Kai Tang

Background: Left bundle branch area pacing (LBBAP) with atrioventricular node (AVN) ablation has emerged as a promising therapy for patients with atrial fibrillation (AF) and symptomatic heart failure (HF). However, it remains unclear which patients are likely responders and which may derive limited benefit. Objective: This study aimed to identify predictors of unfavorable therapeutic outcomes following this ‘ablate and pace’ therapy. Methods: In this retrospective analysis, consecutive patients with successful LBBAP and AVN ablation were included. Baseline characteristics and long-term outcomes were assessed. Multivariable Cox regression and reclassification analysis were used to evaluate the predictors of heart failure hospitalization (HFH). Results: Ninety-eight patients (age 73.1 ± 8.9 years; ventricular rate 93.6 ± 18.7 bpm; 41.8% male) were enrolled. During 43.9 ± 19.4 months of follow-up, 19 (19.4%) patients experienced HFH. Three independent risk factors were identified for HFH: impaired renal function (eGFR ≤ 60 mL/min/1.73 m²; HR: 7.9), left atrial enlargement (LAD ≥ 50 mm; HR: 4.8), and male sex (HR: 3.9). A risk stratification model incorporating these factors effectively discriminated patients with minimal versus high HFH risk. All patients with three risk factors experienced HFH within 2 years, whereas none of the 25 patients without any risk factors experienced the endpoint during 113 patient years of follow-up. Conclusions: The eGFR ≤ 60 mL/min/1.73 m², LAD ≥ 50 mm, and male sex were likely predictors of poor therapeutic outcomes to ‘ablate and pace’ therapy in patients with AF and HF. Patients without any of these risk factors had minimal HFH risk, whereas ≥2 risk factors showed a markedly higher risk. This may help to identify potential patients who are less likely to benefit from this combined approach, although prospective validation is needed before clinical application.