ABLATE versus PACE: Pacemaker strategy reduces clinically relevant events in older patients with persistent atrial fibrillation
Randomised trial shows substantially fewer hospitalisations and repeat interventions than pulmonary vein isolation. The benefit was partly offset by more heart failure events and permanent pacemaker dependence.
In the final “Late Breaking Clinical Trials” session of the ESC Congress 2026 in Munich, Germany, Professor Joachim R. Ehrlich of St. Josefs-Hospital Wiesbaden presented the results of the ABLATE versus PACE trial. The investigator-initiated study, funded independently of industry, compared two fundamentally different strategies in 196 symptomatic patients aged 75 years or older with persistent atrial fibrillation and preserved left ventricular function: pacemaker implantation followed by AV node ablation, and pulmonary vein isolation.
The median age of participants was 81 years who were randomised 1:1 at twelve centres in Germany and Austria. The primary endpoint comprised hospitalisation for atrial arrhythmia or heart failure, (outpatient) electrical cardioversion, and upgrade to cardiac resynchronisation therapy. Although it was an “asymmetric endpoint” – it represented clinically meaningful events after each treatment representing healthcare utilization. Follow up was twelve months.
Key result:
Within one year, the primary endpoint occurred in 24 of 98 patients assigned to the pacemaker strategy and in 45 of 98 patients assigned to pulmonary vein isolation, corresponding to 24% versus 46%. The hazard ratio was 0.45, 95% confidence interval 0.27 to 0.74, P = 0.002. A total of 29 versus 84 primary endpoint events (including recurrent events) were recorded, rate ratio 0.31, P < 0.0001.
The difference was driven mainly by arrhythmia-related events. After pacemaker implantation and AV node ablation, there were only three repeat hospitalisations for atrial arrhythmia and one outpatient cardioversion, compared with 54 and 19 events respectively after pulmonary vein isolation. Conversely, heart failure hospitalisations were more frequent with the pacemaker strategy, with 23 versus 11 events. Four patients in this group subsequently required an upgrade to cardiac resynchronisation therapy, compared with none after pulmonary vein isolation.
Overall safety profiles were similar. Treatment associated complications occurred in 11% of patients in the pacemaker group and 10% after pulmonary vein isolation. There was also no clear difference in all-cause mortality or stroke, although the trial was not designed to detect differences in these hard outcomes. Quality of life improved in both groups. At the same time, mean left ventricular ejection fraction at twelve months was about four percentage points lower in the pacemaker group. In the pulmonary vein isolation group, 20 patients underwent a repeat ablation within one year.
Clinically, the findings highlight that in elderly patients with persistent atrial fibrillation, the overall burden of treatment may be an important outcome. The pacemaker strategy can largely avoid arrhythmia related repeat interventions, but it leaves patients permanently pacemaker dependent and may be associated with a greater heart failure burden. Future trials should evaluate the role of conduction system pacing in this setting.
The trialists concluded that, in older patients, this strategy should be considered as a preferred treatment option. Age, comorbidities, duration of atrial fibrillation, procedural risk and patient preferences remain central to shared decision making.
Long term follow up is ongoing and planned for up to five years. The results were published simultaneously with the congress in the European Heart Journal. The study was supported by the German Heart Foundation, which had no role in study design, data collection, analysis or interpretation.
Cite: “ABLATE vs. Pace” at ESC 2026 Late-breaking Trials. touchCARDIO. September 29, 2026.
Disclosure: Andreas Boehmer has received grant/research support from German Heart Foundation. Joachim Ehrlich has received grant/research support and speaker’s bureau participation outside of the reported trial from Medtronic. This content has been developed independently by Touch Medical Media for touchCARDIO. No funding was received in the publication of this article.
Editor: Heather Hall, Managing Editor
touchCARDIO coverage of ESC Congress 2026: This content has been developed independently by Touch Medical Media for touchCARDIO. It is not affiliated with the ESC. Views expressed are the speaker’s own and do not necessarily reflect the views of Touch Medical Media.
