When should atrioventricular (AV) node modifications be considered for atrial fibrillation (Afib) (AF) and how should pacemakers be programmed?

Updated: Apr 09, 2019
  • Author: Lawrence Rosenthal, MD, PhD, FACC, FHRS; Chief Editor: Jeffrey N Rottman, MD  more...
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Answer

Atrioventricular (AV) node modification may be an alternative in patients with persistent atrial fibrillation (AF) and an uncontrolled ventricular response despite aggressive medical therapy. Catheter ablation of the AV junction permanently interrupts conduction from the atria to the ventricles.

Because the result is permanent AV block, a permanent ventricular pacemaker is required. AF may still be present, but the pacemaker governs the ventricular response. The risk of thromboembolism is unchanged, and patients still require anticoagulation; however, most patients are relieved of their symptoms. During the first 1-3 months, the pacing rate must be programmed in the 80- to 90-beat range to prevent torsade de pointes, which presumably occurs because of slow ventricular rates and early after-depolarizations. In patients with ventricular dysfunction (left ventricular ejection fraction < 50%) and permanent ventricular pacing, a biventricular device may be appropriate. [139] Improvements in left ventricular size and function, functional class, and quality-of-life scores have been demonstrated. [140]


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