Persistent Atrial Fibrillation With Conduction System Pacing or Pulmonary Vein Isolation

BACKGROUND: Conduction system pacing (CSP) combined with atrioventricular node ablation (AVNA) is a feasible option for symptomatic atrial fibrillation (AF), but comparative studies with pulmonary vein isolation (PVI) are limited. OBJECTIVES: The aim of this study was to compare the clinical outcomes of CSP+AVNA and PVI in patients with persistent AF and a left atrial size. METHODS: This observational study included patients with persistent AF and a left atrial size >50 mm received PVI or CSP+AVNA (ablate and pace [AP]) from 2016 to 2022. Clinical outcomes, AF recurrence, and the composite endpoint of heart failure hospitalization and cardiac death were assessed. RESULTS: Out of 718 screened patients, 473 received PVI and 245 received AP. The AP strategy was associated with higher composite risk in univariate analysis (HR: 2.84; 95% CI: 1.79-4.50; P < 0.001) but not after multivariate adjustment (HR: 1.10; 95% CI: 0.54-2.23; P = 0.795). After 1:1 matching (n = 174), left ventricular ejection fraction improved similarly in both groups. Over an average 40 months' follow-up, the composite endpoint was similar between groups (propensity score matching [PSM]-AP: 14.9% vs PSM-PVI: 16.1%; P = 0.864). AF recurred in 54.0% in the PSM-PVI group and atrioventricular conduction recurred in 1.2% in the PSM-AP group. CONCLUSIONS: In this observational study, outcomes were numerically similar between PVI and AP in patients with persistent AF and enlarged left atria. Given the limited sample size and residual confounding, these results should be considered hypothesis-generating pending confirmation from randomized trials.