Feasibility and Safety of Atrioventricular Node Pacing in a Patient With Heart Failure and Atrioventricular Block

BACKGROUND: Conduction system pacing (CSP) serves as a physiological alternative for managing heart failure and atrioventricular block. CASE SUMMARY: A 77-year-old woman was admitted with worsening shortness of breath. Her diagnoses included chronic heart failure classified as NYHA functional class IV, permanent atrial fibrillation, third-degree atrioventricular block after pacemaker implantation, and rheumatic heart valve disease. Atrioventricular node pacing (AVNP) was successfully achieved, with a stable threshold of 0.75 V at 0.4 ms. Over a 2-year period, the patient's left ventricular ejection fraction improved from 26% to 44%, left ventricular end-diastolic diameter decreased from 63 to 56 mm, and NYHA functional classification improved from IV to II. DISCUSSION: AVNP may present a viable alternative for patients experiencing failure of His bundle pacing and left bundle branch pacing. This case demonstrates to our knowledge the first report of AVNP with sustained electrophysiological stability and clinical efficacy during a 2-year follow-up, thereby addressing existing gaps in the applicability of CSP for patients with anatomically complex conditions. TAKE-HOME MESSAGE: AVNP may provide an alternative for patients with failure of traditional CSP.