Pacing or ablation: which is better for paroxysmal atrial fibrillation related tachycardia-bradycardia syndrome?

Purpose: To evaluate the outcome of AF ablation in patients with paroxysmal atrial fibrillation (AF) related tachycardia-bradycardia syndrome and to compare the efficacy of catheter ablation with a strategy of permanent pacing plus anti-arrhythmic drugs (AAD). Methods: Forty-three consecutive patients with paroxysmal AF and prolonged symptomatic sinus pauses on termination of AF referred to our hospital for ablation were evaluated. According to current Guideline, each patient of this group (ABL group) was assigned with a "pacemaker recommendation level" before ablation and at the end of follow-up. In another 57 patients, paroxysmal AF was treated with anti-arrhythmic drug and a pacemaker was implanted due to AF related tachycardia-bradycardia syndrome. These patients were used as control (PM group) in the present study. Results: All the 43 patients in the ABL group fulfilled Class I indication for pacemaker implantation at baseline but they actually underwent AF ablation. Re-evaluation after 20.1±9.6 months of follow-up showed that 36/43 (83.7%) patients were free from AF and no longer need a pacemaker (Class III indication) (Figure 1a). More patients in the PM group were on antiarrhythmic drugs (PM 40.4%, ABL 4.7%, P<0.001) while sinus rhythm maintenance at the end of follow-up was remarkably higher in the ABL group (83.7%, vs. 21.1% in PM group, P<0.001) (Figure 1b). Conclusion: In patients with paroxysmal AF related tachycardia-bradycardia syndrome, AF ablation seems to be superior to a strategy of pacing plus AAD. Pacemaker implantation can be waived in the majority of patients after a successful ablation.