Long‐Term Outcomes of AV Node Ablation Plus CRT Compared to AF Catheter Ablation in Patients With AF and HFrEF

BACKGROUND: Catheter ablation is an established rhythm-control strategy for atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF), while atrioventricular node ablation with cardiac resynchronization therapy (AVNA+CRT) is often used in older patients with advanced disease when durable rhythm control is less feasible. Comparative long-term outcomes remain unclear. METHODS: Using the TriNetX Research Network, we identified adults with HFrEF and AF from 2016 who underwent AF ablation or AVNA+CRT from 2016-2023 and 2016-2020 for the 2- and 5-year analysis, respectively. Propensity score matching was performed separately using 58 prespecified covariates. Outcomes included embolic events (stroke/systemic embolism), all-cause mortality, heart failure (HF) hospitalization, and heart transplant/left ventricular assist device (LVAD) implantation. RESULTS: The 2-year cohort included 16,276 patients (2899 AVNA+CRT; 13,377 AF ablation); the 5-year cohort included 7370 patients (1463 AVNA+CRT; 5907 AF Ablation). After matching, AVNA+CRT was associated with higher all-cause mortality (RR 1.580, 95% CI 1.389-1.799), HF hospitalization (RR 1.106, 95% CI 1.040-1.176), and heart transplant/LVAD implantation (RR 2.381, 95% CI 1.142-4.975), with no difference in embolic events at 2 years. At 5 years, AVNA+CRT remained associated with higher mortality (RR 1.350, 95% CI 1.198-1.522; p < 0.001), while HF hospitalization, embolic events, and heart transplant/LVAD implantation did not differ significantly. CONCLUSION: In a large propensity matched HFrEF-AF cohort, AVNA+CRT was associated with higher mortality at 2 and 5 years than AF ablation, with excess HF hospitalization and transplant/LVAD at 2 years, whereas HF hospitalization rates were similar at 5 years. Prospective studies are needed to refine patient selection in older, medically complex patients.