Pacemaker-implantation and atrioventricular-node ablation vs pulmonary vein isolation for elderly patients with persistent atrial fibrillation: the ABLATE versus PACE trial.

Abstract

Population aging is increasing atrial fibrillation (AF) prevalence. In elderly patients with persistent AF, pulmonary-vein isolation (PVI) has limited success, but is widely used. Pacemaker-implantation with atrioventricular-node ablation (PM+AVNA) provides effective symptom control, but the relative effects of PM+AVNA versus PVI on hospitalisations and other outcomes in the elderly remain unknown. This investigator-initiated, multicentre, open-label trial randomised patients aged≥75 years with symptomatic persistent AF and normal left-ventricular ejection fraction to PM+AVNA or PVI treatment-strategies. The primary endpoint was a composite of hospitalisation for atrial arrhythmia or heart failure, outpatient electrical cardioversion or upgrade to cardiac resynchronisation therapy for left-ventricular dysfunction. Secondary endpoints included all-cause death, stroke, treatment-related complications and quality of life. Twelve centres in Germany and Austria randomised 196 patients (median age 82 years). At 12 months, a first primary endpoint event occurred in 24 of 98 patients (24%) assigned to PM+AVNA and 45 of 98 patients (46%) assigned to PVI (hazard ratio 0.45, 95% confidence interval 0.27 to 0.74; P=0.002). A total of 29 and 84 primary endpoint events occurred respectively, consisting principally of AF-hospitalisations and cardioversions in the PVI group (54 and 19 respectively, vs 3 and 1 in PM+AVNA group) and of heart failure-hospitalisations in the PM+AVNA Group (23, vs 11 in PVI group). The incidence of cardiovascular complications and mortality, as well as qualityof-life, were not statistically different. In elderly patients with persistent AF, PM+AVNA was associated with fewer primary endpoint events than PVI over a 12-month follow-up period.