ABLATE Versus PACE: PVI or AV Node Ablation and PM Implantation for Elderly Patients With Persistent AF

Atrial fibrillation is the most common cardiac arrhythmia and is a major public and represents a major public health problem with increasing healthcare costs and increased mortality risk.

In case of recurrent symptomatic atrial fibrillation current guidelines recommend pulmonary-vein isolation (PVI) as invasive treatment option. However, 5-year arrhythmia-free survival estimate is 29% after single catheter ablation. Although the long-term success rates in maintaining sinus rhythm are higher than with drug-based rhythm control, they are still moderate, especially in older patients with comorbidities. Therefore, repeated interventions are often necessary.

An effective method for frequency control is atrioventricular (AV) node ablation after implantation of a pacemaker ("ablate-and-pace"). In this case, the ventricular rate is only set by the pacemaker and can be programmed according to the patient's needs.

There are some theoretical disadvantages of this treatment option (pacemaker dependency, reduction of cardiac outpout due to lack of atrial contraction) which is why this method nowadays is almost exclusively used in older (and physically less active) patients.

The ABLATE versus PACE trial is a prospective randomized clinical trial comparing at 196 these two treatment options in terms of rehospitalizations due to cardiovascular causes and quality of life in elderly patients (≥ 75 years) with normal ejection fraction (≥ 50%).

Inclusion criteria

• Persistent AF according to current ESC guideline (2020)
• Symptoms EHRA classification II - IV despite guideline indicated medical therapy
• Age ≥ 75 years
• Capability of giving written informed consent

Exclusion criteria

• impaired systolic left ventricular function (ejection fraction < 50%)
• High-grade (III°) left cardiac valvular disease
• pre-implanted pacemaker
• bradycardia-indication for pacemaker
• Surgical coronary revascularization (within the last 90 days) or current triple therapy after stent PCI
• contraindication for PVI or pacemaker-implantation
• contraindication for oral anticoagulation
• body-mass-index BMI > 40 kg/m2
• inability to give written informed consent
• concomitant participation in another registered trial
• life expectancy < 12 months
• reversible cause of AF (e.g. thyrotoxicosis, alcohol ingestion)