Outcomes of Atrioventricular Node Ablation Following Recurrent Atrial Fibrillation After Prior Ablation

Outcomes of Atrioventricular Node Ablation Following Recurrent Atrial Fibrillation After Prior Ablation | Authorea try { document.documentElement.classList.add('js'); } catch (e) { } var _gaq = _gaq || []; _gaq.push(['_setAccount', 'G-8VDV14Y67G']); _gaq.push(['_trackPageview']); (function() { var ga = document.createElement('script'); ga.type = 'text/javascript'; ga.async = true; ga.src = ('https:' == document.location.protocol ? 'https://ssl' : 'http://www') + '.google-analytics.com/ga.js'; var s = document.getElementsByTagName('script')[0]; s.parentNode.insertBefore(ga, s); })(); Skip to main content Preprints Collections Wiley Open Research IET Open Research Ecological Society of Japan All Collections About About Authorea FAQs Contact Us Quick Search anywhere Search for preprint articles, keywords, etc. Search Search ADVANCED SEARCH SCROLL This is a preprint and has not been peer reviewed. Data may be preliminary. 12 June 2025 V1 Latest version Share on Outcomes of Atrioventricular Node Ablation Following Recurrent Atrial Fibrillation After Prior Ablation Authors : Ramalingam Vadivelu 0000-0002-7195-3648 , Atul Verma , Tomy Hadjis , Martin Bernier , Vidal Essebag , and Jacqueline Joza [email protected] Authors Info & Affiliations https://doi.org/10.22541/au.174976755.54229396/v1 239 views 142 downloads Contents Abstract Information & Authors Metrics & Citations View Options References Figures Tables Media Share Abstract Background : Although ablation techniques for atrial fibrillation (AF) continue to evolve, many patients experience recurrent arrhythmia. Those who remain symptomatic despite medical therapy and are deemed ineligible for redo AF ablation are referred for pacemaker implantation and atrioventricular node ablation (AVNA), so-called pace-and-ablate therapy. Objectives: To characterize patients undergoing AVNA following recurrent AF after prior catheter ablation, and to evaluate the impact of pace and ablate therapy on unplanned hospitalizations for AF or heart failure (HF). Secondary objectives include the incidence of pacing-induced cardiomyopathy (PICM) and resumption of spontaneous AV node conduction. Methods: This is a retrospective cohort analysis of all patients undergoing pace-and-ablate therapy for recurrent AF following prior ablation at the McGill University Health Centre between June 2018 and January 2025. Results: Out of a total of 346 AVNA procedures, 32 patients underwent pace-and-ablate therapy for recurrent AF post catheter ablation, median age 77.7 years (IQR: 72.2, 81), 62.5% female, 96.9% hypertension, and 40.6% heart failure with preserved ejection fraction (HFpEF). The baseline left ventricular ejection fraction (LVEF) was 49.9±13% and left atrial volume index 41.4±15 ml/m2. The majority had persistent AF (78.1%) and underwent an average of 1.4 ± 0.6 previous AF ablations. The median time from AF ablation to AVNA was 2.5 years (IQR 0.8, 6.1). Approximately 40.6% of the patients underwent RV pacing, 37.5% biventricular pacing, and 21.9% left bundle branch area pacing (LBBaP). The average number of hospital admissions pre-AF ablation, post-AF ablation, and post-AVNA was 1.7±1.1, 2.1±1.3, and 0.8±0.4, respectively, after a median follow-up of 1.7 years post-AVNA. This was consistent with an 81.3% reduction in hospitalization (Odds ratio: 0.0095, 95% CI: 0.0023–0.0395, P<0.001); number needed to treat (NNT) = 2 (for every 2 patients undergoing pace-and-ablate therapy, one hospitalization was prevented) . PICM was seen only in those who underwent RV pacing, and the risk of PICM from standard RV pacing was 7.7% Conclusion : Pace and ablate therapy is a safe and effective procedure in patients with recurrent AF after prior AF ablation. Earlier consideration of AVNA in patients with a higher number of comorbidities should be considered. Our findings suggest a potential trend toward improved outcomes with biventricular or conduction system pacing in the setting of AVNA, though the limited sample size precludes definitive conclusions. Outcomes of Atrioventricular Node Ablation Following Recurrent Atrial Fibrillation After Prior Ablation Vadivelu Ramalingam MD, Atul Verma MD, Tomy Hadjis MD, MSc, Martin Bernier MD, Vidal Essebag MD PhD, Joza Jacqueline MD MSc McGill University Health Centre, McGill University, Montreal, Canada Running title: Pace and ablate therapy for recurrent AF post AF ablation Key words Atrial Fibrillation, AV node ablation, Pace and Ablate, Resynchronization, conduction system pacing Word count: 5449 Figures: 3, Tables: 3 Conflict of interest statement: JJ receives external research grant support from Medtronic and honoraria from Abbott and Medtronic, unrelated to this manuscript. JJ is the recipient of a Clinical Research Scholar Award from the Fonds de recherche du Québec-Santé (FRQS), unrelated to this manuscript. A.V. reports being a consultant for Biosense Webster, Medtronic, Adagio Medical, Medlumics unrelated to this manuscript. VE has received honoraria from Abbott, Adagio, Biosense Webster, Boston Scientific, and Medtronic, unrelated to this manuscript. VE is the recipient of a Clinical Research Scholar Award from the Fonds de recherche du Québec-Santé (FRQS), unrelated to this manuscript. All other authors have nothing to declare. Funding: None Address for correspondence: Dr. Jacqueline Joza MD, MSc McGill University Hospital Centre, Montreal, Canada [email protected] 514-934-1934 ext. 43157 Outcomes of Atrioventricular Node Ablation in Patients after Failed Atrial Fibrillation Ablation Abstract Background : Although ablation techniques for atrial fibrillation (AF) continue to evolve, many patients experience recurrent arrhythmia. Those who remain symptomatic despite medical therapy and are deemed ineligible for redo AF ablation are referred for pacemaker implantation and atrioventricular node ablation (AVNA), so-called pace-and-ablate therapy. Objectives: To characterize patients undergoing AVNA following recurrent AF after prior catheter ablation, and to evaluate the impact of pace and ablate therapy on unplanned hospitalizations for AF or heart failure (HF). Secondary objectives include the incidence of pacing-induced cardiomyopathy (PICM) and resumption of spontaneous AV node conduction. Methods: This is a retrospective cohort analysis of all patients undergoing pace-and-ablate therapy for recurrent AF following prior ablation at the McGill University Health Centre between June 2018 and January 2025. Results: Out of a total of 346 AVNA procedures, 32 patients underwent pace-and-ablate therapy for recurrent AF post catheter ablation, median age 77.7 years (IQR: 72.2, 81), 62.5% female, 96.9% hypertension, and 40.6% heart failure with preserved ejection fraction (HFpEF). The baseline left ventricular ejection fraction (LVEF) was 49.9±13% and left atrial volume index 41.4±15 ml/m2. The majority had persistent AF (78.1%) and underwent an average of 1.4 ± 0.6 previous AF ablations. The median time from AF ablation to AVNA was 2.5 years (IQR 0.8, 6.1). Approximately 40.6% of the patients underwent RV pacing, 37.5% biventricular pacing, and 21.9% left bundle branch area pacing (LBBaP). The average number of hospital admissions pre-AF ablation, post-AF ablation, and post-AVNA was 1.7±1.1, 2.1±1.3, and 0.8±0.4, respectively, after a median follow-up of 1.7 years post-AVNA. This was consistent with an 81.3% reduction in hospitalization (Odds ratio: 0.0095, 95% CI: 0.0023–0.0395, P<0.001); number needed to treat (NNT) = 2 (for every 2 patients undergoing pace-and-ablate therapy, one hospitalization was prevented) . PICM was seen only in those who underwent RV pacing, and the risk of PICM from standard RV pacing was 7.7% Conclusion : Pace and ablate therapy is a safe and effective procedure in patients with recurrent AF after prior AF ablation. Earlier consideration of AVNA in patients with a higher number of comorbidities should be considered. Our findings suggest a potential trend toward improved outcomes with biventricular or conduction system pacing in the setting of AVNA, though the limited sample size precludes definitive conclusions. Abbreviations used in the manuscript AF - Atrial Fibrillation AVNA - Atrioventricular Node Ablation BMI - Body Mass Index CABG - Coronary Artery Bypass Surgery CAD - Coronary Artery Disease COPD - Chronic Obstructive Pulmonary Disease CTI - Cavo-Tricuspid Isthmus Ablation DM - Diabetes Mellitus HFrEF - Heart Failure with Reduced EF HFmEF - Heart Failure with Mid-Range EF HFpEF - Heart Failure with Preserved EF IQR - Interquartile Range (25th Percentile, 75th Percentile) LA - Left Atrial LAVI - Left Atrial Volume Index LBBaP- Left Bundle Branch Area Pacing LVEF - Left Ventricular Ejection Fraction OSA - Obstructive Sleep Apnoea PAP - Pulmonary Artery Pressure PVI - Pulmonary Vein Isolation PWI - Posterior Wall Isolation RV - Right Ventricular STD - Standard Deviation Introduction Atrial fibrillation (AF) is a prevalent and clinically significant arrhythmia for which ablation is an established treatment strategy. Early rhythm control strategies for the management of AF are favoured. 1 Although AF ablation is highly effective as an early rhythm control strategy in patients with paroxysmal or early persistent AF, its success is less pronounced in those with multiple comorbidities or in long-standing persistent AF, where recurrence remains a common challenge. 2-4 The optimal management of recurrent AF following catheter ablation remains a matter of ongoing debate. In younger patients with structurally normal hearts, repeat ablation is generally considered the preferred strategy. However, in older patients or those with significant comorbidities who are not suitable candidates for repeat ablation, therapeutic options become more limited. For these patients, symptom control is often pursued through rate-control strategies, where a subset may ultimately require a “pace-and-ablate” approach involving permanent pacemaker implantation followed by atrioventricular nodal ablation (AVNA). Data remain limited regarding the clinical outcomes of patients with recurrent AF following ablation who are not eligible for repeat ablation. This study aims to: 1. Characterize the clinical characteristics of patients undergoing a pace-and-ablate strategy after AF recurrence post-ablation; and 2. Evaluate the rate of HF hospitalizations preceding and following AVNA. As secondary aims, this study will also determine the rate of pacing-induced cardiomyopathy (PICM) over long-term follow-up and the frequency of spontaneous resumption of sinus rhythm post-AVNA. Study design A single-centre retrospective analysis of consecutive patients undergoing pace-and-ablate therapy was performed. Eligible patients included those who received pace-and-ablate therapy between June 2018 and January 2025 and had undergone prior AF ablation. The study protocol was approved by the local Institutional Review Board. Patient identification and Data collection Comprehensive patient identification was performed using multiple electronic sources, including hospital records, procedural logs, and pacemaker databases. These datasets were cross-referenced and validated through manual chart review. Detailed information was collected on patient demographics, medical history, echocardiographic parameters, hospitalization summaries (both internal and external), outpatient clinic records, and procedural reports. The H2FPEF score was used to assess the prevalence of HFpEF in those with EF >50%, where a score of ≥ 6 was consistent with HFpEF. 5,6 Procedural Details Atrial Fibrillation Ablation All AF ablation procedures were performed under general anaesthesia using radiofrequency energy, guided by three-dimensional electroanatomic mapping, in accordance with standard protocol. 7 Acute pulmonary vein isolation (PVI) was achieved in every patient. Additional ablation strategies—including posterior wall isolation (PWI), linear ablation, cavo-tricuspid isthmus (CTI) ablation, and left atrial flutter ablation—were applied at the discretion of the operator, based on the AF subtype and clinical context. Pacemaker Implantation The choice of pacing modality—standard right ventricular (RV) pacing, biventricular pacing (BiVP), or left bundle branch pacing (LBBP)—was based on operator preference and consideration of the patient’s left ventricular ejection fraction (LVEF). RV and coronary sinus (CS) leads were implanted using conventional techniques. CS leads were positioned in a mid to basal posterolateral vein, guided by venous anatomy, capture thresholds, and Q-LV intervals. LBBaP was performed with lumenless leads, following established implantation protocols. 8-11 Atrioventricular Node Ablation (AVNA) Following confirmation of appropriate pacemaker function, devices were temporarily programmed in back-up VVI mode. AVNA was performed via a right femoral venous approach in most of the patients. A 4 or 8 mm non-irrigated ablation catheter was used in most cases; otherwise, an irrigated 3.5mm catheter was used. The His signal was mapped, and ablation delivered posterior to this region, targeting the compact AV node where a far-field His signal and prominent atrial electrogram were observed. Ablation was continued until a complete AV block was achieved. Post-procedure, the pacing rate was increased to 80 bpm to reduce the risk of prolonged QT-related ventricular arrhythmia. At follow-up (6 to 8 weeks post-procedure), the pacing rate was reduced to a maintenance rate of 60-70 bpm. Statistical analysis Continuous variables were reported as mean ± standard deviation or median (Interquartile range (IQR)), and categorical variables were reported as frequencies and percentages. To assess AVNA’s impact on hospitalization rates, absolute risk reduction (ARR) and odds ratio (OR) were calculated. ARR reflected the difference in hospitalization rates pre- and post-AVNA, while relative risk reduction (RRR) expressed this change relative to baseline risk. The number needed to treat (NNT), as the inverse of ARR, estimated how many patients would require AVNA to prevent one hospitalization. Fisher’s exact test assessed the significance of rate differences. ARR and OR were reported with 95% confidence intervals (CI), with the OR CI calculated using the Wald method. A p-value < 0.05 was considered significant. Analyses were performed using SPSS Statistics v27.0 (SPSS, Chicago, IL) Results Baseline characteristics A total of 346 patients underwent pace and ablate therapy from June 2018 to January 2025. Of these, 9.2% (32/346) had a prior AF ablation and were included in the final analysis. Nineteen patients underwent AVNA following recurrence after one prior AF ablation. The remaining 13 patients underwent two or more attempts at AF ablation prior to undergoing pace-and-ablate therapy. Together, these 32 patients formed the final cohort (Figure 1). Baseline clinical and echocardiographic characteristics are summarized in Table 1. The median age of the study cohort was 73 years (IQR: 25 th percentile- 75 th percentile: 69.3–77) at the time of AF ablation and 77.7 years (IQR: 72.2–81) at the time of AVNA. Females comprised 62.5% of the population (Table 1). Comorbidities included hypertension (97%), diabetes mellitus (22%), obstructive sleep apnea (28.1%), prior stroke (9.4%), COPD or asthma (21.9%), chronic kidney disease (CKD) (9.4%), coronary artery disease (CAD) (15.6%) and mean body mass index (BMI) was 29.4 ± 8.2 kg/m². Baseline echocardiographic parameters showed the mean LVEF 49.9 ± 13.2%, left atrial volume index 41.4 ± 15.2 mL/m², and pulmonary artery pressure 37 ± 18 mmHg. The prevalence of Heart Failure with reduced EF (HFrEF), Heart Failure with mid-range EF (HFmEF), and HFpEF was 28.1%, 18.8%, and 40.6%, respectively. The prevalence of HFpEF was 76.5% among patients with LVEF > 50%, with a mean H 2 FPEF score of 6.2±1.1. Notably, 46.9% of patients had a LVEF < 50%, suggesting a considerable prevalence of reduced or mildly reduced LV systolic function. Procedural characteristics Patients who recurred post-ablation and underwent a pace-and-ablate strategy underwent an average of 1.4 ± 0.6 previous AF ablations. The median duration between the first diagnosis of AF and ablation was 2 years (IQR: 1.75, 4). The ablation strategies used were PVI alone in 50%, PVI+PWI in 18.8%, PVI+PWI+CTI in 25%, PVI scar ablation in 3.1%, and PVI+LA flutter ablation in 3.1%. Cavo-tricuspid isthmus ablation (CTI) was done as an adjunct procedure in 62.5% of the patients after AF ablation. The median arrhythmia-free survival following the first AF ablation was 148 days (IQR: 95, 450). Repeat AF ablation was done in 40.6%, and the median duration between the first and second ablation was 377.5 days (IQR: 155.5, 700.5). The median time from the first AF ablation to AVNA was 2.5 years (IQR: 0.8, 6.1). The type of pacemaker implantation prior to AVNA was RV septal pacing in 40.6%, biventricular pacing in 37.5%, and LBB pacing in 21.9% of patients. The observed frequencies of single-chamber, dual-chamber, and biventricular pacemakers were 18.8%,43.7%, and 37.5%, respectively. The median time from pacemaker implantation to AVNA was 113 days (12.5,1218.3). The median number of RF applications for AVNA was 6.5 (IQR: 5,10.25). All but one had undergone AVNA by right-sided approach via the right femoral venous route. A sheath was used in 43.8% of the patients, and an irrigated ablation catheter was used in 40.6% of the patients. There were no instances of pacemaker malfunction secondary to AVNA. In three patients (9.4%), the intrinsic AV node conduction resumed spontaneously, resulting in hospitalisations post-AVNA. They were subjected to redo AVNA, after which no further hospitalisations were encountered. The median follow-up duration post-AVNA was 1.7 years (IQR: 0.7,4.7). Procedural characteristics of AF ablation, pacemaker implantation and AVNA are shown in Table 2 Clinical outcomes Hospitalization for Heart Failure or Recurrent Atrial Fibrillation The average number of hospital admissions pre-AF ablation, post-AF ablation, and post-AV node ablation was 1.7±1.1, 2.1±1.3, and 0.8±0.4, respectively. ( Table 3) The hospitalisation rate before and after AVNA was 93.8% and 12.5%, respectively (Figure 2) . The ARR, representing the absolute difference in hospitalisation rates before and after AVNA, was 81.3% (95% CI: 66.2% – 96.2%; P<0.001), indicating a substantial reduction. Additionally, the OR was 0.00952 (95% CI: 0.0023–0.0395; P<0.001), demonstrating a significantly lower likelihood of hospitalisation after AVNA. The relative risk reduction (RRR) in hospitalization was 86.7%, and the relative risk of hospitalization post AVNA was 0.13. Pacing induced cardiomyopathy The overall incidence of PICM was 3% (1/32), occurring exclusively in the subgroup of patients who underwent RV pacing, where the incidence was 7.7% (1/13). The affected patient had received a pacemaker with an RV septal lead, two years prior to AVNA, and was hospitalized within one-year post-AVNA for heart failure. A diagnosis of PICM was established, and the patient subsequently underwent an upgrade to biventricular pacing. No cases of PICM were observed in patients who received LBB pacing or biventricular pacing. Spontaneous return of AV node conduction post-AVNA Three patients (9.4%) were hospitalized due to AF with rapid ventricular after resumption of AV node conduction after AVNA. One patient had hypertrophic obstructive cardiomyopathy with severe pulmonary artery hypertension. Another patient had undergone left-sided AVNA after multiple failed attempts from the right side. The average duration of recurrence of AV conduction post-AV node ablation was 31.7±9 days. They were subjected to repeat AV node ablation, after which there were no further hospitalisation episodes. Figure 3 illustrates the clinical outcomes following AVNA Mortality In total, three patients died during the follow-up period at 2.7, 4.9, and 1.4 years post-AVNA, respectively. The causes of death in two patients were related to cancer, and in one patient, the cause was unknown. There were no instances of malignant ventricular arrhythmias or sudden cardiac deaths noted in our cohort. No lead failures were documented in any of the study subjects Discussion In patients undergoing pace-and-ablate therapy for recurrent AF following prior AF ablation, nearly 50% had an LVEF 50% had a diagnosis of HFpEF. The average number of hospital admissions pre-AF ablation, post-AF ablation, and post-AV node ablation was 1.7±1.1, 2.1±1.3, and 0.8±0.4, respectively, after a median follow-up of 1.7 years post-AVNA. This was consistent with an 81.3% reduction in hospitalization (Odds ratio: 0.0095, 95% CI: 0.0023–0.0395, P<0.001); and NNT was 2. PICM was seen in 7.7%, exclusively in those undergoing RV pacing. There was a 9.4% recurrence rate following AVNA. To our knowledge, this is the first study reporting on pace-and-ablate therapy following recurrence post AF ablation. Catheter ablation has become the standard of care for the management of symptomatic AF, particularly in patients who are refractory to or intolerant of medications. It has demonstrated superiority over pharmacologic therapy for rhythm control and is recommended as a Class I indication. 12-17 In patients with persistent AF, the probability of maintaining sinus rhythm at two years following a single ablation without AAD use is only 40–45%. 18 Even with ongoing advancements in mapping and ablation techniques, the long-term recurrence rate remains high, reaching 52% at four years of follow-up. 19 While repeat ablation procedures and concomitant antiarrhythmic therapy improve outcomes, the likelihood of maintaining sinus rhythm at five years is approximately 50% for patients with persistent AF and declines to 40% in those with long-standing persistent AF. 20 In our cohort, the median duration of AF-free survival following the first ablation was 148 days. Known predictors of recurrence include advanced age, female sex, hypertension, OSA, persistent AF, AF duration initial AF diagnosis, early recurrence within the blanking period, and prior failed ablation. 21 Our study population demonstrated a high burden of such risk factors, with a predominance of persistent AF (78.1%), widespread hypertension, advanced age, female predominance, OSA, and elevated BMI. Approximately half of all patients with AF have HFpEF. 22-24 The risk for both conditions increases with age above 60, particularly in those with hypertensive heart disease, where progressive diastolic dysfunction results in deterioration of atrial and ventricular function. 24,25 This interdependence contributes to symptomatic dyspnea with minimal exertion, and increased heart failure hospitalizations and cardiac mortality. In our study, the prevalence of HFpEF was 76% in those with an LVEF >50%. Pace-and-ablate therapy has been shown to improve quality of life and reduce HF hospitalizations. 26-29 As a result of reduced hospitalizations and emergency room visits, there is a proven cost-effectiveness benefit. 30 However, early enthusiasm for widespread adoption of the AVNA strategy was tempered by concerns regarding pacing-induced cardiomyopathy (PICM), particularly due to the high burden of RV pacing. In a retrospective study of 55 patients with drug refractory AF, undergoing pace and ablate strategy, nearly 50% of patients with high RV pacing burden developed left ventricular dyssynchrony at a mean follow-up of 3.8 ± 1.7 years, which was associated with worsening HF symptoms, progressive LV dysfunction, and chamber dilatation. 31 A meta-analysis reported a pooled PICM prevalence of 12%, with key risk factors including native QRS duration, baseline LVEF, RV pacing percentage, and paced QRS width. 32 In our study, the incidence of PICM was 7.7%, consistent with previously reported rates. In this study, there were no acute procedural complications associated with AVNA. Although the acute success rate was 100%, the rate of recurrent AV node conduction at follow-up was higher than expected. The literature on resumption of AV node conduction after AVNA is limited yet consistent with the findings in this study. Yeung-Lai-Wah et al reported a 12% recurrence rate of AV node conduction after pace and ablate therapy at a mean follow-up period of 12 ± 6 months. 33 The need for redo AVNA due to return of AV node conduction was 2.9% in a meta-analysis involving 4,886 patients. 34 Control of ventricular rate before AVNA, avoiding transaortic route, using a sheath for proper contact, mapping proper ‘His’ signal, using irrigated ablation catheter in difficult cases with optimised power and duration of RF energy application during AVNA are some of the key strategies to reduce the risk of resumption of AV node conduction. The need for left-sided approach (retrograde aortic route) in our study was 3.1%. The need for a left-sided approach after an unsuccessful right-sided ablation in the literature was 6.9%. 34 In patients at high risk of recurrence post AF ablation, it remains a difficult decision as to whether to proceed with a redo AF ablation vs adopt a pace and ablate strategy. Several trials are expected to be initiated soon or have started enrollment. The ABLATE versus PACE trial is an ongoing RCT that expects to enroll 196 patients who are randomized to an initial strategy of PVI by cryoablation vs RV pacing with AVNA. 35 The ABACUS Trial (NCT06207383) aims to evaluate a pace-and-ablate strategy with biventricular cardiac resynchronization therapy (CRT) or conduction system pacing (CSP)-CRT as compared to de novo AF ablation in persistent AF and HF hospitalization within the preceding year. REDO AF is a pilot RCT that will evaluate recurrent AF patients post any prior number of AF ablations, randomized either to a strategy of redo AF ablation vs LBBP and AVNA. Limitations A retrospective observational cohort study is inherently limited by factors such as selection bias, information bias, and confounding variables. Adopting strict criteria for selecting study subjects and following uniform protocols for data extraction and cross-checking records were followed to reduce biases. Our study, despite being limited by a small sample size, is unique as it represents subjects with prior failed AF ablation undergoing AVNA. Due to the non-randomized nature of the study, the results cannot be generalized to the general population with the same condition. Large multicentric randomized clinical trials comparing redo AF ablation vs AV node ablation in persistent AF patients with prior failed AF ablation/s are needed to compare the benefits of each intervention in reducing hard clinical outcomes such as hospitalization for AF/or HF and other major adverse cardiac events. The findings from such trials can be used to treat recurrent AF patients, who have exhausted AF ablation and are intolerant or refractory to AAD, with more clarity and scientific evidence Conclusion AVNA is a safe and effective therapeutic option for patients with symptomatic AF recurrence following prior AF ablation. Despite the limitations imposed by sample size, our results align with emerging evidence that biventricular or conduction system pacing may offer clinical advantages. Future studies with an adequate sample size are needed to establish this conclusively. Larger studies are needed to better predict those who should be selected for a pace-and-ablate strategy as opposed to a redo AF ablation. References 1. Kirchhof P, Camm AJ, Goette A, Brandes A, Eckardt L, Elvan A, Fetsch T, van Gelder IC, Haase D, Haegeli LM, Hamann F. Early rhythm-control therapy in patients with atrial fibrillation. New England Journal of Medicine. 2020 Oct 1;383(14):1305-16 2. 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Baseline characteristics of patients undergoing pace and ablate strategy following recurrence post AF ablation Age at AF ablation, Median (IQR), years 73 (69.3, 77) Age at AV Node ablation, Median (IQR), years 77.7 (72.2, 81) Male, N (%) 12 (37.5) Female, N (%) 20 (62.5) BMI, Median (IQR), kg/sq.m 28.2 (23, 31.8) Paroxysmal AF, N (%) 7 (21.9) Persistent AF, N (%) 25 (78.1) Hypertension, N (%) 31 (96.9) DM, N (%) 7 (21.9) Prior Stroke, N (%) 3 (9.4) Valvular lesions, N (%) None 29 (90.6) Severe valve lesions(non-rheumatic) 2 (6.3) Post-valve repair or replacement 1 (3.1) HFrEF, N (%) 9 (28.1) HFmEF, N (%) 6 (18.8) HFpEF, N (%) 13 (40.6) OSA, N (%) 9 (28.1) COPD or Bronchial Asthma, N (%) 7 (21.9) CAD, N (%) 5 (15.6) Post CABG, N (%) 1 (3.1) CKD, N (%) 3 (9.4) Pre-AVNA use of anti-arrhythmic drugs (AAD), N (%) 1 AAD 17 (53.1) 2 AADs 13 (40.6) No AAD 2 (6.3) LVEF at AF ablation, Median (IQR), % 55 (40, 60) LVEF at AV node ablation, Median (IQR), % 50 (40, 60) LVEF <50%, N (%) 15 (46.9) LAVI, Median (IQR), ml/sq.m 38 (29, 50) PA pressure, Median (IQR), mm Hg 34 (27, 40) Table 2: Procedural characteristics Time from first AF diagnosis to AF ablation (years), Median (IQR) 2 (1.75,4) Initial ablation strategy, N (%) PVI 16(50%) PVI+PWI 6 (18.8%) PVI +LA flutter 1(3.1%) PVI+PWI+CTI 8(25%) PVI +scar ablation 1(3.1%) CTI (%) 20 (62.5%) Initial ablation energy source Radiofrequency energy 32(100%) Duration of sinus rhythm maintenance following first AF Ablation (days), Median (IQR) 148 (95, 450) Number of patients undergoing repeat AF ablation, N (%) 13 (40.6%) Average number of AF ablations, mean ± STD 1.4 ± 0.6 Duration between first and second ablation (days), Median (IQR) 377.5(155.5,700.5) Pacemaker characteristics Biventricular pacing, N (%) 12 (37.5%) RV septal pacing, N (%) 13 (40.6%) LBB pacing, N (%) 7 (21.9%) Single chamber, N (%) 6 (18.8%) Dual chamber, N (%) 14 (43.7%) Biventricular, N (%) 12 (37.5%) Number (%) of patients receiving ICD lead, N (%) 4 (12.5%) AV Node ablation (AVNA) Time from AF ablation to AVNA, Median (IQR), years 2.5 (0.8, 6.1) Time from Pacemaker implantation to AVNA, Median (IQR), days 113 (12.5,1218.3) Repeat AVNA was done in N, (%) 3 (9.4%) Median follow-up duration post-AVNA, Median (IQR), years 1.7 (0.7,4.7) Median number of RF Lesions for AVNA 6.5 (5,10.25) Median Power (watts) 50 (40,60) Median RF duration (seconds) 226 (181,337) Sheath use N (%) 14 (43.8%) Irrigated ablation catheter usage, N (%) 13 (40.6%) Right- sided AVNA (antegrade approach), N (%) 31 (96.9%) Table 3: Hospitalization Rates Average number of hospital admissions, post-AF ablation and pre-AVNA (Mean ±STD) 2.1±1.3 Average number of hospital admissions, post-AVNA (Mean ±STD) 0.8 ± 0.4 Hospitalisation pre-AF ablation, N (%) 31(96.9%) Hospitalisation post-AF ablation and pre-AVNA, N (%) 30(93.8%) Hospitalisation post AVNA*, N (%) * 1 HF hospitalisation due to PICM (3.1%) * 3 AF hospitalisations due to resumption of native AV conduction (9.4%) 4(12.5%) Figures with legends Figure 1: Patient flow Figure 2: Clustered bar chart illustrating hospitalization before and after AVNA. A significant reduction in hospitalization was noted after AVNA, with an absolute risk reduction of 81.3%. Orange colour: Hospitalization; Green colour: No Hospitalization Figure 3: Graphic illustration of outcomes following AVNA Information & Authors Information Version history V1 Version 1 12 June 2025 Copyright This work is licensed under a Non Exclusive No Reuse License. Authors Affiliations Ramalingam Vadivelu 0000-0002-7195-3648 McGill University Health Centre View all articles by this author Atul Verma McGill University Health Centre View all articles by this author Tomy Hadjis McGill University Health Centre View all articles by this author Martin Bernier McGill University Health Centre View all articles by this author Vidal Essebag McGill University Health Centre View all articles by this author Jacqueline Joza [email protected] McGill University Health Centre View all articles by this author Metrics & Citations Metrics Article Usage 239 views 142 downloads .FvxKWukQNSOunydq8rnd { width: 100px; } Citations Download citation Ramalingam Vadivelu, Atul Verma, Tomy Hadjis, et al. Outcomes of Atrioventricular Node Ablation Following Recurrent Atrial Fibrillation After Prior Ablation. Authorea . 12 June 2025. 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