Superior Versus Inferior Approach to Atrioventricular Node Ablation After Left Bundle Branch Area Pacing

Atrioventricular node (AVN) ablation after left bundle branch area pacing (LBBAP) is currently recommended as an effective rate-control strategy in patients with permanent atrial fibrillation, but the exact timing and the optimal venous approach are less standardized.

The current study aimed to compare the feasibility of the superior approach with the standard femoral vein approach for AVN ablation after LBBAP in a single pace-and-ablate procedure.

We compared 46 patients with a superior approach and 46 with an inferior approach for AVN ablation after LBBAP based on procedural parameters such as procedural time, fluoroscopy time, ablation time, number of applications, mean power, and temperature.

LBBAP significantly reduced the QRS duration in both groups. Except for a higher R-wave detection in the inferior approach group, all other pacing-related parameters showed no statistically significant differences. The AVN ablation procedure was successful in all patients during the index procedure and from the right atrial side. The total procedural time was significantly shorter with the superior approach. The ablation time, number of applications, mean power, and total fluoroscopy time were similar between the two groups. No periprocedural complications were recorded. The pacing threshold improved in both groups at the 6-months follow-up. One patient in the superior approach group demonstrated recovery of AVN conduction, requiring an additional ablation procedure.

As part of a single pace-and-ablate procedure, AVN ablation via the pacemaker pocket had shorter total procedural time and non-significantly different procedural characteristics and outcomes than the standard femoral vein approach.