Ablate and Pace in Cardiogenic Shock: A Rescue Strategy Combining Av Node Ablation and CRT for Refractory Atrial Fibrillation

Atrioventricular node ablation (AVNA) combined with biventricular pacing (CRT) is a guideline-recommended (Class IIA) therapy for rate control in patients with atrial fibrillation (AF) and high ventricular rates refractory to medical therapy. This study evaluates the efficacy of the "ablate and pace" strategy in patients with cardiogenic shock (CS), where uncontrolled tachycardia exacerbates hemodynamic deterioration. From September 2018 to September 2023, 25 patients with cardiogenic shock were admitted to our CCU. All patients had dilated cardiomyopathy (60% ischemic, 40% non-ischemic), a mean age of 74 years, and were predominantly male (77%). They were already on optimized medical therapy, including inotropes, to maintain adequate blood pressure. All patients had an implantable cardioverter-defibrillator (ICD) and permanent AF, with high ventricular rates (mean heart rate at admission: 128 bpm) leading to acute decompensation. At admission, mean systolic blood pressure was 83±7 mmHg, NT-proBNP levels were 24,756 pg/mL, and mean ejection fraction (EF) was 22%. Due to the inability to achieve rate control pharmacologically, AVNA followed by CRT-D upgrade was performed. CRT-D implantation was successful in 22/25 patients (88%). Left ventricular lead positions were anterolateral (41.7%), lateral (41.7%), and posterolateral (16.6%). Complications included hematoma in 7% of cases. The mean biventricular QRS duration was 124±9 ms. After an initial pacing rate of 90 bpm, patients were reprogrammed to a lower rate of 70 bpm. At follow-up (mean 19±10 months), patients showed excellent rate control (mean heart rate: 70 bpm), significant stabilization of blood pressure (mean systolic BP: 93±5 mmHg vs. 83±7 mmHg at baseline, p < 0.0001), improved cardiac function (mean EF: 28% vs. 22% at baseline), and reduced NT-proBNP levels (12,172 pg/mL vs. 24,756 pg/mL at baseline, p < 0.0001). Survival at follow-up was 75%, with 35% of patients experiencing episodes of heart failure exacerbation. Appropriate ICD interventions occurred in 25% of patients, and spontaneous restoration of sinus rhythm was observed in 2 patients. The "ablate and pace" strategy (AVNA combined with CRT-D upgrade) is an effective and life-saving intervention for rate control in patients with refractory AF and cardiogenic shock. It significantly improves hemodynamic parameters and cardiac function, representing a critical therapeutic option in high-risk settings where traditional approaches are insufficient.