AV Node Ablation and Conduction System Pacing Versus Biventricular Pacing in Patients With AF and HF

Area of Science:

• Cardiology
• Electrophysiology
• Heart Failure Management

Background:

• Atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF) often necessitate atrioventricular node ablation (AVNA) and permanent pacing.
• Biventricular pacing (BiVP) and conduction system pacing (CSP) are pacing options, but direct comparisons in this high-risk group are limited.

Purpose of the Study:

• To compare the efficacy and safety of CSP versus BiVP in patients with AF and HFrEF undergoing AVNA.
• To evaluate differences in cardiac function, clinical outcomes, and procedural metrics between CSP and BiVP.

Main Methods:

• A systematic review and meta-analysis following PRISMA guidelines.
• Searched PubMed, Scopus, and Web of Science for studies comparing CSP and BiVP in adults with AF and HFrEF undergoing AVNA.
• Analyzed outcomes including mortality, heart failure hospitalizations, LVEF, QRS duration, NYHA class, and pacing parameters using a random-effects model.

Main Results:

• Six studies (N=766) were included, with CSP associated with significantly reduced all-cause mortality (RR 0.64) and improved NYHA class (MD -0.64) and QRS duration (MD -33.56 ms).
• A trend towards lower heart failure hospitalizations was observed with CSP (RR 0.77), but did not reach statistical significance.
• Left ventricular ejection fraction (LVEF) improvement, procedure duration, and fluoroscopy times did not differ significantly between groups. Subgroup analysis showed lower pacing thresholds for left bundle branch area pacing (LBBP) compared to BiVP.

Conclusions:

• CSP demonstrates potential symptomatic and electrocardiographic benefits over BiVP in patients with AF and HFrEF undergoing AVNA.
• A possible improvement in major clinical outcomes with CSP warrants further investigation in larger randomized trials.