Atrioventricular node ablation (AVNA) and ventricular pacing can be an effective option in patients with non-controlled atrial fibrillation. Right ventricular pacing (RVP) induces ventricular desynchronization and increases the long-term risk of heart failure. His bundle pacing (HBP) is an appealing alternative, however there is still limited data about the feasibility of AVNA after HBP.

To evaluate feasibility and safety of HBP followed by AVNA.

We included all patients who underwent AVNA after HBP for non-controlled atrial arrhythmia in three hospitals between 2017 and 2021. AVNA procedures were performed with an 8 mm-tip ablation catheter.

HBP before AVNA was attempted in 77 patients and successful in 71 (92%), with a backup right ventricular lead implanted in 7. AVNA was performed during the same procedure in 10 patients. A complete AV block was obtained in 54 of 71 patients (76%). Modulation of the AV node conduction was obtained in 12 patients (17%). AVNA failures were observed in 5 patients; in one of these, AVNA was stopped after the first RF application for acute His Bundle capture (HBC) threshold increase to 3.5V. In all AVNA failures, atrial signal could be recorded on the HBP lead indicating an implant position close to the atrial aspect of the tricuspid valve. The mean AVNA procedure duration was 42±22min, and mean fluoroscopy duration was 5.0±6.6min (1.7±2.5Gy.cm²). A mean number of 6±8 RF applications (280±377sec) were delivered. Acute HBC threshold elevation>1V @ 0.5ms occurred in 10 patients (14%) with return to baseline value at day 1 in the majority of them (80%). There was no lead dislodgment during the AVNA procedures. The baseline native QRS duration was 102±22ms and the paced QRS duration was 108±16ms. Mean HBC threshold at implant was 1.25±0.8V@0.5ms and did not increase at 3 months follow-up (1.20±0.8@0.5ms). AV node re-conduction was observed in 8 patients (11%). No ventricular lead revision was required during a mean follow-up period of 2.2 years (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. Implanting the lead on the ventricular side avoiding atrial signal recording would facilitate AVNA.