Ablating the Imperceptible: A Novel Application of Para-Hisian Pacing

In some elderly patients with atrial fibrillation, especially in combination with heart failure, a rate control strategy may be preferred. When pharmacological therapy is ineffective or not tolerated, it is reasonable to perform atrioventricular (AV) node ablation with ventricular pacing. We describe a case in which this approach was necessary for management. However, the presence of periprocedural, drug-induced AV block just before ablation provided a unique and challenging circumstance. We discuss the steps taken to ensure a successful procedure.