Catheter ablation for atrial fibrillation in patients with heart failure with reduced versus preserved ejection fraction; a systematic review and meta-analysis
Authors: Oraii A , Parkash R , Wong J A , Mcintyre W F , Razeghi G , Kowalik K , Belley-Cote E , Zamiri N , Connolly S J , Tang A S L , Healey J S 
Published: November 2023

Abstract

Background
Catheter ablation is superior to pharmacological therapies for lowering adverse cardiovascular outcomes in patients with both atrial fibrillation (AF) and heart failure with reduced ejection fraction (HFrEF). Yet, it is uncertain whether patients with heart failure with mildly reduced or preserved ejection fraction (HFpEF) derive the same treatment benefit from catheter ablation.

Purpose
This systematic review and meta-analysis aimed to assess whether the efficacy of AF catheter ablation in reducing all-cause mortality and heart failure events is different in patients with HFrEF versus HFpEF.

Methods
We searched MEDLINE, Embase, and Cochrane Central to September 2022 for randomized controlled trials in patients with heart failure comparing catheter ablation for AF with medical therapy (defined as rate or rhythm control with medications, device implantation, and/or cardioversion). The outcomes of interest were all-cause mortality and heart failure events (i.e. hospitalization or worsening). Pairs of reviewers systematically screened the eligible studies and used random-effects models to combine data. We contacted authors of eligible studies to obtain unpublished data on heart failure subgroups. We used an interaction p-value to test the statistical significance of difference between subgroups with HFrEF and HFpEF.

Results
A total of 8 studies (2118 participants, mean age: 65.6 years, 28.1% women) assessed the effect of catheter ablation on all-cause mortality in patients with AF and heart failure. We found no statistical evidence of a different effect for AF catheter ablation in reducing all-cause mortality in patients with HFrEF (196 events, RR 0.67, 95% CI: 0.50-0.90) compared to those with HFpEF (77 events, RR 0.95, 95% CI: 0.39-2.30) – p for subgroup differences=0.46.
In addition, 7 studies (2057 participants, mean age: 65.8 years, 29% women) evaluated the effect of catheter ablation on heart failure events in patients with AF and heart failure. As compared to conventional medical therapies, AF catheter ablation significantly reduced the risk of heart failure events in patients with HFrEF (285 events, RR 0.59, 95% CI: 0.48-0.72); however, it had little or no effect on heart failure events in those with HFpEF (106 events, RR 0.93, 95% CI: 0.65-1.32). Interaction analysis showed significant effect modification for AF catheter ablation in patients with HFpEF – p for subgroup differences=0.03.

Conclusion
Catheter ablation is superior to conventional medical therapies for reducing all-cause mortality in patients with AF and heart failure. However, its beneficial effect on heart failure events may be limited to patients with HFrEF. The available evidence on patients with HFpEF is insufficient for a definitive conclusion. Future trials are warranted to study the prognostic effect of catheter ablation in patients with AF and HFpEF.All-cause MortalityHeart Failure Events