Catheter Ablation versus Medical Therapy of Atrial Fibrillation in Patients with Heart Failure: An Updated Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background: Atrial fibrillation (AF) and heart failure (HF) often coexist and synergistically contribute to an increased risk of hospitalization, stroke, and mortality. Objective: To compare the efficacy of catheter ablation (CA) versus medical therapy (MT) in HF patients with AF. Methods: Electronic databases were queried for randomized controlled trials (RCTs) of CA versus MT of AF in patients with HF. Risk ratios (RRs), mean differences (MDs), and 95% confidence intervals (CIs) were measured using the Mantel−Haenszel method. Results: A total of nine RCTs enrolling 2155 patients met the inclusion criteria. Compared to MT, CA led to a significant reduction in the composite of all-cause mortality and HF hospitalization (24.6% vs. 37.1%; RR: 0.65 (95% CI: 0.53−0.80); p < 0.0001), all-cause mortality (8.8% vs. 13.6%; RR: 0.65 (95% CI: 0.51−0.82); p = 0.0005), HF hospitalization (15.4% vs. 22.4%; (RR: 0.67 (95% CI: 0.54−0.82); p = 0.0001), AF recurrence (31.8% vs. 77.0%; RR: 0.36 (95% CI: 0.24−0.54); p < 0.0001), and cardiovascular (CV) death (4.9% vs. 8.4%; RR: 0.58 (95% CI: 0.39−0.86); p = 0.007). CA improved the left ventricular ejection fraction (MD:4.76% (95% CI: 2.35−7.18); p = 0.0001), 6 min walk test (MD: 20.48 m (95% CI: 10.83−30.14); p < 0.0001), peak oxygen consumption (MD: 3.1 2mL/kg/min (95% CI: 1.01−5.22); p = 0.004), Minnesota Living with Heart Failure Questionnaire score (MD: −6.98 (95% CI: −12−03, −1.93); p = 0.007), and brain natriuretic peptide levels (MD:−133.94 pg/mL (95% CI: −197.33, −70.55); p < 0.0001). Conclusions: In HF patients, AF catheter ablation was superior to MT in reducing CV and all-cause mortality. Further significant benefits occurred within the ablation group in terms of HF hospitalizations, AF recurrences, the systolic function, exercise capacity, and quality of life.

Keywords: atrial fibrillation; catheter ablation; heart failure; medical therapy; randomized controlled trials; recurrence.

Figure 1

Evidence search and selection of the preferred reporting items for systematic reviews and meta-analyses (PRISMA). * Medline, Cochrane, Journals@Ovid, Scopus.

Figure 2

Composite Endpoint, All-Cause Mortality, HF Hospitalizations. Forest plots displaying a decrease in the composite endpoint (a), all-cause mortality (b), and HF hospitalizations (c) in patients with AF and HF undergoing CA versus MT. CI: confidence interval; HF: heart failure.

Figure 3

AF Recurrence and CV Death. Forest plots displaying risk ratio in AF recurrence (a) and cardiovascular death (b) between the ablation and drug groups. AF: atrial fibrillation; CI: confidence interval; CV: cardiovascular; LVEF: left ventricular ejection fraction.

Figure 4

LVEF and 6MWT. Forest plots displaying mean differences in LVEF (a) and 6MWT (b) between the ablation and drug groups: 6MWT: 6-minute walk test; CI: confidence interval; LVEF: left ventricular ejection fraction; SD: standard deviation.

Figure 5

VO₂ max, MLHFQ, and BNP. Forest plots displaying mean differences in VO₂ max (a), MLHFQ (b), and BNP (c) between the ablation and drug groups. CI: confidence interval; MLHFQ: Minnesota Living with Heart Failure Questionnaires; SD: standard deviation; VO₂ Max: peak oxygen consumption.

Figure 6

Sensitivity Analysis for the Composite Endpoint. Forest plots displaying a decrease in the composite endpoint in the sensitivity analysis: (a) catheter ablation vs. rate control, (b) LVEF ≤ 50%, (c) persistent AF. CI: confidence interval; HF: heart failure.