Catheter ablation of atrial fibrillation improves outcomes in heart failure: An updated meta‐analysis

Catheter ablation is an important treatment option to improve the prognosis of heart failure. However, data from two recent important randomized clinical trials question the efficacy of radiofrequency catheter ablation (RFCA) in patients with advanced heart failure (HF). ¹ , ² On the other hand, the CASTLE‐HTx 2023 study shines a more positive light on the effectiveness of RFCA. ³ Due to these recent conflicting results, we performed an updated meta‐analysis to evaluate the significance of RFCA in improving the prognosis of patients with HF.

We used the method proposed by the Cochrane Collaboration and met the reporting criteria of the Preferred Reporting Items for Systematic Review and Meta‐analysis (PRISMA) guidelines for 2020. ⁴ On 2023 October 01, a database search was performed using PubMed, Web of Science Core Collection and Cochrane advanced search. Meta‐analysis was performed using RevMan 5.41 (Cochrane Collaboration, London, UK) and R Statistical Software (v3.5.1, Boston, MA, USA). Inverse variance with random effects model was used to weight each study in the meta‐analysis of integrated risk ratios. A P value <0.05 was considered statistically significant. Our literature search identified 9 RCTs for analysis. ¹ , ² , ³ , ⁵ , ⁶ , ⁷ , ⁸ , ⁹ , ¹⁰ Table 1 summarizes the characteristics of the enrolled trials: the nine RCTs enrolled 1349 patients, of whom 677 were randomized to the RFCA group and 672 to the non‐RFCA group.

Table 1.

Characteristics of included studies.

	Number of patients	Age (mean) of RFCA group	Age (mean) of non‐RFCA group	LVEF	NYHA class	Ischaemic aetiology	Persistent AF	CRT‐D	Ablation strategy	Medical strategy	Monitoring AF recurrence	Overall successful rate of RFCA	Significant improvement after RFCA
MacDonald et al. 2011	41	62.3	64.4	LVEF ≤ 35%	II‐III	49%	100%	NA	PVI ± linear ablation	Rate control	24 h Holter	50%	LVEF
ARC‐HF, 2013	52	64	62	LVEF ≤ 35%	II‐III	33%	100%	21%	PVI + linear ablation + CFAEs	Rate control	24 h Holter	88%	Quality of life
CAMTAF, 2014	50	55	60	LVEF ≤ 50%	II‐III	26%	100%	NA	PVI ± linear ablation ± CFAEs	Rate control	48 h Holter	73%	LVEF, peak oxygen consumption, quality of life, serum BNP, NYHA functional class
AATAC, 2016	203	62	60	LVEF ≤ 40%	II‐III	62%	100%	100% (ICD or CRT‐D)	PVI ± linear ablation ± CFAEs	Amiodarone	Cardiac implantable electronic device	70%	Mortality, unplanned hospitalization, LVEF, 6MWD, Quality of life
CAMERA‐MRI, 2017	66	59	62	LVEF ≤ 45%	II–IV	0%	100%	NA	PVI ± linear ablation	Rate control	Implantable loop recorder	75%	LVEF, Serum BNP, NYHA functional class
CASTLE‐AF, 2018	363	64	64	LVEF ≤ 35%	I–IV	46%	67%	28%	PVI ± linear ablation	Rhythm and Rate control	Cardiac implantable electronic device	63%	Mortality, HF hospitalization, LVEF
AMICA, 2019	140	65	65	LVEF ≤ 35%	II–III	50%	100%	44%	PVI ± linear ablation ± CFAEs	Rhythm and Rate control	ECG‐monitoring card	74%	NA
RAFT‐AF, 2022	240	65	67	LVEF ≤ 45%	II–III	40%	92%	18%	PVI ± linear ablation ± CFAEs	Rate control	14 day ambulatory monitoring (CardioSTAT)	99%	LVEF, 6MWD, serum NT‐proBNP, Quality of Life
CASTLE HTx, 2023	194	62	65	LVEF ≤ 35%	II–IV	39%	56%	38%	PVI ± linear ablation	Rhythm and Rate control	Implantable cardiac device	56%	LVEF, AF burden

Abbreviations: AF, atrial fibrillation; BNP, brain natriuretic peptide; CFAE, continuous fractionated atrial electrogram; ECG, electrocardiogram; LVEF, left ventricular ejection fraction; NYHA, New York Heart Association; PVI, pulmonary vein isolation.

Figure 1A shows the risk ratio of all‐cause mortality in the RFCA‐treated group versus the non‐treated group. Compared to medical therapy, RFCA for AF was associated with a significant reduction in all‐cause mortality [RR, 0.53 (95% CI, 0.38–0.74) <0.001, I ² = 0%, P for heterogeneity = 0.42]. Figure 1B shows the risk ratio for heart failure hospitalization; RFCA was associated with a significant reduction in HF hospitalization [RR, 0.58 (95% CI, 0.47–0.73), P < 0.001, I ² = 0%, P for heterogeneity = 0.70]. A significant risk reduction was also observed with RFCA for the composite endpoint of all cause‐mortality and heart failure hospitalization [RR, 0.63 (95% CI, 0.50–0.79), P < 0.001, I ² = 0%, P for heterogeneity = 0.85] (Figure 1C). For serious adverse events, there was no significant group difference between the RFCA and medical therapy groups [RR, 1.17 (95% CI, 0.96–1.43) P = 0.12, I ² = 23%, P for heterogeneity = 0.23]. For recurrence of atrial fibrillation, the RFCA group had significantly fewer recurrences than the medical treatment group [RR, 0.38 (95% CI, 0.27–0.53), P < 0.001, I ² = 65%, P for heterogeneity = 0.02]. RFCA showed no significant difference in improvement compared to the pharmacotherapy group regarding the 6 min walk distance. However, it did show significant improvements in LVEF, peak O₂ consumption and quality of life as evaluated by the Minnesota Living with Heart Failure questionnaire (Figure 2).

Figure 1.

Impact of RFCA on prognosis of heart failure patients with reduced ejection fraction. (A) All‐cause mortality; (B) Hospitalization for heart failure; (C) Composite outcome (all‐cause mortality and hospitalization for heart failure).

Figure 2.

Impact of RFCA on clinical parameters in patients with heart failure and reduced ejection fraction. (A) LVEF; (B) 6 min walk test; (C) Peak O₂ consumption; (D) Quality of Life (Minnesota Living with Heart Failure questionnaire).

Despite some heterogeneity, the comprehensive evidence suggests that RFCA improves cardiac outcomes and reduces hospitalizations. Our meta‐analysis underscores the significant therapeutic potential of RFCA in patients with concurrent heart failure and atrial fibrillation.

Kato, S. , Azuma, M. , Kodama, S. , Horita, N. , and Utsunomiya, D. (2024) Catheter ablation of atrial fibrillation improves outcomes in heart failure: An updated meta‐analysis. ESC Heart Failure, 11: 3449–3452. 10.1002/ehf2.14919.