Superior approach from the pocket for atrioventricular junction ablation performed at the time of conduction system pacing implantation

<bold>Background: </bold>Conduction system pacing (CSP) and atrioventricular junction ablation (AVJA) improve outcomes in patients with symptomatic, refractory atrial fibrillation (AF). Superior approach (SA) from the pocket via axillary or subclavian vein has been proposed as an alternative to the conventional femoral venous access (FA) to perform AVJA.<bold>Objective: </bold>To assess the feasibility and safety of SA for AVJA performed simultaneously with CSP, and to compare this approach with FA.<bold>Methods: </bold>A prospective, observational study, enrolling consecutive patients with symptomatic, refractory AF undergoing simultaneous CSP and AVJA.<bold>Results: </bold>A total of 107 patients were enrolled: in 50, AVJA was primarily attempted with SA, in 69 from FA. AVJA with SA was successful in 38 patients (76.0%), while in 12 patients, a subsequent FA was required. AVJA from FA was successful in 68 patients (98.5%), while in one patient, a left-sided approach via femoral artery was required. Compared with FA, SA was associated with a significantly longer duration of ablation (238.0 +/- 218.2 vs. 161.9 +/- 181.9 s; p = .035), a significantly shorter procedure time (28.1 +/- 19.8 vs. 19.8 +/- 16.8 min; p = .018), an earlier ambulation (2.7 +/- 3.2 vs. 19.8 +/- 0.1 h; p < .001), and an earlier discharge from procedure completion (24.0 +/- 2.7 vs. 27.1 +/- 5.1 h; p < .001). After a median follow-up of 12 months, the rate of complications was similar in the two groups (2.0% in SA, 4.3% in FA; p = .483).<bold>Conclusion: </bold>Simultaneous CSP and AVJA with SA is feasible, with a safety profile similar to FA. Compared to FA, this approach reduces the procedure times and allows earlier ambulation and discharge.