Ablate and pace: palliating the symptoms?

Abstract

Atrioventricular (AV) junction ablation (producing AV block) followed by pacemaker implantation is the most common nonpharmacologic treatment for patients affected by atrial fibrillation (AF) not controlled by antiarrhythmic drugs. In expert hands, the efficacy of producing complete AV block is usually >95% if a sequential right- and left-side approach is used; regression of AV block late after ablation (which requires a second procedure on a different day) occurs in <5% of cases. The clinical efficacy of ablate and pace therapy in controlling arrhythmic symptoms and improving overall quality of life is well established for patients with paroxysmal AF, although not yet for patients with persistent and permanent AF, owing to the lack of sufficient clinical studies. Ablation and pacing is clinically unsuccessful in a minority of cases. There have been little data available on long-term effects of this treatment on cardiac performance, morbidity, and survival. Although concern has arisen from some case reports, no evidence of adverse effect has ever been shown in controlled trials. Ablation and pacing does not seem to increase thromboembolic risk. We estimate that in Europe, about 396,000 patients with paroxysmal AF not controlled by drug therapy could therefore be candidates for ablate and pace therapy. Permanent forms of AF are even more frequent, but it is unknown how many are refractory to drug therapy. The recommended pacing mode is DDDR with mode switching for paroxysmal/persistent AF and VVIR for permanent AF.