Pacing of Left Bundle Branch Area and Atroventricular Node ablatIon in Patients With Symptomatic Atrial Fibrillation

Inclusion: Patients who meet all of the following inclusion criteria 1)-6). 1. Permanent atrial fibrillation 2. Age ≥ 65 years 3. Refractory or intolerant to antiarrhythmic drugs, rate control medications, or catheter ablation 4. New York Heart Association (NYHA) functional class II- IV 5. LVEF \> 40% (within the past 3 months) 6. Patients with at least one of the following: 1. HF hospitalization (defined as HF as the major reason for hospitalization or treatment for HF lasting ≥12 hours and including treatment with intravenous (IV) diuretics at a healthcare facility) within 12 months 2. Elevated NT-proBNP (\>900 pg/ml) in the 30 days prior to enrollment Exclusion: Patients who meet at least one of the following exclusion criteria 1)-11). 1. Asymptomatic atrial fibrillation 2. Life expectancy to \< 12 months. 3. Primary moderate to severe valvular disease (except for functional mitral valve regurgitation or tricuspid valve regurgitation) 4. Mechanical tricuspid valve replacement 5. Severe chronic kidney disease (estimated Glomerular Filtration Rate ≤ 15 ml/1,73 m2 or receiving renal replacement treatment including hemodialysis or peritoneal dialysis) 6. Obstructive hypertrophic cardiomyopathy 7. Infiltrative cardiomyopathy (amyloidosis, sarcoidosis, Fabry disease, others) 8. Acute coronary syndrome or coronary revascularization (CABG or PCI) \<3 months 9. Severe primary pulmonary disease such as cor pulmonale, irreversible lung disease requiring inhalers, oxygen supplementation 10. Pacemaker/ICD/CRT treatment ongoing, or current pacemaker indication 11. Simultaneous participation in a different randomized clinical trial