AV junction ablation (producing AV block) followed by implantation of a pacemaker is a well established, generally accepted treatment for patients with paroxysmal atrial fibrillation (PAF) not controlled by antiarrhythmic drugs. In expert hands, the efficacy of producing complete AV block is usually > 95% if a sequential right and left side approach is used; regression of AV block late after ablation (which requires a second procedure on a different day) occurs in fewer than 5% of cases.1-4 There have been only a few small studies, but ablate and pace treatment seems to be highly effective and superior to drug treatment in controlling symptoms of the arrhythmia and improving overall quality of life.4-6 In this respect, the study of Marshall et al in this issue7 provides further evidence of the beneficial effect of this treatment. In particular, using validated instruments for outcome measurements in pacemaker recipients, the authors found a pronounced decrease in the magnitude of specific symptoms of arrhythmia and an improvement in physical, socioeconomic, and psychological aspects of quality of life.

Nevertheless ablate and pace treatment is palliative. Indeed, in contrast to other ablative procedures—that is, those used for the treatment of AV nodal reentrant tachycardia and accessory bypass tracts, in which the ablation can be considered curative—AV junction ablation is unable to eliminate the electrophysiological substrate of the disease and works only indirectly through the control of irregular and fast ventricular rate. In other words, an old disease (uncontrolled PAF) is replaced by another disease (iatrogenic AV block and pacemaker dependency). Moreover, the procedure is necessarily associated with a pacemaker implant and there are small but definite risks of short and long term complications. For these reasons, many cardiologists and electrophysiologists have concerns about the wide use of this new treatment, and some refute the …