Navigating the Challenges of Refractory Heart Failure with atrioventricular and biventricular dyssynchrony: Clinical Reflections and Lessons Learned

Introduction Heart failure (HF), a complex clinical syndrome arising from structural or functional cardiac impairment, carries substantial morbidity with 30% early readmission rates within three months post-discharge and strong mortality associations (1) . The pathophysiological interplay between atrial fibrillation (AF) and HF presents particular clinical challenges, as their concomitant presence portends worse prognoses than either condition in isolation (2) . Moreover, biventricular dyssynchrony emerges as a critical pathophysiological determinant of impaired ventricular filling and reduced cardiac output (3) . The tripartite convergence of these conditions creates a high-risk clinical scenario requiring sophisticated therapeutic strategies. Here we present a therapeutic paradigm employed sequential interventions, highlighting clinical reflections and lessons learned from a staged interventional approach. Methods A therapeutic paradigm employed sequential interventions: initial atrioventricular node ablation (AVNA) with BiV-CRTD implantation, followed by delayed AF radiofrequency ablation 18 months later. Results The patient experienced relief from dyspnea, accompanied by enhanced performance on the 6MWT. The postoperative ECG demonstrated narrowed QRS complex duration,alongside improvements in LVEF and cardiac chamber dimensions. Near 100% biventricular pacing capture was achieved, with progressively optimized left ventricular lead parameters, dynamically decreasing pro-BNP levels and the maintenance of sinus rhythm one year after the AF ablation, collectively confirming the therapeutic benefits. Conclusion Correcting AV, interventricular, and intraventricular dyssynchrony is crucial. The efficacy of CRT varies individually due to myocardial viability, target vessel anatomy, and patterns of delayed cardiac activation. Reducing RV lead output to minimize pacemaker battery consumption in pacemaker-dependent patients with suboptimal LV lead parameters carries substantial risks. Although AVNA can achieve near-complete biV pacing in patients with persistent atrial fibrillation, this approach should be exercised with caution. For future management, Bachmann's bundle pacing may be considered, while left bundle branch area pacing represents a viable alternative when LV lead parameters remain unsatisfactory.