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Despite improvements in our understanding of the mechanisms underlying atrial fibrillation (AF) and significant advancements in the treatment options available, optimal management and symptom relief remains a challenge in some patients. In patients with medically refractory AF more aggressive measures may be required, including percutaneous catheter ablation (pulmonary vein isolation, with or without additional substrate modification) or atrioventricular (AV) junction ablation with concomitant insertion of a permanent pacemaker. The latter option, widely known as an ‘ablate and pace’ strategy, may be preferable in patients who want a definitive, albeit palliative, treatment of their symptoms and are not willing to take the risks and potential recurrences associated with AF ablation or are not suitable for that procedure.
The ablate and pace strategy for severe, symptomatic AF has been available for many years and has been shown in a number of small studies to provide significant symptom relief and improved quality of life in selected patients with AF.1 2 The situation, however, becomes more complex in patients with AF and heart failure. Right ventricular (RV) pacing after AV junction ablation has been shown to cause both acute and long-term left ventricular (LV) dyssynchrony.3 Consequently, insertion of a biventricular pacemaker and cardiac resynchronisation therapy (CRT) may be better than RV pacing alone in patients with AF and pre-existing LV dysfunction undergoing AV junction ablation. In the recently published, prospective, multicentre Ablate and Pace in AF (APAF) trial, 186 patients who had undergone successful CRT implantation and AV junction ablation were randomly assigned to receive optimised echo-guided CRT (97 patients) or RV apical pacing (89 patients).4 Mean LV ejection fractions (LVEF) …