Ablate and pace strategy for atrial fibrillation: pacing modalities, ablation approaches and impact on patient outcomes.

Introduction: In patients with symptomatic, refractory atrial fibrillation the ablate and pace (A&P) strategy (pacemaker implantation followed by atrio-ventricular junction ablation (AVJA)) is superior to medical therapy in improving quality of life and prognosis. Despite its well-proven benefits, this invasive therapeutic option is still underutilized in clinical practice. The choice of pacing modality (right ventricular pacing, biventricular pacing, BVP, or conduction system pacing, CSP) is crucial and can have significant clinical implications. In particular, in recent years CSP is emerging as an alternative to BVP, showing a good effectiveness and safety profile. Other important aspects are the timing of ablation, the approach used for AVJA, and the correct device programming after AVJA.
Areas Covered: This article reviews the currently available evidence on this therapeutic strategy with a particular focus on its impact on patient outcome, recognized indications, technical considerations, and future perspectives.
Expert Opinion: With the availability of more robust evidence confirming the better effectiveness and safety profile of CSP compared to conventional pacing modalities, in the next few years CSP will become the standard pacing modality in candidates for A&P. The routine adoption of this pacing modality could lead to a wider use of A&P in clinical practice.