Atrioventricular Junction Ablation for Cardiac Resynchronization Therapy in Atrial Fibrillation: An Updated Systematic Review, Meta-Analysis, and Meta-Regression Including Contemporary Randomized Trials.

Atrial fibrillation is a common cause of suboptimal cardiac resynchronization therapy (CRT) delivery because intrinsic atrioventricular conduction reduces effective biventricular capture. We performed an updated systematic review and meta-analysis evaluating atrioventricular junction ablation (AVJA) versus no AVJA or pharmacological rate control in CRT recipients with atrial fibrillation. PubMed, Scopus, and Cochrane Library were searched through February 16, 2026. Sixteen studies were included, comprising 14 observational cohorts and 2 randomized trials. AVJA significantly increased biventricular pacing (mean difference 8.80 percentage points, 95% confidence interval [CI] 5.99-11.61). All-cause mortality (risk ratio [RR] 0.74, 95% CI 0.51-1.10), cardiovascular mortality (RR 0.79, 95% CI 0.49-1.27), and heart failure hospitalization (RR 0.73, 95% CI 0.18-2.97) were directionally favorable but not statistically significant. Remodeling, functional, quality-of-life, and clinical responder outcomes were modest or neutral. Contemporary device-therapy data suggested fewer inappropriate shocks and ventricular arrhythmia-related therapies with AVJA, although reporting heterogeneity precluded formal pooling. AVJA remains a dependable CRT-optimization strategy for selected patients with atrial fibrillation, especially when biventricular pacing is inadequate, but contemporary evidence supports a more measured interpretation of downstream clinical benefit.