Effectiveness and safety of AV node ablation after His bundle pacing in patients with uncontrolled atrial arrhythmias

Abstract

Introduction In patients with uncontrolled atrial fibrillation, atrioventricular (AV) node ablation after permanent His bundle pacing (p‐HBP) could be a therapeutic option for heart rate (HR) control. We aimed to demonstrate the advantages of AV node ablation with p‐HBP, and to describe its effectiveness and safety. Methods This descriptive observational study included patients with uncontrolled permanent atrial arrhythmias who were candidates for HR control (January 2019 to July 2020) and underwent p‐HBP and AV node ablation. Results A total of 39 patients were included. The median left ventricular ejection fraction (LVEF) was 55% (45–60); 46.1% in NYHA class II and 43.6% in NYHA class III. p‐HBP was achieved in 92.3% (n = 36), and AV node ablation was successfully performed in all patients. The LVEF improved in patients with reduced LVEF (baseline, 35% [23.8–45.3%]; follow‐up, 40% [35–56.5%], p < 0.05); the NYHA class also showed improvement (baseline, 71.4% patients in class III and 7.1% in class II, and at follow‐up, 78.6% patients in class II and 14.3% in class I). In patients with previously normal LVEF, LVEF remained stable; nevertheless, a significant NYHA class improvement was observed (baseline, 63.6% class II and 31.8% class III patients; follow‐up, 54.5% class I and 45.5% class II patients). The His thresholds and lead parameter values did not significantly change during the follow‐up and remained stable. Conclusions In patients with uncontrolled atrial arrhythmias who underwent AV node ablation after p‐HBP, the NYHA class improved and the LVEF increased in those with reduced baseline LVEF. The values of pacing parameters were acceptable and remained stable during the follow‐up.

Biventricular versus Conduction System Pacing after Atrioventricular Node Ablation in Heart Failure Patients with Atrial Fibrillation

“…Huang et al [ 12 ] noted that NYHA classification improved to 1.4 ± 0.4 after 1 year of HBP from the baseline 2.9 ± 0.6 in patients with reduced LVEF. Symptomatic benefits of CSP modalities combined with AVNA were also demonstrated in similar studies [ 19 , 29 ]. The present study did not demonstrate significant NYHA class or diuretics intake decline in BiV group, short follow-up did not allow deeper evaluation of potential clinical benefits.…”

Atrioventricular junction ablation in patients with conduction system pacing leads: A comparison of His-bundle vs left bundle branch area pacing leads

“…Su et al 13 reported 5 patients (6%) with significant increase in HBP capture threshold from 1.05 V at implant to 3.25 V at 0.5 ms at median follow-up of 192 days, and 3 patients required lead revision. Our study reported higher chronic lead-related outcomes compared to previous studies, likely due to less stringent HBP threshold acceptance criteria at implant, longer follow-up duration, 11,14 and differences in inclusion criteria. 13 For example, Su et al 13 excluded patients who had His-bundle injury or increased HBP thresholds with ablation or patients who had regained AV nodal conduction at early follow-up.…”

“…Overall acute success rate of achieving AV block in patients with HBP was 94% in our study, which is comparable to success rates of 92%-95% reported in previous studies. 11,14 By using more stringent criteria, Su et al 13 reported a lower success rate of 86% for achieving permanent HBP in refractory AF patients referred for simultaneous HBP implantation and AVJ ablation. In their study, reported reasons for failure included inability to implant HBP lead in 5 patients, injury to the His bundle by ablation with increase in capture threshold 1 V at 0.5 ms in 2 patients, failed AVJ ablation in 2 patients, and resumption of AV nodal conduction within q1 month in 4 patients.…”

“…AVJ ablation in the setting of HBP has been shown to be safe and feasible in small, sin-gle5center studies. [11][12][13][14] We previously reported significantly elevated capture thresholds and lead revision rates for HBP leads at intermediate-term follow-up. 15 Data on AVJ ablation in the presence of LBBAP leads are limited, and only 1 study previously compared the outcomes of AVJ ablation in consecutive patients with CSP leads.…”

Atrioventricular node ablation and pacing for atrial tachyarrhythmias: A meta-analysis of postoperative outcomes

“…Finally, it should be emphasized that almost 70% of the AVNA and pace analyzed and presented studies are retrospective and, for this reason, should serve to generate hypotheses for further prospective investigations rather than to guide our future clinical decisions. Moreover, in the last few years, there have been tremendous technological advances in AF catheter ablation (i.e., contact force, high power, short duration ablation, and pulsed-field ablation), including technologies that are still evolving in their daily clinical application, such as conduction system pacing, and that will hopefully improve the safety and efficacy of percutaneous treatment of AF, and eventual cardiac stimulation after AVNA [26,27]. These advancements have primarily not been included in the presented studies, and future investigations led by multidisciplinary teams should evaluate, possibly in a prospective randomized fashion, the clinical and economic impact of alternative approaches for selected AF patients unresponsive to the most modern percutaneous and pharmacological management.…”