Aims To determine long-term effects of atrioventricular junction ablation and pacing (AVJAP) on cardiac function and quality of life.Methods and results Prospective follow-up was performed on consenting patients recruited in two participating centres representing majority of the Australian intervention randomized control of rate in atrial. fibrillation trial (AIRCRAFT) cohort after 4-7 years. All patients underwent history, physical examination, 24 h ambulatory ECG monitoring, and transthoracic echocardiogram. Quality of life questionnaires in original AIRCRAFT trial were re-administered including CAST, assessment quality of life, and sickness impact profile. Of the 63 eligible patients, 14 refused participation, and 1 patient was lost to follow-up. The remaining 48 patients (25 mates, current mean age 74 +/- 7.5 years), 23 randomized to AVJAP and 25 to pharmacologic therapy (MED) were re-evaluated. In the MED group, LVEF was 62 +/- 11% at baseline, 63 +/- 10% at 6 months, 64 +/- 9% at 12 months, and 59 +/- 12% at 5 years (P < 0.01). In the AVJAP group LVEF was 54 +/- 19% at baseline, 55 +/- 13% at 6 months, 53 +/- 15% at 12 months, and 51 +/- 17% at 5 years (P = 0. 02). NYHA functional class was not statistically different between MED and AVJAP patients (1.4 vs. 1.5, P = 0.48). Death occurred in 10 MED and 5 AVJAP patients. Survival analysis incorporating all 63 patients showed no statistical difference between the 2 treatment groups (P = 0.26). The CAST quality of life questionnaire revealed that patients in the AVJAP group had fewer symptoms of irregular heart beat (P < 0.001), chest pain (P = 0.02), and difficulty breathing (P = 0.02). Psychosocial scores and overall life satisfaction were similar (P > 0.05).Conclusion In this long-term follow-up of the AIRCRAFT cohort, similar decline in LVEF and NYHA class was observed in both treatment groups. AVJAP patients have better quality of life with fewer symptoms. Based on improved quality of life, ablate and pace strategy for permanent atrial fibrillation should be considered for highly symptomatic patients refractory to pharmacologic therapy.