Background: Atrial fibrillation (AF) is the most common sustained arrhythmia in adult population with increased prevalence particularly in elderly. AV node ablation and pacemaker insertion (ablate and pace) is a widely accepted strategy for heart rate control in patients with symptomatic AF when rhythm control strategy fails or is deemed inappropriate. Patients usually receive a right ventricular pacing only type of pacemaker unless they got severe left ventricular systolic dysfunction. RV pacing is known to cause LV dysfunction in pacing dependent patients and might have adverse clinical effects on long term follow up. In this study, we aim to review the short and intermediate outcomes of patients who received ablate and pace strategy at University hospitals of Leicester between 2014 and 2019.
Methods: A retrospective analysis of clinical data of symptomatic atrial fibrillation patients treated with AVNA between 2014 and 2019 was conducted. Inclusion criteria were: 1. Symptomatic AF inappropriately controlled with other measures. Exclusion criteria: 1. Patients undergoing follow up in different hospitals where they were referred to our center for the AVNA only. 2. Patients lost to follow up. 3. Patients with incomplete data. Initial sample size was 262 patients; thirty patients were excluded due to the above reasons. Final sample size was 206 patients. The outcomes assessed by our study were annual mortality rate, hospitalizations due to heart failure and the need for upgrade to biventricular pacing system.
Results: Two hundred and six patients met the inclusion criteria, eighty-five (41.3%) were males and 121 females (58.7%); mean age was 74.01, SD +/- 7.93 years. Median follow up was 35.6 +/-24.4 months. All patients had uncomplicated procedures with no prolonged hospitalization. Thirty-one patients (15.04%) died during follow up till present. Twenty-seven patients (13.1%) were hospitalized, at least once, due to worsening heart failure symptoms. Twelve patients (5.8%) had multiple admissions for decompensated heart failure post ablation. One hundred and eight patients (52.4%) had right ventricular pacing only while 98 patients (47.6%) received a biventricular pacemaker/defibrillator. Sixteen patients of the former (14.8%) had to undergo upgrade from PPM to CRT as a result of worsening heart failure symptoms. Additional twelve patients (11.1%) required hospitalization due to heart failure decompensation. The incidence for heart failure hospitalization or deterioration in NYHA class was (25.9%) in patients with RV pacing group versus (17.3%) in CRT group (P=0.02). There was no significant mortality difference between both groups.
Conclusion: Significant adverse outcomes were observed following ablate and pace strategy including mortality and worsening heart failure particularly in patients with right ventricular only pacing. Further prospective studies are needed to assess whether a physiological pacing like His bundle pacing might improve the outcome.