Abstract 17261: Maintenance of Sinus Rhythm After His Bundle Pacing and AV Nodal Ablation in Patients With Recurrent Atrial Fibrillation After Catheter Ablation

Abstract

Background: Catheter ablation (CA) is the most effective means of rhythm control for atrial fibrillation (AF) but is not curative. Irregular and rapid ventricular activation by AF begets AF. Cardiac resynchronization and atrioventricular nodal (AVN) ablation have been associated with favorable atrial remodeling and spontaneous reversion to sinus rhythm in patients with longstanding atrial fibrillation. Hypothesis: We hypothesized that in patients with longstanding persistent AF who had failed CA, AVN ablation and His bundle pacing (HBP) may improve maintenance of sinus rhythm. Methods and Results: A total of 13 patients (5 female, age 69±8.7 years, 8 with HFrEF, BMI 29 ±5 kg/m 2 ,LVEF 38±15%, NYHA 3±0.6) underwent simultaneous AVN ablation and HBP an average of 531 days (Range 1-2158 days) after CA for AF with recurrent AF. Prior to AVN ablation and HBP these patients had a median 9-year history of AF (IQR: 5-15 years) with a median of 2 prior cardioversions (IQR: 1-4) and 2 prior CA. All patients had failed at least 1 antiarrhythmic drug. In 3 patients HBP induced cardiac resynchronization of pre-existing bundle branch block and in 8 patients HBP was fused with ventricular pacing to optimize QRS duration. 12 of 13 patients had an atrial lead. All patients underwent cardioversion at the time of the procedure. In a median of follow up of 21 months (IQR:4-74 months), 7 of the 13 patients (54%) had no device detected or clinical recurrence of AF. In follow up LVEF increased to 46±12.7% and NYHA class to 2 ±0.2. Of patients with recurrence, 3 underwent CA and had no recurrence of AF in subsequent follow up. Conclusion: In patients with advanced longstanding persistent AF, a strategy of AVN ablation and HBP allowed for ventricular rate control with a narrow QRS. This approach resulted in a lower than expected rate of AF recurrence.