underwent ICD implantation only. Left ventricular (LV) ejection fraction, LV end‐systolic volume, New York Heart Association (NYHA) classification, shock therapies, and drug therapy were assessed during follow‐up. Overall, 31 patients received ICD implantation with optimal drug therapy (group 1). atrioventricular node ablation combined with His‐Purkinje conduction system pacing was successfully achieved in 52 patients (group 2). During follow‐up, patients in group 2 had lower incidence of inappropriate shock (15.6% versus 0%, P

With the advent of conduction system pacing, the threshold for performing 'ablate and pace' procedures for atrial fibrillation has gone down markedly in many centres due to the ability to provide a simple and physiological means of pacing the ventricles. This article reviews the technical considerations for this strategy as well as the current evidence, recognized indications, and future perspectives., Competing Interests: Conflict of interest: RT- Abbott, Medtronic, Biotronik, Boston Scientific, -speaking honoraria., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Society of Cardiology.)

BackgroundLinear accelerator–based stereotactic radiosurgery delivered to cardiac arrhythmogenic foci could be a promising catheter‐free ablation modality. We tested the feasibility of in vivo atrioventricular (AV) node ablation in swine using stereotactic radiosurgery. Methods and ResultsFive Large White breed swine (weight 40–75 kg; 4 females) were studied. Single‐chamber St Jude pacemakers were implanted in each pig. The pigs were placed under general anesthesia, and coronary/cardiac computed tomography simulation scans were performed to localize the AV node. Cone beam computed tomography was used for target positioning. Stereotactic radiosurgery doses ranging from 35 to 40 Gy were delivered by a linear accelerator to the AV node, and the pigs were followed up with weekly pacemaker interrogations to observe for potential electrocardiographic changes. Once changes were observed, the pigs were euthanized, and pathology specimens of various tissues, including the AV node and tissues surrounding the AV node, were taken to study the effects of radiation. All 5 pigs had disturbances of AV conduction with progressive transition into complete heart block. Macroscopic inspection did not reveal damage to the myocardium, and pigs had preserved systolic function on echocardiography. Immunostaining revealed fibrosis in the target region of the AV node, whereas no fibrosis was detected in the nontargeted regions. ConclusionsCatheter‐free radioablation using linear accelerator–based stereotactic radiosurgery is feasible in an intact swine model.

BackgroundClinical benefits from His bundle pacing (HBP) in heart failure patients with preserved and reduced left ventricular ejection fraction are still inconclusive. This study evaluated clinical outcomes of permanent HBP in atrial fibrillation patients with narrow QRS who underwent atrioventricular node ablation for heart failure symptoms despite rate control by medication. Methods and ResultsThe study enrolled 52 consecutive heart failure patients who underwent attempted atrioventricular node ablation and HBP for symptomatic atrial fibrillation. Echocardiographic left ventricular ejection fraction and left ventricular end‐diastolic dimension, New York Heart Association classification and use of diuretics for heart failure were assessed during follow‐up visits after permanent HBP. Of 52 patients, 42 patients (80.8%) received permanent HBP and atrioventricular node ablation with a median 20‐month follow‐up. There was no significant change between native and paced QRS duration (107.1±25.8 versus 105.3±23.9 milliseconds, P=0.07). Left ventricular end‐diastolic dimension decreased from the baseline (P

Introduction Atrioventricular node (AVN) ablation is usually a simple procedure but may sometimes be challenging. We aimed at identifying pre-procedural clinical predictors of challenging AVN ablation. Methods Patients referred for AVN ablation from 2009 to 2015 were retrospectively included. Baseline clinical data, procedural variables and outcomes of AVN ablation were collected. A “challenging procedure” was defined 1) total radiofrequency delivery to get persistent AVN block ≥ 400 s, 2) need for left-sided arterial approach or 3) failure to obtain AVN ablation. Results 200 patients were included (71 ± 10 years). A total of 37 (18.5%) patients had “challenging” procedures (including 9 failures, 4.5%), while 163 (81.5%) had “non-challenging” ablations. In multivariable analysis, male sex (Odds ratio (OR) = 4.66, 95% confidence interval (CI): 1.74–12.46), body mass index (BMI, OR = 1.08 per 1 kg/m 2 , 95%CI 1.01–1.16), operator experience (OR = 0.40, 95%CI 0.17–0.94), and moderate-to-severe tricuspid regurgitation (TR, OR = 3.65, 95%CI 1.63–8.15) were significant predictors of “challenging” ablations. The proportion as a function of number of predictors was analyzed (from 0 to 4, including male sex, operator inexperience, a BMI > 23.5 kg/m 2 and moderate-to-severe TR). There was a gradual increase in the risk of “challenging” procedure with the number of predictors by patient (No predictor: 0%; 1 predictor: 6.3%; 2 predictors: 16.5%; 3 predictors: 32.5%; 4 predictors: 77.8%). Conclusions Operator experience, male sex, higher BMI and the degree of TR were independent predictors of “challenging” AVN ablation procedure. The risk increases with the number of predictors by patient. [ABSTRACT FROM AUTHOR]