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 pen-procedural complications and mid-term (>= 1-year) survival. Results Six RCTs (n = 772 patients; mean age 62 +/- 11 years, 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; I-2 = 87%; p < 0.001), greater increase in 6MWT distance (MD 25.1 metres; 95% CI, 0.6-50; I-2 = 94%; p = 0.04), improved QoL with greater reduction in MLHFQ scores (MD 9.03; 95% CI, 2.5-15.6; I-2 = 47%; p = 0.007), and significantly reduced mid-term mortality (relative risk 0.52; 95% CI, 0.4-0.8; I-2 = 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.