The ablate and pace strategy may be considered a viable therapy in the palliative management of patients with medically refractory highly symptomatic atrial fibrillation (AF). The overall success rate is approaching 100%, the inhospital course is usually event free, and the procedure is a relatively safe therapeutic option. There is no doubt that one of the major findings after atrioventricular (AV) node ablation is the significant reduction of cardiac symptoms and health care use, while exercise tolerance and quality of life significantly improved after the procedure. It is also well accepted that catheter ablation and pacemaker (PM) implantation are usually associated with significant improvement in left ventricular ejection fraction, particularly in patient with AF and reduced systolic function at baseline. On the other hand, AV node ablation seems unlikely to have a negative effect on long term survival. The mortality rate in some reports have raised concerns about excess deaths (mainly sudden deaths) attributable to AV node ablation and pacing therapy. These findings are not confirmed by recent data. Modulation of the AV node has been more recently introduced in the clinical practice in order to avoid permanent complete AV block and lifetime PM dependency. AV node modulation procedure is effective in approximately 70% of cases. The short duration of following periods does not allow to draw definitive conclusions concerning the potential evolution of AV node conduction disorders. Both AV node ablation and AV node modulation, when successful, are effective means to improve quality of life and cardiac performance in patients with medically refractory AF. The exact place of these procedures is, today, a matter of debate which is more controversial in patients with paroxysmal AF than with uncontrolled permanent AF.