Catheter ablation for treatment of atrial fibrillation in patients with heart failure with reduced ejection fraction: A systematic review and meta-analysis

Background: Atrial fibrillation (AF) among patients with heart failure with reduced ejection fraction (HFrEF) is associated with adverse clinical outcomes. Our primary aim was to evaluate patient-centered outcomes and surrogate outcomes following catheter ablation (CA) of AF among patients with HFrEF compared to standard medical therapy with or without device therapy (atrioventricular node ablation and cardiac resynchronization therapy). Methods: A systematic literature review was performed limiting our searches to randomized control trials reporting outcomes of CA compared to standard medical therapy with or without device therapy were included. Patient-centered outcomes were relative reduction in all-cause mortality, heart failure readmissions, and recurrence of AF. Surrogate outcomes of interest were change in ejection fraction, change in peak oxygen consumption, reduction in brain natriuretic peptide levels, change in 6-minute walk distance, and change in Minnesota living with heart failure score. Results: Seven randomized control trials (Patient n = 721) met our inclusion criteria. All trials used radiofrequency energy for CA of AF. CA for AF was associated with significantly lower all-cause mortality (Risk ratio [RR] = 0.52, 95% confidence interval [CI] = 0.35-0.76, P = 0.001, I² = 0%), lower rate of heart failure readmission (RR = 0.58, 95% CI = 0.46-0.74, P < 0.001, I² = 0%) and lower rate of AF recurrence (RR = 0.33, 95% CI = 0.22-0.50, P < 0.001, I² = 68%) as compared to standard medical therapy. Surrogate outcomes showed a similar benefit favoring CA. Conclusion and Relevance: Catheter ablation for AF in HFrEF is associated with improvement in patient-centered outcomes and surrogate outcomes when compared to standard medical therapy with or without device therapy.