Does a Pacemaker Make a Difference? Long-Term Outcomes Post-AF Ablation in Tachy-Brady Syndrome

Tachy-brady syndrome (TBS), a subtype of sinus node dysfunction, is characterized by alternating bradyarrhythmia and supraventricular tachyarrhythmias. While catheter ablation (CA) for atrial fibrillation (AF) offers improved long-term outcomes, many patients with TBS undergo permanent pacemaker (PPM) implantation to manage symptomatic bradycardia or enable rate-control therapy. Data on long-term outcomes postablation, stratified by PPM status, are limited.

We conducted a retrospective analysis within the multicenter ITHACA registry, which includes patients who underwent AF ablation across five Northwell Health centers from 2015 to 2021. Patients with TBS were stratified by PPM status at index ablation. Primary outcomes were composite failure (AF recurrence with continued antiarrhythmic drug [AAD] use, cardioversion beyond the blanking period, or repeat ablation) beyond the 3-month blanking period at 12 months and last follow-up, and all-cause hospitalization. Secondary outcomes included beta-blocker and AAD use postablation. Comparisons were performed using Chi-square tests.

Among 3,440 patients who underwent AF ablation, 111 (3.2%) had TBS; 54 (49%) had a PPM at index ablation. Thirty-four patients were lost to follow-up. Remaining 77 patients had a median follow-up of 44.2 months. Of those without a PPM at ablation, 26 (46%) required delayed PPM (median 292 days postablation). At 12 months, composite failure rates were similar between PPM and no-PPM groups (42% vs. 40%, p = 0.93) and remained comparable at last follow-up (44% vs. 47%, p = 0.91). Hospitalization was significantly higher in the PPM group compared to no-PPM (85% vs. 62%, p = 0.01). Subgroup analysis revealed that delayed PPM patients had higher failure at 12 months (65% vs. 42%, p = 0.001) and at last follow-up (73% vs. 44%, p = 0.056). Furthermore, there was numerically higher readmission between delayed PPM vs no PPM group (69% vs 54%, p = 0.87). More patients in the PPM group remained on beta-blockers at last follow-up (61% vs. 35%, p = 0.002), while AAD use declined across groups.

In TBS patients undergoing AF ablation, overall failure rates did not differ by initial PPM status, though there was a higher hospital readmission in PPM group, suggesting a potential sicker population. Furthermore, delayed PPM implantation was associated with higher failure and more hospitalizations, suggesting earlier or concurrent PPM may benefit selected patients. Larger prospective studies are needed to define predictors and optimize management.