Procedural Management of Atrial Fibrillation in Older Patients

Atrial fibrillation (AF) is becoming increasingly prevalent worldwide because of population aging and the widespread availability of continuous rhythm monitoring. While medical therapy remains central to management, several procedural strategies are being considered for older patients, including catheter ablation with pulsed field ablation (PFA), atrioventricular node ablation with conduction system pacing (CSP), leadless pacemaker (LPM) implantation, and percutaneous left atrial appendage occlusion (LAAO). Catheter ablation is an established therapy that reduces AF burden and improves quality of life; however, the role of catheter ablation in older patients has historically been limited by higher complication rates and greater arrhythmia recurrence. The emergence of PFA may expand the role of ablation because of its procedural efficiency and favorable safety profile, although randomized data in older patients remain limited. A pace-and-ablate strategy with CSP offers an alternative for older patients with symptomatic persistent AF or tachy-brady syndrome. Indeed, by engaging the native conduction system, CSP provides more physiological ventricular activation and may reduce the risk of pacing-induced cardiomyopathy. LPMs avoid the lead- and pocket-related complications associated with transvenous pacemakers and may be especially advantageous in frail older patients with multiple comorbidities. LAAO is a potential strategy for stroke prevention that is often proposed for patients unable to tolerate long-term anticoagulation, although randomized data remain conflicting. This narrative review evaluates the current evidence supporting these procedures in older patients with AF.