Five-year outcomes after pulmonary vein isolation versus atrioventricular nodal ablation with pacing in patients ≥75 years with persistent atrial fibrillation: a propensity-matched analysis

Background The optimal ablation strategy for elderly patients with persistent atrial fibrillation (AF) remains uncertain. Both pulmonary vein isolation (PVI) and atrioventricular (AV) nodal ablation with permanent pacing are used in clinical practice, but comparative long-term data in elderly populations are limited. Purpose To compare 5-year clinical outcomes following PVI versus AV nodal ablation with dual-chamber pacemaker implantation in patients ≥75 years with persistent AF. Methods Using the TriNetX United States Collaborative Network, we identified patients aged ≥75 years with persistent AF undergoing PVI (n=32,808) or AV nodal ablation with dual-chamber pacing (n=3,798) between 2014 and 2024. Propensity score matching (1:1) incorporating demographics, comorbidities, medications, laboratory values, and echocardiographic parameters including left ventricular ejection fraction generated two balanced cohorts (n=3,285 each). Outcomes included all-cause mortality, all-cause hospitalisation, heart failure hospitalisation, ischaemic stroke, and a rhythm-related composite (AF or heart failure hospitalisation, electrical cardioversion, or upgrade to cardiac resynchronisation therapy). These were assessed from a 90-day landmark after the index procedure with follow-up to 5 years using Kaplan-Meier and Cox regression analyses. Results After matching, baseline characteristics were well balanced (mean age 84 years; 63% female). Over 5 years, PVI was associated with lower all-cause mortality (11.5% vs 22.4%; HR 0.49, 95% CI 0.43-0.55; p<0.001) and fewer heart failure hospitalisations (38.8% vs 43.0%; HR 0.84, 95% CI 0.78-0.91; p<0.001). Ischaemic stroke rates were similar (3.0% vs 3.5%; HR 0.82, 95% CI 0.63-1.08, p=0.152). PVI was also associated with modestly higher all-cause hospitalisation (59.7% vs 56.4%; HR 1.13, 95% CI 1.06-1.21; p<0.001) and a higher rhythm-related composite outcome (70.0% vs 60.5%; HR 1.28, 95% CI 1.20-1.36; p<0.001). (Figure 1) Conclusion In patients aged ≥75 years with persistent AF, PVI was associated with lower mortality and fewer heart failure hospitalisations compared with AV nodal ablation with pacing, although with higher all-cause hospitalisation and rhythm-related composite events. These findings underscore important trade-offs between rhythm and rate strategies in elderly patients and warrant prospective studies to optimise patient selection in this growing population.