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41.14 Rate control: ablation and device therapy (ablate and pace)
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Published:July 2018
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This version:April 2020
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Abstract
The atrioventricular junction ablation (AVJA) and pacing method has been a well-known strategy since the 1980s. It is nowadays essentially performed in two groups of patients. First of all, it is indicated in atrial fibrillation (AF) patients who have failed rhythm control with pulmonary vein isolation ablation and different medical rate control strategies. The procedure dramatically reduces symptoms and it is associated with an increase in ejection fraction in patients with AF-induced cardiomyopathy. The second group of patients is represented by heart failure patients with a cardiac resynchronization system presenting with a low biventricular pacing percentage due to a high AF burden. Several studies have documented the necessity to achieve the highest biventricular pacing to maximize cardiac resynchronization therapy (CRT) benefits. In this context of AF patient with CRT, AVJA is the only tool that allows complete rhythm regularization and heart rate control, thus favouring a ‘pure’, constant delivery of CRT, while negative chronotropic drug use is limited and device algorithms only partially effective. An improvement of symptoms, of left ventricular function, as well as survival benefit has been clearly documented after AVJA in AF CRT patients. The procedure is usually safe and effective; nonetheless, it is often perceived as a potentially harmful therapy that should be avoided as much as possible because it causes pacemaker dependency. However, no studies on conventional ablate and pace therapy have reported significant complications during the follow-up. Furthermore, the aforementioned benefits of AVJA in the heart failure population seem to well overweigh possible risks associated with pacemaker dependency.
Update:
Small amends have been made to the chapter.
Two new references have been added.
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