Atrioventricular nodal ablation and pacemaker implantation in patients with atrial fibrillation.

In drug-resistant, poorly tolerated atrial fibrillation, atrioventricular (AV) junction catheter ablation can be proposed as the last-resort option. Technically, the procedure is easy to perform and relatively safe. Interruption of the AV conduction implies the insertion of a permanent pacemaker. In patients with chronic atrial fibrillation, a VVIR pacemaker is inserted. For those having severely symptomatic episodes of paroxysmal atrial fibrillation, DDDR mode-switching devices are more appropriate. Results are remarkable. The treatment is highly effective in controlling symptoms and improving general well-being. Exercise capacity is also increased. Left ventricular ejection fraction may increase after ablation, an effect that is mainly apparent in patients with markedly depressed myocardial function. Consumption of healthcare resources has been shown to decrease significantly in the aftermath of AV junction ablation. However, sudden-death risk has been invoked as a limiting factor for the procedure. This may be due to AV-block-related ventricular tachyarrhythmias, occurring early after ablation, whereas the reasons for late sudden deaths are somewhat more obscure. It is unclear whether such events are procedure-related or rather secondary to the underlying heart disease. Thus, AV junction ablation for refractory atrial fibrillation remains the only nonpharmacologic, alternative therapy that is performed on a routine basis. Failure of newer therapeutic approaches should further reinforce the clinical impact of this procedure in the future.