Catheter Ablation Versus Medical Therapy for Atrial Fibrillation in Patients With Heart Failure: A Meta-Analysis of Randomised Controlled Trials

Background: Catheter ablation (CA) is highly efficacious for symptomatic atrial fibrillation (AF) but data predominantly comes from patients with preserved ventricular function. We performed an updated systematic review and meta-analysis of randomised controlled trials (RCT) comparing CA versus medical therapy for AF associated with heart failure (HF).

Methods: Medline, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL) were searched for RCTs reporting clinical outcomes of CA versus medical therapy for AF in HF patients with ≥6 months' follow-up (atrioventricular-node ablation/device therapy studies excluded). Primary endpoint was change in left ventricular ejection fraction (LVEF). Secondary endpoints were 6-minute walk test (6MWT) distance, quality of life (QoL; measured by the Minnesota Living with Heart Failure Questionnaire [MLHFQ]), peri-procedural mortality, major peri-procedural complications and mid-term (≥1-year) survival.

Results: Six RCTs (n=772 patients; mean age 62±11years, LVEF 30±9%) were included. Catheter ablation, compared to medical therapy was associated with: greater improvement in LVEF (mean difference [MD] 5.67%; 95% Confidence Interval [CI], 3-8; I²=87%; p<0.001), greater increase in 6MWT distance (MD 25.1 metres; 95% CI, 0.6-50; I²=94%; p=0.04), improved QoL with greater reduction in MLHFQ scores (MD 9.03; 95% CI, 2.5-15.6; I²=47%; p=0.007), and significantly reduced mid-term mortality (relative risk 0.52; 95% CI, 0.4-0.8; I²=0%; p=0.001). Freedom from AF after ≥1 procedure was 71%; major complications occurred in 8% of patients.

Conclusion: Catheter ablation is superior to medical therapy for AF in patients with heart failure resulting in greater improvement in LVEF, quality of life and functional status, with a survival benefit.