Impact of ablate and pace on clinical outcomes, quality of life and healthcare utilization in patients with atrial fibrillation

Abstract Background Atrioventricular (AV) node ablation is classified as a class IIa recommendation with level of evidence B in the 2024 ESC guidelines for the management of atrial fibrillation (AF) (‘ablate and pace’ strategy). Previous studies have primarily focused on the impact of AV node ablation on NYHA class and left ventricular ejection fraction. Effects of AV node ablation on healthcare utilization and quality of life remain unclear. Purpose To assess the impact of AV node ablation in patients with uncontrolled AF on clinical outcomes, quality of life and healthcare utilization. Methods Data from patients who underwent AV node ablation between January 2019 and August 2023 at a single heart centre in the Netherlands was analysed at 2 time-intervals: one year prior (pre-ablation period) and one year after the AV node ablation (post-ablation period). Study outcomes included clinical outcomes (mortality at 90 days and one year, bleeding complications during admission, phrenic nerve paralysis during admission, thromboembolic complications at 72 hours, pneumothorax during admission, infection within 90 days, vascular complications at 30 days and cardiac tamponade), quality of life measured with the SF-36 questionnaire following the procedure and at one year follow-up, and healthcare utilization (number of holter analyses, electrocardiograms, electrical cardioversions, additional AF ablation (e.g. PVI), PM or ICD upgrade independent of AV node ablation, outpatient clinic visits, readmissions and emergency department visits). Results A total of 181 patients underwent AV node ablation. Median age was 77 years (IQR 71 - 81 years) and 43.6% were male. Type of AF was divided in paroxysmal (25.4%), persistent (47.5%) or longstanding persistent (27.1%). 90-days mortality rate was 2.8% (n = 5) and one year mortality rate was 11.0% (n = 20). None of the patients died related to the AV node ablation, but all deaths were attributed to advanced heart failure. One patient (0.6%) developed a minor vascular complication. No other clinical events were observed. Quality of life was improved in 66.2% of patients and remained equal in 11.8% of patients. In the year after AV node ablation, healthcare utilization was significantly decreased, with less holter analyses (p = <.001), electrocardiograms (p = <.001), electrical cardioversions (p = <.001), additional AF ablations (p <.001), PM or ICD upgrades (p <.001), outpatient clinic visits (p <.001), readmissions (p <.001) and emergency department visits (p = <.001). Conclusion AV node ablation was associated with a significant reduction in healthcare utilization, an increase in quality of life and very low rate of adverse events. AV node ablation should be considered as additional treatment in patients with AF.