Determining Good Candidates for Atrioventricular Junction Ablation and Device Therapy and Which Device to Implant - Review

Sep 30, 2026

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The review evaluates the ‘ablate-and-pace’ strategy, combining atrioventricular junction ablation with permanent pacing, for symptomatic atrial fibrillation patients with poor rate control or AF-mediated cardiomyopathy. Evidence from recent trials and meta-analyses supports improvements in functional status, reduced hospitalisations, and possible survival benefits, especially when paired with CRT or conduction system pacing. Success depends on careful patient selection, including specific candidate phenotypes, and appropriate device choice, with guidance to avoid right ventricular pacing when possible.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages8

Reading Time20 min

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Abstract

Atrioventricular (AV) junction ablation and the ‘ablate-and-pace’ strategy

Pathophysiological rationale for AV junction ablation in AF with heart failure

AF phenotypes and mechanisms leading to HF

Tachycardia-induced cardiomyopathy

REVIEW Clinical Electrophysiology and Ablation Determining Good Candidates for Atrioventricular Junction Ablation and Device Therapy and Which Device to Implant Arnaud Bisson ,1,2 Thibaut Lenormand,1 Mathieu Jacobs 1 and Laurent Fauchier 1,2 1. Service de Cardiologie, Centre Hospitalier Régional Universitaire et Faculté de Médecine de Tours, Tours, France; 2. Inserm UMR1327 ISCHEMIA Membrane Signalling and Inflammation in Reperfusion Injuries, Université de Tours, Tours, France Abstract The ‘ablate-and-pace’ strategy, combining atrioventricular junction ablation with permanent pacing, has re-emerged as a valuable therapeutic option for patients with AF who are symptomatic, have poor rate control or develop AF-mediated cardiomyopathy. While historically considered a last-resort treatment, recent randomised trials and meta-analyses support its efficacy in improving functional status, reducing hospitalisationsand potentially enhancing survival, particularly when paired with CRT or conduction system pacing. The success of this approach depends on careful patient selection and appropriate device choice. Candidates include patients with uncontrolled ventricular rates, tachycardia–bradycardia syndrome, symptomatic bradycardia or those with poor CRT response due to persistent AF. Right ventricular pacing should be avoided when possible, in favour of biventricular or conduction system pacing, which preserves synchrony and reduces pacing-induced cardiomyopathy. This review discusses clinical scenarios, prognostic considerations, and current device options – including leadless systems – offering a practical guide for tailoring atrioventricular junction ablation-based therapies to individual patient profiles. Keywords Atrioventricular junction ablation, AF, heart failure, cardiac resynchronisation therapy, conduction system pacing Received: 11 July 2025 Accepted: 3 October 2025 Citation: Arrhythmia & Electrophysiology Review 2025;14:e33 . DOI: [https://doi.org/10.15420/aer.2025.41](https://doi.org/10.15420/aer.2025.41)[ ](https://doi.org/10.15420/aer.2025.41)[Disclosure:](Disclosure: AB has received consulting fees and honoraria from AstraZeneca)[ AB has received consulting fees and honoraria from AstraZeneca](Disclosure: AB has received consulting fees and honoraria from AstraZeneca), Bayer, BMS/Pfizer, Medtronic, Vifor Pharma and Alnylam. TL has received consulting fees from Bayer, BMS/Pfizer, Boehringer Ingelheim and Novo Nordisk and honoraria from AstraZeneca, Boston Scientific, Medtronic and Novo Nordisk. All other authors have no conflicts of interest to declare. Correspondence: Laurent Fauchier, Service de Cardiologie, Centre Hospitalier Regional Universitaire et Faculté de Médecine de Tours, 2 Boulevard Tonnellé, 37000 Tours, France. E: [laurent.fauchier@univ-tours.fr](laurent.fauchier@univ-tours.fr) Copyright: © The Author(s) 2025. This work is open access and is licensed under CC BY-NC 4.0. Users may copy, redistribute and make derivative works for non-commercial purposes, provided the original work is cited correctly. Atrioventricular (AV) junction ablation (AVJA) combined with permanent pacing – commonly referred to as the ‘ablate-and-pace’ strategy – has emerged as a therapeutic option in selected patients with AF, particularly those with heart failure (HF) or poor rate control despite optimal medical therapy.1 Beyond its historical use in controlling tachycardia, AVJA may alleviate the deleterious effects of RR interval irregularity (irregulopathy) and improve cardiac function in AF-related cardiomyopathy. The clinical benefit of AVJA depends not only on patient selection but also on the pacing modality employed, with growing interest in biventricular pacing (BiVP) and conduction system pacing (CSP) as alternatives to right ventricular pacing (RVP). In this review, we examine the pathophysiological rationale for AVJA in AF and HF, clinical indications and patient selection, and current options for

FAQs

What is the ‘ablate-and-pace’ strategy and when is it used in AF?

It combines atrioventricular junction ablation with permanent pacing. It is discussed as a therapeutic option for selected AF patients, particularly those who are symptomatic, have poor rate control, or develop AF-mediated cardiomyopathy.

What evidence supports the efficacy of AV junction ablation with permanent pacing?

Recent randomised trials and meta-analyses are described as supporting improvements in functional status and reductions in hospitalisations, and potentially enhancing survival, especially when paired with CRT or conduction system pacing.

How should pacing modality influence device selection for AV junction ablation candidates?

The review emphasizes that success depends on choosing an appropriate pacing modality. Right ventricular pacing should be avoided when possible, favoring biventricular or conduction system pacing to preserve synchrony and reduce pacing-induced cardiomyopathy.

Sep 30, 2026

Uploaded by Marglet