Key result
Cardiac resynchronization therapy did not significantly differ from right ventricular pacing in the composite of all-cause mortality and heart failure hospitalization among patients with atrial fibrillation managed through a pace-and-ablate strategy (HR 1.24, p=0.206).
Why the study?
The pace-and-ablate strategy is second-line therapy for rate control in persistent symptomatic AF, but its long-term effects on clinical outcomes required evaluation.
Does a pace-and-ablate strategy with right ventricular pacing compared to cardiac resynchronization therapy affect the composite of all-cause mortality and heart failure hospitalization in patients with atrial fibrillation?
Cohort (n=298)
Yes
Does a pace-and-ablate strategy with right ventricular pacing compared to cardiac resynchronization therapy affect the composite of all-cause mortality and heart failure hospitalization in patients with atrial fibrillation?
Hazard Ratio: 1.24 (95% CI 0.89–1.73)
Absolute Event Rate: 49% vs 47%
p-value: p=0.206
In patients with atrial fibrillation undergoing a pace-and-ablate strategy, long-term mortality and heart failure hospitalization rates are high, but there is no significant difference in the primary composite outcome between those receiving guideline-directed right ventricular pacing versus cardiac resynchronization therapy.
High long-term mortality/HFH rates warrant caution in selection; supports CRT in reduced LVEF while leaving RVP outcomes open for prospective trials.
BACKGROUND: The pace-and-ablate strategy is second -line therapy to obtain rate control in patients with persistent symptomatic atrial fibrillation (AF) when other treatment options fail. This study aims to evaluate long-term effects on clinical outcomes following pace-and-ablate strategy in AF patients. METHODS: This retrospective study includes patients who underwent successful pacemaker implantation (right ventricular pacing (RVP) or cardiac re-synchronization therapy (CRT)) followed by atrioventricular node ablation (AVNA) between 2010 and 2020. Patients were treated according to the prevailing guidelines. The primary endpoint was a composite of all-cause mortality and heart failure hospitalization (HFH). Secondary endpoints were individual outcomes of all-cause mortality, HFH, and left-ventricular ejection fraction (LVEF) change. RESULTS: Two hundred ninety-eight patients were included, 162 undergoing RVP, and 136 receiving CRT, with a median follow-up of 5.8 years [4.1-8.0]. The primary endpoint occured in 47% of the RVP group and 49% of the CRT group (p = 0.206). All-cause mortality occurred in 36% of the RVP group and in 45% of the CRT group (p = 0.005). HFH occurred in 22% of the RVP group and in 15% of the CRT group (p = 0.328), with 17(10%) upgrades to CRT in the RVP group. Median LVEF in the RVP group remained stable (56% [49-60] to 53% [43-57]; p = 0.081), while it improved in the CRT group (31% [22-38] to 43% [32-51]; p < 0.001). CONCLUSION: Mortality and HFH in patients with AF managed through a pace-and-ablate strategy are high. Reassuringly, LVEF deterioration requiring upgrade to CRT is uncommon in patients undergoing RVP with normal baseline LVEF before AVNA. CRT improves LVEF in patients with reduced LVEF before AVNA.
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Koll et al. (2025) conducted a cohort in Atrial fibrillation (n=298). Cardiac resynchronization therapy (CRT) vs. Right ventricular pacing (RVP) was evaluated on Composite of all-cause mortality and heart failure hospitalization (HFH) (HR 1.24, 95% CI 0.89-1.73, p=0.206). Cardiac resynchronization therapy did not significantly differ from right ventricular pacing in the composite of all-cause mortality and heart failure hospitalization among patients with atrial fibrillation managed through a pace-and-ablate strategy (HR 1.24, p=0.206).
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