Atrioventricular node ablation and pacing for atrial tachyarrhythmias: A meta-analysis of postoperative outcomes

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

“…48 A meta-analysis of 93 studies including 11 343 patients who underwent AVNA with either RV pacing or biventricular pacing showed periprocedural complications of arrhythmia, HF, and lead dislodgement in 2% to 2.5%, 49 few long-term data, and worse outcomes in younger patients with reduced EF and RV pacing. 49 Overall, these data showed improved mortality in patients with HF who are treated with cardiac resynchronization therapy (CRT), at the risk of increased device-related complications. 49 The APAF-CRT (Ablate and Pace in Atrial Fibrillation plus Cardiac Resynchronization Therapy) mortality trial of 133 subjects with AF, HF, and narrow QRS was stopped early due to a HR of 0.26 for all-cause mortality, also suggesting that when AVNA is performed in patients with HF, CRT is preferable to conventional RV pacing.…”

“…Early and late complication rates are not inconsequential, specifically in young patients in view of the risk of pacemaker-mediated cardiomyopathy, and long-term follow-up data are scant. 9 Although few studies concerning AVNA and pacing report complication rates for the pacemaker implant, the overall risk of lead dislodgement or failure is approximately 2%, and many operators perform both AVNA and pacemaker implant during the same procedure. 9,13,24 Practice patterns vary, however, and a European survey indicated up to 80% of operators will choose to perform AVNA 1 to 3 months after pacemaker implantation to reduce risk of adverse outcome due to early lead dislodgement.…”

“…8 If AVNA and pacing are performed concomitantly, ideally, leads should be placed first to ensure adequate lead function. HF after AVNA is attributed to the deleterious effects of RVP, 26 and risk is correlated with baseline cardiac function. 9 The PAVE (Post AV Nodal Ablation Evaluation) trial compared outcomes in patient with persistent AF and uncontrolled rates undergoing AVNA and RVP with AVNA and biventricular pacing (BiVP) and found an improvement in 6-minute walk test and EF, but benefit was predominantly seen in subjects with EF <45% or New York Heart Association (NYHA) class II to III HF at baseline. 27 Not all patients appear to be at high risk of HF after AVNA and RVP.…”

“…20–22,47 A meta-analysis comparing outcomes with AVNA or medications showed, in 2 studies analyzing patients with reduced EF, a modest, yet significant +4% increase in EF in patients undergoing AVNA and RV pacing, while patients with normal EF at baseline did not show a significant change. 48 A meta-analysis of 93 studies including 11 343 patients who underwent AVNA with either RV pacing or biventricular pacing showed periprocedural complications of arrhythmia, HF, and lead dislodgement in 2% to 2.5%, 49 few long-term data, and worse outcomes in younger patients with reduced EF and RV pacing. 49 Overall, these data showed improved mortality in patients with HF who are treated with cardiac resynchronization therapy (CRT), at the risk of increased device-related complications.…”

“…Overall, long-term data on outcomes after AVNA are limited, and no evidence supports AVNA as first-line therapy. 9…”