Left bundle branch pacing plus atrioventricular node ablation in a 91-year-old patient with tachycardia-bradycardia syndrome early after PCI

We present a 91-year-old female with tachycardia-bradycardia syndrome (TBS) presenting with prolonged asystole up to 8.1 s, 1 month after percutaneous coronary intervention (PCI) while receiving uninterrupted dual antithrombotic therapy (clopidogrel 75 mg daily and rivaroxaban 10 mg daily; aspirin had been discontinued one month after PCI). After failure of antiarrhythmic drug therapy, she underwent left bundle branch pacing (LBBP) without interruption of dual antithrombotic therapy (clopidogrel and rivaroxaban), followed by atrioventricular node ablation (AVNA) for refractory rapid ventricular response. The procedure was successful, with complete relief of syncope, palpitations, and chest pain during the 6-month follow-up measured from AVNA. This case illustrates the feasibility of a staged LBBP and AVNA strategy in a carefully selected very elderly patient with TBS and recent PCI when conventional pharmacological rate control was unsuccessful, and may provide a reference for similar high-risk patients.