Atrial fibrillation (AF) is an increasingly common condition in the aging population that can be difficult to treat with medical therapy. Tachycardia resulting from AF often results in symptoms, impaired quality of life and can lead to a tachycardia-mediated cardiomyopathy. When rhythm control and pharmacologic rate control are ineffective options, atrioventricular nodal ablation may provide a more practical approach that is both definitive and effective in controlling AF. This article reviews the rationale and current evidence for atrioventricular nodal ablation combined with pacemaker therapy in elderly patients with recurrent AF. The evidence and rationale for cardiac resynchronization therapy and future directions are also described.