When would you consider AV nodal ablation in CRT-non-responders with persistent atrial fibrillation?

AV node ablation is the most definitive method for rate control. In this scenario where the patient already has CRT and is a nonresponder, what I do next depends on age of the patient, how symptomatic the patient is, whether the rates are elevated causing the CRT pacing percentage to be suboptimal and what has already been tried. If the patient is a candidate for rhythm control, either with an antiarrhythmic drug or an ablation, that would be the preferred approach. It also depends on the heart rate in AF. If the rates are well controlled with medication and the CRT pacing percentage is >90%, it is unlikely doing an AVN ablation would add much. However, if the patient’s ability to tolerate medications is limited due to low blood pressure, s...