Outcomes of Atrioventricular Node Ablation Following Recurrent Atrial Fibrillation After Prior Ablation

Background : Although ablation techniques for atrial fibrillation (AF) continue to evolve, many patients experience recurrent arrhythmia. Those who remain symptomatic despite medical therapy and are deemed ineligible for redo AF ablation are referred for pacemaker implantation and atrioventricular node ablation (AVNA), so-called pace-and-ablate therapy. Objectives: To characterize patients undergoing AVNA following recurrent AF after prior catheter ablation, and to evaluate the impact of pace and ablate therapy on unplanned hospitalizations for AF or heart failure (HF). Secondary objectives include the incidence of pacing-induced cardiomyopathy (PICM) and resumption of spontaneous AV node conduction. Methods: This is a retrospective cohort analysis of all patients undergoing pace-and-ablate therapy for recurrent AF following prior ablation at the McGill University Health Centre between June 2018 and January 2025. Results: Out of a total of 346 AVNA procedures, 32 patients underwent pace-and-ablate therapy for recurrent AF post catheter ablation, median age 77.7 years (IQR: 72.2, 81), 62.5% female, 96.9% hypertension, and 40.6% heart failure with preserved ejection fraction (HFpEF). The baseline left ventricular ejection fraction (LVEF) was 49.9±13% and left atrial volume index 41.4±15 ml/m2. The majority had persistent AF (78.1%) and underwent an average of 1.4 ± 0.6 previous AF ablations. The median time from AF ablation to AVNA was 2.5 years (IQR 0.8, 6.1). Approximately 40.6% of the patients underwent RV pacing, 37.5% biventricular pacing, and 21.9% left bundle branch area pacing (LBBaP). The average number of hospital admissions pre-AF ablation, post-AF ablation, and post-AVNA was 1.7±1.1, 2.1±1.3, and 0.8±0.4, respectively, after a median follow-up of 1.7 years post-AVNA. This was consistent with an 81.3% reduction in hospitalization (Odds ratio: 0.0095, 95% CI: 0.0023–0.0395, P<0.001); number needed to treat (NNT) = 2 (for every 2 patients undergoing pace-and-ablate therapy, one hospitalization was prevented) . PICM was seen only in those who underwent RV pacing, and the risk of PICM from standard RV pacing was 7.7% Conclusion : Pace and ablate therapy is a safe and effective procedure in patients with recurrent AF after prior AF ablation. Earlier consideration of AVNA in patients with a higher number of comorbidities should be considered. Our findings suggest a potential trend toward improved outcomes with biventricular or conduction system pacing in the setting of AVNA, though the limited sample size precludes definitive conclusions.