Ventricular rate control is essential in the management of atrial fibrillation. Atrioventricular node ablation (AVNA) and ventricular pacing can be an effective option when pharmacological rate control is insufficient. However, right ventricular pacing induces ventricular desynchronisation in patients with normal QRS and increases the risk of heart failure on long-term. His bundle pacing (HBP) is a physiological alternative. There is still very limited data about the feasibility of AVNA after HBP.

To evaluate feasibility and safety of HBP followed by AVNA in patients with non-controlled atrial arrhythmia.

We included all patients who underwent AVNA for non-controlled atrial arrhythmia after HBP implantation in 3 hospitals. No back-up ventricular lead was implanted. AVNA procedures were performed with 8 mm-tip ablation catheters.

AVNA after HBP lead implantation was performed in 50 patients. AVNA was successful in 36 of 50 patients (72%). Modulation of the AV node conduction was obtained in 8 patients (16%). The mean procedure duration was 44±25min, and mean fluoroscopy duration was 5.9±7.7min. A mean number of 6.6±9.0 RF applications (315±450 s) were delivered to obtain complete/incomplete AV block. Acute HB capture (HBC) threshold increase>1V occurred in 9 patients (18%) with return to baseline value at day 1 in 6. There was no lead dislodgment. Mean HBC threshold after AVNA was 1.25±0.78V@0.5ms. AV node re-conduction was observed in 6 patients (16.7%). No ventricular lead revision was required during the follow-up period. The baseline native QRS duration was 102±21ms and the paced QRS duration was 107±18ms (Fig. 1).

AVNA combined with HBP for non-controlled atrial arrhythmia is feasible and does not compromise HBC but seems technically difficult with significant AV nodal re-conduction rate. The presence of a back-up ventricular lead could have changed our results and would require further evaluation.