Efficacy of catheter ablation for atrial fibrillation in heart failure: a meta-analysis of randomized controlled trials.

The study aims to evaluate whether rhythm control by catheter ablation is superior to medical therapy for the patients with atrial fibrillation (AF) and heart failure (HF). The literatures were searched by using PubMed, Cochrane Library, Embase, and Web of Science databases up to 12 October 2023. The randomized controlled trials (RCTs) comparing rhythm control using catheter ablation vs. medical therapy in AF patients with HF were pooled. The primary outcomes included all-cause mortality, HF re-hospitalization, and stroke, and the secondary outcomes included left ventricular ejection fraction (LVEF), atrial tachyarrythmia recurrence, quality of life (Minnesota Living with Heart Failure Questionnaire score, MLHFQ score), 6 min walking distance (6MWD), the level of N-terminal B-type natriuretic peptide precursor (NT-proBNP), and adverse events. Nine RCTs involving in 2293 patients met the inclusion criteria. Compared with medical therapy, catheter ablation reduced all-cause mortality [10.07% (121/1201) vs. 15.26% (175/1147), risk ratio (RR):0.60, 95% confidence interval (CI): 0.48-0.74, P < 0.00001, I = 0%] and the rate of HF re-hospitalization (RR: 0.65, P = 0.02, 95% CI: 0.45 to 0.94, I = 74%), but had no obvious difference in incidence of stroke (RR: 0.67, P = 0.27, 95% CI: 0.32 to 1.38, I = 0%). Catheter ablation enhanced LVEF [mean difference (MD), 6.26%, P < 0.00001, I = 89%], reduced AT recurrence (RR: 0.37, P < 0.00001, 95% CI: 0.26 to 0.52, I = 89%), improved the quality of life (MLHFQ score) (MD: -6.83, P = 0.003, I = 67%), elevated 6MWD (MD: 15.92, P = 0.006, I = 76%), and diminished the level NT-proBNP (MD: -44.19, P < 0.00001, I = 75%), but had no significant difference in adverse events [25.81% (310/1201) vs. 30.25% (347/1147), RR: 0.81, 95% CI: 0.65-1.01, P = 0.06, I = 55%]. Catheter ablation as rhythm control strategy substantially enhances the survival rate, reduces HF re-hospitalization, increases the rate of sinus rhythm maintenance, improves the left ventricular function and the quality of life for AF patients with HF, and has similar safety, compared with medical therapy. The rhythm control by catheter ablation may be a better strategy for the AF patients with HF.