Determining Good Candidates for Atrioventricular Junction Ablation and Device Therapy and Which Device to Implant

The 'ablate-and-pace' strategy, combining atrioventricular junction ablation with permanent pacing, has re-emerged as a valuable therapeutic option for patients with AF who are symptomatic, have poor rate control or develop AF-mediated cardiomyopathy. While historically considered a last-resort treatment, recent randomised trials and meta-analyses support its efficacy in improving functional status, reducing hospitalisations and potentially enhancing survival, particularly when paired with CRT or conduction system pacing. The success of this approach depends on careful patient selection and appropriate device choice. Candidates include patients with uncontrolled ventricular rates, tachycardia-bradycardia syndrome, symptomatic bradycardia or those with poor CRT response due to persistent AF. Right ventricular pacing should be avoided when possible, in favour of biventricular or conduction system pacing, which preserves synchrony and reduces pacing-induced cardiomyopathy. This review discusses clinical scenarios, prognostic considerations, and current device options - including leadless systems - offering a practical guide for tailoring atrioventricular junction ablation-based therapies to individual patient profiles.