Concern about the potential risks of anti-arrhythmic drugs has grown at a time of rapid development of non-pharmacologic treatment for cardiac arrhythmias by catheter based techniques. This began with the relatively crude method of high energy, direct current (DC) ablation of the AV junction (AVJ), which was described in 1982 by both Gallagher et al. and Scheinman et al, but has become much more refined with the advent of radiofrequency ablation. Chronic success rates of 94% and 88% have been in reports, but in current practice now approaches 100%. Patients undergoing catheter ablation of the AVJ subsequently receive a permanent ventricular pacemaker, usually equipped with a sensor that provides a ‘physiological’ increase in heart rate in response to exercise, to simulate the normal increase in heart rate. Whilst ventricular pacing is not as efficient as normal conduction, this combination of AVJ ablation and pacing appears to be responsible for improving left ventricular function in certain patients. This effect is presumably achieved by slowing and/or regularizing ventricular contraction, but the exact mechanism remains unclear. Several groups have now reported that patients in chronic AF with ventricular dysfunction may experience improvement in ventricular function following AVJ ablation, but with continuing underlying AF. Rosenqvist et al. reported in 1990 that 4 of 5 patients with ejection fractions <35% prior to ablation showed significant increases in ejection fraction at long-term follow-up. Heinz et al. reported in 1992 that left ventricular fractional shortening increased from 28.9% to 35.8% in ten patients who underwent AVJ ablation. The safety of AVJ ablation appears to be at least as good as medical therapy. A recent, retrospective study which directly examined this issue in well-matched groups of AF patients treated with medications (137 patients), DC ablation (63 patients) or RF ablation (132 patients) showed no difference in total mortality, cardiac-related mortality or sudden death between the three treatment groups. Quality of life after AVJ ablation and pacing, as judged by patients, improves dramatically. One recent study assessed quality of life on a five-point scale (1 = poor, 5 = excellent) and found that this measure improved significantly from 1.6+_0.8 prior to ablation to 3.6+1.1 at follow-up (2.3+1.2 years). The same study evaluated the patients’ ability to perform routine activities, of daily living (1 = very limited, 3 = not limited) and found that this parameter also improved significantly from 2.0+0.4 prior to ablation to 2.4+_0.3 at follow-up. Costs of health care as assessed by hospital admissions and MD visits also fell very significantly. Patients treated with a mean of greater than 6 anti-arrhythmic drugs prior to ablation consumed less than one such drug per patient after ablation.