We recommend AV junction ablation and implantation of a permanent pacemaker in symptomatic patients with uncontrolled ventricular rates during AF despite maximally tolerated combination pharmacologic therapy. (Recommendation Strong, Quality Moderate)<br /><br /><b>Values and preferences: </b>This recommendation places a high value on the results of many small randomized trials and one systematic review reporting significant improvements in QOL and functional capacity as well as a decrease in hospitalizations for AF following AV junction ablation in highly symptomatic patients.