Key result
Pacemaker with AV-node ablation cuts major events ~55% versus PVI in elderly persistent AF.
Why the study?
In elderly patients with persistent AF, PVI has limited success, and the relative effects of PM+AVNA versus PVI on hospitalisations and other outcomes were unknown.
Does pacemaker-implantation with atrioventricular-node ablation reduce the composite of hospitalisation for atrial arrhythmia/heart failure, outpatient cardioversion, or CRT upgrade compared to pulmonary vein isolation in elderly patients (≥75 years) with symptomatic persistent atrial fibrillation and normal LVEF?
RCT (n=196)
Open-label
randomised
Yes
Does pacemaker-implantation with atrioventricular-node ablation reduce the composite of hospitalisation for atrial arrhythmia/heart failure, outpatient cardioversion, or CRT upgrade compared to pulmonary vein isolation in elderly patients (≥75 years) with symptomatic persistent atrial fibrillation and normal LVEF?
Hazard Ratio: 0.45 (95% CI 0.27–0.74)
Absolute Event Rate: 24% vs 46%
p-value: p=0.002
In elderly patients with persistent atrial fibrillation, a pace-and-ablate strategy significantly reduced the composite of arrhythmia/heart failure hospitalizations, cardioversions, and CRT upgrades compared to pulmonary vein isolation at 12 months.
Supports PM+AVNA over PVI in elderly persistent AF; extends symptom data to fewer hospitalizations and cardioversions.
Background and Aims Population aging is increasing atrial fibrillation (AF) prevalence. In elderly patients with persistent AF, pulmonary-vein isolation (PVI) has limited success, but is widely used. Pacemaker-implantation with atrioventricular-node ablation (PM+AVNA) provides effective symptom control, but the relative effects of PM+AVNA versus PVI on hospitalisations and other outcomes in the elderly remain unknown. Methods This investigator-initiated, multicentre, open-label trial randomised patients aged≥75 years with symptomatic persistent AF and normal left-ventricular ejection fraction to PM+AVNA or PVI treatment-strategies. The primary endpoint was a composite of hospitalisation for atrial arrhythmia or heart failure, outpatient electrical cardioversion or upgrade to cardiac resynchronisation therapy for left-ventricular dysfunction. Secondary endpoints included all-cause death, stroke, treatment-related complications and quality of life. Results Twelve centres in Germany and Austria randomised 196 patients (median age 82 years). At 12 months, a first primary endpoint event occurred in 24 of 98 patients (24%) assigned to PM+AVNA and 45 of 98 patients (46%) assigned to PVI (hazard ratio 0.45, 95% confidence interval 0.27 to 0.74; P=0.002). A total of 29 and 84 primary endpoint events occurred respectively, consisting principally of AF-hospitalisations and cardioversions in the PVI group (54 and 19 respectively, vs 3 and 1 in PM+AVNA group) and of heart failure-hospitalisations in the PM+AVNA Group (23, vs 11 in PVI group). The incidence of cardiovascular complications and mortality, as well as qualityof-life, were not statistically different. Conclusions In elderly patients with persistent AF, PM+AVNA was associated with fewer primary endpoint events than PVI over a 12-month follow-up period.
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Boehmer et al. (2026) conducted an RCT in persistent atrial fibrillation (n=196). Pacemaker-implantation with atrioventricular-node ablation vs. Pulmonary vein isolation was evaluated on composite of hospitalisation for atrial arrhythmia or heart failure, outpatient electrical cardioversion or upgrade to cardiac resynchronisation therapy for left-ventricular dysfunction (HR 0.45, 95% CI 0.27 to 0.74, p=0.002). In elderly patients with persistent AF, pacemaker implantation with AV-node ablation reduced hospitalisation, cardioversion, or CRT upgrade compared to PVI (HR 0.45; 95% CI 0.27-0.74; P=0.002).
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