Atrial fibrillation is common in later life. The goals of therapy are maintenance/restoration of sinus rhythm and control of ventricular rate when atrial fibrillation occurs. The only nonpharmacologic therapy of proven benefit is atrioventricular junction ablation and pacing, but this approach is irreversible and requires clear guidelines for patient selection. In paroxysmal atrial fibrillation, ablation and pacing carries a high risk of progression to permanent atrial fibrillation within 6 months but is indicated only when at least two appropriate drug strategies have failed. In persistent atrial fibrillation, ablation and pacing will inevitably result in permanent atrial fibrillation; this may influence the decision for pacemaker type and the timing of the procedure. In permanent atrial fibrillation, there is clear evidence for benefit, especially in those with reduced left ventricular function. In conclusion, ablation and pacing offers symptomatic and functional benefit to patients with drug-refractory atrial fibrillation. Timing of the intervention relates to response to other pharmacologic therapy.