Long-term Outcomes of Atrioventricular Node Ablation and Pacemaker Therapy for Rate Control in Atrial Fibrillation: Insights from a 10-year Nationwide Analysis

Background: Atrioventricular node ablation (AVNA) is an effective rate-control strategy for patients with AF refractory to medical therapy. However, data on long-term survival outcomes and prognostic factors in this population remain limited. Thus, we aimed to evaluate long-term mortality in patients with refractory AF who underwent AVNA in a single country. Methods: We conducted a nationwide retrospective cohort study including all patients who underwent AVNA followed by permanent pacing (n=435) in Estonia from 2012 to 2022. The primary endpoint was all-cause mortality. Comparisons were made between CRT and right ventricular (RV) pacing, AVNA timing (≤6 months and later following device implantation) and by patient sex. Results: Acute success was achieved in 418 (96.1%); mean age was 73.2 ± 10.2 years and 56.5% were female. Median follow-up was 4.2 years (range 2 days to 12.9 years), with median survival of 7.8 years. No significant survival difference was observed between CRT and RV pacing overall nor in ad hoc AVNA and pacemaker implantation cases. Among CRT recipients, early AVNA (≤6 months post-implantation) significantly reduced mortality risk compared with later AVNA (HR 0.48; 95% CI [0.24-0.96]; p=0.038). In RV-paced patients, timing showed no survival impact, but renal function independently predicted mortality (p<0.001). Survival was similar between sexes. Conclusion: In this 10-year nationwide cohort, AVNA with permanent pacing resulted in survival comparable to local population norms. CRT provided no universal survival benefit over RV pacing, but early AVNA was associated with significantly improved outcomes in CRT recipients.