Clinical Outcomes After Ablation of the AV Junction in Patients With Atrial Fibrillation: Impact of Cardiac Resynchronization Therapy

BACKGROUND Patients with atrial fibrillation (AF) often undergo AV junction ablation (AVJA) and pacemaker implantation. Right ventricular (RV) pacing contributes to increased risk of heart failure (HF), which may be mitigated by biventricular pacing. We sought to determine the impact of AVJA concurrent with RV versus biventricular pacemaker implantation on AF and HF hospitalizations. METHODS AND RESULTS The MarketScan Commercial and Medicare Supplemental claims database was used to select 18- to 100-year-old patients with AF with pacemaker implantation. Patients were divided into those with an RV and a biventricular pacemaker and further into those who did (AVJA+) or did not undergo concurrent ablation. Separately, the AVJA+ group was divided into those receiving RV versus biventricular pacemakers. AF and HF hospitalization rates were compared between groups after matching on demographics, comorbidities, and baseline hospitalization rates. The study included 24 361 patients, with RV (n=23 377) or biventricular (n=984) pacemakers; 1611 patients underwent AVJA. AVJA+ was associated with reduced AF hospitalization risk (RV hazard ratio [HR], 0.31; P<0.001; biventricular HR, 0.20; P=0.003) compared with no AVJA. However, HF hospitalization risk was increased for RV (HR, 1.63; P=0.001), but not biventricular (HR, 0.98; P=0.942), pacemakers. In AVJA+ patients, biventricular pacing was associated with reduced risk of HF hospitalization versus RV pacing (HR, 0.62; P=0.017). CONCLUSIONS In a large cohort of patients with AF, AVJA+ significantly reduced AF hospitalizations, irrespective of whether an RV or a biventricular pacemaker was implanted. However, AVJA was associated with a marked HF hospitalization increase in patients with an RV pacemaker, which was ameliorated with biventricular pacing.