Catheter Ablation of Atrial Fibrillation in Patients with Heart Failure: a Trial-Level Meta-Analysis.

INTRODUCTION:Many patients with heart failure (HF) have or develop atrial fibrillation (AF), which may contribute to worsening symptoms, hospitalisations and mortality. Whether catheter ablation improves outcomes in patients with HF and AF receiving guideline-recommended pharmacological therapy (GRPT) is controversial. AIMS:A systematic review and meta-analysis of relevant randomised controlled trials (RCT)s on the role of catheter ablation in patients with AF and HF. METHODS:Public databases for trials published prior to 17th March 2025 and investigating the effects of catheter ablation on morbidity and mortality in patients with HF and AF were searched. Outcomes of interest were all-cause and cardiovascular mortality, adverse events due to HF or AF, changes in left ventricular ejection fraction (LVEF), 6-Minute Walking Distance (6-MWD) and Minnesota Living With Heart Failure Questionnaire (MLWHFQ) scores. RESULTS:Altogether, thirteen RCTs including 2,490 patients (predominantly aged <65 years; of whom 73% were men and 79% reported persistent AF) were identified. Blinding of intervention was not attempted. Only three RCTs assessed the effect of catheter ablation in patients with preserved LVEF. Overall, compared to GRPT alone, catheter ablation was associated with lower all-cause mortality (hazard ratio [HR]: 0.58; 95% confidence interval [CI]: 0.44-0.76), cardiovascular death (HR: 0.52; 95% CI: 0.36-0.74) and adverse events related to HF or AF (HR: 0.69; 95% CI: 0.53-089). In addition, catheter ablation improved LVEF (+6% mean difference (MD)[95% CI: +4% to +9%]) and MLWHFQ (-12 points MD [95% CI: -18 points to -6 points]), with a trend to enhanced 6-MWD (+18 meters MD [95% CI: -1 meter to +38 meters]). CONCLUSIONS:For a selected group of patients with chronic HF and AF enrolled in un-blinded RCTs, catheter ablation improved cardiac function, wellbeing and outcomes, including all-cause mortality. Further RCTs are required to determine whether the benefits of catheter ablation extend to a broader population of patients at higher risk of procedural failure and recurrent AF.