Efficacy of Atrioventricular Node Ablation Versus Medical Rate Control for Enhancing CRT Response in Permanent Atrial Fibrillation: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

The benefit of atrioventricular (AV) node ablation over medical rate control for enhancing cardiac resynchronization therapy (CRT) response in permanent atrial fibrillation remains uncertain. Four major databases were searched from inception to May 21, 2026. Eligible randomized controlled trials enrolled adults with permanent or persistent atrial fibrillation and heart failure receiving, or considered for, CRT. Outcomes included all-cause mortality, cardiovascular mortality, implantable cardioverter-defibrillator (ICD) therapies, and biventricular pacing percentage. Risk ratios (RRs) or mean differences with 95% confidence intervals (CIs) were pooled using inverse-variance methods. Five randomized controlled trials were included in our work, and 4 contributed to quantitative synthesis. No significant decrease in all-cause mortality was detected with AV node ablation (RR: 0.70, 95% CI, 0.23-2.10, P = 0.5223), the composite endpoint (RR: 0.79, 95% CI, 0.43-1.45, P = 0.4394), cardiovascular mortality (RR: 0.87, 95% CI, 0.42-1.79, P = 0.7022), or appropriate ICD therapy (RR: 0.93, 95% CI, 0.39-2.22, P = 0.8617). AV node ablation reduced inappropriate ICD therapy (RR: 0.09, 95% CI, 0.01-0.66; P = 0.0180) and increased biventricular pacing percentage (mean difference, 11.66%, 95% CI, 7.70-15.61; P < 0.0001). Sensitivity analyses were consistent. AV node ablation may improve CRT delivery and diminish inappropriate ICD therapy, but randomized evidence does not show consistent diminution in mortality or heart failure hospitalization.