Simultaneous conduction system pacing and atrioventricular node ablation via axillary vs femoral access

Outcomes of combined left bundle branch area pacing with atrioventricular nodal ablation in patients with atrial fibrillation and pulmonary disease

INTRODUCTION

Concomitant left bundle branch area pacing (LBBAP) with atrioventricular (AV) nodal ablation is emerging as a viable management option in atrial fibrillation refractory to medical management. Its viability in patients with pulmonary disease and atrial fibrillation is unknown.

METHODS AND RESULTS

This is a retrospective, observational cohort study in consecutive patients who underwent concomitant LBBAP with AV nodal ablation with advanced pulmonary disease at the Cleveland Clinic Fairview Hospital between January 2019 and January 2023. Patient characteristics, comorbidities, and medication use were extracted via chart review. Rates of hospitalizations, medication use, and structural disease seen on echocardiography were compared before and after the procedure. There were 27 patients with group 3 pulmonary hypertension who underwent the procedure. In the 24 months preprocedure, there were 114 admissions for heart failure or atrial fibrillation compared to 9 admissions postprocedure (p < .001). Mean follow up was 17.3 ± 12.1 months. There were no significant complications or lead dislodgements. Echocardiographic characteristics were similar prior to and after pacemaker implantation. Use of medications for rate and rhythm control was common preprocedure, and was reduced dramatically postprocedure.

CONCLUSION

This small, retrospective cohort study suggests concomitant LBBAP with AV nodal ablation may be safe and efficacious for management of atrial fibrillation in patients with advanced pulmonary disease.

"Ablate and Pace" with Conduction System Pacing: Concomitant versus Delayed Atrioventricular Junction Ablation

Objectives: Conduction system pacing (CSP) and atrioventricular junction ablation (AVJA) improve the outcomes in patients with symptomatic, refractory atrial fibrillation (AF). In this setting, AVJA can be performed simultaneously with implantation or in a second procedure a few weeks after implantation. Comparison data on these two alternative strategies are lacking. Methods: A prospective, multicentre, observational study enrolled consecutive patients with symptomatic, refractory AF undergoing CSP and AVJA performed in a single procedure or in two separate procedures. Data on the long-term outcomes and healthcare resource utilization were prospectively collected. Results: A total of 147 patients were enrolled: for 105 patients, CSP implantation and AVJA were performed simultaneously (concomitant AVJA); in 42, AVJA was performed in a second procedure, with a mean of 28.8 ± 19.3 days from implantation (delayed AVJA). After a mean follow-up of 12 months, the rate of procedure-related complications was similar in both groups (3.8% vs. 2.4%; p = 0.666). Concomitant AVJA was associated with a lower number of procedure-related hospitalizations per patient (1.0 ± 0.1 vs. 2.0 ± 0.3; p < 0.001) and with a lower number of hospital treatment days per patient (4.7 ± 1.8 vs. 7.4 ± 1.9; p < 0.001). Conclusions: Concomitant AVJA resulted as being as safe as delayed AVJA and was associated with a lower utilization of healthcare resources.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation.

METHODS

A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate.

STRUCTURE

Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.

Superior approach from the pocket for atrioventricular junction ablation performed at the time of conduction system pacing implantation

BACKGROUND

Conduction system pacing (CSP) and atrioventricular junction ablation (AVJA) improve outcomes in patients with symptomatic, refractory atrial fibrillation (AF). Superior approach (SA) from the pocket via axillary or subclavian vein has been proposed as an alternative to the conventional femoral venous access (FA) to perform AVJA.

OBJECTIVE

To assess the feasibility and safety of SA for AVJA performed simultaneously with CSP, and to compare this approach with FA.

METHODS

A prospective, observational study, enrolling consecutive patients with symptomatic, refractory AF undergoing simultaneous CSP and AVJA.

RESULTS

A total of 107 patients were enrolled: in 50, AVJA was primarily attempted with SA, in 69 from FA. AVJA with SA was successful in 38 patients (76.0%), while in 12 patients, a subsequent FA was required. AVJA from FA was successful in 68 patients (98.5%), while in one patient, a left-sided approach via femoral artery was required. Compared with FA, SA was associated with a significantly longer duration of ablation (238.0 ± 218.2 vs. 161.9 ± 181.9 s; p = .035), a significantly shorter procedure time (28.1 ± 19.8 vs. 19.8 ± 16.8 min; p = .018), an earlier ambulation (2.7 ± 3.2 vs. 19.8 ± 0.1 h; p < .001), and an earlier discharge from procedure completion (24.0 ± 2.7 vs. 27.1 ± 5.1 h; p < .001). After a median follow-up of 12 months, the rate of complications was similar in the two groups (2.0% in SA, 4.3% in FA; p = .483).

CONCLUSION

Simultaneous CSP and AVJA with SA is feasible, with a safety profile similar to FA. Compared to FA, this approach reduces the procedure times and allows earlier ambulation and discharge.

Role of conduction system pacing in ablate and pace strategies for atrial fibrillation

With the advent of conduction system pacing, the threshold for performing 'ablate and pace' procedures for atrial fibrillation has gone down markedly in many centres due to the ability to provide a simple and physiological means of pacing the ventricles. This article reviews the technical considerations for this strategy as well as the current evidence, recognized indications, and future perspectives.

Left Bundle Branch Area Pacing and Atrioventricular Node Ablation in a Single-Procedure Approach for Elderly Patients with Symptomatic Atrial Fibrillation

BACKGROUND

Implantation of a permanent pacemaker and atrioventricular (AV) node ablation (pace-and-ablate) is an established approach for rate and symptom control in elderly patients with symptomatic atrial fibrillation (AF). Left bundle branch area pacing (LBBAP) is a physiological pacing strategy that might overcome right ventricular pacing-induced dyssynchrony. In this study, the feasibility and safety of performing LBBAP and AV node ablation in a single procedure in the elderly was investigated.

METHODS

Consecutive patients with symptomatic AF referred for pace-and-ablate underwent the treatment in a single procedure. Data on procedure-related complications and lead stability were collected at regular follow-up at one day, ten days and six weeks after the procedure and continued every six months thereafter.

RESULTS

25 patients (mean age 79.2 ± 4.2 years) were included and underwent successful LBBAP. In 22 (88%) patients, AV node ablation and LBBAP were performed in the same procedure. AV node ablation was postponed in two patients due to lead-stability concerns and in one patient on their own request. No complications related to the single-procedure approach were observed with no lead-stability issues at follow-up.

CONCLUSIONS

LBBAP combined with AV node ablation in a single procedure is feasible and safe in elderly patients with symptomatic AF.

The role of conduction system pacing in patients with atrial fibrillation

Conduction system pacing (CSP) has emerged as a promising novel delivery method for Cardiac Resynchronisation Therapy (CRT), providing an alternative to conventional biventricular epicardial (BiV) pacing in indicated patients. Despite increasing popularity and widespread uptake, CSP has rarely been specifically examined in patients with atrial fibrillation (AF), a cohort which forms a significant proportion of the heart failure (HF) population. In this review, we first examine the mechanistic evidence for the importance of sinus rhythm (SR) in CSP by allowing adjustment of atrioventricular delays (AVD) to achieve the optimal electrical response, and thus, whether the efficacy of CSP may be significantly attenuated compared to conventional BiV pacing in the presence of AF. We next evaluate the largest clinical body of evidence in this field, related to patients receiving CSP following atrioventricular nodal ablation (AVNA) for AF. Finally, we discuss how future research may be designed to address the vital question of how effective CSP in AF patients is, and the potential hurdles we may face in delivering such studies.

Sex-Related Differences in Patient Selection for and Outcomes after Pace and Ablate for Refractory Atrial Fibrillation: Insights from a Large Multicenter Cohort

Background: A pace and ablate strategy may be performed in refractory atrial fibrillation with rapid ventricular response. Objective: We aimed to assess sex-related differences in patient selection and clinical outcomes after pace and ablate. Methods: In a retrospective multicentre study, patients undergoing AV junction ablation were studied. Sex-related differences in baseline characteristics, all-cause mortality, heart failure (HF) hospitalizations, and device-related complications were assessed. Results: Overall, 513 patients underwent AV junction ablation (median age 75 years, 50% men). At baseline, men were younger (72 vs. 78 years, p < 0.001), more frequently had non-paroxysmal AF (82% vs. 72%, p = 0.006), had a lower LVEF (35% vs. 55%, p < 0.001) and more frequently had cardiac resynchronization therapy (75% vs. 25%, p < 0.001). Interventional complications were rare in both groups (1.2% vs. 1.6%, p = 0.72). Patients were followed for a median of 42 months in survivors (IQR 22−62). After 4 years of follow-up, the combined endpoint of all-cause death or HF hospitalization occurred more often in men (38% vs. 27%, p = 0.008). The same was observed for HF hospitalizations (22% vs. 11%, p = 0.021) and all-cause death (28% vs. 21%, p = 0.017). Sex category remained an independent predictor of death or HF hospitalization after adjustment for age, LVEF and type of stimulation. Lead-related complications, infections, and upgrade to ICD or CRT occurred in 2.1%, 0.2% and 3.5% of patients, respectively. Conclusions: Pace and ablate is safe with a need for subsequent device-related re-interventions in 5.8% over 4 years. We found significant sex-related differences in patient selection, and women had a more favourable clinical course after AV junction ablation.