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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Atrial fibrillation &#40;AF&#41; has become a major epidemic and is associated with high morbidity and mortality&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Pacemaker treatment combined with atrioventricular &#40;AV&#41; node ablation is an effective treatment in patients with atrial arrhythmias and symptoms due to high ventricular rate refractory to pharmacological treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Another group that benefits from AV node ablation is patients with heart failure &#40;HF&#41;&#44; AF and cardiac resynchronization therapy &#40;CRT&#41; with a low percentage of biventricular pacing&#46; AV node ablation has been shown to increase the percentage of biventricular pacing and thus enhance the therapeutic effects of CRT&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">However&#44; AV node ablation is not without risks&#46; Right ventricular pacing induces left ventricular dyssynchrony&#44; which in turn impairs cardiac function&#46; There is also an increased risk of sudden death after AV node ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">3</span></a> In addition&#44; the long-term performance of pacing devices is not flawless&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Hence the relevance of long-term results after a pace-and-ablate strategy&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The article by Manuel et al&#46; in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> describes the retrospective experience of a Portuguese tertiary center with the longest follow-up ever published after AV node ablation&#46; The authors followed a highly varied population of 123 patients who had undergone AV node ablation for a median of 8&#46;5 years &#40;8&#46;8-11&#46;8&#41;&#46; Most of the patients presented uncontrolled supraventricular tachycardia that resulted in HF&#44; tachycardiomyopathy&#44; inappropriate implantable cardioverter-defibrillator &#40;ICD&#41; shocks and other severe symptoms related to tachycardia&#46; Ten &#40;8&#37;&#41; patients were treated due to low biventricular pacing percentage&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The most common arrhythmia was AF &#40;65&#37;&#41;&#46; All AV node ablation procedures were successful and there were no major complications&#46; Thirteen &#40;11&#37;&#41; patients had previously implanted devices and all the others were implanted at the time of AV node ablation&#46; The final distribution of devices was 90 pacemakers &#40;82&#37;&#41;&#44; seven CRT pacemakers &#40;6&#37;&#41;&#44; nine CRT defibrillators &#40;8&#37;&#41; and four ICDs &#40;4&#37;&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Unexpectedly&#44; there were no device-related complications during this long follow-up&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The authors report improvements in HF functional class and fewer hospitalizations and unplanned emergency department visits due to HF&#46; There were no differences in left ventricular ejection fraction &#40;LVEF&#41; or left ventricular end-diastolic diameter before and after the procedure&#46; The authors do not clarify the timeframe of these clinical and echocardiographic changes&#46; For this reason&#44; the magnitude and pattern of benefits cannot be fully elucidated&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">At the end of the follow-up mortality was 23&#37;&#46; There is no information regarding causes of death&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Despite these gaps&#44; this article highlights the importance of AV node ablation&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In a meta-analysis of randomized trials comparing pace-and-ablate with drug therapy&#44; overall mortality at one year was 3&#46;5&#37; in the pace-and-ablate group&#44;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">6</span></a> similar to the findings of Manuel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> It should be borne in mind that no robust data support survival benefit after a pace-and-ablate strategy&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Elucidation of the causes of death is of paramount importance&#46; AV node ablation is associated with a small &#40;2-4&#37;&#41; risk of sudden death&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">7</span></a> It is important to note that the vast majority of those who experience sudden cardiac death had a significant number of risk factors&#44; including reduced left ventricular function&#44; advanced HF&#44; and a history of ventricular arrhythmias&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Programming the pacemaker at higher ventricular pacing rates &#40;minimum 90 bpm&#41; for the first 1-2 months following ablation has been a way to mitigate the risk of proarrhythmic bradycardia&#44; which can result in sudden death&#44; but pacemaker dysfunction is another possible cause of sudden death&#46; With this concern in mind&#44; many centers postpone AV node ablation until pacemaker electronics are reassessed&#46; Alternatively&#44; a simultaneous procedure like that of Manuel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">5</span></a> would be less burdensome&#46; The vascular access for the ablation catheter could even be the same as for the pacemaker&#46; By not reporting causes of death&#44; the present article fails to clarify this important issue&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The assessment of symptoms&#44; improvement in ventricular function and reduction in hospitalizations and emergency department visits is a matter of debate&#46; Most studies&#44; including that by Manuel et al&#46;&#44; included patients with and without reduced LVEF&#46; Patients with reduced LVEF could be expected to improve due to reversal of tachycardiomyopathy or increased biventricular pacing percentage&#46; On the other hand&#44; patients without reduced LVEF could worsen because of pacing-induced dyssynchrony&#46; Some patients could improve by one mechanism and worsen by the other and the final outcome would be difficult to predict&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In general&#44; several retrospective studies&#44; randomized controlled trials&#44; and meta-analyses have reported positive evidence that pace-and-ablate is a valuable palliative therapy for highly symptomatic&#44; drug-refractory AF patients&#46; Many retrospective studies have documented significant acute and long-term improvement in left ventricular function&#44; symptoms&#44; cardiac performance&#44; exercise tolerance&#44; clinical outcomes&#44; and quality of life&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">There have been several randomized controlled trials comparing a pace-and-ablate strategy with medical therapy&#46; Pace-and-ablate was effective in controlling symptoms and improving quality of life but showed no benefit regarding death or left ventricular function&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Some meta-analyses have reported improvements in patients with symptomatic&#44; drug-refractory AF&#46; Wood et al&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> found that exercise duration&#44; LVEF&#44; quality of life&#44; symptoms&#44; and hospital admissions improved significantly&#46; Chatterjee et al&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> found in their meta-analysis that in the therapeutic management of refractory AF&#44; AV node ablation was associated with improvement in symptoms and quality of life&#46; In addition&#44; patients with reduced LVEF demonstrated an improved echocardiographic outcome compared to medical therapy alone&#46; However&#44; there was no survival advantage&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">For the subgroup of patients with CRT and low pacing percentage the benefit is beyond doubt&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">10</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The debate on the effects of AV node ablation on left ventricular function and clinical outcomes of HF is ongoing and reports of these effects are not consistent&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Meanwhile&#44; in order to avoid the deleterious effects of long-term right ventricular pacing on left ventricular function&#44; biventricular pacing has been proposed as an alternative to right ventricular pacing&#46; CRT significantly reduces hospitalizations for HF and significantly improves functional capacity and left ventricular function&#44; volumes and diameter in comparison with right ventricular pacing&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">11</span></a> The PAVE study<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">12</span></a> randomized 184 patients with a mean LVEF of 46&#37; to biventricular pacing or right ventricular pacing following AV node ablation&#46; Both groups showed an improvement in 6-min walk distance compared with baseline&#46; Of interest&#44; the two pacing modalities did not differ until six months after the procedure&#44; when a slight deterioration in the right ventricular pacing group resulted in a significant difference between the two groups&#46; The right ventricular pacing group showed a significant fall in LVEF within six weeks which persisted at six months&#46; On the other hand&#44; LVEF in the biventricular pacing group did not change from baseline values&#46; Patients with impaired LVEF at baseline who underwent biventricular pacing showed the greatest improvement&#46; Furthermore&#44; patients with New York Heart Association class II or III heart failure who received biventricular pacing improved significantly more than those who received right ventricular pacing&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The current guidelines give CRT a class IIa recommendation&#44; level of evidence B&#44; for patients with AF and left ventricular dysfunction who are candidates for AV node ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">13</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">Huang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">14</span></a> demonstrated that permanent His bundle pacing is safe and stable in HF patients with AF who had narrow QRS and underwent AV node ablation&#46; They observed a significant improvement in functional class and echocardiographic LVEF and reduced use of diuretics in HF therapeutic management&#46; Current results make His bundle pacing an attractive pacing modality before AV node ablation&#44; preserving ventricular synchrony&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Patients with AV node ablation become chronotropically incompetent&#46; This condition may be corrected by rate-adaptive pacing&#46; While rate-responsive pacing can help these patients to adapt during exercise&#44; it can also elicit an excessive increase in heart rate with possible deleterious effects&#46; Device programming should be meticulous&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">A less radical alternative to AV node ablation is AV node modulation&#46; Although the results are less predictable&#44; it avoids the need for a pacemaker and can be thought of as a step between drugs and AV node ablation&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">15</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Ablate-and-pace is a useful and easy therapy but should be regarded as a last resort&#46; It makes patients pacemaker-dependent and thereafter prone to pacing-induced dyssynchrony&#44; pacemaker dysfunction and infection&#46; Although the markers for a worse prognosis after ablate-and-pace are not completely elucidated&#44; care must be taken when choosing the pacing device&#44; particularly in patients with impaired systolic function and HF&#46; For these patients a more physiological pacing modality&#44; like biventricular pacing or His bundle pacing&#44; should be considered&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">The author has no conflicts of interest to declare&#46;</p></span></span>"
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