Improved survival in patients with atrial fibrillation and heart failure undergoing catheter ablation compared to medical treatment: A systematic review and meta‐analysis of randomized controlled trials

Abstract

Introduction Increasing evidence has suggested improved outcomes in atrial fibrillation (AF) patients with heart failure (HF) undergoing catheter ablation (CA) as compared to medical therapy. We sought to investigate the benefit of CA on outcomes of patients with AF and HF as compared to medical therapy. Methods and Results A systematic review of PubMed, Embase, and Cochrane Central Register of Clinical Trials was performed for clinical studies evaluating the benefit of CA for patients with AF and HF. Primary endpoint was all‐cause mortality. Secondary endpoints included atrial‐arrhythmia recurrence and improvement in left ventricular ejection fraction (LVEF). Eight randomized controlled trials were included with a total of 2121 patients (mean age: 65 ± 5 years; 72% male). Mean follow‐up duration was 32.9 ± 14.5 months. All‐cause mortality in patients who underwent CA was significantly lower than in the medical treatment group (8.8% vs. 13.5%, RR 0.65, 95% confidence interval [CI] 0.51−0.83, p = .0005). A 35% relative risk reduction and 4.7% absolute risk reduction in all‐cause mortality was observed with CA. Rates of all‐atrial arrhythmia recurrence were significantly lower in the CA group (39.9% vs. 69.6%, RR: 0.55, 95% CI: 0.40−0.76, p = .0003). Improvement in LVEF was significantly higher in patients undergoing CA (+9.4 ± 7.6%) as compared to conventional treatment (+3.3 ± 8%) (mean difference 6.2, 95% CI: 3.6−8.8, p < .00001). Conclusion CA for AF in patients with HF decreases all‐cause mortality, improves all‐atrial arrhythmia recurrence rate and LVEF when compared to medical management. CA should be considered the treatment of choice to improve survival in this select group of patients. Nonetheless, the benefit of CA in patients with severely reduced ejection fraction and New York Heart Association class IV HF has not been clearly elucidated.

Best Practice Guide for Cryoballoon Ablation in Atrial Fibrillation: The Compilation Experience of More than 1000 Procedures

“…The indispensability of AF ablation in the management of patients with concomitant heart failure has been both shown in landmark trials and confirmed in meta-analyses. Indeed, a recent review [ 40 ] reported that, in the population of heart failure patients at functional stages I–III, catheter ablation decreases all-cause mortality and improves all-atrial arrhythmia recurrence rate as well as cardiac function when compared to medical management—findings are still inconclusive regarding the sickest heart failure patients, at functional stage IV. Focusing on CB ablation, long-term outcomes on functional stage and ejection fraction appear favorable and equivalent to those achieved with the RF-based approach [ 41 , 42 ].…”

Atrial fibrillation ablation in heart failure patients: Where do we stand in 2023? – State of the art review

“…This confusion is reflected in the widespread variation in the use of AF ablation across and within given geographies. 36,37 Fortunately, several prospective, randomized studies comparing AF ablation to usual care approaches (AATAC, AMICA, ARC-HF, CABANA, CAMERA-MRI, CAMTAF, CASTLE-AF, RAFT-AF, PABA, CAS-TLE HTx) 26,31,[38][39][40][41][42][43][44][45][46] and meta-analyses [47][48][49][50][51][52][53][54] have been performed to provide clinicians with information and minimize uncertainty.…”

“…Fortunately, several prospective, randomized studies comparing AF ablation to usual care approaches (AATAC, AMICA, ARC‐HF, CABANA, CAMERA‐MRI, CAMTAF, CASTLE‐AF, RAFT‐AF, PABA, CASTLE HTx) 26,31,38–46 and meta‐analyses 47–54 have been performed to provide clinicians with information and minimize uncertainty.…”

Efficacy and feasibility of cryoballoon ablation for atrial fibrillation in patients with heart failure: A large‐scale multicenter study

“…The study did not include non-HF patients undergoing cryoballoon ablation or a comparable group of those HF patients undergoing radiofrequency ablation for AF or a medication-only group. 23,24 The study did not assess symptom recovery, NYHA class, or quality of life after the follow-up period. 11 The LVEF groups of HF patients were stratified based on the LVEF determined on echocardiography before the procedure time, and the value of LVEF might have changed according to recent HF onset and management thereafter.…”