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Ablate and Pace Strategy — EECC MCQ

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HardHeart FailureAblate and Pace StrategyEECC

A 72-year-old woman with HFrEF (LVEF 28%) has chronic AF with a ventricular rate of 130 bpm despite bisoprolol 10 mg and digoxin 125 microg. She is severely symptomatic (NYHA IV) and has been admitted 3 times in 6 months with decompensation. Rate control is inadequate. What strategy should be considered?

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Correct answer: C — AV-node ablation with cardiac resynchronisation therapy

In patients with HFrEF and AF with inadequate rate control despite maximally tolerated beta-blocker and digoxin, the 'ablate and pace' strategy (AV node ablation + CRT pacemaker) provides definitive rate control by rendering the patient pacemaker-dependent. CRT (not RV-only pacing) is essential to avoid pacing-induced dyssynchrony. The 2024 ESC AF Guidelines and 2023 HF Guidelines recommend this strategy as Class IIa. The APAF-CRT trial demonstrated that AV junction ablation + CRT significantly reduced all-cause mortality and HF hospitalisation compared with pharmacological rate control in elderly patients with permanent AF and narrow QRS. AF ablation (PVI) may be considered but has lower success rates in long-standing persistent AF with HFrEF.

Reference: ESC (2024): AF Guidelines; ESC (2023): HF Guidelines; APAF-CRT Trial: https://bnf.nice.org.uk/