Clinical Burden of Post-ablation Atrial Fibrillation Recurrence in East Asia: A Systematic Literature Review

Abstract

Aim:

This study aimed to systematically review and synthesise existing real-world evidence on the clinical characteristics and outcomes of patients with post-ablation AF recurrence in east Asia.

Methods:

Following the PRISMA guidelines, main Chinese- and English-language databases were searched for observational studies published from 2019 to 2024. Inclusion criteria targeted East Asian patients aged ≥18 years with post-ablation AF recurrence. Two independent reviewers conducted study selection, data extraction and quality assessment using the Newcastle–Ottawa Scale. Meta-analyses were performed using a random effects model to synthesise the extracted data.

Results:

A total of 68 studies involving 28,750 patients were included. Paroxysmal AF accounted for about half of the population (53.4%; 95% CI [47.8–58.9]). Common comorbidities included hypertension (52.6%; 95% CI [50.2–55.0]), coronary artery disease (17.2%; 95% CI [12.9–22.5]) and diabetes (16.8%; 95% CI [14.9–18.8]). The AF recurrence rates after repeat ablation (21.4%; 95% CI [16.6–27.1]) and antiarrhythmic drug therapy (19.6%; 95% CI [18.0–21.2]) were similar. Recurrence was higher in patients with late recurrence (32.6%; 95% CI [26.9–38.8]) than those with early recurrence (21.5%; 95% CI [17.9–25.6]). The pooled 3-year incidence of major events included heart failure hospitalisation (3.2%; 95% CI [2.8–3.6]), ischaemic stroke (1.2%; 95% CI [0.9–1.7]) and cardiovascular-related death (0.3%; 95% CI [0.1–0.5]).

Conclusion:

Post-ablation AF recurrence in East Asia imposes a considerable disease burden with high recurrence rates even after repeated ablation or antiarrhythmic drug therapy. The presence of prevalent comorbidities and measurable risks of morbidity and mortality further contribute to the long-term clinical and economic burdens of AF.

AF is the most common clinical arrhythmia worldwide.1 It markedly increases the risk of ischaemic stroke, heart failure, renal dysfunction and dementia, leading to substantial morbidity and mortality.2,3 In addition to its clinical consequences, AF severely diminishes quality of life (QOL) and imposes a heavy economic burden.

Catheter ablation has emerged as a first-line therapy for symptomatic AF, outperforming antiarrhythmic drugs (AAD) in achieving and maintaining sinus rhythm, reducing hospitalisations and improving QOL.4,5 However, recurrence after catheter ablation remains common, with rates reaching approximately 40.6% in paroxysmal AF and up to 75% in persistent AF.6 These recurrence rates present a critical barrier to achieving durable clinical success and highlight an unmet need for better post-ablation disease management.

Recurrent AF is associated with a wide range of adverse consequences, including persistent symptoms (e.g. palpitations, fatigue, shortness of breath), emotional distress and an increased risk of thromboembolic events.7–9 Patients with AF recurrence often require repeat ablation procedures, on-going use of AADs and anticoagulants and more frequent follow-up, leading to higher healthcare usage and costs. Real-world data suggest that the economic burden of AF recurrence after ablation is considerable, driven by repeat hospitalisations, emergency visits and productivity losses.10,11 Moreover, the unpredictability of recurrence can negatively impact patients’ mental health and perceived treatment satisfaction, further reducing their health-related QOL.12 As such, reducing post-ablation recurrence and managing its consequences remain priorities in AF care pathways, particularly in ageing populations with rising AF prevalence.

While numerous studies have explored AF recurrence in Western populations, data specific to East Asia remain limited and fragmented. Regional differences in AF epidemiology, stroke risk profiles, clinical practice patterns and genetic predispositions may influence both recurrence rates and the associated disease burden. Furthermore, healthcare systems and reimbursement structures vary widely across East Asian countries, affecting access to treatment and post-ablation care. Therefore, a systematic literature review (SLR) synthesising real-world evidence from East Asia is essential to comprehensively understand the clinical consequences of post-ablation AF recurrence in this population. Such evidence can inform regionally tailored disease management strategies, support policymaking and guide future research priorities.

Methods

This study was designed as a SLR to synthesise existing real-world evidence on the disease burden of post-ablation AF recurrence in East Asia, including China, Japan and South Korea. The latest PRISMA statement was followed to conduct this SLR.

Data Sources and Search Strategy

We systematically searched China National Knowledge Infrastructure, Wanfang Data and VIP Database in Chinese, and Embase, MEDLINE and Web of Science in English. The search covered studies published from 2019 to 2024. In addition, the search focused on real-world studies including patients with post-ablation AF recurrence from East Asia, which included China, Japan and South Korea. The search strategies were developed by combining the keywords for AF, recurrence, catheter ablation and selected countries (Supplementary Tables 1 and 2).

Study Selection and Data Extraction

The initial literature search was conducted using predefined search strategies tailored to each included bibliographic database. Search results from all databases were pooled, and duplicate references were removed. The titles and abstracts of the identified studies were then screened based on predefined inclusion and exclusion criteria. This SLR included observational studies conducted in three East Asian countries – China, Japan and South Korea – that focused on patients with AF who experienced post-ablation recurrence. Only studies published in English or Chinese were included because the researchers lacked language proficiency in Japanese and Korean.

References were excluded if they were clinical trials, non-human studies, narrative reviews, clinical guidelines, case reports, letters, expert opinions or commentaries. Furthermore, to minimise potential bias associated with low-quality evidence and small sample sizes, studies were excluded if they received fewer than three stars on the Newcastle–Ottawa Scale or included fewer than 20 patients. An Excel-based data extraction form was developed to systematically capture relevant information on the clinical burden of post-ablation AF recurrence. Extracted data included patient demographics, AF subtype (paroxysmal or persistent), CHA₂DS₂-VASc and HAS-BLED scores, echocardiographic parameters of cardiac anatomy, comorbidities, treatment effectiveness (including pulmonary vein [PV] reconnection rate and recurrence rate), AF-related morbidity and all-cause or AF-specific mortality.

Statistical Analysis

To address the objectives of this SLR, all extracted data were categorised into key domains, including patient demographics and clinical characteristics, AF recurrence patterns, treatment-related outcomes, AF-related morbidity and mortality. Quantitative evidence synthesis was performed using two complementary approaches depending on the consistency of data definitions and reporting formats across studies. For variables that were consistently defined and reported in two or more studies, single-arm meta-analyses were conducted to generate pooled estimates. For continuous variables with reported means and standard deviations, pooled means and 95% CIs were calculated. For dichotomous outcomes, pooled proportions were estimated using a random-effects model to account for potential heterogeneity across study populations and settings. For variables that could not be synthesised using meta-analytic techniques, due to heterogeneity in outcome definitions, inconsistent reporting formats or limited sample size, weighted averages were calculated to provide descriptive summaries. Weighting was based on the sample size of each contributing study. When only a single study reported a given variable, the result was presented descriptively without synthesis. This two-pronged evidence synthesis strategy ensured that pooled estimates were generated where appropriate, while preserving data transparency and interpretability for heterogeneous outcomes.

Subgroup analyses were performed for patients who were stratified by AF subtypes (paroxysmal AF versus persistent AF), time to post-ablation recurrence (early recurrence [time to recurrence ≤3 months, blanking period] versus late recurrence [time to recurrence >3 months]) and treatment types for post-ablation AF recurrence (repeat ablation versus AAD). Subgroup comparisons were conducted using Cochran’s Q (a non-parametric test). All single-arm meta-analyses used a random-effects model.

Results

Based on the search strategy, a total of 893 references were initially retrieved. After removing duplicates, 639 references remained. Following title and abstract screening, 197 references were identified for full publication review. Based on the inclusion and exclusion criteria, 68 references were ultimately included (63 full publications and five abstracts) for data extraction and evidence synthesis (Figure 1).

Figure 1: Literature Search Flowchart.

Characteristics of Patients with Post-ablation AF Recurrence

Of the 68 included studies (involving 28,750 patients), 57 (Supplementary Table 3) involving 16,122 patients reported the characteristics of individuals with post-ablation AF recurrence (Table 1). Based on pooled data, the mean age was 62.3 years (95% CI [61.0–63.6]), and 67.5% (95% CI [65.0–69.9] were male. Regarding AF type, 53.4% (95% CI [47.8–58.9]) had paroxysmal AF. The mean disease duration was 44.6 months (95% CI [34.8–54.3]). Risk scores indicated moderate thromboembolic and bleeding risks, with a mean CHA₂DS₂-VASc score of 2.0 (95% CI [1.9–2.2]) and HAS-BLED score of 1.2 (95% CI [0.7–1.7]). Echocardiographic assessments revealed an average left ventricular ejection fraction of 61.6% (95% CI [60.5–62.6]) and a mean left atrial diameter (LAD) of 41.2 mm (95% CI [40.5–42.0]). The mean left ventricular diastolic diameter (LVDD) and systolic diameter (LVDS) were 48.4 mm (95% CI [47.1–49.7]) and 32.2 mm (95% CI [31.2–33.2]), respectively. The average left atrial volume index (LAVI) was 34.3 ml/m² (95% CI [28.6–40.1]). Comorbidities were common in this population. The most prevalent cardiovascular comorbidities were hypertension (52.6%; 95% CI [50.2–55.0]), coronary artery disease (17.2%; 95% CI [12.9–22.5]), heart failure (13.8%; 95% CI [11.4–16.8]) and stroke (10.8%; 95% CI [9.1–12.7]). Metabolic disorders such as hyperlipidaemia (25.7%; 95% CI [17.2–36.5]) and diabetes (16.8%; 95% CI [14.9–18.8]) were also prevalent.

Table 1: Pooled Characteristics of Patients with Post-ablation AF Recurrence from the Included Studies.

Variable	Studies (n)	Sample Size	Point Estimation [95% CI]
Demographics
Mean age (years)	56	16,083	62.3 [61.0–63.6]
Male (%)	56	16,063	67.5% [65.0–69.9]
Mean BMI (kg/m2)	39	10,159	24.6 [24.3–24.9]
Disease Characteristics
Paroxysmal AF (%)	33	14,610	53.4% [47.8–58.9]
Mean disease duration (months)	26	4,997	44.6 [34.8–54.3]
Mean CHA2DS2-VASc score	29	9,705	2.0 [1.9–2.2]
Mean HAS-BLED score	4	3,834	1.2 [0.7–1.7]
Echocardiogram Mean LVEF (%) Mean LAD (mm) Mean LVDD (mm) Mean LVDS (mm) Mean LAVI (ml/m2)	45 49 10 5 4	13,263 14,918 3,800 496 1,503	61.6% [60.5–62.6] 41.2 [40.5–42.0] 48.4 [47.1–49.7] 32.2 [31.2–33.2] 34.3 [28.6–40.1]
Comorbidities (%)
Cardiovascular diseases
Hypertension	55	16,157	52.6% [50.2–55.0]
Coronary artery disease	26	11,147	17.2% [12.9–22.5]
Heart failure	40	15,315	13.8% [11.4–16.8]
Stroke/embolism/transient ischaemic attack	37	14,901	10.8% [9.1–12.7]
Sick sinus syndrome	1	100	8.0% [4.1–15.2]
Heart disease	3	2,108	7.9% [6.8–9.1]
Angina pectoris	1	2,047	7.0% [6.0–8.2]
Cerebrovascular disease	3	205	6.8% [3.0–14.5]
Angiopathy	13	6,591	5.7% [3.8–8.4]
Metabolic diseases
Hyperlipidaemia	9	1,725	25.7% [17.2–36.5]
Diabetes	55	16,157	16.8% [14.9–18.8]
Thyroid diseases	3	548	6.9% [3.1–14.6]
Other
Kidney disease	4	240	10.0% [5.0–19.0]

LAD = left atrium diameter; LAVI = left atrial volume index; LVDD = left ventricular end diastolic diameter; LVDS = left ventricular end-systolic inner diameter; LVEF = left ventricular ejection fraction.

Several studies reported patient characteristics stratified by AF subtype (Supplementary Table 4) and time to recurrence (Supplementary Table 5). Based on pooled data, patients with persistent AF were generally older, exhibited more pronounced structural cardiac changes and had a higher burden of comorbidities compared with those with paroxysmal AF (Table 2). Specifically, the mean age was 64.5 years (95% CI [61.0–68.1]) for persistent AF versus 58.9 years (95% CI [55.9–62.0]) for paroxysmal AF. The LAD was greater in persistent AF (43.3 mm versus 40.1 mm) than in paroxysmal AF. Interestingly, LVDD was higher in paroxysmal AF (50.0 mm versus 47.0 mm) than in persistent AF. Patients with persistent AF also had higher proportions of hyperlipidaemia (37.4% versus 23.0%), diabetes (21.2% versus 14.3%) and heart failure (18.2% versus 7.0%).

Table 2: Pooled Characteristics of Patients with Post-ablation AF Recurrence by AF Subtypes.

Variable	Paroxysmal AF			Persistent AF			p-value
	Studies (n)	Sample Size (n)	Point Estimation [95% CI]	Studies (n)	Sample Size (n)	Point Estimation [95% CI]
Demographics
Mean age (years)	11	689	58.9 [55.9–62.0]	9	512	64.5 [61.0–68.1]	0.018
Disease Characteristics
Mean LAD (mm)	11	689	40.1 [38.6–41.7]	6	398	43.3 [41.2–45.5]	0.016
Mean LVDD (mm)	1	91	50.0 [49.2–50.8]	1	176	47.0 [46.3–47.8]	<0.001
Comorbidities (%)
Hyperlipidaemia	1	74	23.0% [14.8–33.9]	1	123	37.4% [29.3–46.3]	0.037
Diabetes	10	750	14.3% [11.9–17.0]	10	551	21.2% [15.2–28.9]	0.038
Heart failure	6	391	7.0% [4.3–11.3]	6	342	18.2% [11.2–28.1]	0.006

LAD = left atrium diameter; LVDD = left ventricular end diastolic diameter.

Forty-three studies (n=15,396) reported characteristics stratified by timing of post-ablation AF recurrence (Table 3). Compared with early recurrence, late recurrence was associated with more pronounced structural heart changes and a higher burden of cardiovascular comorbidities. Patients with late recurrence had larger mean LVDD (49.6 mm versus 46.6 mm) and LVDS (32.6 mm versus 31.2 mm). Interestingly, LAVI was lower in the late recurrence group (32.5 ml/m² versus 39.7 ml/m²). Furthermore, coronary artery disease (23.7% versus 10.7%) and previous major bleeding events (4.6% versus 0.8%) were more prevalent in patients with late recurrence. In contrast, cardiomyopathy was slightly more common in patients with early recurrence (7.3% versus 4.6%).

Table 3: Pooled Characteristics of Patients with Post-ablation AF Recurrence by Timing of Recurrence.

Variable	Early Recurrence			Late Recurrence			p-value
	Studies, n	Sample Size	Point Estimation [95% CI]	Studies, n	Sample Size	Point Estimation [95% CI]
Demographics
Male (%)	8	6,050	73.0% [67.6–77.8]	35	9,346	66.7% [64.0–69.4]	0.040
Disease characteristics
LVDD (mm, mean)	3	1,208	46.6 [46.1–47.2]	6	2,528	49.6 [48.0–51.1]	<0.001
LVDS (mm, mean)	1	176	31.2 [30.4–32.0]	3	282	32.6 [31.6–33.5]	0.034
LAVI (ml/m2, mean)	1	907	39.7 [39.3–40.1]	3	596	32.5 [26.1–38.9]	0.028
Comorbidities (%)
Coronary artery disease	2	3,967	10.7% [9.8–11.7]	12	4,557	23.7% [17.9–30.6]	<0.001
Cardiomyopathy*	2	301	7.3% [4.9–10.9]	2	2,714	4.6% [3.9–5.5]	0.041
Previous major bleeding events	1	907	0.8% [0.4–1.6]	1	3,063	4.6% [3.9–5.4]	<0.001

*Cardiomyopathy type unknown. LAVI = left atrial volume index; LVDD = left ventricular end diastolic diameter; LVDS = left ventricular end-systolic inner diameter.

Pulmonary Vein Reconnection and Recurrence of Treatments for Post-ablation AF Recurrence

Eleven studies evaluated PV reconnection rates following secondary ablation in patients experiencing AF recurrence after initial ablation (Supplementary Table 6). Among these, 10 studies involving 1,107 patients investigated radiofrequency ablation (RFA), while two studies including 87 patients focused on cryoablation (CBA). Across studies, the pooled PV reconnection rate was notably higher for RFA at 57.0% (95% CI [49.8– 63.9]) compared with 37.1% (95% CI [25.1–50.8]) for CBA.

Six studies evaluated treatment approaches for post-ablation AF recurrence, including repeat ablation (six studies with 6,016 patients) and AAD therapy (one study with 2,359 patients). The pooled recurrence rates were similar between the two approaches: 21.4% (95% CI [16.6–27.1]) for repeat ablation and 19.6% (95% CI [18.0–21.2]) for AAD therapy. When stratified by recurrence timing, the recurrence rate following secondary ablation was lower in patients with early recurrence (21.5%; 95% CI [17.9– 25.6]) compared with those with late recurrence (32.6%; 95% CI [26.9– 38.8]). The pooled treatment outcomes for post-ablation AF recurrence are illustrated in Figure 2, and references of included studies are provided in Supplementary Table 7.

Figure 2: Pooled Recurrence Rate of Treatments for Post-ablation AF Recurrence.

Three-year Incidence Rate of Clinical Outcomes in Patients with Post-ablation AF Recurrence

The pooled 3-year hospitalisation rate for heart failure was reported in three studies involving 8,879 patients, with an estimated rate of 3.2% (95% CI [2.8–3.6]).13–15 Data from a single study of 3,063 patients showed a 3-year incidence rate of ischaemic stroke at 1.2% (95% CI [0.9–1.7]).16 The 3-year cardiovascular-related death rate was 0.3% (95% CI [0.1–0.5]) and the incidence of major bleeding events was 0.6% (95% CI [0.4–0.9]), both also based on one study of 3,063 patients.16 The pooled results for these clinical outcomes are illustrated in Figure 3.

Figure 3: Pooled 3-year Incidence Rates of Clinical Outcomes in Patients with Post-ablation AF Recurrence.

Discussion

AF is a common and multifaceted arrhythmia with a rapidly growing global burden – driven in part by population ageing and increasing comorbidities – and is associated with substantial morbidity and mortality.17 Notable regional variations exist in AF epidemiology, clinical outcomes and management strategies, reflecting differences in healthcare systems, access to therapies and the availability of specialised ablation centres.17 Within this context, this SLR provides an integrated synthesis of real-world evidence on the characteristics, treatment outcomes and clinical outcomes of post-ablation AF recurrence in East Asian populations. The findings highlight the complexity of AF recurrence, identify relevant risk factors and offer insights into the relative effectiveness of current post-ablation interventions, thereby underscoring the importance of region-specific evidence to support improved management of recurrent AF and informed, evidence-based clinical decision-making.

One of the most consistent findings across the included studies is the presence of structural changes in the left atrium among patients with recurrent AF. The mean LAD (41.2 mm) and LAVI (34.3 ml/m²) observed in the included cohorts suggest that atrial enlargement is not only common but likely plays a pivotal role in the pathogenesis of recurrence. These structural abnormalities reflect atrial remodelling, a process involving fibrosis, dilation and altered conduction pathways, which can disrupt normal electrical signalling and facilitate re-entry circuits.18 These findings highlight the need for pre-ablation structural assessments (e.g. echocardiographic measurement of LAD and LAVI) to better predict recurrence risk. They also suggest that therapies targeting structural remodelling, such as upstream therapies (e.g. RAAS inhibitors, statins) or fibrosis-modulating interventions, may complement ablation to improve long-term rhythm outcomes.19,20 Studies from Europe and North America have shown a similar association between atrial enlargement and AF recurrence, suggesting that left atrial volume may serve as a risk assessment tool that, when combined with other prognostic factors, can help optimise patient selection for ablation.21,22

The review demonstrated that patients with persistent AF had significantly worse structural and clinical profiles than those with paroxysmal AF. Persistent AF was associated with greater atrial and ventricular dimensions, higher rates of dyslipidaemia, diabetes and heart failure and an older age profile. These patients represent a more advanced disease stage in which structural remodelling and systemic comorbidities are commonly observed among patients with persistent AF and may contribute to or reflect advanced disease processes associated with recurrence and adverse outcomes.

These results underscore the importance of aggressive risk factor management, particularly in patients with persistent AF. Prior to ablation, clinicians should consider not only the rhythm status but also the presence of comorbidities and degree of structural remodelling. Integrated management of cardiovascular risk factors, including blood pressure, glycaemic control, lipid levels and heart failure, should be standard practice to enhance procedural success and prevent recurrence.23,24

The stratification of recurrence into early and late revealed distinct characteristics. Patients with early recurrence had greater atrial volume overload, but smaller ventricular dimensions. In contrast, late recurrence was more strongly associated with coronary artery disease, cardiomyopathies and a history of major bleeding. This suggests that early recurrence may be influenced by transient procedural factors (e.g. inflammation, incomplete lesion formation). Late recurrence tended to occur in patients with more extensive structural remodelling or comorbid disease, suggesting possible associations rather than established mechanisms. Early recurrence should not automatically be considered a treatment failure. Close monitoring beyond the initial blanking period is essential. For patients with early recurrence, optimisation of procedural techniques and antiarrhythmic therapy during the healing phase may help suppress late recurrence.25,26 In contrast, late recurrence may warrant more aggressive risk factor modification and consideration of repeat ablation if structural and functional recovery remains insufficient.27

Our pooled analysis indicates that RFA has a notably higher PV reconnection rate than CBA. This difference likely reflects the point-by-point nature of RFA, where small gaps can occur even with optimised lesion guidance, whereas CBA creates a more uniform circumferential lesion that better maintains long-term isolation.28,29 Clinically, the higher reconnection rate with RFA may contribute to a greater risk of AF recurrence or repeat procedures.30–32 However, this comparison should be interpreted with caution given variations in operator experience, ablation technologies and reconnection assessment methods across studies.

In addition, repeated ablation and AAD demonstrated comparable long-term rhythm control, with similar recurrence rates (approximately 20%). The recurrence rate following repeat ablation remained relatively high (21.4%), and late recurrence was more frequent than early recurrence (32.6% versus 21.5%). This suggests that while repeat ablation can be effective, it does not fully eliminate the risk of recurrence, particularly in patients showing evidence of on-going remodelling or multiple comorbidities, which are associated with a higher likelihood of recurrence. These findings support the use of individualised treatment strategies based on patient preference, risk tolerance and overall health status. For some patients, repeat ablation may offer durable rhythm control and symptom relief, especially when performed with advanced imaging and mapping technologies.33 However, for others, particularly those with high procedural risk or limited atrial recovery, pharmacological therapy may be a reasonable and equally effective alternative.34 It should be noted that evidence directly comparing repeat ablation and AAD therapy is limited, with only one study providing head-to-head data. Therefore, caution is warranted in interpreting these results, and further research is needed to robustly compare these treatment strategies.

Pulsed field ablation (PFA) represents a paradigm shift in the catheter-based treatment of AF, achieving myocardial-selective ablation through the non-thermal mechanism of irreversible electroporation.35 Although early clinical outcomes are promising, the durability of PFA lesions – particularly over mid- and long-term follow-up – remains a critical area of investigation.35 Compared with conventional thermal ablation modalities such as radiofrequency and cryoballoon ablation, PFA offers potential advantages including enhanced tissue selectivity, reduced collateral injury and a potentially improved safety profile; however, robust comparative and long-term efficacy data remain limited.36 Notably, this review did not identify clinical studies evaluating PFA specifically in EastAsian populations, highlighting a substantial evidence gap. Future research should prioritise region-specific prospective studies and real-world analyses to establish the long-term efficacy, lesion durability and clinical role of PFA within the broader management of AF.

Despite active rhythm control strategies, patients with recurrent AF faced a non-trivial burden of adverse outcomes. The pooled data revealed a 3-year heart failure-related hospitalisation rate of 3.2%, a 3-year incidence of ischaemic stroke was 1.2%, a 3-year incidence of major bleeding events was 0.6% and 3-year cardiovascular death was 0.3%. These figures illustrate that AF recurrence may reflect broader systemic vulnerability and underlying cardiovascular risk, emphasising the need for holistic management. Continued rhythm monitoring and stroke prevention remain crucial even after initial rhythm restoration. All patients with recurrent AF should be evaluated for oral anticoagulation based on their stroke risk, regardless of symptomatic burden.37 Furthermore, efforts to prevent progression to heart failure – including early intervention, use of guideline-directed therapies and regular follow-up – can reduce hospitalisations and improve outcomes.38

These results also underscore the need for multidisciplinary care models that include cardiologists, electrophysiologists and primary care providers. While our review summarises adverse clinical outcomes, data on patient-reported outcomes such as QOL are limited. Clinically, recurrent AF often significantly impacts QOL, affecting physical functioning and emotional wellbeing.12,39 The lack of consistent QOL data represents a limitation and underscores the need for future studies integrating patient-centred outcomes in this patient population.

In the included studies, the vast majority were funded by non-industry sources or did not report funding, with only two out of 68 studies receiving support from commercial entities. This suggests that the potential influence of industry sponsorship on the overall findings of this review is likely limited. Nevertheless, it is important to acknowledge that studies with commercial funding may have a higher likelihood of reporting positive outcomes or selective results, as highlighted in prior research. Although the proportion of industry-sponsored studies in this review is small, readers should consider funding sources when interpreting study results, and future systematic reviews should continue to assess the financial dimension to ensure transparency and minimise potential bias.

Limitations

This is the first systematic review specifically addressing post-ablation AF recurrence in East Asian people, with notable strengths including a large pooled sample, standardised selection criteria and detailed subgroup analyses. However, significant limitations remain. The exclusion of literature published in languages other than English and Chinese, variability in ablation techniques and potential publication bias may limit the generalisability of findings. Crucially, the lack of patient-level data precluded meta-regression or the construction of robust multivariable risk prediction models. Heterogeneity in follow-up duration and outcome definitions undermined the comparability of long-term outcomes across studies.

Another important limitation is the lack of evidence on post-ablation AAD use in the literature, highlighting a critical evidence gap and indicating that systematic data on post-ablation pharmacologic management are currently lacking. More importantly, this review highlights a critical evidence gap regarding patient-reported outcomes on QOL and long-term clinical outcomes, such as stroke, heart failure, bleeding and mortality, in patients with post-ablation AF recurrence. Only a few studies reported such clinical endpoints, often with short or inconsistent follow-up periods. This limits our ability to assess the full disease burden and long-term prognosis, particularly in real-world settings.

While recurrent AF is consistently associated with adverse structural and clinical characteristics, the evidence synthesised in this review is primarily observational; therefore, causality cannot be inferred. Recurrent AF may serve as a marker of advanced disease or a contributor to on-going remodelling; future longitudinal and mechanistic studies are warranted to clarify these relationships. There remains an unmet clinical and research need to generate high-quality longitudinal evidence that can guide long-term management strategies and support health economic evaluations aimed at reducing the burden of AF recurrence post-ablation in East Asia.

Conclusion

The identified evidence from East Asia highlights that post-ablation AF recurrence is commonly associated with structural heart changes, comorbidities and AF type. While repeat ablation and pharmacological therapy show similar short-term effectiveness, neither fully prevents long-term recurrence. Critically, there is a lack of long-term data on outcomes such as stroke, heart failure and mortality in patients with post-ablation AF recurrence from East Asia. This evidence gap limits our understanding of the full disease burden and hinders optimal long-term management for post-ablation AF recurrence in East Asia. Future studies should prioritise long-term follow-up to better inform clinical decisions and healthcare planning for post-ablation AF recurrence in East Asia.

Clinical Perspective

• Post-ablation AF recurrence is common in East Asia, often associated with structural heart changes and prevalent comorbidities, highlighting the need for early risk assessment.

• Repeat ablation and antiarrhythmic drug therapy achieve similar short-term rhythm control, but neither fully prevent recurrence, emphasising the need for individualised management strategies.

• Late recurrence is linked to more comorbidities and structural remodelling, underscoring the importance of on-going monitoring, risk factor management and holistic care.

• Evidence gaps on long-term outcomes suggest the need for studies to guide region-specific clinical decision-making.

Funding Statement

The study was supported by grants from the National Nature Science Foundation of China (Grant No. 82170292 & 82370422 to RS), Hunan Provincial Natural Science Foundation Key Project (Grant No. 2025JJ30043 to RS), Hunan Provincial Health Commission Scientific Research Project (Grant No. A202303018910 to RS), Hunan Province Health and Medical High-level Talent Major Project (Grant No. 20230494 to RS)