News · Heart & Metabolic
Pacemakers outperformed catheter ablation for irregular heart rhythm in patients over 75
Catheter ablation is the standard offer for persistent atrial fibrillation, and it works less well the older the patient. Randomizing 196 people with a median age of 82 tested the blunter alternative.
- About a quarter of the pacemaker group hit the main endpoint against nearly half on ablation.
- The gap came mostly from rhythm hospital admissions and repeat cardioversions.
- Heart failure admissions ran the other way, higher in the pacemaker group.
- Deaths, strokes, complications and quality of life were not measurably different.
- 196 patients randomized at twelve centers over twelve months, median age 82.
Medicine prefers fixing the problem to working around it, and usually that instinct is right.
For atrial fibrillation the fix is catheter ablation, which destroys the small areas of tissue firing off the disordered signals and aims to restore a normal rhythm. It has become the standard offer, and it succeeds less often the older and longer-standing the fibrillation is.
The workaround is cruder and older. Fit a pacemaker, then deliberately sever the electrical connection between the upper and lower chambers so the chaos upstairs never reaches the pump. The fibrillation continues; the pulse becomes regular because a device is setting it.
Why anyone would choose the workaround
Because it always works. The failure mode of ablation is that the rhythm comes back, and in an 82-year-old with persistent fibrillation it often does.
The cost is permanence. If you destroy the natural connection, the lower chambers depend on the device for the rest of the person’s life, and that is a large thing to accept. It is why the approach is normally reserved for people who have run out of alternatives.
Population aging is increasing atrial fibrillation prevalence, which makes the question of what to offer older patients steadily less academic.
The trial
Writing in the European Heart Journal, investigators at twelve centers in Germany and Austria randomized 196 patients aged 75 or older, with a median age of 82, all with symptomatic persistent fibrillation and normally pumping hearts.
Half received the pacemaker approach. Half received ablation. The endpoint counted admissions for the rhythm or for heart failure, outpatient shocks to restore rhythm, and upgrades to a more complex device.
What happened
Roughly a quarter of the pacemaker group had an event against nearly half of the ablation group, a difference large enough to be well clear of chance.
The composition of that difference matters more than the headline. Admissions for the rhythm itself and repeat cardioversions were overwhelmingly in the ablation group, which is what you would expect if the rhythm keeps returning.
Heart failure admissions went the other way, more common in the pacemaker group. That is the recognized cost of pacing the heart from a single point over time, and it is not a trivial one.
What did not differ
Deaths. Strokes. Cardiovascular complications. And quality of life, which is the one most likely to surprise people.
Fewer hospital visits without a measurable improvement in how patients rated their lives is an awkward pairing. It may mean the quality-of-life instrument was too blunt, or that twelve months is too short, or that avoiding admissions matters less to patients than it does to health systems.
What this does not settle
Twelve months is a short horizon for a decision that is permanent. Heart failure from long-term pacing develops over years, and the trend was already visible within the first year.
The trial was also open-label, so everyone knew which treatment they had received. That does not affect deaths, and it can affect softer endpoints such as when someone is admitted or offered a cardioversion.
196 patients is small, and this is one trial in two countries.
Where it lands
If you have AFib, your heart beats irregularly and sometimes much faster than normal, and for most patients ablation remains the reasonable first attempt.
What this changes is the standing of the alternative for the oldest patients. A treatment usually described as the last resort produced fewer events than the standard one over a year, without more deaths or complications, in exactly the group where the standard one works least well. That is enough to make it a genuine option to discuss rather than a fallback to reach for once everything else has failed.
People also ask
What did the trial find?
At 12 months, a first primary endpoint event occurred in 24 of 98 patients (24%) assigned to pacemaker with atrioventricular node ablation and 45 of 98 (46%) assigned to pulmonary vein isolation (hazard ratio 0.45; 95% CI 0.27-0.74; P = 0.002). Cardiovascular complications, mortality and quality of life were not statistically different between groups.
What are the two treatments?
Pulmonary vein isolation burns or freezes tissue to stop the abnormal signals and restore normal rhythm. The alternative fits a pacemaker, then deliberately blocks the natural connection between the upper and lower chambers so the pacemaker sets the rate instead.
Does the second approach cure the fibrillation?
No. The upper chambers keep fibrillating. It stops that chaos from reaching the pumping chambers, so the pulse becomes regular and controlled while the underlying rhythm problem continues.
Why does that mean lifelong pacemaker dependence?
Because the natural electrical connection has been destroyed on purpose. The heart's lower chambers then rely on the device, which is a permanent commitment and the main reason the approach is usually held back.
What drove the difference?
Mostly admissions for the rhythm itself and repeat electrical cardioversions, both far more common after ablation. Heart failure admissions went the other way and were more common in the pacemaker group, which partly offsets the gain.
Does this apply to younger patients?
No. Everyone was 75 or older with a median age of 82, and the trial exists precisely because ablation succeeds less often in this group. A younger patient with more years ahead faces a different calculation about permanent pacemaker dependence.
What should an older person with atrial fibrillation take from this?
That there is more than one reasonable option and the trade-offs differ, which is a conversation to have with a cardiologist rather than a decision to reach alone. This is general information rather than medical advice.