IMR Press / RCM / Volume 24 / Issue 11 / DOI: 10.31083/j.rcm2411333
Open Access Original Research
Conversion to Sinus Rhythm in Refractory Atrial Fibrillation Patients after Atrioventricular Node Ablation with Conduction System Pacing
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1 Department of Cardiology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
2 Faculty of Medicine, University of Ljubljana, 1000 Ljubljana, Slovenia
*Correspondence: (David Žižek)
Rev. Cardiovasc. Med. 2023, 24(11), 333;
Submitted: 9 April 2023 | Revised: 30 June 2023 | Accepted: 5 July 2023 | Published: 24 November 2023
(This article belongs to the Special Issue New Insights into Cardiac Implantable Electronic Devices)
Copyright: © 2023 The Author(s). Published by IMR Press.
This is an open access article under the CC BY 4.0 license.

Background: “Ablate and pace” strategy is a reasonable treatment option in refractory atrial fibrillation (AF) when sinus rhythm (SR) cannot be achieved with catheter ablation or pharmacological therapy. Atrioventricular node ablation (AVNA) combined with conduction system pacing (CSP), with left bundle branch pacing (LBBP) or His bundle pacing (HBP), is gaining recognition since it offers the most physiological activation of the left ventricle. However, the incidence of conversion to SR after AVNA with CSP is not known. The purpose of the investigation was to determine the incidence of spontaneous conversion to SR and its predicting factors in patients undergoing CSP and AVNA. Methods: Consecutive refractory symptomatic AF patients undergoing AVNA with CSP at our institution between June 2018 and December 2022 were retrospectively analyzed. Twelve lead electrocardiogram (ECG) recordings were analyzed at each outpatient follow-up visit. Echocardiographic and clinical parameters were assessed at baseline and six months after the implantation. Results: Sixty-eight patients (male 42.6%, age 71 ± 8 years, left ventricular ejection fraction 40 ± 15%) were included. Thirty-seven patients (54.4%) received HBP and 31 (45.6%) LBBP. During follow-up, spontaneous conversion to SR was registered in 6 patients (8.8%); 3 in the HBP group and 3 in the LBBP group. Baseline characteristics of patients who converted to SR did not differ from non-sinus rhythm (NSR) patients except for left atrial volume index (LAVI), which was significantly smaller in the SR group (45 mL/m2 (41–51) vs. 60 mL/m2 (52–75); p = 0.002). Multiple regression model confirmed an inverse association between LAVI and conversion to SR even after considering other clinically relevant covariates (odds ratio 1.273, p = 0.028). At follow-up, LAVI did not change in any group (SR: p = 0.345; NSR: p = 0.508). Improvement in New York Heart Association (NYHA) class was comparable in both groups. Conclusions: Spontaneous conversion to SR after AVNA combined with CSP is not uncommon, especially in patients with smaller left atria. Further studies are warranted to clarify which patients should be considered for initial dual-chamber device implantation to provide atrio-ventricular synchrony in case of SR restoration.

atrial fibrillation
conduction system pacing
left bundle branch pacing
His bundle pacing
atrioventricular node ablation
sinus rhythm
Fig. 1.
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